Depressive Symptoms in Primary Care: Preparing for the Initial Visit

00:01 Hi, my name is Kimberly Oman and I am a nurse practitioner with prescriptive authority.

00:08 In my practice, I see patients who present with symptoms of mental illness in an outpatient setting.

00:16 Unfortunately, one of the most common patient concerns I hear patients report is persistent sadness or depression.

00:26 This can be challenging in the primary care setting, because diagnosing and treating depression is not as straightforward as you would think.

00:34 My goal for today is to show you an example of how a provider facilitates a therapeutic conversation in an initial visit with the person presenting with depressive symptoms.

00:48 Keep in mind that the goal of this visit is to establish rapport, determine the level of depression, assess comorbid symptoms such as anxiety, substance abuse, or other disorder features, screen for suicidality and self-harm risk, and to discuss goals for treatment and develop a treatment plan There is some information that I obtained before the visit that I might have access to before I actually meet the patient.

01:18 Sometimes this this information is available electronically, or the patient has filled out some paper assessments prior to their visit.

01:28 Jessica Jones is a 30-year-old female complaining of depressed mood.

01:33 She's not currently taking any prescription medication.

01:37 She denies a prior psychiatric history.

01:40 She filled out a PHQ-9 prior to her, her visit.

01:45 Her score was 14, which indicates moderate depression.

01:49 She filled out a GAD-7 with a score of eight, indicating mild anxiety.

01:55 You can find more information about those assessment tools in our downloadable materials.

02:03 Please keep in mind that although your screening tools are positive for both depression and anxiety, they do not determine diagnosis.

02:12 You do.

02:14 Screening tools are just that tools that may be used to objectify patient history and support your diagnosis of the patient.

02:24 So as I'm going through the office intake forms that I had available before seeing the patient, there are a few things that I might pay closer attention to.

02:36 Please keep in mind that some of the information we have here might not be available until you actually interview the patient, or if you have access to an EHR from another provider or primary care notes from a different provider.

02:50 You may be able to review this prior to your visit.

02:53 So let's please keep in mind that Jessica has normal labs, a thyroid, a complete blood count, a comprehensive metabolic panel within the previous year were normal.

03:06 She denies any past psychiatric history.

03:09 She's not previously taken any psychotropic medication.

03:13 She has no history of inpatient psychiatric stays.

03:17 Jessica denies a childhood psychiatric history, and she also denies any previous suicide attempts or history of self-harm.

03:27 As far as past medical history, Jessica denies any chance of pregnancy.

03:31 She reported having a tubal ligation.

03:34 She does have a history of anemia during pregnancy, but when most recent labs were checked, her blood count was fine. She does have a history of a C-section, but denies having any complications from surgery, and she denies any additional past medical history.

03:52 Jessica denies any significant weight changes, but admits to steadily gaining some weight over the past year. Jessica denies any allergies.

04:03 She's not currently taking any prescription medication, although she does report occasionally taking a multivitamin. So after reviewing Jessica's information, we know she had normal lab work a year ago, which means she probably doesn't have any chronic illness that could be the source of her depressive symptoms.

04:24 It wouldn't be a bad thing to recheck her labs.

04:28 Jessica is not pregnant.

04:29 She's not currently taking psychotropic medication.

04:33 There's no major psychiatric history that we should be concerned about.

04:38 She does have that history of anemia, and she has been gaining weight, but will certainly take a look into that when we speak with her.

04:47 After reviewing Jessica's history further, we understand that she does not use tobacco.

04:53 She drinks about 2 to 3 mixed drinks per month, and she denies binge drinking.

04:58 She does admit to recreational marijuana use every few months, but she denies additional substance use.

05:05 Jessica's psychosocial history includes a bachelor's degree in elementary education.

05:11 She taught second grade for two years after college, and now she's a stay-at-home mom.

05:15 She currently lives at home, married for six years to her husband.

05:20 She admits to some marital strain but generally has good family support.

05:25 She reports having two children, ages four and two.

05:29 She denies exercising routinely.

05:32 As far as her family's psychiatric history, which definitely needs to be taken into consideration as we're forming our treatment plan.

05:40 We need to remember that her sister has some history of depression and anxiety, and we believe that she does take some medications, although we're not sure what her sister takes.

05:52 It's also important to keep in mind that her sister is her biological sister, and they are genetically related to some degree.

06:00 When I see these details about Jessica's substance use, there are some red flags that we need to consider. Consistent alcohol use and even occasional recreational marijuana use can contribute to depressed mood. Marijuana is not recommended for mental illness, and we certainly don't want Jessica consuming alcohol while she's taking her psychotropic medication, so we need to be sure we discuss this with her later.