Psychiatric Assessment Script for Mood Disorders
Immediate Safety Screening (Conduct First)
Before proceeding with any formal assessment, immediately evaluate for conditions requiring emergency psychiatric referral: 1, 2, 3
- Risk of harm to self or others - Ask directly about active and passive suicidal ideation, including thoughts of suicide or death, suicide plans, and prior suicide attempts (including aborted or interrupted attempts, with details of context, method, damage, potential lethality, and intent) 1, 3
- Risk of harm to others - Assess for homicidal ideation, prior aggressive behaviors (homicide, domestic or workplace violence, physically or sexually aggressive threats or acts), and current psychotic or aggressive thoughts 1
- Severe agitation - Requires urgent psychiatric evaluation 3
- Psychosis - Presence of hallucinations, delusions, or disorganized thinking demands immediate psychiatric consultation 1, 3
- Confusion or delirium - Requires immediate medical evaluation to rule out organic causes 1, 3
If any of these are present, facilitate a safe environment, initiate one-to-one observation, and refer immediately for emergency evaluation by a licensed mental health professional. 1, 2
Demographic and Identifying Information
Document the following basic information: 1
- Age, gender, race/ethnicity
- Living situation and social support
- Occupation and functional status
- Reason for presentation today
Depression Screening (Primary Assessment Tool)
Administer the Patient Health Questionnaire-9 (PHQ-9) as the first-line screening instrument for all patients requiring mood assessment. 2
PHQ-9 Administration and Scoring
The PHQ-9 consists of 9 items assessing depressive symptoms over the past 2 weeks. Begin with the first two items: 1, 2
- "Little interest or pleasure in doing things" (anhedonia)
- "Feeling down, depressed, or helpless" (depressed mood)
If the patient scores 0-1 on both items combined, no further depression screening is needed at this time. 1
If the patient scores 2 or 3 on either item (occurring more than half the time or nearly every day), complete the remaining 7 items of the PHQ-9. 1
PHQ-9 Score Interpretation
Use a cutoff score of ≥8 (not the traditional cutoff of 10) for detecting depression in medical and psychiatric populations: 1, 2
- 1-7: Minimal symptoms - no or minimal depression, effective coping skills 1
- 8-14: Moderate symptoms - subthreshold depressive symptoms, functional impairment present 1, 3
- 15-19: Moderate to severe symptoms - most depressive symptoms present, significant functional impairment 1, 3
- 20-27: Severe symptoms - requires immediate psychiatric referral 1, 3
Patients with PHQ-9 scores ≥15 require referral to psychiatry or psychology. 2, 3
Critical PHQ-9 Item: Suicidal Ideation
Item 9 asks: "Thoughts that you would be better off dead or hurting yourself in some way." 1
- Any endorsement of this item (score >0) requires immediate clinical follow-up and detailed suicide risk assessment 1
- Do not omit this item, as doing so artificially lowers the total score and may miss patients with significant suicidal ideation 1
Anxiety Assessment
Following depression screening, assess anxiety symptoms using the Generalized Anxiety Disorder-7 (GAD-7) scale. 2, 3
GAD-7 Score Interpretation
Total scores range from 0-21: 2, 3
- 0-4: Minimal anxiety
- 5-9: Mild anxiety
- 10-14: Moderate anxiety
- 15-21: Severe anxiety
Bipolar Disorder Screening (Critical for Mood Disorder Assessment)
Prior to initiating any antidepressant treatment, patients with depressive symptoms must be adequately screened for bipolar disorder, as treating bipolar depression with antidepressants alone may precipitate a manic or mixed episode. 4
Screening Questions for Bipolar Disorder
Ask about distinct, spontaneous periods of mood changes with the following features: 5
- Elevated, expansive, or irritable mood lasting at least 4 days (hypomania) or 7 days (mania)
- Decreased need for sleep (not insomnia, but feeling rested after less sleep)
- Psychomotor activation (increased energy, activity, talkativeness, racing thoughts, distractibility)
- Impulsive or risky behaviors (spending sprees, sexual indiscretions, reckless driving)
Mood Disorder Questionnaire (MDQ)
Administer the Mood Disorder Questionnaire to screen for lifetime presence of manic or hypomanic symptoms. 6, 7, 8
- The MDQ is a brief self-report screening instrument that identifies patients most likely to have bipolar spectrum disorders 8
- Sensitivity can be increased by having a significant other also rate the patient 7
Risk Factors for Bipolar Disorder
Document the following risk factors: 1, 3, 4
- Family history of bipolar disorder, mania, or suicide
- Early age of onset (late teens to early 20s, particularly before age 21) 6, 9
- High recurrence of depressive episodes 9
- Atypical depression features (hypersomnia, psychomotor agitation) 9
- Poor response to antidepressant treatment or antidepressant-induced activation 6
History of Present Illness
Current Mood Episode Characteristics
Document the following for the current episode: 1
- Onset and duration of current symptoms
- Mood symptoms: Depressed mood, anhedonia, irritability, elevated mood
- Neurovegetative symptoms: Sleep changes (insomnia vs. hypersomnia), appetite/weight changes, energy level, psychomotor changes (agitation vs. retardation)
- Cognitive symptoms: Concentration difficulties, indecisiveness, feelings of worthlessness or guilt, suicidal ideation
- Anxiety symptoms: Worry, panic attacks, physical anxiety symptoms 1
- Functional impairment: Impact on work, school, relationships, self-care 3
- Precipitating stressors: Family conflict, relationship breakup, bullying, academic difficulties, legal troubles 1
Psychiatric Review of Systems
Systematically assess for: 1
- Anxiety symptoms and panic attacks
- Sleep abnormalities, including sleep apnea
- Impulsivity
- Psychotic symptoms (hallucinations, delusions)
- Obsessive-compulsive symptoms
- Eating disorder symptoms
- Trauma symptoms
Past Psychiatric History
Prior Mood Episodes
- Number and frequency of prior depressive episodes (assess for rapid cycling: ≥4 episodes per year) 5
- Number and characteristics of prior manic or hypomanic episodes
- Age at onset of first mood episode 9
- Pattern of episodes: Seasonal pattern, postpartum onset, mixed features
Prior Suicidal and Self-Harm Behaviors
Assess in detail: 1
- Prior suicidal ideation, plans, and attempts (including aborted or interrupted attempts)
- Details of each attempt: context, method, damage, potential lethality, intent
- Prior intentional self-injury without suicidal intent
Prior Aggressive Behaviors
Document: 1
- Prior homicidal or aggressive ideation
- Prior aggressive behaviors (homicide, domestic or workplace violence, physically or sexually aggressive threats or acts)
Prior Psychiatric Diagnoses and Treatment
Record: 1
- All prior psychiatric diagnoses
- History of psychiatric hospitalizations and emergency department visits
- Past psychiatric treatments (type, duration, doses)
- Response to past treatments (which medications helped, which did not)
- Adherence to past and current treatments
Substance Use History
Assess current and past use of all substances, as substance use disorders are highly comorbid with mood disorders and can mimic or exacerbate mood symptoms. 1, 5
Document: 1
- Tobacco use: Current and past use
- Alcohol use: Frequency, quantity, pattern of use
- Cannabis and other illicit drugs: Marijuana, cocaine, heroin, hallucinogens, stimulants
- Prescription medication misuse: Opioids, benzodiazepines, stimulants
- Over-the-counter medications and supplements
- Current or recent substance use disorder or change in substance use patterns
Medical History
Medical conditions and medications can cause or contribute to mood symptoms and must be ruled out before attributing symptoms solely to a primary mood disorder. 1, 2
Current and Past Medical Conditions
Document: 1
- Allergies or drug sensitivities
- All current medications (prescribed, over-the-counter, herbal, supplements, vitamins) and their side effects
- Relationship with primary care provider
- Past or current medical illnesses and related hospitalizations
- Neurological or neurocognitive disorders or symptoms (seizures, stroke, dementia, head injuries) 1
- Endocrinological diseases (thyroid disorders, diabetes, Cushing's syndrome)
- Infectious diseases (HIV, hepatitis C, syphilis, Lyme disease)
- Cardiopulmonary conditions
- Physical trauma, including head injuries
- Sexual and reproductive history (menstrual irregularities, pregnancy, postpartum period)
Medical Causes of Mood Symptoms
First, treat medical causes of depressive symptoms (e.g., unrelieved pain, fatigue) and delirium (e.g., infection, electrolyte imbalance) before attributing symptoms to a primary mood disorder. 1
Common medical causes to consider: 5
- Thyroid disorders (hypothyroidism, hyperthyroidism)
- Interferon administration
- Corticosteroid use
- Neurological conditions (stroke, multiple sclerosis, Parkinson's disease)
- Vitamin deficiencies (B12, folate, vitamin D)
Family Psychiatric History
Family history is a critical risk factor for mood disorders, particularly bipolar disorder. 3, 4
Document family history of: 1, 3, 4
- Depression
- Bipolar disorder or mania
- Suicide or suicide attempts
- Anxiety disorders
- Substance use disorders
- Psychotic disorders
- Psychiatric hospitalizations
Social and Developmental History
Assess: 1
- Childhood and adolescent development: Developmental milestones, school performance, peer relationships
- Trauma history: Physical abuse, sexual abuse, emotional abuse, neglect, witnessing violence
- Current social support: Family relationships, friendships, romantic relationships
- Living situation: Stable housing, homelessness, runaway status 1
- Occupational and educational functioning
- Legal history: Arrests, incarcerations, current legal problems
- Cultural and religious background
- Sexual orientation and gender identity (LGBTQ+ individuals are at higher risk for mood disorders and suicide) 1
Mental Status Examination
Document objective observations: 1
- Appearance: Grooming, hygiene, dress, eye contact
- Behavior: Psychomotor activity (agitation, retardation), cooperation, impulsivity
- Speech: Rate, volume, tone, fluency
- Mood: Patient's subjective report ("How would you describe your mood?")
- Affect: Observed emotional expression (range, intensity, appropriateness, congruence with mood)
- Thought process: Linear, tangential, circumstantial, flight of ideas, loose associations
- Thought content: Suicidal ideation, homicidal ideation, delusions, obsessions
- Perceptual disturbances: Hallucinations (auditory, visual, tactile)
- Cognition: Orientation, attention, concentration, memory
- Insight: Patient's understanding of their illness
- Judgment: Decision-making capacity, risk assessment
Collateral Information
Interview family members, caregivers, or other individuals who have knowledge about the patient's symptoms and functioning, as patients frequently minimize the severity of their symptoms. 1, 3
Obtain collateral information about: 1, 3
- Observed mood changes and behaviors
- Functional impairment in different settings (home, work, school)
- Adherence to treatment
- Substance use
- Suicidal or aggressive behaviors
Diagnostic Clarification
If moderate to severe symptoms are detected through screening (PHQ-9 ≥15), conduct a full diagnostic interview using DSM-5 criteria to determine if the patient meets criteria for a mood disorder. 2, 3
Structured Diagnostic Interviews
The gold standard for diagnosis is a structured clinical interview, such as the Structured Clinical Interview for DSM (SCID) or the Mini International Neuropsychiatric Interview (MINI). 2, 5, 3
DSM-5 Criteria for Major Depressive Episode
A major depressive episode requires: 4
- At least 5 of the following 9 symptoms present during the same 2-week period, representing a change from previous functioning
- At least one symptom must be either (1) depressed mood or (2) loss of interest or pleasure
- Symptoms:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all or almost all activities
- Significant weight loss or gain, or decrease or increase in appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive guilt
- Diminished ability to think or concentrate, or indecisiveness
- Recurrent thoughts of death, suicidal ideation, or suicide attempt
Differential Diagnosis
- Bipolar disorder (bipolar I, bipolar II, cyclothymia)
- Personality disorders (particularly borderline personality disorder, which can present with mood instability) 5
- Adjustment disorder with depressed mood
- Persistent depressive disorder (dysthymia)
- Substance/medication-induced depressive disorder
- Depressive disorder due to another medical condition
- Bereavement (though this does not exclude major depression)
Comorbidity Assessment
Nearly all patients with mood disorders have at least one comorbid psychiatric disorder, most frequently anxiety disorders. 6
- Anxiety disorders: Generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobias (use GAD-7) 2, 3
- Obsessive-compulsive disorder 4
- Post-traumatic stress disorder 5
- Attention-deficit/hyperactivity disorder (can mimic bipolar disorder) 5
- Substance use disorders 1, 7
- Eating disorders 4
- Personality disorders
Functional Assessment
Assess the degree of functional impairment across multiple domains, as this informs treatment planning and prognosis. 3
Document impairment in: 3
- Occupational functioning: Work performance, absenteeism, job loss
- Academic functioning: School attendance, grades, ability to complete assignments
- Social functioning: Relationships with family, friends, romantic partners
- Self-care: Hygiene, nutrition, medication adherence
- Activities of daily living
Risk Stratification and Disposition
High-Risk Patients (Immediate Psychiatric Referral)
Refer immediately for emergency psychiatric evaluation if: 1, 2, 3
- Active suicidal ideation with plan or intent
- Recent suicide attempt
- Homicidal ideation or recent aggressive behavior
- Severe depression with psychotic features
- Severe agitation or impulsivity
- Acute mania or mixed episode
- Delirium or acute confusion
Moderate-Risk Patients (Urgent Psychiatric Referral)
Refer to psychiatry or psychology within 1-2 weeks if: 2, 3
- PHQ-9 score ≥15
- Moderate to severe depression without immediate safety concerns
- Suspected bipolar disorder
- Treatment-resistant depression
- Complex comorbidities
- Need for medication management
Lower-Risk Patients (Outpatient Management)
Patients with PHQ-9 scores 8-14 may be managed in primary care or outpatient psychiatry with close monitoring. 1, 2
Monitoring Plan
All patients being treated with antidepressants must be monitored closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of treatment or at times of dose changes. 4
Warning Signs Requiring Immediate Evaluation
Monitor for the following symptoms, which may represent precursors to emerging suicidality or worsening depression: 4
- Anxiety
- Agitation
- Panic attacks
- Insomnia
- Irritability
- Hostility
- Aggressiveness
- Impulsivity
- Akathisia (psychomotor restlessness)
- Hypomania or mania
Families and caregivers should be alerted to monitor for these symptoms and report them immediately to healthcare providers. 4
Follow-Up Schedule
- Initial follow-up: Within 1-2 weeks of starting treatment 7
- Subsequent follow-ups: Every 2-4 weeks during the first 3 months, then monthly or as clinically indicated 7
- Reassess PHQ-9 and GAD-7 at each visit to monitor symptom changes 7
Documentation and Communication
Standardized instruments should not replace direct interview by a clinician, but should supplement clinical judgment. 3
Document: 1
- All assessment findings
- PHQ-9 and GAD-7 scores
- Suicide risk assessment and safety plan
- Diagnostic formulation
- Treatment plan
- Referrals made
- Patient and family education provided
Communicate directly with the receiving psychiatrist or psychologist when making referrals, particularly for high-risk patients. 1