Depressive Symptoms in Primary Care: Narrowing the Differential

00:01 When the patient presents face to face, make sure to note her behavior and appearance and her mood and affect. If baseline vital signs have not been obtained, it would be prudent to check them.

00:14 On her chart, her chief complaint is listed as I just don't want to do anything. So let's meet our patient, shall we? Hey, Jessica.

00:27 My name is Kimmy Oman.

00:28 I'm a nurse practitioner.

00:29 I'm glad to meet you today.

00:31 Nice to meet you, too.

00:33 I'm going to go through your history with you.

00:35 I'm going to ask you a bunch of questions.

00:38 Alright. And we're going to see what we can do to help with medication.

00:41 I need you to know that I am definitely not a therapist, but any medical questions you might have or questions about medication? I'm here for you.

00:49 Okay. Okay. So we're going to go through your history and we're going to ask a bunch of questions, and we will go from there. Alright.

00:55 Okay. Alright.

00:57 Can you tell me what's going on today? I just don't want to do anything.

01:03 I just. I mean, I love my kids, but I'm just getting so frustrated.

01:11 I'm with my kids all the time, and I'm just not funny anymore.

01:15 I mean, they need me and they want me to play with them.

01:19 But then I just sit there and they.

01:25 And I'm getting mad because I just I just want to do the bare minimum.

01:33 I mean, they're clean and they fit, but everything is a chore.

01:39 I mean, I would love just to stay in bed.

01:42 If I could stay in bed, that would be great.

01:46 I have zero energy.

01:49 I don't want to do anything.

01:51 And. And I love my husband.

01:55 But I want nothing to do with my husband.

01:59 And so he's frustrated and I don't want him to touch me.

02:03 And I just I don't want to do anything with anybody.

02:11 And I, I just know he's going to leave me, and I'm.

02:15 And I'm gaining weight and I don't and I, and I just, I just eat all the time and and I'm and I'm just I have to do something.

02:34 Alright.

02:35 Okay. I know this isn't easy.

02:38 Okay. As Jessica is giving me her history, I'm very clearly hearing her meet criteria for a depressive episode.

02:48 She's experiencing anhedonia, feelings of guilt and worthlessness, a lack of motivation. Jessica's feeling excessively fatigued.

02:58 She's feeling down, sad, and she's feeling easily irritated.

03:03 She's been overeating.

03:06 We need some specific details if we are to arrive, though at a more specific diagnosis.

03:12 So this is just a friendly neighborhood reminder.

03:15 We don't have all day long to speak with Jessica.

03:18 Put away your thoughts right now of open ended questions, and let's get some more objective information.

03:25 For instance, how long has Jessica been feeling this way? We understand she's depressed and we are concerned about patient safety but continue to work on, continue working on building your rapport.

03:40 How long have you been feeling this way? I guess I mean, on and off for the last few years, but I mean, I always seem to bounce back like before.

03:58 I mean. It's definitely worse this time.

04:04 It's just not going away.

04:05 And these last few months, it's just getting really bad.

04:13 So we know that Jessica has been depressed more often than not for at least two weeks.

04:19 Additionally, it seems she has experienced similar symptoms in the past.

04:24 But how do we know if this is simply unipolar depression? Keep in mind a major depressive episode will also manifest in bipolar disorder, so we do need to ask some simple screening questions.

04:38 If at all, we suspect bipolar disorder.

04:41 You must consider whether you feel comfortable addressing and treating Jessica's depression in the primary care setting. Have you ever felt on a high when not under the influence of any substances? You mean like when I've smoked weed? It's important to discern when Jessica experienced a high.

05:04 If she experienced a high while not under the influence of substances, there is greater concern that we may have a bipolar patient.

05:14 Has there ever been a period of time when you stayed up for several days or more, with little to no sleep and increased energy, and you were not under the influence of substances? I wish, I mean, it would be nice to have some energy and want to do something.

05:33 I mean, I can't think of a time when I ever went more than a day or two without sleep.

05:40 I mean, I think it was like when I was in college or something.

05:45 Great. It sounds more and more like there is less likelihood of Jessica being bipolar.

05:51 This will help simplify our treatment plan, although we also still need to screen for psychosis, which can be another game changer.

05:59 If you are questioning at all whether the patient might be experiencing psychosis.

06:04 Once again, it is time to strongly consider a referral outside of the primary care setting.

06:13 Has there ever been a time where you've seen or heard anything that other people don't? Um, not that I know of.

06:22 No, nothing like that.

06:25 This question often takes patients off guard, likely because they are not psychotic.

06:31 It's often helpful to rephrase the question if you're standing in an empty room, do you ever feel like someone or something might be standing there with you? No, nothing like that.

06:47 Psychosis is seeming highly unlikely.

06:50 So realistically, you have probably been in the room about 20 minutes at this point, and unfortunately, the pressure is on to wrap up, so you'll have to focus on assessing suicide risk and Jessica's interest in treatment options.

07:06 Are you having any suicidal thoughts or are you having any thoughts of self-harm? Have you had any thoughts of hurting anyone else? No I don't.

07:22 I don't think I want to die.

07:25 Uh, I just I just want to go away.

07:31 I'm just.

07:34 I'm failing at everything I do, and, I mean, I wouldn't hurt myself, and I wouldn't hurt anyone else.

07:48 I just can't do anything right.

07:53 I know this is difficult.

07:56 Remember, Jessica is raising young, vulnerable children, so we definitely need to ask if she has any thoughts of harming others.

08:05 If she had said yes or hesitated, you would need to probe a little further and whether she's had thoughts of acting on them or if she's ever had a plan.

08:15 There are no big red flags for suicidality, but it is time to dig a little deeper.

08:20 We need to ensure patient safety and assess if there are any acute safety concerns.

08:26 Sometimes the language is tricky, so asking different ways can help.

08:33 Have you ever thought of ways to make yourself go away? No. I mean.

08:43 I mean, it just sounds so nice not to have to deal with anything, but, I mean, I, I do want to get better, and that's why I'm here.

08:57 I want to be here for my kids and my husband.

09:01 Jessica has just identified some protective factors, so knowing that she is safe and not currently considering self-harm, we can manage this situation comfortably in an outpatient setting.

09:16 We don't need to consider emergency placement.

09:19 We don't need to complete a safety plan or make an immediate referral to a therapist.

09:25 We can transition to a conversation about our interest in treatment.

09:30 Medication and or therapy are great considerations for Jessica.

09:36 Remember, be sure to document clearly that Jessica has denied any suicidal or homicidal thoughts, and she is not considered a safety risk to herself or others.

09:48 Let's see what we can do to help you start feeling better.

09:52 Thank you.