Depression

This is exactly the expression I use when I am portraying depression.
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One of my favorite cases is depression. I know it sounds weird, but I love seeing how students handle it. Some are remarkably kind and empathetic, while some want to pass me over to a counselor as soon as humanly possible.

Regardless, here's feedback I often give learners dealing with a patient suffering from depression:

• Match the patient's energy: When a learner enters my room cheerfully and remains cheerful throughout the encounter despite my obviously uncheerful affect, I feel as if we are inhabiting two completely different realities. When the learner adjusts to more closely match my energy at the beginning of the encounter, I feel more understood and comfortable. However, as the authority, it's important the learner matches my emotional level without being pulled into it entirely. If the learner goes too far, I won't feel confident they will be able to pull us both out.

• Shape the conversation: Learners often want to jump into a depression screening as soon as they think I have depression. The traditional LMNOPQRSTU format doesn't always seem applicable because there is often no physical pain, but honestly, even with depression it's a good place to start because it helps me establish an HPI, which helps me feel heard. This also allows me to answer several easier questions to establish trust & safety with the learner before moving onto the more emotionally charged depression screening questions. Save the self-harm and suicide questions until the end (more on this below).

• Focus: Once a learner suspects depression, s/he usually wants to fix it. But it's impossible to fix depression in a 15-minute session. So I encourage learners to find better goals for the encounter. For instance, I think some good goals are to establish trust, assess my safety and get me to come back for another appointment. Anything else that gets handled is a bonus (within the confines of that case's learning goals, of course).

• Listen: I frequently tell learners during emotional and/or sensitive encounters, "Your job is to keep proving you are a safe person to talk to." So every active listening skill is critical to establish trust and safety: sincerity & other non-verbal cues, reflection, open-ended questions, validation, empathy, framing for sensitive questions, avoiding interruption & judgment, etc.

• Know when to keep things moving: Very occasionally I have a learner who is so empathetic and open to listening that we don't make any progress. As a patient, this can feel as if I've wasted my visit. So during feedback I talk with learners about how make progress while while remaining a trustworthy listener. This often involves setting achievable goals, a clear framework, collaboration, summarization, reflection, and the occasional kindly redirection.

• Showing the work: Even if it's completely obvious to the learner, depression may not be obvious to me, or may be associated with stigma I am unable to verbalize/recognize. Many patients do not come in for depression. They come in because they're tired or unable to concentrate, for example. So if the learner jumps to depression without explaining how it relates to my chief complaint(s), I will feel labeled instead of understood. If the learner asks questions or performs exams that don't seem related to my chief complaint(s) (like the mini mental status exam, for instance), it is likely to affect my trust in the learner and impair my motivation to return to this or any other medical professional.

• Asking about self-harm/suicide: I usually tell learners to leave this question until last because the answer could radically change everything and is the hardest question for me to answer. Plus, any question asked after this feels incredibly trivial. Everything a learner has done up up to this point to build trust, safety & rapport will allow me to feel more comfortable answering. How a learner asks this question is vital to ensuring a truthful answer, requiring appropriate framing & sincerity. I tell learners that changing their tone, posture, and eye contact are really helpful. Using my name helps focus me. 

If I admit to suicidal/self-harm thoughts, using validation & normalization can help convey acceptance and support: "Thank you for telling me that, [name]. It's very normal for someone going through what you're going through to have those thoughts. If you ever have thoughts like that from here on out, I want you to call [x]." Wait to assess my reaction. When it seems like I am ready to move on, without belaboring the point, offer hope by transitioning to the plan: "So, let's talk about how we get you feeling better."

If I deny those thoughts, then great! Validation & normalization are still useful to help transition to the plan and create a buffer in case I am lying: "I'm glad to hear that, [name]. Because it's very normal for someone going through what you're going through to have those thoughts. If you ever have thoughts like that I want you to call [x]." And then transition to the plan in the same way: "So, let's talk about how we get you feeling better."

• Identify and replace coping strategies first: if the learner remembers to ask about drugs/alcohol, and then recommends I take medications without addressing my alcohol usage, I cringe inside as an SP. But worse, if the learner realizes I am drinking too much, s/he often recommends I stop drinking while I am on medications -- and as a patient I often react by being visibly worried/agitated/concerned. Because nothing terrifies me more than the idea that my only coping strategies will be ripped away, I feel a lot less likely to follow up on the learner's recommendations. So as an SP I am really impressed with learners who understand the FIRST first step is replacing (or skillfully reducing my dependence on) unhealthy coping strategies.

• Simplify the plan: When I am depressed, too many choices feel overwhelming. So when learners tell me all the things they want me to do to help me manage my depression (often involving changes to exercise, diet, alcohol/drugs, medications, and/or therapy), as a patient I can feel myself shut down. Any one of those things can be its own major project! A more successful strategy might be limiting the options to the most successful candidates based on what the learner has gleaned about the patient during the encounter. Another good strategy would be to ask the patient: which of these limited options sounds like something I would want to begin when I leave the office? This respects my autonomy even in the midst of a difficult time, helps me feel invested in the plan and motivates me to return for followup.