Endocrine psychiatric comorbidity in metabolic disorders: Integrative mechanisms and traditional Chinese medicine

Table 4 Pragmatic interpretation framework for the minimal screening package and stepped-care triggers

Measure	Score range	Risk tier (suggested)	Suggested stepped-care trigger in metabolic-endocrine clinics
PHQ-9	0-4	Low	Monitor; provide brief education on sleep regularity, activity planning, and stress hygiene; re-screen if symptoms persist or self-management becomes difficult
	5-9	Low-moderate	Consider brief, skills-based support and reassess; explore functional impact and adherence barriers
	10-14	Moderate	Consider structured, module-targeted intervention and closer follow-up; evaluate co-occurring anxiety/insomnia and treatment burden
	15-19	High	Prompt more comprehensive assessment (including function and safety) and consider referral/co-management with mental health services, while continuing metabolic care
	20-27	High	Urgent specialist evaluation should be considered when severe symptoms are present, particularly with marked functional impairment or safety concerns; coordinate integrated management and monitor metabolic effects of psychotropic treatment where applicable
GAD-7	0-4	Low	Monitor; provide brief stress-management and sleep regularity guidance
	5-9	Low-moderate	Consider short, skills-based interventions and reassess
	10-14	Moderate	Consider structured intervention and closer follow-up; assess hyperarousal and its interaction with sleep and glycaemic variability
	15-21	High	Prompt comprehensive assessment and consider referral/co-management; review medication effects and adherence barriers
ISI (preferred)	0-7	Low	Provide sleep regularity counselling; monitor
	8-14	Moderate	Consider brief behavioural insomnia management and reassess; evaluate common contributors (e.g., pain, nocturia)
	15-21	High	Prompt targeted insomnia intervention and closer follow-up; consider differentiating insomnia phenotype from sleep-disordered breathing when clinically indicated, and consider targeted screening for obstructive sleep apnea in higher-risk metabolic phenotypes1
	22-28	High	Consider specialist sleep/mental health referral when severe insomnia persists or functional impairment is substantial, and consider sleep evaluation when sleep-disordered breathing is suspected
PSQI (alternative)	≤ 5	Low	Generally indicates acceptable sleep quality; monitor and reinforce regularity
	> 5	Elevated	Suggests impaired sleep quality; consider further assessment (including insomnia severity and possible sleep-disordered breathing) and module-targeted sleep intervention

¹Cut-offs reflect commonly used screening conventions and should be interpreted in clinical context. Escalation may be warranted regardless of total score when functional impairment is substantial, symptoms deteriorate rapidly, or safety concerns (including suicidality) are identified. Where relevant, sleep complaints should be interpreted with attention to phenotype, as suspected sleep-disordered breathing may warrant targeted evaluation in parallel with insomnia-focused behavioural strategies.

PHQ-9: Patient Health Questionnaire 9; GAD-7: Generalized Anxiety Disorder 7; ISI: Insomnia Severity Index; PSQI: Pittsburgh Sleep Quality Index.