Driving Out Depression: A Comprehensive Consultation

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It may seem like an exaggeration to say that a successful outcome for treating depression begins right at the initial mental health consultation, but that is often the case.

Unfortunately, many people who seek help for mental health problems, like depression and anxiety, feel embarrassed, ashamed, and reticent to talk about the feelings and symptoms they have been experiencing. But keep in mind that the more you share, the better your doctor will be able to determine a diagnosis and appropriate treatment. In fact, preparing for your consultation can be especially helpful, as it's easy to forget to relay important information if you become anxious when speaking with a doctor for the first time about feeling depressed or sharing a family history of mental health problems.

The psychiatric interview is so essential to the ultimate success of treatment that there is an 800+-page tome for professionals devoted to the topic. (It's called Psychiatric Interviewing: The Art of Understanding—A Practical Guide for Psychiatrists, Psychologists, Counselors, Social Workers, Nurses, and Other Mental Health Professionals by Shawn Christopher Shea, M.D.) Yet if someone were to hear me interview a new patient, it might at first sound as though we were just having a casual conversation—"How are you feeling?" "How long have you been feeling this way?" "Has anyone in your family suffered from a similar problem?"

But I am not just shooting the breeze when I ask patients these questions. I am using a time-tested diagnostic procedure taught to us in medical school, which is as laser-focused as an X-ray, blood pressure monitor, stethoscope, or any other medical screening device.

It is an information-gathering tool commonly referred to in the medical community by the acronym S.O.A.P., which stands for Subjective, Objective, Assessment, and Plan.

The S.O.A.P. interview process is broken down into four parts:

1. Subjective: Sharing your experience

Remember that the key to the consultation is you. Determining a diagnosis is detective work and you are the key to the mystery. You, the patient, are the expert on how you feel, what you have experienced, and your family, medical, and medication history. The more you share, the better. Medication for depression is very symptom specific. Each person who presents with depression may have a different constellation of symptoms. The most successful treatment is tailored to your precise symptoms.

While some people come into my office bursting to unload feelings that have been festering for weeks, months, or years, others are reluctant to share and need to be prompted. I generally book a double session for an initial consultation so that I have time to carefully listen to a patient describe their problem and background. In many medical clinics, patients are required to fill out symptom checklists and medical, medication, and family history forms before seeing the doctor. Whatever format your health provider uses, be as forthcoming as you can about what mental health, behavioral, job, and relationship challenges you are facing. Sometimes people suffer from two simultaneous (known as co-morbid) conditions, like Attention Deficit Disorder and depression. Knowing all the symptoms a patient is facing is essential to making an appropriate assessment. Often, I will ask patients for recent lab test results or the results of other health screenings to rule out possible medical conditions.

Depression disrupts sleep, increases memory loss, and heightens anxiety and cloud thinking. By jotting down your symptoms and questions in advance of your medical visit and taking notes during it, you’ll be sure to make the most of your time with your health practitioner.

2. Objective: Observing your physical, emotional, and medical presentation

The objective part of the psychiatric consultation focuses on the doctor's role. It begins the moment you walk into your doctor’s office, log on to a telehealth appointment, or call to schedule an appointment. There is so much to be learned from listening to, looking at, and being sensitive to the mood and physicality of someone who is in distress.

The tone of voice, appearance, posture, demeanor, attitude, hygiene, grooming, emotional expression, the pacing and patterns of speech, eye contact or lack of eye contact, and thought processes all contain clues to a person's state of mind.

A patient's capacity for judgment, insight into their condition, and empathy for others (which usually drops severely in depression and may barely be present in schizophrenia) are also key qualities to observe. If someone has thoughts of or plans for suicide or harming others, a doctor has an obligation to act and may contact a family member. If a patient has severe memory problems, it may be necessary to conduct a mental status exam to rule out dementia.

3. Assessment: Making the diagnosis

Once we've pulled together all relevant information, it's time for an assessment. When I tell patients that what they are experienced is clinical depression, they are often surprised. The fact is, depression is a misleading name for a condition that has so many varied and seemingly unrelated symptoms.

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Depression and anxiety are linked, and many people with depression may find their mood more anxious than depressed. There is also a strong cognitive component to depression. You may find that ruminating thoughts are hindering your concentration and focus. You may find it almost impossible to make a decision or problem solve in any constructive way.

A tendency to see everything in a negative light is often more prominent in depression than sadness or irritability. Obsessional thoughts, worries, anxieties, and regrets may be so overwhelming that it becomes impossible to believe that relief is possible. A feeling of remorse for all you've done wrong or not accomplished and a sense that nothing will work out in the future are manifestations of a hyper-focus on the negative.

In addition to mood and cognitive symptoms, there are also physical signs of depression, including problems with eating, sleeping, sexual interest, and bodily pains. When I explain to patients that their constellation of symptoms leads me to believe they are suffering from depression, some are shocked.

"What do you mean I'm depressed? I don't cry all day. I'm just anxious," is a typical response.

Another common reaction: "Of course I'm depressed. Wouldn't you be if you had my problems?"

Frequently, though, there is great relief. Finally, my patients understand that seemingly unrelated physical, emotional, and cognitive symptoms are tied up in one condition.

4. Plan–Outlining the route to recovery

Depression is very treatable. I firmly believe in taking the time to educate patients about the condition and what the treatment process will look like. In my experience, when people are prepared for what the road to recovery will look like, they are less likely to become anxious if treatment doesn't immediately become effective. They have a grasp of the timeline and what to expect. After all, having depression is anxiety-provoking, and knowing what to anticipate—and when—is key to staying calm.

I've discovered that many patients who have been told by other health practitioners that they have "treatment resistant depression" stopped taking medication before it became effective. They panicked and, unintentionally, sabotaged their own treatment. Had they been prepared for how long it would take for medication to work and what side effects they might expect and how to prevent them, their treatment outcome would have been far better. I reassure patients that their depression is treatable. We just need to proceed slowly and carefully, tracking how they are responding to medication and tweaking it as needed. And, of course, medication is not the sole answer. Therapy, meditation, and wellness practices all contribute to a positive outcome.

By the time you finish your consultation, you should feel relieved. You should have a clear understanding of your diagnosis, the recommended treatment, and what that process will look like. Be sure you have expressed your concerns and received answers to your questions. You should also be encouraged to have follow-up sessions with your doctor so that your progress can be tracked. Starting treatment for depression is embarking on a journey. You deserve to be given a roadmap with good directions, clear signposts and detours you may encounter, and feel confident that you'll reach your desired destination of recovery.