Assessing Mood Disorders I: Depressive Disorders

Diagnosis of the different types of depressive disorders begins with diagnosis of a major depressive episode (Table 23.1). Once you become expert at assessing the presence of the NVSs of depression, you will be able to diagnose quickly major depression, atypical depression, seasonal affective disorder (SAD), and dysthymic disorder.

KEY POINT

It is equally important that you know when not to diagnose a depressive disorder. Major depression tends to receive a dis-proportionate amount of attention in mental health education, partly because it is genuinely common and partly because we are so good at treating it. Nonetheless, you do a disservice to a patient by diagnosing him with major depression if instead he has an adjustment disorder with depressed mood and would benefit more from brief psychotherapy than from medication.

MAJOR DEPRESSIVE EPISODE

Mnemonic: SIGECAPS

A useful mnemonic to guide your questioning of the NVSs of depression is SIGECAPS. It was devised by Dr. Carey Gross
at MGH and refers to what one might write on a prescription sheet for a depressed, anergic patient: SIG: Energy CAPSules. Each letter refers to one of the major diagnostic criteria for major depressive disorder:

TABLE 23.1. DSM-IV-TR criteria for major depressive episode

Five or more of the following symptoms have been present for at least 2 weeks; at least one of the symptoms is either (a) depressed mood or (b) loss of interest or pleasure.
	Depressed mood most of the day, nearly every day
	Markedly diminished interest or pleasure in all, or almost all, activities
	Decrease in appetite or significant weight loss
	Insomnia or hypersomnia
	Psychomotor agitation or retardation
	Fatigue or loss of energy
	Feelings of worthlessness or excessive or inappropriate guilt
	Diminished concentration or indecisiveness
	Thoughts of death or SI
	Mnemonic: SIGECAPS
Adapted from American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. Washington, DC: American Psychiatric Association.

Sleep disorder (either increased or decreased)^*

Interest deficit (anhedonia)

Guilt (worthlessness,^* hopelessness,^* regret)

Energy deficit^*

Concentration deficit^*

Appetite disorder (either decreased or increased)^*

Psychomotor retardation or agitation

Suicidality

For dysthymic disorder, two of the six starred symptoms must be present.

Asking about the Symptoms of Depression

The main difficulty for beginning clinicians is in translating the DSM-IV-TR terminology into language that is meaningful for the patient. A related difficulty is distinguishing truepositive from false-positive responses to questions about symptoms. Most people experience some of the symptoms of major depression to some degree at some time. Establishing that your patient has symptoms severe enough to meet DSM-IV-TR criteria takes creativity, persistence, and experience.

In this chapter, I discuss techniques for assessing each of the NVSs in turn. First, here are some general tips:

Establish that the symptom is truly a change from baseline. Many patients may have difficulties with concentration, energy, appetite, and so forth that may be chronic and have little to do with depression. If so, these symptoms cannot “count” toward your diagnosis of a major depressive episode.

CLINICAL VIGNETTE

An intern was interviewing a 45-year-old nightclub owner. When asked, “How have you been sleeping for the past 2 weeks?” the patient responded, “Terribly. I can’t fall asleep before 4 a.m., and then I get up at 10. I’m always tired.” The resident considered this statement sufficient to meet criteria for the insomnia of depression, until the patient mentioned that this had been his sleep pattern for the past 6 years, and that it had been unchanged over the past 2 weeks. The patient was referred to a sleep clinic and was eventually diagnosed with sleep apnea.

Establish that the symptom has occurred almost every day for 2 weeks. Many patients may react to upsetting events with a few days of NVSs. This does not constitute a major depressive episode, although it may be an adjustment disorder with depressed mood. It’s useful to remind patients that you are asking about a specific period.

Think back carefully: Have you felt depressed pretty much every day over the past 2 weeks?
Try not to ask leading questions. An example of a leading question is “Has your depression made it hard for you to concentrate?” This implies that decreased concentration would be expected, and a suggestible or malingering patient might answer with a false “yes.” An example of a nonleading question would be “Do you think your concentration has been better or worse than normal over the past 2 weeks?” Of course, you can substitute any of the NVSs for “concentration” in this template.

Screening Questions

Are you depressed?

One study showed that this simple question had 100% sensitivity and specificity in diagnosing major depression in the terminally ill, outperforming elaborate screening instruments such as the Beck Depression Inventory (Chochinov et al. 1997).

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