What is the recommended approach to history taking for low mood in a 10‑minute general practitioner consultation?

History Taking for Low Mood in a 10-Minute GP Consultation

Begin by directly asking two screening questions: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" 1, 2

Initial Screening Approach

• Use the PHQ-2 as your entry point (the two questions above), which takes less than 1 minute and has 73.7% sensitivity for detecting major depressive disorder 2
• If either question is positive (score ≥2), proceed immediately to the full PHQ-9, which assesses all nine DSM criteria and takes 3-5 minutes to complete 2, 3
• The PHQ-9 has 89.5% sensitivity and 77.5% specificity at a cutoff of ≥11, though ≥8 may be more appropriate in some populations 2, 3

Critical Safety Assessment (Must Complete First)

• Immediately assess suicidal ideation by asking directly: "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?" 2, 4
• Pay particular attention to PHQ-9 item 9 (thoughts of self-harm) - any endorsement of specific plans or intent requires immediate emergency psychiatric evaluation 2, 4
• Self-administered scales are valuable because adolescents and adults may disclose suicidality on paper that they deny verbally 2

Essential History Components (Prioritize These in Time-Limited Consultation)

Symptom Characterization

• Ask patients to provide specific examples when they use terms like "memory loss," "confusion," or "low mood" - their definitions often differ substantially from clinical meanings 1
• Distinguish between sadness as a normal response to circumstances versus the illness called "depression" that requires medical intervention 5
• In adolescents, specifically ask about irritability and oppositional behavior, as these may be the primary manifestation rather than sadness 2

Temporal Profile

• Determine when symptoms first appeared, how they evolved in frequency and intensity, and whether they are episodic or persistent 1
• Patients commonly frame their history around a triggering event (surgery, trauma), but you must dissociate symptom description from their perceived causal mechanism 1
• Avoid accepting "normal aging" or stress as sufficient explanations without thorough evaluation 1

Functional Impairment Assessment

• Assess specific domains: work performance (concentration, decision-making, attendance), relationships, and self-care activities 4
• Document concrete examples of how symptoms interfere with daily functioning, not just patient's subjective distress 4

Screen for Bipolar Disorder Risk

• Before considering antidepressant treatment, ask about past hypomanic or manic episodes (decreased need for sleep, racing thoughts, impulsive behavior, elevated mood) 3, 4
• Undiagnosed bipolar disorder can be precipitated by antidepressants 4

Comorbid Conditions

• Screen for anxiety disorders, PTSD, and substance use, as these affect treatment selection and outcomes 3
• Ask about somatic symptoms: migraine/headache, fatigue, irritable bowel syndrome, and pelvic pain are strong predictors of mood disorders (HR 1.15-1.32) 6

Collateral Information

• Interview family members or informants separately when possible, as disagreement between patient and informant perspectives provides valuable diagnostic clues 1
• Patients and companions may not recognize behavioral or mood symptoms as related to the presenting problem 1

Common Pitfalls to Avoid

• Do not rely on screening scores alone for diagnosis - false-positive rates are 60-76% in primary care settings 3
• GPs correctly identify only 33.8% of people with mild depression and 48.4% of those with distress using clinical judgment alone 7
• Do not assume absence of current suicidal ideation means low risk if the patient has previously attempted suicide 2
• Patients often reject the notion of a medical cure and emphasize self-management, which can clash with GP priorities 5
• Listen actively to the patient's perspective - participants consistently identify the importance of GPs listening, but often feel this does not happen 5

Management Algorithm Based on PHQ-9 Score

• PHQ-9 1-7 (mild): Provide education about depression, ensure adequate coping skills and access to resources, consider reassessment at future visits 2, 3
• PHQ-9 8-14 (moderate): Evaluate for risk factors (family history, previous episodes, trauma), consider referral to psychology/psychiatry, offer low-intensity interventions 2, 3
• PHQ-9 15-27 (severe): Make immediate referral to psychology/psychiatry, assess for risk of harm to self or others, evaluate for medical or substance-induced causes 2, 3

Documentation Requirements

• Record PHQ-9 score with interpretation 4
• Document specific functional limitations that prevent work or daily activities 4
• Note any positive responses to suicidal ideation questions 2, 4