PCSII Depression/Anxiety/Strong Emotions 2024 Document

Questions for Thought What concerns do you have about caring for anxious or depressed patients? Will you be comfortable asking about suicidal ideation? What concerns do you have about encountering a patient with strong emotions? Which do you think you will feel more comfortable with- fear, anger, or...

Questions for Thought What concerns do you have about caring for anxious or depressed patients? Will you be comfortable asking about suicidal ideation? What concerns do you have about encountering a patient with strong emotions? Which do you think you will feel more comfortable with- fear, anger, or sadness? Which might you be least comfortable with? Depression/Anxiety/Strong Emotions Lee Scott, MD [email protected] 2 Objectives 1. Describe how and why depression and anxiety diagnoses are missed. 2. Respond appropriately to tears and other non-verbal cues associated with depressed or anxious mood using the empathy skills previously learned in this course. 3. Use available screening tools for depression, suicidality, and anxiety. 4. Describe the importance of screening for suicidality. 5. Inform patients about depression in an appropriate manner. 6. Attend to somatic symptoms of anxiety and depression appropriately. 7. Differentiate anxiety disorders from medical conditions and drug effects. 8. Discuss the origins of patients’ strong emotions. 9. Respond appropriately to patients’ sadness, anger, or fear. 3 Depression Think about… What concerns do you have about caring for depressed patients? Will you be comfortable asking about suicidal ideation? How can you assist patients in accepting a diagnosis of depression? 4 Depression Depression has a high prevalence in both primary care and specialty settings. Studies show that in primary care practice, 30-70 percent of depression is missed. Why?! 5 Depression - Impediments to diagnosis and treatment Typical impediments that contribute to the difficulty of finding and managing depression include the following: Afflicted patients often complain only of their physical symptoms and fail to report their sad feelings Clinicians frequently fail to connect somatic problems with other clues to the presence of depression. Patients who directly express sadness are more likely to be grieving a loss than suffering with depression, which confuses clinicians. Some clinicians are uncomfortable discussing emotions or lack good skills to do so; moreover, even if clinicians suspect depression, many are reluctant to explore it further because they think exploration will add too much time to a visit. Clinicians’ ineffective response to tears or non-verbal cues. Personal beliefs or culture that don’t accept depression as a diagnosis or sees it as a weakness. Time constraints present in a busy clinical practice. 6 Clinician Skills -Responding to tears Some clinicians think that tearfulness distracts from the “real” work of medicine, but nothing could be further from the truth. Tears usually signal an important life issue that will interfere with diagnosis and treatment if it is ignored. Tears may signal the presence of a depressive illness. Allow the patient to cry. Generally less than a minute Responses brief attentive silence legitimizing statements passing a tissue box “I am sure I would be quite upset if I were in this situation.” “I’m so sorry” “Anyone would be distressed in this type of situation” “I can see this is very hard for you.” 7 Clinician Skills -Attending to non-verbal signals For many patients: Expressing feelings about sadness or emotion is difficult Emphasizing their distress from somatic symptoms such as insomnia, poor appetite or lack of energy is more comfortable Watch for these non-verbal cues of possible depression: Looking down when speaking, sighing frequently or taking in a breath as though about to sigh and then speaking instead with a breathy quality to the voice Reaching for the eyes or dabbing at them , although there are no tears, or patients’ eyes may start to glisten, as though about to cry. Making helplessness gestures (a shoulder shrug, an upturned hand gesture followed by dropping the hand to the lap or table). Trailing off voice volume by the end of a sentence or having a “flat” voice quality. Name what you see: “You seem sad to me.” “You seem down to me.” Also note how you feel! If you suddenly feel sad about or sorry for the patient, that empathic feeling is often related to your patient’s underlying sad affect. 8 2 question screen for depression In the last 2 weeks: Have you felt down, depressed or hopeless? Have you had little interest or pleasure in doing things (you usually enjoy)? Learn this! Use this! 9 10 11 12 Don’t memorize this. 13 “SIG-E-CAPS” 14 SUICIDE Suicide assessment is of vital importance. Every patient with Major Depressive Disorder is at risk, and 50% of patients who eventually commit suicide visit a primary care clinician in the weeks before they take their lives. Suicide is one of the top 10 causes of death in all age groups, and one of the top two causes in young adults and teenagers. Asking patients about suicide does not increase suicide risk. To the contrary, patients experience inquiry as a measure both of caring and competence. The conversation reduces anxiety and facilitates partnership in suicide prevention. 15 SUICIDE Question #9 of the PHQ9 is a compound question that asks: “In the last two weeks, have you had thoughts that you would be better off dead or of hurting yourself in some way?” If a patient responds affirmatively, you need to first distinguish whether they have “active” or “passive” suicidal ideation. You can say something like this: “Reviewing your responses on this screening form, I see that you have been having thoughts of self harm during the past two weeks. Do you have thoughts of actually killing yourself?” 16 SUICIDE If the patient indicates the presence of “active” self-harm thoughts, follow-up questions can identify patients who require urgent evaluation by a psychiatrist. Risk factors include : adolescent age gay or lesbian orientation Use Dr. Parker’s slides for alcoholism learning this info. psychosis chronic physical illness lack of social support prior use or consideration of methods that are generally lethal (a gun rather than pills). Elderly white men are at highest risk for successful suicide. The P4 screener is evidence-based and asks about the “4 P s” Past history of suicide attempt Suicide Plan Probability of following through Protective factors. Common protective factors can be remembered using the mnemonic the “4Fs” (Family, Faith, Fear of failure, Future hope). 17 The P4 Screener Suggested empathic transition statement to the questions in the P4 screen. “I would like to understand a bit more about your life situation at this time.” Plan: Past Attempt: Probability: Protective: Ask: Do you have a plan about how you might hurt yourself? If yes, then ask follow-up questions to assess if they have the available means to follow through with their plan. "Have you been stockpiling pills? Do you have a firearm?" etc. Ask: “Have you ever made an attempt on your life?” If “Yes,” ask, “Can you tell me some more about that?” Ask: “Having a thought is different from actually carrying out a plan. How likely are you to actually follow through on your thoughts of hurting yourself?” Not at all, somewhat, very likely Ask: “Is there any reason why you would not follow through on your plan?” 18 MANAGEMENT Inform patients about the illness and inform them about medications, counseling and self-management. Help patients establish both short- term and long-term goals. Support patients’ action plans and help them learn from examining successes and failures. See Health Care Communications module for details on these steps. I am only reviewing “Inform patients about the Illness” during this lecture. 19 Inform patients about depression Patients seldom accept and adhere to treatment without learning how depression works and developing optimism that interventions might make them feel better. The keys to effectively informing patients about depression are to: elicit the patient’s perspectives respond with empathy present “small chunks” of information directed at their beliefs using simple language. Respond to non-verbals and use the skills of normalization, symptom assumption and transitioning (see Health Care Communication). Check frequently for patients’ understanding. Reviewing a patient’s responses on the PHQ9 is an effective way of transitioning to a conversation about diagnosis and management. (next slide) 20 Inform patients about depression “I’d like to go over with you the meaning of your responses to the questions I asked (or “on the form you filled out”). In the same way we use mammograms or colonoscopy to check for cancer, practice guidelines suggest that we routinely ask these questions and add up the responses. Your answers (or your symptoms) and your score suggests that you are suffering from the illness of depression. What do you think about this?” After patients respond to this question, offer short concrete statements, followed by pauses that allow patients to reflect and speak. When you pause, patients often offer statements and questions that facilitate your presentation of additional emotionally relevant and effective information, now specifically addressing their own concerns. Too often, caregivers speak in paragraphs that are too long and confuse and overwhelm patients. Follow your presentation of “small chunk” facts or ideas with pauses or check for understanding. Actively dialogue about the primacy of somatic and physical symptoms, and call attention to depression as an independent and treatable cause of suffering. 21 Inform patients about depression -chunks “While everyone gets sad once in a while and particularly when bad things happen, depression is a different story.” “Depression comes from chemical imbalances in the brain that result in a persistent sadness or loss of enjoyment and even hopelessness. These brain chemistry changes also produce poor sleep and other physical problems like low energy, change in appetite, pain in the belly or back, or headaches.” “The good news is that this illness process is treatable.” “Good data show that outcomes of other illnesses – such as diabetes, heart trouble, and more improve with treatment of depression.” “We usually prescribe either antidepressants and/or counseling.” “What do you think…are you willing to consider treatment for your depression?” 22 Inform patients about depression Some clinicians compare depression to other chronic illnesses with chemical deficiencies, such as hypothyroidism or diabetes. “Depression is a deficiency problem like diabetes. If your pancreas makes too little insulin, your sugar goes up. In depression certain parts of your brain make too little serotonin and the deficit seriously affects how you think and feel.” “Teach back” is another basic skill that can be used to ensure patients understanding. You might say something like this: “I’ve given you a lot of information about depression and its treatment. Just so that I know that I was clear would you mind telling me back what you understand?” or “I’ve given you a lot of information about depression today, if your husband or daughter asked you what we discussed, how would you explain it to them?” 23 Attend to somatic symptoms Many patients are concerned that the clinician may discount physical symptoms and miss an important somatic diagnosis like cancer, heart disease, or thyroid problems. This concern is understandable, because many of us have heard stories about serious or fatal treatment delays because a clinician "explained away" pain or fatigue as depression or implied that it was "in your head." In this case, clinicians can maintain a multidirectional approach. Explicitly discuss somatic symptoms so that useful dialogue about treatment is not impeded by patients' concern that the meaning of body symptoms might be ignored or discounted. Evaluate physical symptoms with respect and concern and treat them conservatively and responsively. Simultaneously treat the depressive syndrome as an independent cause of suffering and disability. "I understand the stomach pain is a problem. We will investigate it thoroughly, and I am prescribing a medication that should lower acid production. I would also like you to consider treatment for another condition that I think causes some of your suffering: depression." 24 Final thoughts and Key Principles -Depression The illness of depression is a serious and sometimes lethal medical condition. Every patient with depression must be assessed for suicidality. Eliciting patients’ perspectives and responding supportively to their beliefs facilitates their acceptance of a diagnosis of depression and their active participation in treatment. Clinicians initiate effective treatment when they partner with patients to explore options, construct personal goals and establish action strategies. Normalize the diagnosis of depression Don`t be afraid of tears, name the emotion, offer the tissue box Non-verbal and para-verbal signs of depression Don`t be afraid of opening "Pandora`s Box" Addressing the true underlying issues actually saves time and allows care to be delivered more efficiently Partner with the patient. Actively listening is very therapeutic. Depression is very prevalent. Routine screening can help identify patients with depression in your practice. Screening tools are effective The PHQ9 and other screening tools are effective in identifying depression. Depression is often co-morbid with other chronic diseases Chronic disease is dependent on self management. When depression is effectively treated, mood improves and patients have more motivation for self care activities that lead to improved control of other chronic disease. 25 Anxiety and Panic Disorder Think about … What concerns do you have about caring for anxious patients? Will you be comfortable telling a patient that you think they have an anxiety disorder? 26 Anxiety- Key Principles Patients with anxiety disorders are more likely to present with physical symptoms than to complain that they feel anxious, nervous, worried or upset. Attempts to dismiss the relevance of somatic symptoms increase their anxiety. Patients will be reassured that you are taking them seriously when you explore their somatic symptoms carefully, even when the symptoms seem likely to be manifestations of anxiety. Anxiety can be "catching," so take steps to calm yourself so that you can approach anxious patients in a relaxed and reassuring manner. As you explore somatic symptoms, be certain to include gentle inquiry about family dynamics, work and recent stressors or concerns. Ask about prior similar symptoms, and/or treatment for an anxiety disorder or a mood disorder. A family history of phobias, obsessive-compulsive behavior, panic attacks, agoraphobia, social anxiety or shyness, or alcoholism or substance abuse predisposes patients to anxiety disorders. 27 Anxiety Clinicians frequently miss this diagnosis despite the high prevalence. fail to explore patients' current worries, concerns and recent stressors do not ask whether the patient has previously had similar symptoms, and/ or treatment for an anxiety disorder or a mood disorder. Instead, focus on "ruling out" an exhaustive list of illnesses that "might" produce the patients' somatic symptoms, often ordering unproductive expensive studies. Anxiety disorders are serious medical illnesses that cause disabling anxiety and fear. Unlike episodic anxiety caused by a stressful event such as a business presentation or a first date, anxiety disorders are relentlessly distressing, disrupting patients' lives with irrational fear and dread. Effective treatments are available, and research is yielding improved therapies that can help most people with anxiety disorders lead fulfilling lives. 28 Anxiety Anxiety disorders include: panic disorder obsessive-compulsive disorder post-traumatic stress disorder (PTSD) generalized anxiety disorder phobias (social phobia, agoraphobia, and specific phobia). People who are medically ill often exhibit anxiety. Depression often accompanies anxiety disorders and, when it does, it needs to be treated as well. 29 Anxiety Screening When a patient shows nervousness, whether verbally or nonverbally, or when a patient has multiple somatic symptoms not obviously connected to a medical problem, seek more information so that you can establish or reject the diagnosis of an anxiety disorder. Anxiety disorders are so prevalent in primary care settings and so frequently undiagnosed that you should consider regular anxiety screening for every patient. USPSTF recommends screening everyone between the ages of 8 and 64 years annually. 30 GAD-7 GAD = 10 or greater 89% sensitivity 31 Anxiety Always respond to a patient’s anxious mood, and use the empathy skills of reflection, understanding, legitimation, support, partnership and respect. “You seem quite [tense][restless][nervous][anxious][upset].” “Well, you’re restless and seem to be having a hard time concentrating on what we’re discussing. Is something distracting you? Can you tell me about it?” “I can see this is upsetting for you to talk about.” “Many people in your shoes feel exactly like you feel.” Differentiate anxiety disorders from medical conditions and drug effects. Examples: Hyperthyroidism Withdrawal Seizures Arrythmias Pulmonary disease Don’t label something as anxiety too quickly! Use your screening tool! 32 Simple screen for Panic Disorder The first two questions have 94% sensitivity to detect panic disorder if either is positive. In the past 6 months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy? yes___ no___ In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn’t catch your breath? yes___ no___ IF YOU ANSWERED YES TO QUESTION #1 OR TO QUESTION #2, THEN CONTINUE WITH QUESTIONS 3-5, OTHERWISE, STOP (0 = NO PANIC DISORDER). Did any of these spells or attacks ever happen in a situation when you were not in danger or not the center of attention? yes___ no___ How many times have you had a spell or attacks in the past month? (Check one.) Hasn’t happened at all in the past month ___ Once___ 2 to 3 times___ 4 to 10 times___ More than 10 times___ In the past month, how worried have you been that spells or attacks might happen again? (Check one.) Not at all worried___ Somewhat worried___ Very worried___ 33 Strong Emotions Think about … What concerns do you have about encountering a patient with strong emotions? Which do you think you will feel more comfortable with- fear, anger, or sadness? Which might you be least comfortable with? 34 Strong Emotions- Key Points Strong emotions are normal when facing illness or injury, a natural human response to life-changing events, and as predictable as getting wet after jumping into the ocean. Respond to patients’ strong emotion with empathic statements and gestures; they will strengthen the clinical alliance and promote healing. Your patients will think that you do not understand their experience, or that it does not matter to you, if you try to “fix” their strong emotions. Strong emotion needs your empathic response, not "fixing". Strong emotions can originate in the patient or the clinician, or originate from their interactions. Identifying the origin of emotions promotes clear boundaries and enhanced clinical effectiveness. Taking time to explore your responses to patients' emotions promotes personal and professional growth and therapeutic competence. 35 Empathy At a practical level, empathy refers to imagining or vicariously experiencing another person’s emotional state. We can never know precisely what another person experiences and what it feels like to be them, but it is the willingness to imagine that matters in clinical settings. Seeking to comprehend patients’ emotional experience helps us overcome the feeling that patients are a challenge. When we respond empathically to patients’ emotions, we make a therapeutic intervention of fundamental importance, one which enhances healing as well as patients’ capacities for hope and for taking effective action. 36 Empathy cont’d Clinicians powerfully signal their genuine concern when they respond to emotion with empathic statements supported by empathic nonverbal behavior. NURS and PEARLS help learners to remember various effective empathic statements that build trust and relationship. NURS - Name, Understand, Respect, and Support PEARLS - Partnership, Empathy, Appreciation (and Apology), Respect, Legitimation and Support. Whatever your words, and however awkward or unskilled you feel, if you are genuine in your intention to understand, your attempt will be helpful. 37 Responding to Sadness, Anger or Fear Studies have shown that addressing emotions helps shorten interviews and builds trust, in both surgical and primary care visits. Unfortunately, clinicians commonly disregard emotions. Sometimes clinicians think they lack the skills to manage the flow and timing of the interview. Sometimes they cannot shift their focus from biomedical aspects back to the person. “You seem sad (upset, down or perhaps pensive) today.” “Losing your job when your husband has been out of work must be very scary.” “The last few months of your wife’s illness have been really hard.” “You seem angry. Have I done something to upset you?” “Anyone would be upset after being kept waiting in a cold room dressed in a flimsy gown.” “I can understand that you would be upset with me for not prescribing the oxycodone, when that’s the main reason you came in today.” “I understand that you are angry and I want to help.” 38 Anger- Boundaries and Safety There are times when you would choose not to empathize, when it is more appropriate to place boundaries on the patient’s anger. For example, when patients are so upset that they cannot listen, when they have lost control or when they threaten the safety of others. The best way to place limits is to describe the conditions in which you are willing to continue to engage with them. Importantly, speaking at low volume and with nonaggressive postures is very helpful. This gives the patient the choice of whether to de-escalate and continue to be heeded or, alternatively, to lose the audience and certain other freedoms: “I’m willing to continue this conversation so long as you exhibit the same respect towards me that I am giving you.” If disregarded, your own limit-setting should escalate: “If you continue to disrupt our ability to conduct care safely, I will need to call Security.” If patients continue to be disruptive, it’s best to disengage. Continued discussion usually only “fuels the fire.” It is appropriate to leave the room, to hang up the telephone or to call Security. Your own safety takes precedence over being therapeutic. Your own gut feeling about personal safety is generally reliable, and being attuned to a sense of danger is but another aspect of self-awareness. 39 Anger -extreme anger Exhibitions of extreme anger are unusual and may signal other feelings or diagnoses. For example, intense anger may be a way of insulating oneself from intense fear, such as that presented by a lethal diagnosis or a threat to one’s child. Anger that might have been more moderately expressed can be disinhibited by alcohol and other drugs. Personality disorders and delusional thinking can manifest as extreme anger, so such demonstrations should prompt consideration of substance abuse, sociopathy or schizophrenia. 40 Anger -remaining professional One challenge of anger is balancing empathy with enough “detachment” to remain professional. The patient’s anger may not be directly towards us personally, but feeling personally attacked can make us defensive. And responding in a defensive manner - “You did not hear what I said” – usually worsens the situation, because it implies that the other person is at fault, somehow. Sometimes it helps to remind ourselves that although patients’ anger may be directed at us, its origin lies in the patients’ circumstances. If you find yourself becoming angry and/or defensive, stop and reflect upon your responses to patients' emotions 41 Tomorrow’s Small Group Activity You will interview 3 standardized patients. 8:05 or 9:05 8:20 or 9:20 8:35 or 9:35 See Canvas for full details. The SPs will rotate out at 12 minutes: 12 minutes for interview 1 3 minutes for brief discussion 12 minutes for interview 2 3 minutes for brief discussion 12 minutes for interview 3 3 minutes for brief discussion 10:00 am Large Group Debrief Dr. Scott Dr. Alston 42 Tomorrow’s Activity Designate 1-3 students as the interviewers for each room. Use different interviewers in each room! Students who are not interviewing should take notes and also be available to jump in if the interviewers ask for help! You can decide on your own “ground rules” for this activity. You may call time-outs. You may restart the interview (with same or different interviewer). You may ask the patient for feedback at the end. You must complete a form that asks for your diagnosis/diagnoses for each of the 3 patients. Will be on Canvas. Email to Dr. Scott and Dr. Alston when finished with the 3rd interview discussion. 43 Questions? General course or grading questions? ACOM PCS Course Director email: [email protected] Office hours available by appointment: Lee Scott, MD [email protected] Lauren Clemmons, DO [email protected] 44