What evaluation is recommended for an adult patient presenting with grief after a relative's death, beyond administering the Patient Health Questionnaire-9 (PHQ-9) for depression symptoms?

Evaluation Beyond PHQ-9 for Grief-Related FMLA Documentation

For a patient presenting with grief after a relative's death requiring FMLA documentation, you must conduct a focused clinical assessment beyond the PHQ-9 to distinguish normal grief from major depressive disorder, assess functional impairment, and screen for suicidal ideation—all of which are necessary to justify medical leave and determine appropriate treatment. 1

Critical Safety Assessment (Must Be Done First)

• Immediately assess for suicidal ideation and self-harm risk, regardless of PHQ-9 score, by directly asking: "Have you ever thought about killing yourself or wished you were dead?" and "Have you ever done anything on purpose to hurt or kill yourself?" 1, 2
• If the patient endorses specific plans or intent for self-harm, facilitate emergency psychiatric evaluation before proceeding with FMLA paperwork 1, 3
• Pay particular attention to PHQ-9 item 9 (thoughts of self-harm), as this requires immediate action even if the total score is low 2, 1

Distinguishing Grief from Major Depressive Disorder

The key clinical distinction is that grief involves sadness and yearning for the deceased, while depression involves pervasive hopelessness, worthlessness, and inability to experience pleasure. 4

Symptoms Specific to Depression (Not Present in Uncomplicated Grief):

• Pervasive hopelessness and helplessness that extends beyond the loss itself 4, 5
• Feelings of worthlessness or excessive guilt unrelated to actions around the death 4
• Complete inability to experience pleasure (anhedonia) in all domains of life 4
• Active desire to die rather than passive thoughts about joining the deceased 5
• Ruminative thoughts about death and suicide beyond normal grief reactions 5

Symptoms That Overlap (Cannot Distinguish):

• Frequent crying, weight loss, sleep disturbance, and thoughts of death are present in both grief and depression, making them unreliable for differentiation 5
• These overlapping symptoms are why the PHQ-9 alone is insufficient for this evaluation 4, 5

Required Functional Assessment for FMLA

You must document specific functional impairments to justify medical leave:

• Assess ability to perform work duties: concentration, decision-making capacity, attendance reliability, and interpersonal functioning 2
• Determine duration and severity of functional impairment in occupational and social domains 2
• Document whether symptoms interfere with daily activities beyond what would be expected in normal grief 4

Additional Clinical History Elements

Psychiatric History and Risk Factors:

• Screen for past hypomanic or manic episodes before considering antidepressant treatment, as undiagnosed bipolar disorder can be precipitated by grief-related stress 3
• Identify history of prior depressive episodes, anxiety disorders, PTSD, or substance use 2
• Assess for complicated grief factors: sudden/traumatic death, ambivalent relationship with deceased, lack of social support 6, 7

Timeline and Symptom Evolution:

• Determine when the death occurred and how symptoms have progressed since then 4
• Normal grief typically decreases in intensity over time, while depression remains persistent or worsens 4
• Assess whether the patient had depressive symptoms before the loss or if they emerged afterward 6

Social and Contextual Factors:

• Evaluate social support systems and whether the patient is experiencing secrecy or stigma around the death 7
• Assess for anticipatory grief if the death was expected versus sudden 7
• Document relationship to the deceased (parent, sibling, child, spouse) as this impacts grief intensity 6

Physical Examination Considerations

While a comprehensive physical exam is not required for FMLA grief documentation, you should:

• Assess for signs of self-neglect (poor hygiene, significant weight loss) that indicate severe functional impairment 4
• Rule out medical causes of depressive symptoms if clinically indicated (thyroid dysfunction, anemia, medication side effects) 3
• Document psychomotor agitation or retardation if present, as this suggests major depression rather than grief 2

Documentation Requirements for FMLA

Your clinical note must include:

• PHQ-9 score with interpretation (scores ≥8 suggest clinically significant symptoms requiring intervention) 1, 8
• Clear statement of whether the patient meets criteria for major depressive disorder versus uncomplicated grief 4, 5
• Specific functional limitations that prevent work performance 2
• Treatment plan (psychotherapy, medication, or both) with expected duration 2, 6
• Prognosis and anticipated timeline for return to work 4

Treatment Implications Based on Your Assessment

If Uncomplicated Grief (PHQ-9 <8, no depression criteria):

• Pharmacotherapy is not indicated and may be harmful 5
• Provide psychosocial support, acknowledge grief, encourage open expression of emotions 4
• FMLA may still be appropriate for brief period if functional impairment is significant 4

If Major Depressive Disorder (PHQ-9 ≥8 with depression-specific symptoms):

• Initiate SSRI treatment (e.g., escitalopram) combined with psychotherapy 8, 6
• For PHQ-9 scores 8-14: low-intensity interventions with possible medication 1, 8
• For PHQ-9 scores ≥15: immediate psychiatric referral and high-intensity treatment 1, 3
• Reassess with repeat PHQ-9 in 4-6 weeks after treatment initiation 3

Common Pitfalls to Avoid

• Do not rely solely on PHQ-9 score to distinguish grief from depression, as symptom overlap makes this unreliable 4, 5
• Do not assume absence of suicidal ideation means low risk—patients with prior attempts remain at elevated risk even without current ideation 1
• Do not prescribe antidepressants for uncomplicated grief, as ongoing pharmacotherapy is generally not beneficial and may be harmful 5
• Do not miss bipolar disorder screening before starting antidepressants, as grief can unmask underlying bipolar illness 3