Mental Status Exam in Depression

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Mental Status Exam in Depression

APPEARANCE
•Well-kept and presentable? Lacks motivation and energy to bathe or properly groom and dress
themselves or appear dishevelled?
•Evidence of self-harm such as cut marks, burns, or scars?
•Noticeable evidence of weight loss or gain?

BEHAVIOR
•Generalized "psychomotor retardation" visible generalized slowing of
movements and speech?
• Stooped posture with few spontaneous movements, and a downcast gaze with minimal eye
contact with the interviewer.
•At its most extreme, depression can present as grossly regressed behaviour, not bathing, soiling
themselves, and mute. Such patients are likely exhibiting catatonic behaviours and should be
worked up for and treated as such.
•Low and numb. Appears tearful and visually despondent.
• "Psychomotor agitation" which is a term used to describe excessive motor activity associated
with a feeling of inner tension. Behaviours seen include hand wringing, hair pulling, pulling of
clothes, pacing, fidgeting, and inability to sit still.

SPEECH / LANGUAGE
•Many depressed patients have decreased rate and volume and variation in tone of speech.
AKA slow, soft, and monotone. This is not always the case.
•Severely depressed patients may have paucity of speech (alogia), which is a lack of
unprompted speech. They may respond to questions with single words and exhibit delayed
responses to questions. You may have to literally wait over a minute for them to respond to a
question.

MOOD / AFFECT
•Mood described as "depressed" but just as common they will describe one of the many flavors of
depression to include -> numb, hopeless, worthless, guilty, irritable, zombie-like, sad, exhausted,
miserable, dark, dejected, paralyzed, drowning, heart-broken, bleak, etc...
•Denied depressed feelings but does not appear to be particularly depressed at first glance.
Family members or employers often bring or send these patients for treatment because of social
withdrawal, generally decreased activity, or other behaviours.
•The emotional range: blunted or constricted? Constricted is a mild reduction in the range and
intensity of emotional expression. Blunted is a significant reduction and is a greater reduction than
constricted. Flat is the complete absence of emotional expression which is more common in
schizophrenia but can also be seen in very severe depression.
•While a reduced emotional range is classic in depression, some patients show more lability and
have rapid and abrupt shifts in affective expression such as appearing numb one moment and
then crying hysterically the next.
•The word dysphoric is used to describe a negative mood state that is less extreme than
depression. It is the experience of feeling discontent and, in some cases, indifference to the
world. This is commonly seen as a lifelong pattern in patients with persistent depressive disorder
(PDD).
•Depressed patients can sometimes be guarded, which means filtering their emotional expression
and using caution in disclosing information.

THOUGHT PROCESS / THOUGHT CONTENT


•Depressed patients often have negative views of themselves and of the world.
•Perseverations (non delusional rumination) about negative themes to include guilt, loss, death,
and suicide.
•Clearly described in your documentation the extent of their suicidal (and homicidal) thoughts and
include their specific thoughts, their intent, plans, research, preparatory actions, etc.
•According to Kaplan and Sadock about 10% of all depressed patients have marked symptoms
of a thought disorder, usually thought blocking and profound poverty of thought. 

PERCEPTUAL DISTURBANCES
•Depressed patients with delusions or hallucinations are said to have a major depressive
episode with psychotic features.
•Mood-congruent delusions/hallucinations are consistent with a depressed mood and include
themes of failure, guilt, sinfulness, worthlessness, poverty, persecution, and terminal
illnesses. Mood-incongruent delusions/hallucinations might involve grandiose themes,
exaggerated power, knowledge, and worth. If this happens then consider a psychotic based
illness.

COGNITION
•Commonly obtained through a general sense of cognitive functioning obtained through
conversation, however additional tests (MMSE, MoCA) can expand this exam if needed.
•Most depressed patients are oriented to person, place, and time although some may not have
sufficient energy or interest to answer questions about these subjects during an interview.
•Over half of patients with depression have a resultant cognitive impairment and can include
impaired memory, learning, executive function, concentration, and processing speed. Such
patients commonly complain of impaired concentration and forgetfulness.

INSIGHT / JUDGEMENT
•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a
problem?
•Depressed patients' descriptions of their disorder often overemphasize their symptoms, their
disorder, and their life problems. It can be difficult to convince such patients that improvement is
possible.
•Judgment is best assessed by reviewing patients' actions in the recent past and their behaviours
during the interview.

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