What questions should be asked to assess a possible mood disorder?

Questions to Ask Someone Who May Have a Mood Disorder

Start by asking two simple screening questions about depressed mood and anhedonia: "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?" These two questions are as effective as longer screening instruments for detecting depression 1, 2, 3.

Initial Screening Questions

Core Mood Assessment

• Ask about depressed mood: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" 1, 2
• Ask about anhedonia: "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" 1, 2
• Alternative single question approach: Ask about emotional quality of life on a 0-100 scale, where 100 is perfect emotional health and 0 is the worst imaginable (a score <50 has 93% specificity for depression) 4
• Generic mood question: "Have you been experiencing stress, anxiety, unhappiness or difficulty coping?" (This detects 80% of anxiety disorders and performs well for both depression and anxiety) 5

If Initial Screening is Positive: Use PHQ-9

When either of the two screening questions is positive, administer the full PHQ-9 to assess depressive symptoms systematically 6. The PHQ-9 asks about the following over the past 2 weeks:

1. Little interest or pleasure in doing things 6
2. Feeling down, depressed, or hopeless 6
3. Trouble falling or staying asleep, or sleeping too much 6
4. Feeling tired or having little energy 6
5. Poor appetite or overeating 6
6. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down 6
7. Trouble concentrating on things, such as reading the newspaper or watching television 6
8. Moving or speaking so slowly that other people could have noticed, or the opposite—being so fidgety or restless that you have been moving around a lot more than usual 6
9. Thoughts that you would be better off dead or of hurting yourself in some way 6

Critical Safety Assessment

Immediate Risk Evaluation

• Ask directly about suicidal ideation: "Have you had recurrent thoughts of death, suicidal ideation without a specific plan, a suicide attempt, or a specific plan to commit suicide?" 7
• Assess risk of harm to self or others: Any patient identified as at risk requires immediate referral for emergency evaluation 6
• Evaluate for psychosis or confusion (delirium): These require immediate psychiatric referral 6

Diagnostic Criteria Questions for Major Depressive Disorder

If screening suggests depression, determine if 5 or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning (at least one symptom must be depressed mood or loss of interest/pleasure) 7:

Mood and Interest

• Depressed mood most of the day, nearly every day (in children/adolescents, this can be irritable mood) 7
• Markedly diminished interest or pleasure in all, or nearly all, activities most of the day, nearly every day 7

Physical Symptoms

• Significant weight loss when not dieting or weight gain (>5% of body weight in a month), or increased/decreased appetite nearly every day 7
• Insomnia or hypersomnia nearly every day 7
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings) 7
• Fatigue or loss of energy nearly every day 7

Cognitive and Emotional Symptoms

• Feelings of worthlessness or inappropriate guilt (which may be delusional) nearly every day 7
• Diminished ability to think or concentrate, or indecisiveness, nearly every day 7
• Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan 7

Anxiety Screening Questions (GAD-7)

Over the past two weeks, ask how often the patient has been bothered by the following 6:

1. Feeling nervous, anxious, or on edge 6
2. Not being able to stop or control worrying 6
3. Worrying too much about different things 6
4. Trouble relaxing 6
5. Being so restless that it is hard to sit still 6
6. Becoming easily annoyed or irritable 6
7. Feeling afraid as if something awful might happen 6

Scoring: 0-4 = minimal anxiety; 5-9 = mild anxiety; 10-14 = moderate anxiety; 15-21 = severe anxiety 6

Functional Impairment Assessment

• Ask about functional impact: "How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?" (Options: Not difficult at all, Somewhat difficult, Very difficult, Extremely difficult) 6
• Assess clinically significant distress or impairment in social, occupational, or other important areas of functioning 7

Exclusion and Differential Diagnosis Questions

Rule Out Other Causes

• Medical causes: Determine if symptoms are due to direct physiologic effects of a substance (drug of abuse, medication) or a general medical condition (e.g., hypothyroidism, interferon administration) 7, 6
• Bereavement: Assess if symptoms are better accounted for by bereavement (symptoms persisting >2 months, marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation suggest depression rather than normal grief) 7

Bipolar Disorder Screening

• Ask about manic/hypomanic episodes: Determine if symptoms meet criteria for a mixed episode (nearly daily fluctuations in mood qualifying for both manic and major depressive episodes) 7
• History of elevated mood: Inquire about periods of abnormally elevated, expansive, or irritable mood to rule out bipolar disorder before diagnosing unipolar depression 7

Additional Context Questions

Risk Factors and Stressors

• Identify possible stressors: Medical illness, cognitive decline, bereavement, institutional placement, unemployment, chronic disease 1
• Family history: Ask about family history of depression or other psychiatric disorders 1
• Substance use: Screen for comorbid substance misuse 1
• Chronic medical conditions: Assess for presence of chronic diseases that increase depression risk 1

Common Pitfalls to Avoid

• Don't rely solely on physical symptoms in patients with medical comorbidities; use tools like the CES-D that are relatively unaffected by physical symptoms 6
• Don't skip the suicide assessment even if the patient seems low-risk; always ask directly about suicidal thoughts 7, 6
• Don't assume risk factors alone indicate depression; the presence of risk factors cannot distinguish depressed from non-depressed patients without symptom assessment 1, 2
• Don't forget to assess anxiety alongside depression, as they frequently co-occur and the generic mood question can screen for both 5