One of the commonest consultations we have in primary care is for low mood and depression. It’s also picked up during consultations where a patient may not have come specifically regarding their mood. As such it’s really important that we have the skills required to tackle this type of consultation.
With experience each of you will develop your own way of working your way through this type of consultation, and setting up your own schedule for reviewing, and providing ongoing care to this cohort of patients. But in the early days of training it can be helpful to hear about how others undertake such consultations, and shape this to fit your own style.
So I will talk through how I approach this type of consultation. I’m not planning to cover all the detail regarding diagnosing depression, and specific management protocols. You can find the most recent NICE guidance on the recognition and management of depression here
NICE uses the DSM-IV criteria for diagnosis of depression. It’s important to know this since this is how you are going to diagnose someone with depression, and recognise the different grades of depression from ‘sub-threshold’ to severe. By understanding the diagnostic criteria you will a) know what you need to ask your patient and b) be able to ascertain what type of treatment you may wish to offer to your patient.
DSM-IV criteria for major depression:
5 or more symptoms
- Depressed mood for more than 2 weeks
- Poor appetite/ Weight loss > 5%
- Insomnia/ Hypersomnia
- Agitation / Psychomotor retardation
- Reduced Libido
- Loss of energy
- Poor concentration
- Thoughts of life not worth living / Suicidal ideation
Categorisation of depression:
- Sub-threshold = < 5 of the above symptoms
- Mild = only 5 (or not many more) of the above symptoms, resulting in only minor functional impairment
- Moderate = Symptoms or functional impairment is between mild and severe
- Severe = Most symptoms, and they have left a major functional impairment.
With the above knowledge we should be able to come up with a diagnosis, and a severity, of depression. However, the important part is how to gather that information. Sure, we could go through each of these symptoms very robotically, but is the person sat in front of us going to open up and be honest if you are undertaking a tick-box exercise? The answer is no!
It is this type of consultation where I find that a golden minute, or possibly two, is the most useful of any type of consultation. Because in that time you can get an idea of what’s going on, to what extent, and you get to look for all the verbal, and non-verbal cues, that will help you interpret what they are saying, and give you ideas of further questions you need to ask. I’m not going to teach you to undertake a mental state examination (I found a really nice summary here if you need to brush up on your skills), but during this opening minute or two you can start to cover some of the areas of the mental state examination. This is really important for considering the impact of symptoms upon the persons level of functioning.
I like to try and gather information regarding their other symptoms by turning the consultation into more of a ‘chat’ than an ‘interview’. I find this makes it more personal, and tends to develop a greater rapport with the patient.
In my head I am trying to be as nosy as possible, and painting a picture of this person’s life. By doing this I can work out what’s going on, why they might be in this position and the amount of support they have. In turn, this is going to help me offer them the best options for management.
What do I tend to ask about?
- One of the big questions I ask is what triggered them to come and see me today in particular – this gives a really useful insight in to their situation.
- I want to know when they last remember being themselves/happy/’normal’
- Have they ever felt like this before? If so what happened at that time
- Can they put a finger on what triggered this episode? Is that ‘something’ still happening?
- Whats their home set up like – Who do they live with? Do they have children? Is home happy or are there stresses? Are their financial or marital concerns?
- What do they do for work? How is their mood impacting upon work, and how does work impact upon their mood? Have they had any time off recently? If so, did things improve?
- What makes them happy normally – Do they have any interests? Do they get time for themselves? Are they still enjoying those things they used to?
- How is their sleep? If they are not sleeping well is it because they struggle to get to sleep, or are they waking. If they struggle to get to sleep – why? What are they thinking/worrying about?
- Are they eating? Do they enjoy mealtimes as before?
- Do they smoke, drink, take drugs?
- Who is in their support network locally – do they have one? Have they got family and good friends locally? Have they talked to any of these people about how they are feeling? Is there any history in the family of low mood/depression/other psychiatric illness?
- Have they got to the point where they’ve felt so low that they have thought about harming themselves in any way? Or thought about ending their own life? If they answer yes to these questions then I am going to ask for more information (I will chat about this more below)
- In anticipation of this appointment, have they thought about what might help them get better? Are there any specific treatments they wanted to talk about? What are their views on taking tablets? Have they taken any medications for mood in the past, or undergone any psychological therapies?
By the end of this questioning I feel like I have a really good grip of whats going on, what it might be sensible to offer, and what my follow up plan will be.
If they answered yes to the question regarding self harm and/or suicidal ideation then I need to talk about this in a bit more depth. I acknowledge that this might be difficult for them to talk about, but that it’s important for them to be as open as they can so that I can help to the best of my ability.
If they express that they have thought about taking their life I ask about what those thoughts have involved? How often they’ve occurred? Do they have any intention of acting upon them? What would stop them from doing so? Have they ever had thoughts like this in the past and have they ever attempted suicide in the past?
Asking these questions allows me to generate a degree of risk. Again, this will alter my management plan. Someone who has clear plans, and no clear support or inhibitive factors is going to make me question whether I ought to make a same day referral to the crisis team. Those with thoughts but no active intention I am going to follow up sooner than those with no thoughts of self harm. At this point I also take into account the demographics of the person sat before me. Male suicides are more common than female, and middle-aged males more likely to commit suicide than anyone else.
Only you can decide what your follow-up consultation interval will be for each patient. You are making your own risk assessment, and often this is affected by our personal level of risk. For me, it might be between 2 days to 4 weeks. I might even follow someone up by telephone the following day if I’m particularly worried, but I don’t feel there’s anything specific that warrants a crisis team referral. Bear in mind that some crisis team referrals are bounced back pretty quickly so even if you do refer, you need to continue with your own follow up plans.
What are the management options?
This will be tailored to the patient in front of you but can range from no treatment if they have sub-threshold depression, or there’s a specific incident driving their mood that they just need to be supported through. It may require low intensity psychological therapies such as self guided or computerised CBT, or medications.
Medication ought to be reserved for those with moderate or severe depression, or where they have a past history of moderate or severe depression. It may be considered if they have had sub-clinical or mild depression that has persisted for a couple of years, or where low intensity psychological therapy has failed.
It is important to consider patients ideas and choice. However, I often make it clear that medication may help the symptoms, but if there is a clear trigger then it is most helpful to address this. Hence why psychological therapies can be very useful. Sometimes it’s the conversation you have that breaks down their barriers and opens them up to trying such therapies. If they are not keen initially I will ask them to think about it and discuss it more next time.
LOCAL TO PETERBOROUGH
- Patients can self – refer for psychological therapies. In those who I feel a re low risk with sub-clinical and mild depression I advocate this. It gives the patient some ownership of their symptoms, and there is less likely to be a non-adherence to treatment if they have chosen to refer themselves.
- We have 111 option 2. By calling 111 and selection option 2 they are put through to a first responder from the mental health trust. They are trained to talk to patients over the phone, with the aim of avoiding A+E attendances. They are also working with Mind (a mental health charity) to provide ‘safe havens’ where people can go out of hours if they are experiencing a crisis.
Please feel free to use the comments section to share your ideas, or ask questions related to the above. Also, would it be helpful for me to post a video of a simulated consultation for this topic?