C. Early morning waking – Explanation

Early morning waking is a classic somatic symptom of depression and often develops earlier than
general insomnia.
Palpitations and nausea and more common with anxiety. Excessive gambling may suggest either a
simple gambling addiction or be part of a hypomanic/manic disorder.
Flash-backs are common in post-traumatic stress disorder.
Depression: screening and assessment

Screening
The following two questions can be used to screen for depression
• ‘During the last month, have you often been bothered by feeling down, depressed or hopeless?’
• ‘During the last month, have you often been bothered by having little interest or pleasure in doing
things?’
A ‘yes’ answer to either of the above should prompt a more in depth assessment.
Assessment
There are many tools to assess the degree of depression including the Hospital Anxiety and
Depression (HAD)
scale and the Patient Health Questionnaire (PHQ-9).

Hospital Anxiety and Depression (HAD) scale
• consists of 14 questions, 7 for anxiety and 7 for depression
• each item is scored from 0-3
• produces a score out of 21 for both anxiety and depression
• severity: 0-7 normal, 8-10 borderline, 11+ case
• patients should be encouraged to answer the questions quickly

Patient Health Questionnaire (PHQ-9)
• asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following
problems?’
• 9 items which can then be scored 0-3
• includes items asking about thoughts of self-harm
• depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe

NICE use the DSM-IV criteria to grade depression:
• 1. Depressed mood most of the day, nearly every day
• 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
every day
• 3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly
every day
• 4. Insomnia or hypersomnia nearly every day
• 5. Psychomotor agitation or retardation nearly every day
• 6. Fatigue or loss of energy nearly every day
• 7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
• 8. Diminished ability to think or concentrate, or indecisiveness nearly every day
• 9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide