Would you diagnose a mood disorder in this patient?

Diagnosing Mood Disorders: A Structured Assessment Approach

You should diagnose a mood disorder only after completing a systematic assessment that includes standardized screening with the PHQ-9, direct clinical interview using DSM-5 criteria, evaluation of functional impairment, and exclusion of medical or substance-induced causes—a positive screening score alone is insufficient for diagnosis. 1, 2

Step 1: Initial Screening with Validated Instruments

• Begin with the Patient Health Questionnaire-9 (PHQ-9) as your primary screening tool, using a cutoff score of ≥8 for detecting depression 2, 3
• Follow with the Generalized Anxiety Disorder-7 (GAD-7) scale to assess anxiety symptoms, with scores interpreted as: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), and 15-21 (severe anxiety) 1, 2, 3
• A high screening score does not establish a diagnosis—it only indicates the need for further assessment, particularly in low-risk populations where positive predictive value may be low 1

Step 2: Immediate Safety Assessment and Triage

• Before proceeding further, evaluate for conditions requiring emergency psychiatric referral: risk of harm to self or others, severe depression or agitation, psychosis, or confusion/delirium 1, 2, 3
• Systematically assess both active and passive suicidal ideation, including thoughts of suicide or death 2
• Patients with PHQ-9 scores ≥15 require referral to psychiatry or psychology 2, 3

Step 3: Diagnostic Clarification Using DSM-5 Criteria

• Conduct a direct clinical interview with the patient and family/caregivers to assess for depressive symptoms based on DSM-5 diagnostic criteria 1
• For major depressive disorder, the patient must have at least 5 of 9 symptoms present during the same 2-week period, including either depressed mood or loss of interest, with symptoms including: significant weight/appetite change, sleep disturbance, psychomotor agitation/retardation, fatigue, guilt/worthlessness, impaired concentration, or suicidal ideation 4, 5
• Probe for other depressive disorders including persistent depressive disorder (dysthymia) and other specified/unspecified depressive disorders using systematic, rigorous assessment methods 1

Step 4: Screen for Bipolar Disorder in All Depression Cases

• Consider bipolar disorder in any patient presenting with depression, as misdiagnosis can lead to inappropriate antidepressant monotherapy, which is contraindicated in bipolar disorder 6, 7
• Look for distinguishing features of bipolar disorder: early age of onset (before age 21), high recurrence, atypical depression features (especially hypersomnia), psychomotor agitation, family history of mania/hypomania, and history of hypomania 8
• Use the Mood Disorder Questionnaire as a brief screening instrument to identify patients most likely to have bipolar spectrum disorders 9

Step 5: Assess Functional Impairment and Comorbidities

• Evaluate functional impairment in key domains: school/work, home, and peer/social settings 1
• Assess for comorbid psychiatric conditions including anxiety disorders, substance use disorders, impulse-control disorders, and other mental health conditions 1
• Use instruments that assess for a range of common comorbid conditions if not already used in initial screening 1

Step 6: Rule Out Medical and Substance-Induced Causes

• Medical or substance-induced causes of depressive symptoms must be determined and treated before making a primary mood disorder diagnosis 1, 2, 3
• Consider medications (e.g., interferon), medical conditions, and substance use as potential etiologies 1

Step 7: Assess Clinical Context and Risk Factors

• Evaluate for risk factors that increase likelihood of mood disorders: previous personal or family history of depression, bipolar disorder, suicide-related behaviors, substance use, or other psychiatric illness 1
• Assess for significant psychosocial stressors including family crises, physical/sexual abuse, neglect, trauma history, foster care, or adoption 1
• Note that adolescents with depression may present with irritability, fatigue, sleep changes, weight changes, academic decline, or family conflict rather than clearly identified depressed mood 1

Critical Pitfalls to Avoid

• Never diagnose based on screening scores alone—standardized instruments should supplement, not replace, direct clinical interview 1, 3
• Do not overlook bipolar disorder in patients presenting with depression, as approximately 50% of bipolar patients' symptomatic time is spent in depressive episodes 7
• Avoid missing substance-induced or medical causes of mood symptoms, which require different treatment approaches 1, 2
• Do not proceed with treatment planning without completing a safety assessment, regardless of diagnostic impression 1