CMN 552
Module 1
Primary Study Guide
University of South Alabama
, CMN 552
Module 1 Primary Study Guide (Mood Disorders)
Carlat Chapter 23
Asking About the Symptoms of Depression
>A related difficulty is distinguishing true-positive 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-5 criteria takes creativity, persistence, and experience.
● Establish that the symptom is truly a change from baseline.
● Establish that the symptom has occurred almost every day for 2 weeks.
>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 2weeks?” Of course, you can substitute any
of the NVSs for “concentration” in this template.
Screening Questions
● Are you depressed?
● How has your mood been recently?
● Have you ever felt very down or depressed, so depressed that your whole life was affected by it for at
least 2 weeks
SIGECAPS Questions
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.
● Recommended time: 1 minute if the screen is negative; 5 minutes if the screen is positive.
Sleep disorder
Have you been sleeping normally? (A good initial screening question for a sleep problem.)
What has your sleep pattern been like lately? (Depending on the adequacy of your patient’s response to this question,
you may or may not need to follow up with the following questions.)
What time do you lie down to fall asleep? What time do you actually fall asleep?(To diagnose difficulty falling asleep.)
Do you sleep through the night or wake up often during the night?(To diagnose frequent awakenings.)
,What time do you usually wake up in the morning? Do you generally feel rested when you wake up?
Do you feel more or less depressed when you wake up? How does your mood change as the day goes on?
(To diagnose early morning awakening and diurnal variation in mood.)
>Interest deficit (anhedonia): Anhedonia is a surprisingly difficult symptom to ascertain. Obviously, no patient
will come right out and say, “Doctor, I’ve been really anhedonic lately.” You will more likely hear words like, “I’m bored all
the time,” “I have no motivation,” or “I don’t care about anything.” One problem is that patients may not understand what
we mean if we ask, “Can you describe your interest level?” or “Have you been taking pleasure in things?” A patient may
only associate pleasure with extraordinary experiences, such as going on vacation, or she may say she has been taking
an interest in things when, in fact, her level of interest has decreased markedly since the onset of depression. Because
of these potential pitfalls, it’s important to be specific in your questioning.
>Before you felt really sad, what sorts of things would you do for fun or relaxation?
What sorts of hobbies did you have? Did you read? Did you play sports or follow the sports teams? Did you go out to
the movies? Did you go out with friends?
This establishes a baseline against which to compare the depressed period. You can then go on to ask about
how the depression has affected the patient’s activities:
Since you have felt depressed, have you noticed that you’ve been any less interested in these pursuits? Have you
found that you’ve been able to enjoy the things you used to enjoy?
Have you given up doing anything that you normally like to do?
*If the person you are evaluating is already on an antidepressant, particularly if this is a selective serotonin reuptake
inhibitor (SSRI), he may seem to have anhedonia, whereas he may actually have “apathy syndrome” secondary to
the antidepressant. This occurs in up to 20% to 30% of patients on newer antidepressants and may be caused by
lowered levels of brain dopamine.
>Guilt, worthlessness, hopelessness: Here, you want to understand how negatively the patient feels about himself.
Starting with questions that assess the patient’s self-worth often works well:
How have you been feeling about yourself, in terms of self-esteem, since you’ve been depressed?
Do you feel that you are essentially a good person, or do you have your doubts? Have you felt especially critical of
yourself lately? These questions touch specifically on the theme of hopelessness: How do you see your future?
Do you have hope that things will get better, or does it look pretty bleak?Do you feel helpless to change your situation?
*Have you felt guilty or regretful about things you’ve done or haven’t done? Like not being productive, not reaching your
potential, being a burden?
Energy deficit: Begin with a screening question.
How has your energy level been over the past couple of weeks?--If the patient answers “Lousy,” make sure that the low
energy coincides with the onset of the depression rather than being a constant feature of her physical state.
Is this a change for you? Did you feel significantly more energetic before your depression?
*Because medical illness can cause anergia in the absence of depression, you may be misled about the source
of the loss of energy, particularly when dealing with patients with chronic medical illnesses or geriatric
patients. In such cases, asking about the energy pattern throughout the day is helpful. Patients with medical illnesses
are at their most energetic when they wake up and then feel worse as the day progresses, whereas depressed
patients often wake up feeling low and anergic and feel better later in the day.
Concentration deficit.
Have you been able to focus on things well? How has your concentration been?(These general questions are
sometimes sufficient for screening purposes.) Have you felt more absentminded than usual? Have you noticed any
changes in your memory?(These get at the pseudodementia sometimes seen in depression.) Have you had problems
making decisions? Sometimes, the first sign of concentration problems is difficulty making basic decisions such as
“What should I make for dinner?” or “Should I go out tonight or not?”If you were to sit down with a newspaper in front of
you, would you be able to read an entire article from start to finish without losing your concentration, or do you have to
, read the same sentence repeatedly? Can you watch a half-hour television show from start to finish without losing your
focus? Have you noticed that you haven’t been able to get quite asmuch done at work as before?
Appetite Since you’ve been depressed, have you noticed that your appetite has increased, decreased, or stayed about
the same? Have you lost or gained weight since you’ve been depressed?Do your clothes fit you differently?
How many meals a day do you eat?-->These questions often lead to more accurate information; you can quantitate how
much the patient is actually eating, and the patient may in fact be surprised to realize that he has been eating less or
more than usual.
Does food taste good to you?->Depressed patients sometimes identify their eating problem not so much as a decrease
in appetite but as a sense that food has become tasteless and unenjoyable, “like cardboard,” as one patient told me.
* if a patient tells you that she overeats when depressed, ask if she binges and purges as well.
Psychomotor agitation and retardation: Although the DSM-5 specifies that psychomotor agitation and retardation
should be diagnosed based on what you observe in the patient during the evaluation, the following questions may also
be helpful: Sometimes when people get depressed, they notice that their movements really slow down, almost as
though their limbs are made of lead. Has that happened to you? (For psychomotor retardation.)
Have you been more restless than usual? Have you been pacing, wringing your hands, unable to sit down for
long? (For psychomotor agitation.)
Suicidality
Seasonal Affective Disorder
Once you have established that the patient has episodes of major depression, ask if these episodes follow any
seasonal pattern. The most common pattern is depression in the winter and euthymia in the summer.
Have you noticed that your depressions consistently come on or get worse in the winter and then go away when the
weather improves? SAD is similar to atypical depression in that reverse NVSs are usually present, such as
carbohydrate craving (with consequent weight gain) and hypersomnia.
If your patient is having difficulty remembering a seasonal aspect of the depression, you can jog his memory by
asking–Do you generally go on vacation to a sunny place during the winter? Do you find that your mood dramatically
improves during the vacation? Obviously, anybody’s mood improves to some extent during vacation, but the patient with
SAD will report a more extreme mood shift that often lasts for several weeks after his return, with a gradual lapse back
into depression thereafter. This mimics the response to light therapy.
Carlat Chapter 24
DIGFAST (manic Episode)
>Distractibility
>Indiscretion (DSM-5’s “excessive involvement in pleasurable activities”)
>Grandiosity
>Flight of ideas
>Activity increase
>Sleep deficit (decreased need for sleep)
>Talkativeness (pressured speech)
* In addition to expansive mood, the patient must qualify for three of the seven DIGFAST symptoms, or four of seven if
the primary mood is irritable. When you ask about the symptoms of mania, precede your questions with something such
as, “During the period last year when you felt high, were you …?” This way, you can ensure that all the symptoms have
occurred within the same time frame.
*Be sure to ask whether these behaviors occurred in the context of alcohol or drug abuse. If so, you’ll have to judge
whether the manic behavior is actually secondary to a substance abuse problem or whether the substance abuse is
secondary to mania. This is often a difficult question to sort out.
Module 1
Primary Study Guide
University of South Alabama
, CMN 552
Module 1 Primary Study Guide (Mood Disorders)
Carlat Chapter 23
Asking About the Symptoms of Depression
>A related difficulty is distinguishing true-positive 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-5 criteria takes creativity, persistence, and experience.
● Establish that the symptom is truly a change from baseline.
● Establish that the symptom has occurred almost every day for 2 weeks.
>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 2weeks?” Of course, you can substitute any
of the NVSs for “concentration” in this template.
Screening Questions
● Are you depressed?
● How has your mood been recently?
● Have you ever felt very down or depressed, so depressed that your whole life was affected by it for at
least 2 weeks
SIGECAPS Questions
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.
● Recommended time: 1 minute if the screen is negative; 5 minutes if the screen is positive.
Sleep disorder
Have you been sleeping normally? (A good initial screening question for a sleep problem.)
What has your sleep pattern been like lately? (Depending on the adequacy of your patient’s response to this question,
you may or may not need to follow up with the following questions.)
What time do you lie down to fall asleep? What time do you actually fall asleep?(To diagnose difficulty falling asleep.)
Do you sleep through the night or wake up often during the night?(To diagnose frequent awakenings.)
,What time do you usually wake up in the morning? Do you generally feel rested when you wake up?
Do you feel more or less depressed when you wake up? How does your mood change as the day goes on?
(To diagnose early morning awakening and diurnal variation in mood.)
>Interest deficit (anhedonia): Anhedonia is a surprisingly difficult symptom to ascertain. Obviously, no patient
will come right out and say, “Doctor, I’ve been really anhedonic lately.” You will more likely hear words like, “I’m bored all
the time,” “I have no motivation,” or “I don’t care about anything.” One problem is that patients may not understand what
we mean if we ask, “Can you describe your interest level?” or “Have you been taking pleasure in things?” A patient may
only associate pleasure with extraordinary experiences, such as going on vacation, or she may say she has been taking
an interest in things when, in fact, her level of interest has decreased markedly since the onset of depression. Because
of these potential pitfalls, it’s important to be specific in your questioning.
>Before you felt really sad, what sorts of things would you do for fun or relaxation?
What sorts of hobbies did you have? Did you read? Did you play sports or follow the sports teams? Did you go out to
the movies? Did you go out with friends?
This establishes a baseline against which to compare the depressed period. You can then go on to ask about
how the depression has affected the patient’s activities:
Since you have felt depressed, have you noticed that you’ve been any less interested in these pursuits? Have you
found that you’ve been able to enjoy the things you used to enjoy?
Have you given up doing anything that you normally like to do?
*If the person you are evaluating is already on an antidepressant, particularly if this is a selective serotonin reuptake
inhibitor (SSRI), he may seem to have anhedonia, whereas he may actually have “apathy syndrome” secondary to
the antidepressant. This occurs in up to 20% to 30% of patients on newer antidepressants and may be caused by
lowered levels of brain dopamine.
>Guilt, worthlessness, hopelessness: Here, you want to understand how negatively the patient feels about himself.
Starting with questions that assess the patient’s self-worth often works well:
How have you been feeling about yourself, in terms of self-esteem, since you’ve been depressed?
Do you feel that you are essentially a good person, or do you have your doubts? Have you felt especially critical of
yourself lately? These questions touch specifically on the theme of hopelessness: How do you see your future?
Do you have hope that things will get better, or does it look pretty bleak?Do you feel helpless to change your situation?
*Have you felt guilty or regretful about things you’ve done or haven’t done? Like not being productive, not reaching your
potential, being a burden?
Energy deficit: Begin with a screening question.
How has your energy level been over the past couple of weeks?--If the patient answers “Lousy,” make sure that the low
energy coincides with the onset of the depression rather than being a constant feature of her physical state.
Is this a change for you? Did you feel significantly more energetic before your depression?
*Because medical illness can cause anergia in the absence of depression, you may be misled about the source
of the loss of energy, particularly when dealing with patients with chronic medical illnesses or geriatric
patients. In such cases, asking about the energy pattern throughout the day is helpful. Patients with medical illnesses
are at their most energetic when they wake up and then feel worse as the day progresses, whereas depressed
patients often wake up feeling low and anergic and feel better later in the day.
Concentration deficit.
Have you been able to focus on things well? How has your concentration been?(These general questions are
sometimes sufficient for screening purposes.) Have you felt more absentminded than usual? Have you noticed any
changes in your memory?(These get at the pseudodementia sometimes seen in depression.) Have you had problems
making decisions? Sometimes, the first sign of concentration problems is difficulty making basic decisions such as
“What should I make for dinner?” or “Should I go out tonight or not?”If you were to sit down with a newspaper in front of
you, would you be able to read an entire article from start to finish without losing your concentration, or do you have to
, read the same sentence repeatedly? Can you watch a half-hour television show from start to finish without losing your
focus? Have you noticed that you haven’t been able to get quite asmuch done at work as before?
Appetite Since you’ve been depressed, have you noticed that your appetite has increased, decreased, or stayed about
the same? Have you lost or gained weight since you’ve been depressed?Do your clothes fit you differently?
How many meals a day do you eat?-->These questions often lead to more accurate information; you can quantitate how
much the patient is actually eating, and the patient may in fact be surprised to realize that he has been eating less or
more than usual.
Does food taste good to you?->Depressed patients sometimes identify their eating problem not so much as a decrease
in appetite but as a sense that food has become tasteless and unenjoyable, “like cardboard,” as one patient told me.
* if a patient tells you that she overeats when depressed, ask if she binges and purges as well.
Psychomotor agitation and retardation: Although the DSM-5 specifies that psychomotor agitation and retardation
should be diagnosed based on what you observe in the patient during the evaluation, the following questions may also
be helpful: Sometimes when people get depressed, they notice that their movements really slow down, almost as
though their limbs are made of lead. Has that happened to you? (For psychomotor retardation.)
Have you been more restless than usual? Have you been pacing, wringing your hands, unable to sit down for
long? (For psychomotor agitation.)
Suicidality
Seasonal Affective Disorder
Once you have established that the patient has episodes of major depression, ask if these episodes follow any
seasonal pattern. The most common pattern is depression in the winter and euthymia in the summer.
Have you noticed that your depressions consistently come on or get worse in the winter and then go away when the
weather improves? SAD is similar to atypical depression in that reverse NVSs are usually present, such as
carbohydrate craving (with consequent weight gain) and hypersomnia.
If your patient is having difficulty remembering a seasonal aspect of the depression, you can jog his memory by
asking–Do you generally go on vacation to a sunny place during the winter? Do you find that your mood dramatically
improves during the vacation? Obviously, anybody’s mood improves to some extent during vacation, but the patient with
SAD will report a more extreme mood shift that often lasts for several weeks after his return, with a gradual lapse back
into depression thereafter. This mimics the response to light therapy.
Carlat Chapter 24
DIGFAST (manic Episode)
>Distractibility
>Indiscretion (DSM-5’s “excessive involvement in pleasurable activities”)
>Grandiosity
>Flight of ideas
>Activity increase
>Sleep deficit (decreased need for sleep)
>Talkativeness (pressured speech)
* In addition to expansive mood, the patient must qualify for three of the seven DIGFAST symptoms, or four of seven if
the primary mood is irritable. When you ask about the symptoms of mania, precede your questions with something such
as, “During the period last year when you felt high, were you …?” This way, you can ensure that all the symptoms have
occurred within the same time frame.
*Be sure to ask whether these behaviors occurred in the context of alcohol or drug abuse. If so, you’ll have to judge
whether the manic behavior is actually secondary to a substance abuse problem or whether the substance abuse is
secondary to mania. This is often a difficult question to sort out.
