General Approach to mood states

Patients with labile affect can be

unpredictable and perplexing to an
inexperienced interviewer

Patients who are profoundly depressed may

be withdrawn and slow to reply, making it
difficult to obtain full information
 SAFETY FIRST
▪Assess patient’s level of agitation
▪Suicide risk
Focus on the current presentation, including the
mood disturbance, neurovegetative
symptoms, and recent stressors
Explore past episodes of abnormal mood,
medical illnesses, medications, and
functional status
Patients with extreme mood states need to be
screened for comorbid psychiatric illnesses
(psychosis, PD and anxiety)
Substance abuse and dependence
CASE 1
Ms. S, a 61-year-old female, was brought to the PES for suicidal ideation and
nihilistic thoughts. She had a past history of depression and had previously
Depressed
been treated with electroconvulsive therapy. During the interview, she did not
make eye contact. Her clothes and hair were unkempt. She appeared fatigued.

Mood States
Her affect was restricted. In a flat voice, she stated, “I am so sad I cannot cry.”
She had no clear and definite plan to end her life, but she did not see any possibility
of recovery. Her goal was to end her inner pain. She had been feeling increasingly
depressed since she ran out of her medications 3 months earlier.
Assessment of depressed mood
state Many patients with depressed mood will
readily admit their distress
Rather than asking closed-ended questions,
the clinician should ask open-ended
questions, which often yield more
accurate information
Symptoms of sadness and/or anhedonia are
essential for the diagnosis of a major
depressive episode
Decline in level of functioning
Ask about major stresses and significant
losses as part of HPI
Ask about previous mood disturbances
Substance use history
 The clinician should acknowledge
the depth and intensity of the
patient’s distress, and allow some
time and silence before continuing
the interview
Mental status examination
Hygiene, eye contact, speech, and thought content
are salient elements
Mood-congruent themes of worthlessness, poverty,
or nihilism signal severe depression, and may at
times reach delusional intensity
Psychotic symptoms are present in 15% of all
depressed patients
In adolescents, psychotic depression may be the first
sign of bipolar disorder
In elderly, depression can be the first sign of
dementia
Always include consideration of medical conditions
that may be associated with depressed mood
Diagnosis
Major depressive episode
Adjustment disorder or bereavement
Bipolar disorder
Psychotic Disorders (Schizophrenia,
Schizoaffective disorder)
Substance-induced mood disorder
Co-morbidity with other psychiatric
illnesses
(anxiety, borderline PD)
Management and
disposition
Determined by risk assessment
Patients with a major depressive
episode who will not be
admitted to a hospital can be
started on antidepressants in
the emergency department
CASE 1 Continued…
Given the high risk for self-harm and her inability to care for herself, Ms. S
was certified as an involuntary patient and observed closely in the PES until
an inpatient bed became available. Her diagnosis was major depressive
disorder, current episode severe.
CASE 2
“Come in, come in!” Mr. M beckoned. “I am so glad to see you! I need to tell
you what is going on. You see, today is not April the first. It is April the truth!”
Elevated
he exclaimed in delight. “I am a security guard for Big Town Mall. Today, I
am to be promoted to field commander. You have the power to release me,

Mood States
doctor, so I can meet my boss. It is up to you! Up to now I have kept people’s
bodies safe. Now, now I know how to keep their souls safe.” Mr. M smiled
with satisfaction and a sense of purpose. His brother had brought Mr. M, age
28, to the PES. Mr. M had slept only 1 or 2 hours per night for the past week
and did not abuse substances.
Assessment of elevated mood
state Asking questions that are short, closed ended,
and focused will increase the amount of useful
information from patients who are very
talkative, circumstantial, or disorganized
Ask questions to elicit a clear timeline of recent
events and explore recent stresses
The interview should end before the patient
escalates, regardless of how little factual
information has been obtained
Information about the longitudinal pattern of
mood disturbance is necessary to determine the
diagnosis
Medication and substance use history
Physical examination
Diagnosis
Bipolar disorder
Schizoaffective disorder
Substance-related disorders
(amphetamine, hallucinogens,
opioids)
Medical conditions
Management and
disposition Provide a calm environment
Seclusion or restraints may be necessary
to contain an agitated patient or
prevent harm to others
Medications should be offered
proactively to prevent a reescalation of
the manic behaviors
Atypical antipsychotics
Benzodiazepines
Mood stabilizers
CASE 2 Continued…
Mr. M did not see the need for hospitalization. Before transfer to the ward,
he became irritable and demanded to be released, but with his brother’s
support and encouragement, he took soluble olanzapine 10 mg orally and
calmed down. He remained calm until transfer to the ward could be arranged
CASE 3
Angry and
Mr. W, a 17-year-old male, was brought to the emergency department by
police for causing a disturbance downtown. He was resistant to the assessment,
angry, and verbally abusive with staff. He refused oral sedatives, was
IrritableMood
uncooperative, and did not interact with his parents. He had a 1-year history of
daily cannabis use, corresponding to an escalation of his anger reactions. His

States
parents were unwilling to have him in their home. He was taking bupropion for
attention-deficit/hyperactivity disorder (ADHD).
Assessment of angry and
irritable mood state
Assessment of a reasonably calm person who was
brought in because of angry and irritable behavior
in the community
Gather specific details about the incident that
precipitated the visit as well as about previous
episodes of anger
Ask open-ended questions
Assessment of a person who is angry at the time of the
interview
Set firm limits
Allow patient to feel heard, to be supported, and to
have his feelings validated
Do not take the anger personally
Diagnosis
Mood disorders
Depressed patients may be irritable
Manic or mixed episode
Paranoid ideation and other psychotic
symptoms
Substance intoxication
Personality disorders (borderline, antisocial)
Children and adolescents
Medical disorders
Diagnosis
Children and adolescents
ODD
ADHD
Medical disorders
Delirium
Dementia
Head injury
Seizure disorders
It is important to remember that
anger is a normal reaction to
many circumstances.
If the anger is situational,
interviewing family members
may quickly reveal their role in
contributing to a patient’s angry
outbursts.
Management and
disposition
Medication may have a role in the management of angry
outbursts if a psychiatric disorder is present
Hospitalization should be considered for psychiatric
patients
Hospitalization or other psychiatric treatment for anger
in the absence of a psychiatric disorder is generally
not indicated
The most appropriate action may be to release these
angry individuals to the custody of law enforcement
Some patients who are in control of their mood state may
benefit from anger management training.
CASE 3 Continued…
An interview
Moreover, with
theMr.
ADHD
W and
appeared
his familywell
reveals
controlled
a 6-year
with his
history
bupropion.
of tantrums
and
Hospitalization
disputes. His was
mother
not admitted
warrantedthatbecause
she hadMr.insulted
W’s anger
him about
appeared
his cannabis
to be
independent
use, social isolation,
of his preexisting
and poorpsychiatric
academic performance.
diagnoses, and Mr.
it would
W refused
not have
to
been
apologize
appropriate
for his angry
to use outbursts.
these diagnoses
His parents
to excuse
wantedhis behavior.
us to keepInstead,
him in the
the
diagnosis
hospital.ofHowever,
parent-child
Mr. Wrelational
did not carry
problempsychiatric
was given.diagnoses
Reluctantly,
otherhisthan
parents
his
took him home. A referral
ADHD and for cannabis
family counseling
abuse. was completed.
Key clinical points
In assessing patients with extreme
moods, the interviewer should always
address safety and risk issues first.

Angry and depressed mood states occur

in a wide range of psychiatric
disorders.
Key clinical points
Obtaining a longitudinal history of
mood states is important in
establishing a mood disorder
diagnosis.

The clinician should screen a patient for

a history of hypomania or mania before
initiating an antidepressant.
Key clinical points
Depression and mania can present with
irritability.

For patients with depression who do not

require admission, the clinician should
initiate treatment in the PES and focus on
maximizing adherence and follow-up.
Key clinical points
For patients with depression who do
not require admission, the clinician
should initiate treatment in the PES
and focus on maximizing adherence
and follow-up.