When someone talks about symptoms of depression or shows physical manifestations of depression, a psychiatrist will often try to get a fuller picture of the current depressive episode through the clinical interview. A number of questions are important to answer:

1. When did these symptoms begin? Or if these symptoms have been present for a long time, when did they get worse?
2. Did anything happen to trigger these symptoms, such as a stressful life event?
3. Are these symptoms constant or do they fluctuate during the course of the day or over the week?
4. Has the person ever felt this way before?
5. Are there any substances involved that could be contributing to these symptoms (e.g. drinking alcohol, using cocaine or speed, etc.)?
6. Are these symptoms interfering with the individual's functioning and to what degree?
7. How are these symptoms affecting the people in the individual's life?
8. Is the person so miserable, emotionally, that he is considering suicide?

Baseline Mood/Affective Temperament

In addition to these standard questions, I also always try to ask patients about how they would describe their baseline mood states, when they are not depressed. Are they happy, upbeat or content? Or are they serious, pessimistic or low-grade depressed by nature? Or somewhere in between? Or, anxious? Or, do they cycle between low moods and high moods (as in cyclothymic affective temperament)?

Because so many people come to me saying that they have been depressed their entire lives, I try to ask them about gradations of depression. I want to know what the longest period of time is that they can be in a good mood - or their best mood. Is it for a few days? A few weeks? A few months? Or even a few years?

Prior Mood Episodes

I always ask patients to estimate the number of depressive episodes they have had in their lives, because this information can influence the treatment recommendations I eventually make. I also ask them to describe how long their worst episodes of depression lasted. And what interventions or life events helped them pull out of it (e.g. medications, psychotherapy, getting involved with someone romantically, reaching out to friends or family more.) All this information is put together in my mind, then, to give me a "map" of the person's mood over time.

As it turns out, some individuals with depression are more or less happy, well-adjusted people who periodically fall into mild, brief depressions or, occasionally, a mild severity major depressive episode. Others, however, have dealt with depression chronically. They have experienced some version of depression in their childhood and, in adulthood, they episodically experience moderate to severe major depressive episodes. Some individuals are chronically low-grade depressed (e.g. as in Dysthymic Disorder) and periodically experience major depressive episodes. (This situation, incidentally, is sometimes referred to as "double depression"). Yet others have chronic major depression and they can go years with symptoms of major depression that interfere with their functioning and sense of well-being.

Individuals with bipolar spectrum mood disorders can also experience abnormal, elevated mood states. Often, these abnormal mood states are associated with increased energy, increased goal-directed activity, increased mental activity (including racing or jumping thoughts), and elevated self-confidence or self-righteousness. These abnormal mood states can include euphoric elevated states, such as in euphoric hypomania or euphoric mania. They also include irritable hypomania and irritable mania. Associated symptoms can include excessive religiosity, grandiosity, paranoia, and hostility. Some individuals with bipolar spectrum mood disorder also experience rapidly shifting and unstable mood states. In any case, if an individual with depression also has a history of abnormal, elevated mood states, rapidly shifting mood states or what is known as temperamental "cyclothymia" or "hyperthymia", it suggests the presence of an underlying bipolar spectrum mood disorder.

Severity of Depression

Certainly, individuals with depression - including major depressive disorder - vary in the severity of their conditions. Some individuals may experience suicidal thoughts or significant neurovegetative symptoms with each episode of depression and, possibly, require acute psychiatric hospitalization. Others develop psychotic symptoms with severe depression (e.g. hearing a voice that tells them that they are a bad person or becoming paranoid and feeling as if everyone thinks negatively about them).

There are individuals who will, sadly, gone on to kill themselves and others who, having made serious attempts that nearly cost them their lives, will still struggle to derive adequate pleasure in their lives.

Having a mental map of an individual's mood over time can also give a sense of how that individual will respond to treatment and what sort of expectation is reasonable, in terms of response to treatment.

For example, individuals who has been severely physically, emotionally or sexually abused in childhood and who have suffered from some form of depression since that age are unlikely, even with the best of our current medications and psychotherapies, to ever report that their mood is as good as someone's without this kind of horrific history. These individuals, unfortunately, have great difficulty attaining long stretches of even and good mood with currently available medications and psychotherapies. Even when their mood is as good as it ever is, they often report a sense of underlying unhappiness, emptiness or lack of inner peace.

In assessing a depressive disorder, psychiatrists will often also want to ascertain two other important pieces of information:

1. To what degree has this person suffered from an anxiety disorder or is currently suffering from anxiety?
2. Does this individual have any features of a bipolar spectrum mood disorder?

Co-occuring Anxiety

Anxiety can mean anything from excessive worrying, tension and difficulty shutting down ones thoughts at night to full-blown panic attacks where physical symptoms are manifest, such as racing heart beat, shortness of breath, shakiness, and sweating. Some people describe anxiety as a powerfully uncomfortable sensation in their abdomen, like a big knot, or a vacuum, or hoards of butterflies. For others, it means obsessive ruminations (i.e. thinking about something repetitively and having a difficult time controlling it). For others, still, it feels as if they were a chicken running about with its head cut off. People sometimes talk about extreme tension in their neck and shoulder muscles when they describe anxiety.

I always ask patients whether they think they have dealt with anxiety or depression more in their lives - or both to about the same extent. Because conventional anti-depressant medications are also very effective for anxiety disorders, mood and anxiety disorders are physiologically related, at some level. Individuals with Generalized Anxiety Disorder normally have a lot of anxiety a lot of the time and periodically fall into depressive episodes. Other individuals suffer from mood symptoms nearly all the time and when they fall into more severe depressions, they experience more anxiety symptoms.

Bipolar Spectrum Mood Disorders

Because depression in the context of an underlying bipolar spectrum disorder may be treated differently than depression that is not part of a bipolar disorder, psychiatrists make a particular effort to inquire about symptoms of a bipolar spectrum mood disorder, in order to make an accurate diagnosis and make appropriate treatment recommendations. To assess whether an individual might have a bipolar spectrum mood disorder, a psychiatrist will usually screen for the typical symptoms of hypomania and mania. These are considered to be abnormal, elevated mood states. The psychiatrist might, for example, inquire about whether an individual has ever experienced any of the following symptoms:

Symptoms of Hypomania, Mania and Bipolar Vulnerability

1. Chronic trouble with mood swings
2. Unstable moods (feeling one mood one minute and a completely different one the next, e.g. going from feeling elated and optimistic to hopeless and suicidal)
3. Trouble with mood cycling between periods of depression and periods of elevated or irritable mood
4. Distinct elevation of mood beyond a normal, good mood (I also always ask how long these mood states last without an intervention)
5. Distinct change in mood characterized predominantly by agitation and irritability (outside of usual depressive mood)
6. Racing thoughts (the sense that one's thoughts are moving very fast or jumping around considerably, sometimes to the point of being difficult to keep up with)
7. Feeling much more energized than usual and having trouble "containing" that energy (again, I ask how long an individual can experience this kind of energy without an intervention of some kind)
8. Not needing to sleep as much (and for how many days in a row?)
9. Impaired judgment from elevated mood states (e.g. excessive spending, risk-taking, pleasure-seeking – or picking fights)
10. Talking so fast that people around them could not understand, took notice or commented about it
11. Feeling distinctly over-confident, so that other people would take note (e.g. uncharacteristic arrogance, haughtiness or charisma)
12. Being much more outgoing and social than their usual personality would predict
13. Feelings of grandiosity (having special worth, significance, power, etc)
14. Delusions of grandeur (believing one is the messiah, for example, or a rock star)
15. Distinct elevation of sex drive and seeking sex and pleasure
16. Needing to use alcohol or marijuana to "come down" or feel "calmer" or "take the edge off"

If a number of these symptoms are endorsed and are reported to have occurred at the same time, it suggests that the individual has an underlying bipolar spectrum mood disorder. I make it a point to ask if these symptoms occurred spontaneously, on their own, or if they were only induced by anti-depressant medications or drugs of abuse. Individuals with underlying bipolar spectrum mood disorders vary in their vulnerability to the abnormal mood states of these conditions. If there is sufficient evidence, in my mind, for a bipolar spectrum mood disorder, I will then inquire about the course of this illness, including how many mood episodes a person has dealt with and how quickly they can go from one mood episode to the next.

Co-Occuring Medical Conditions

Finally, in their efforts to understand as much as possible about an individual's depression, psychiatrists will usually inquire about significant medical conditions - including pain disorders and chronic inflammatory states - and how they may be contributing to the individual's depression.