Major Depressive Disorder: Overcoming Care Challenges

Transcript

This transcript has been edited for clarity.

Michael E. Thase, MD: Hello. I'm Dr Michael Thase, and I'm joined by my colleague, Professor Andrew Penn, for this Care Cues conversation on how we can improve our communication with patients seeking treatment for major depressive disorder. Andrew, if we think of the process of coming into treatment as a journey, is it helpful to think about the journey having different stages?

Andrew D. Penn, MS, PMHNP: Yes, I think so. As clinicians, we often think of that first visit with the patient as the beginning of their treatment, which it is. But by the time somebody actually comes into my office, I feel like they're already halfway home, because it's often that first step that is the hardest. But once we get that process going, then there's obviously the process of deciding what's going on with the patient, and then coming to a decision together to figure out what we're going to do.

Thase: What kind of misperceptions about medication do you still hear from your patients?

Penn: Probably the one that I hear the most is: "Am I going to have to take this for the rest of my life?" — this idea that if you say yes to a medication once, then you're signing up for a lifetime of treatment. As we know, depression, while it can be chronic for many people, is episodic and doesn't need to be treated indefinitely. And that's part of what we're discussing — how long will this course of treatment last?

When people come in and say, "I've already done some research on this," rather than rolling my eyes and thinking, Well, you don't know what you're talking about, I go deeper. I say, "Tell me what you've learned. Tell me what you understand about this condition." And, frankly, a lot of times people are right. They have at least a generalized understanding.

Now, the downside is that there are some internet sites that really promote sort of an oversimplification of the diagnostic process, so sometimes there's a little bit of teaching that has to happen to sort of unlearn some of these oversimplifications that make for great TikTok videos but might not actually be clinically accurate.

Thase: When you think about wrapping up that first session, what are essential elements for you to help make sure there's a second session?

Penn: One of the questions I like to ask is a really open-ended one: "Is there anything that we haven't had a chance to talk about, or I haven't asked you about, that you think is important for me to know to take good care of you?" And this is where you find out about people's families or what's really important to them. The other point is to be really clear about what comes next.

I sometimes print out patient education information that's very clear: "Here's the prescription that we've started today. Here's where you can pick it up. Here's how you take it. This is when our next appointment is. This is how you can contact me if you need to before our next appointment." That way, people feel like they know how to engage with me, and they also know what comes between now and our next appointment.

And sometimes at the end, you might circle back and say, "Did we cover all the things that you felt it was important for us to talk about?"

Thase: What do you think the most important ingredients or elements are when you decide not to recommend an antidepressant?

Penn: I think a lot of people, when they hear that, are actually kind of relieved because they're ambivalent about the idea of medication to begin with. And sometimes those things that are probably not going to respond to medications are things that are more situational in nature. If you're unhappy at your job or your relationship isn't working out, there really aren't medications that are going to address that.

Thase: People who come to see us know we're prescribers, so they've sort of self-selected into seeing a mental health professional who can write a prescription for medication. And in my experience, we start out with saying that there's a range of options — psychotherapy, pharmacotherapy, both. So, when we think about our helping relationship, the productive part of it, sometimes we call it the therapeutic alliance; what tips might you have to foster a therapeutic alliance?

Penn: Yes, it's great when I hear back from patients about what's working and what's not working. It gives us a chance to really troubleshoot. I think that broadcasts to the patient that we're taking them seriously and that we're listening to their concerns, which is really what all patients want to know — that they're going to be taken seriously by their provider. I certainly try to make a low bar to re-engaging. I'll certainly reach out in the time that I'm waiting.

Thase: What's your typical way to go about the possible frayed alliance, or the missing appointment?

Penn: Unfortunately, sometimes people get lost to follow-up; we never get a chance to find out what happened. But more often there's an in-between place. Maybe we start a prescription and the person never picks it up. Or they say, "I took it a couple of times and then I stopped taking it." We want to really take the time to understand that and to see if there are opportunities for either correcting misinformation or thinking about a different treatment plan. By understanding the reason for the ambivalence, we can better understand where to go from there.

Thase: So, if you can't make the call yourself, you might have someone affiliated with your office make the call for the patient who seems to be missing in action?

Penn: Yes, and then really inviting another appointment, even if it's for the person to tell you, "I don't think this is a good plan for me." As long as you have a conversation going, you have the opportunity to make these changes. I think that helps people have a better understanding of what it is that they're dealing with, and it helps them, hopefully, come to the same conclusion that I've come to as a clinician. Then that leads sort of naturally to shared decision-making. Ultimately, I want patients to feel like they have the information they need to make a good decision for their own treatment.

Thase: Of course, part of the assessment is not just the signs, symptoms, level of severity, and so forth; it's also the person's readiness for treatment. What tips do you have about that?

Penn: I think patients are assessing us as much as we are assessing them, if not more. What they're really looking for in us is: Is this person trustworthy? Is this person safe? Can I disclose these things to this clinician that maybe I've never talked to anybody about before in my life? That's a big hurdle to cross. We need to be able to pass that assessment in order for the patient to feel comfortable disclosing these innermost thoughts that they might be coming to us with.

So, Dr Thase, one of the things that we're assessing for with our patients is safety. Of course, the biggest concern that we have for safety in psychiatry is around the issue of suicide. How do you go about talking to your patients about any suicidal thoughts they might be having?

Thase: I think it's important to make sure that it's clear in your conversation that lots of depressed people have thoughts about life not being worth living. Suicide is not a forbidden topic whatsoever. It really is part of our job. What are some of the common mistakes that clinicians might make in evaluating a person's suicidal ideations?

Penn: Probably the biggest mistake anybody can make is not to ask the question. Right? I think there's a lot of fear that people are going to get it wrong, or they're going to put the idea in the patient's head. We know that's not the case. Somebody who's not having suicidal thoughts is not suddenly going to begin to have them just because we raised the question. But the place where we can really make a mistake is to not ask the question at all.

Or we ask the question in such a way that it's actually confusing. We kind of dance around the question. We have to say the word "suicide." And I think that the courage that we show in asking that question also gives the patient courage to give an honest answer. It broadcasts to that patient that we can handle the answer, whatever it is, and that kind of confidence is important to engender in our patients.

Thase: What do you tell your patients about the nature of how antidepressants work, particularly the usual timeline for benefit?

Penn: I'm honest with patients. I tell them that, unfortunately, many of our medications are a little backwards; you're going to get side effects before you get benefits. And if they know that, then a lot of people are willing to go through that process. But unlike, say, an antibiotic, where you might start feeling better after a couple of doses, many of our conventional medications take several weeks to begin to show an effect.

Most reasonable patients will go through those side effects in order to get to the benefit that comes later. But you have to let people know that because it's not intuitively obvious.

Thase: So, Andrew, what's one thing that you could pass on to our Care Cues audience today?

Penn: What we do matters. The treatment decisions we make with our patients matter. But I think what matters just as much, maybe even more, is how we are with patients. That's really the art of what we do. There's something also critical about who we are as people because, really, at the end of the day, medicine, psychiatry, it's a person-to-person experience. That, to me, is what keeps this work always interesting, because each patient is different. I have to learn about each new patient. And that's what keeps it fresh and exciting.

Thase: Andrew, thanks for sharing all this wisdom today, and thank you so much for being with us.

Penn: Thanks for the conversation. I always enjoy chatting with you, Michael.