In the first session of our 2022 depression module, Tyree Grant, LCSW shares the case of 70 year old patient with diagnoses of anxiety and recurrent major depressive disorder (in partial remission) and with a history of sexual trauma and a past history of suicide attempts. Tyree seeks diagnostic clarification, pharmacological consultation, and support identifying appropriate behavioral health referrals. Dr. Michael Katz then gives a presentation on clinical considerations in depression assessment. He goes over common assessment instruments, questions to ask patients, and common comorbidities.
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Case Presentation Case Discussion Didactic Presentation Didactic Q&A I would like to turn over to our case presentation for today. Tyree Grant who is a licensed clinical social worker and part of the care management team at Mount Sinai health partners has a case that's quite interesting um Today for us to listen to. So Tyree take it away. Uh Good afternoon everybody. Um uh Thank you again uh dr Anita and everyone for this opportunity um You know I've appreciated the the previous presentations and um and part of my professional career is just trying to advance my clinical knowledge as much as possible and continue to push myself. So when the the opportunity to present um came arise I you know I'm trying as much as possible to to throw myself um into the fire and and to become more comfortable and also um uh expand my horizons as well. Um so um this patient um is a 70 year old um female um she is um she was a new patient and in the care management program there's kind of two um avenues of where we receive patients. Um The first one is through transitions of care. These patients that are from different sites um coming into the E. D. And discharging. And so we kind of follow up with them on a we get these um these patients are kind of on a daily basis. Um And um also workers are assigned to pods which are kind of clinically based at different sites at Mount Sinai um spread around the city and so this patient happened to have been a referral um from one of the clinics um the provider initially um fills out the referral form uh at first glance, the referral was based off of behavioral health need, um that patient was reporting having increased symptoms of anxiety um and panic, and so I reached out to her and um initially right off the bat, I can kind of sense the anxiety that was kind of prevalent for her. She had reported that for the past couple of weeks, things have intensified um to the point where she couldn't sleep at night, um she was afraid to sleep at night, She was having these panic attacks. Um we briefly kind of tried to, you know, explore what might be her triggers, she really couldn't identify them at the time. Um All she knew was that um thoughts of being alone by herself were too triggering and so fortunately she does have a friend that she's close with, who doesn't live too far from her, who she would essentially spend the night at his place, and so she hasn't slept in her own apartment for about a couple of weeks now. Um And so um one of the things that I uh you know, as as I'm assessing, you know, trying to engage more concerns and so we kind of talked about um you know, some of her um psycho social history and one of the things that came up was that she currently um is unemployed, um she makes most of her income through being a freelance writer. Um and um she's currently on screen which is a supplement three benefit for seniors to kind of freeze the rent, however the rent is already over her current income, it's about 1400, her income from social security is about 1200. Um and so kind of trying to figure out if there were any other stressors. Um So it is a stressor, but um the she finds ways to make ends meet as she says she's very frugal. So she you know, talks about how she she does her own her own hair care, her own um she doesn't eat out a lot. Um She um and she makes some of the additional income by, you know, she said she started crocheting a lot uh and started selling some of the items online, trying to generate some income through e commerce. She um she still does do the freelance writing. Um it's not consistent but when it is um it's it's it's supportive in terms of her finances. She expressed that she also sometimes gets uh you know kind of clerical job from her friend who owns a construction company. So to kind of make ends meet, so you know, so that is a stressor. Unfortunately this we did discuss a possible solution which she's not amenable to at this time, which is she does have an ira and but she's doesn't feel comfortable starting to liquidate it. And so um so it's kind of a uh you know, an expected stressor that she's kind of in this situation in terms of just the housing piece and the finance. Um But she she seems to be pretty grounded in terms of how she's coping with it. Um as we kind of further explored um you know, some of the other parts of her history, she expressed that she hasn't spoken to her family, anyone in her family in quite some time. She's very disconnected from her family, she has two sisters, um but who both have niece daughter, so she has four nieces, but she hasn't had any communication with them. Um as I would kind of try to explore, you know, some of the reasons for the disconnect. Um something came up as we were discussing trauma, um she uh disclosed that she was sexually assaulted by um one of her brother in laws at the age of 19. Uh and so um we I didn't really want to go any further at that point because she was doing her best to to minimize the the experience in order to cope because she used the phrase, well it happened so long ago. And so I kind of took that as a cue that you know uh you know, you know that this wasn't the time to kind of explore that she did express, you know, receiving treatment around that time to work through it. Um But she I did highlight, you know her, you know, and thank her for sharing that with me. Um and and so when it comes to supports that's another stressor. Um She identified, you know, feelings of loneliness, feelings of isolation on top of what most people are experiencing with, how we're dealing with covid. And so every, you know, things have been extremely exacerbated with her. Um She um is reported to be overweight. Um interestingly enough, um at the start of Covid, she admitted to um stress eating, but these past couple of weeks she said that her appetite has been suppressed. She isn't sure if that has anything to do with the medication she's on or um just possibly one of the symptoms of of of either condition. Um I believe the onset for both conditions about 2015, Um she hasn't seen a psychiatrist since 1997. Um and she, one of the other things we kind of talked about was her, kind of her education around her anxiety and depression. She, as I was going through the form, she did report having a lot more symptoms of panic that she isn't having now. So she she's experienced tremors in the past. She has experienced hot flashes in the past, but now it seems to be more focused kind of on the distraction, the chest pains, the the sweating palpitations um as we were going through the assessment. Um Usually when someone said that they don't have any family around one of the questions that I tend to ask is around the healthcare proxy. Um and that was very triggering for her because it it activated the fear of dying. She she did say no, um but then she expressed that she she could feel herself just talking about it was was triggering for her and so we kind of left it there on our initial conversation. Um we did have another conversation after that the following day, where I continued to try to kind of um highlighted because she mentioned that her current friend is her only family. And so I kind of just put it out there to say that we don't have to discuss this, but knowing that there is someone that you could trust to uh to to be that that voice for you um you know, is there and she kind of you know took that as a positive, we um one of the concerns um that she also brought up was uh the symptom of the hypervigilance, she reported being extremely sensitive um and not just not just to uh discussing certain topics, but just to sound, she said um you know, it's one of the reasons why she's been relying on a lot of defense mechanisms, avoiding a lot of things, avoiding going outside because of construction, avoiding, kind of having to interact with people because of just feeling triggered. Uh and so uh we kind of talked about some of the things that she was doing to cope and um she expressed um you know, a combination of things, the sometimes the work that she has to kind of uh immerse herself in in order to gain income has been distracting from some of the symptoms. She also reported, you know, having that friend to to to talk to at times has been helpful. Um She also mentioned that she she did attempt to participate in a um a anonymous group for overeaters but became very anxious um around possibly triggered by people's testimonies. And so she kind of withdrew from that, but she continued to use the information of the readings. And so she, you know, she would often kind of quote some of the readings in terms about um you know, stress eating and so she's you know, very mindful about uh some of her the the symptoms of the conditions and and and and some of the barriers she's having. But there was still a piece of education around um you know, uh the difference between, is she having panic attacks, I mean, you know, paying disorder or or panic attacks and anxiety attacks. And that was one of the things that I was also interested in. Um as we talked about in previous obsessions, she also has a lot of um anxiety around, you know, the medications she's on, she's currently taking. Uh uh PROzac, which was she was taking about 10 mg. Um and she just met where PCP yesterday who suggested increasing it to 20 mg. Um She uses both of the Benzos as needed. Um She has a lot of uh concern about being addicted to it. Um And so that's just that's re triggering her. Um and as we kind of talked about um you know, pursuing connecting her to a psychiatrist uh and as well as a therapist for talk therapy, uh the anxiety around a new provider coming in to handle the medication came up and her expressing, she didn't wanna she didn't want to try a bunch of new things. She didn't want to didn't want to be an experiment and I did my best to reassure her that ideally hopefully that that wouldn't be the case and that there's a process in terms of identifying, you know, using the information that I've gained here that there's a whole process of screening and testing to identify what are the best options. And not to mention she's already been on something for quite, you know, currently and to see how that's working for her. And and so um we we continue to uh to talk about, you know, her history and um she has reported thankfully no past or current s. I behaviors um you know, and so my uh you know, my main questions were around clarity in terms of, you know, the primary diagnosis, um definitely depression and it is definitely anxiety but as as I started to hear more about the trauma PtsD just kinda kinda came to mind um and also, you know, I I personally wanted to have some I guess uh concrete um clarity on the difference between panic uh disorder and you know, um and anxiety attacks um just to gain clarity so that I could also provide that to her as well. Um I think most people kind of just uh colloquially use the word panic attack all the time um and I just want to try to help in giving her some uh some grounding and clarity and hopefully that will kind of help her understand what's happening. Um also um just being able to kind of get some clarity if the current, you know, although this is not my my expertise but being able to kind of have a conversation with the PCP uh about what would be the best uh pharmacological approach um for this patient um and as well as I trying to find the best uh therapeutic approach given the history of trauma and I know that it's a challenge in general to find providers um I uh and but also trying to find providers who specialize in particular approaches is even more of a challenge. Um so just trying to figure out, you know, if if there are availabilities, I know that the uh the insurance is a barrier and the income is a barrier um and so that's my presentation. Yeah, thank you, I really appreciate you um presenting this case in detail. Um I I always find you know um presentations where there's like differential diagnosis particularly in the anxiety pTSD space given the changes that have come with the D. S. M. Five in that realm to be really interesting. Um But I want to open it up for thoughts and questions um from folks um you know if we're here for this case and the questions that Tyree specifically asked around you know what might be going on here diagnostically that might help him as well as options for treatment that he might try to connect this patient to any medical problems Tyree any medical history or medical diagnoses for this patient. Um Other than she the the weight concern um She has acid reflux um Which is she's been prescribed Pepsi to manage that. But other than that her vitals are okay. I would presume that I saw in the chart that her pressure was up maybe about about a month ago. Um You know and so um but other than that she's she's pretty healthy. So I have a question about her medications if that's okay. You had said that she hadn't seen a psychiatrist in some time. Right? So she's on a pretty fairly low dose of the FLUoxetine also on the Xanax was the Xanax round the clock and then the other I think it was KlonOPIN or even maybe one of them was looked like it was as needed and one of them didn't So was one round the clock and then the other one was as needed. So she the ad even was kind of around the clock and taking the Xanax as needed. Has anyone tried to increase her PROzac to see if they can back off the Benzos at all? She just met with her PCP yesterday and she just increased it to 20 to see how that works. And so she's gonna follow with her in a in a week. And she told her to essentially to not take the at event to see how that how that goes. Um She's also mindful of trying not to rely on it at the same time, right? If it's around the clock, it's hard to just stop, you know, maybe you know, taper it down or have it or something. But I you know I'm hoping that I think that the increase in the S. S. R. I might give her a great benefit. Thanks. Am I correct? I read that. So she has she hasn't seen a psychiatrist and it sounds like about, did you say the late nineties? Yeah. And she's also not she has this anonymous uh just like um weight management type group. I forget exactly what type of group that was. Overeaters anonymous. Overeaters anonymous. Okay. And but besides that did you say that she's not connected to any like mental health at all. No not at this time. And then the other question I had was that, you know, you noted that um her symptoms have gotten worse in the last two weeks, Are you particularly talking about, like the hypervigilance and things that have gotten worse or more just across the board? I think a lot of her, a lot of her anxiety, symptom, panic symptoms have as she reported has increased um and because she hasn't really correlated to anything in particular, uh everything seems to be very triggering uh you know, even and and just talking about just talking about her being triggered as triggering. Um and so um so that kind of, you know, and she uses a lot of intellectual ization to kind of explain kind of what's happening, which, you know, I kind of, you know, identified a number of defense mechanisms she was using and to kind of ground herself and um there was a book that she received um uh as she is kind of a workbook for anxiety that she was using. Um so she she is very proactive in trying to cope and manage the symptoms, but they seem to be extremely overwhelming for her. Um and so she's she's hoping that want to kind of get some understanding as to kind of what is it that she has, because when I asked her, she's ever been obsessed with depression, she essentially pretty much um said no, she kind of presumed she was depressed because of all the things she was experiencing, but she didn't seem to have any clear awareness that um that she is depressed and she's not able to identify anything that happened two weeks ago or around that time. No. Did she start by any chance using the workbook around that time? That's a good question. Um uh for definitely for me to follow up on. I think the the some of the things that I think as so one thing that she's having a concern about a tooth and so she and this is I think I mentioned that possible phobia and where she she felt that she had dental phobia because she said that um she um just thinking about going to the dentist was tribute for her but she's having this pain but she doesn't wanna go. And as I kind of you know, I know that a lot of people with anxiety tend to presume that they have phobias. And so I kind of wanted to explore that. And so I asked her a little bit to share a little bit more in the moment she was getting triggered and I was doing this to keep her grounded because I wanted to kind of get more clarity ultimately come to find out that it's it's not really a phobia as it is more so that she has a real uh she had a real experience when she was young. She had a very poor dental hygiene and she had a provider who at the time didn't use uh anesthesia. And so also the pain from having work done kind of continued to resonate with her. She she did when she identified that when she got a provider who took their time, they were patient, she said that she was okay. So she's had other providers in the past where she hasn't been anxious, she hasn't been afraid, but because she no longer has that. So it's kind of this the triggering of something new and trying to find a new provider and now being, you know, concerned of uh is this gonna hurt, Right? And how it's gonna feel because she's had work done where she's been in tremendous pain. And so there's a lot of focus on the physical, the possible perception of of her being in pain. And that's that for her taking her back to me, she was young. And so we kind of talked around around that and just kind of normalizing that, hey, that's a very valid reason to be concerned, you know? Um And so as opposed to it being a phobia where, you know, not so much rational, right? Um David, uh first of all, thank you, I thought it was a really great presentation. Um I had a couple of thoughts on the questions you had about like panic attack versus anxiety and pTSD. Um And I think like for panic attacks. I think that's something that one of the main, like when a patient says that they're having a panic attack and then that they're experiencing panic and then not knowing what exactly they're referring to, that sometimes. Um the main difference for me, it seems like is the level of the physical intensity, like with the panic attack, you would expect to see the level of intensity, like heart palpitations or, or heavy sweating, or like feeling like you're about to have a heart attack, kind of like, intensity that you wouldn't necessarily see in like, intense anxiety that doesn't involve a panic attack. It's like one area to maybe try exploring with her. Um Another thought I had about PTSD question versus other kinds of anxiety disorders is that I think the commonality would be that in both in panic attacks and maybe generalized anxiety disorder and PTSD and all of them, there would likely be an element of avoidance, Starting to avoid certain things for fear of what might happen. Um but then it may be also increased vigilance certain things, but the unique part of PTSD is that we would want to see the re experiencing aspects, so either nightmares or flashbacks or memories popping up that are related to the event or uh that impacted the PTSD and also possible changes in like um how she views things like connected to the event, like looking at the world in a different way of looking at people in a different way because of a particular trauma that happened, I don't know if that brings up like things related, like all sorts of thoughts for you, but for related to what she's been talking about, you know, I appreciate your feedback, especially about kind of the distinction between the panic attacks and the anxiety text to kind of focus on the physical symptoms a little bit more. And you know, she she she did report, you know, as um you know, chest tightness um and and that kind of triggers shortness of breath. Um She didn't really report um experiencing the inability to breathe. Um but she did express that in the past. It's gotten to that point where she felt like she couldn't, and so I think I'm not sure if this is a build up to something that's kind of also my concern. Um um and I as she talks about having trouble sleeping at night, I didn't wanna um really go into detail or try to explore if she's having night terrors or if she's having dreams and I think what you mentioned, I think would be really helpful to kind of her perception um about individuals. Um You know, she, I don't know if there's a because of so much loss from family, uh you know, and disconnect, I'm not sure if I haven't really explored how she handles some of the other relationships. She was, she she was married, she met her husband uh ex husband in college, they were married for about 20 years and then divorced. I never had had an opportunity to kind of explore um if any of her conditions played a role in that. Um And so because she's so sensitive, I'm trying to take my time with kind of unpacking some of this stuff, I don't want to scare her too much, and but she but I think it helps them to kind of look a little bit more because it's very possible that that may be what's underlying, because she does she does suppress a lot naturally. Um and and kind of um superficially acknowledges some of the things, but kind of opened the lid and closes it if I can describe, you know what she's experiencing. So it's very difficult to kind of uh explore it more, especially, you know, it's not necessarily my role to do that I do appreciate and love the opportunity to to um connect with patients on that level, but I try to try to keep a healthy balance right. I really appreciate you noting that piece about sort of, you know, with what's in scope for your engagement with her that comes up pretty regularly in our conversations um you know, when we've had primary care providers present as well, right? Like, you know, there's so much that we want to explore and learn and understand, but there's all these other things that we also have to do and time constraints and scope constraints which are important and appropriate for boundaries are around our own work and engagement, so I appreciate you raising that. Um you know, I'm still stuck on, sort of the symptom exacerbation, exacerbation in two weeks, like, you know, just because it's sort of like, well, you know, it's great to understand her and get the diagnostic clarification, which is important. Um and it's important for patients right to sometimes have this is what I think is going on can be very validating and very helpful for them to feel very reassured. So it's helpful in that in that sense, but I'm also eager to figure out, sort of what might we offer her then, right? With, with that understanding that would be materially different from what she's experiencing now, assuming what she's getting now is not enough, she needs something else. And if that's if that's the piece that you're kind of struggling to figure out, I'm hopeful that, you know, focus on the call, have some suggestions around, like, have you tried this or might she tried this or might this be going on and this is the next step that we would potentially try to go to so that you do something for her. Um you know what I mean, beyond clarifying the label because I don't know that for a patient, like knowing anxiety attack versus panic attack to them, the distress feels any less or more, you know, so I'm curious, sort of a focus on the caller hearing anything in this story that is making you feel like this is what you think is going on and therefore this might be the direction to go in. Um I was happy to hear that she's meeting with the Primary care doctor, you know, given her age, she's 70 and then she's had these acute symptoms over the last couple of weeks which are physiological, right, the palpitations, chest pain. So just to ensure that there's nothing medical or organic going on and precipitating these symptoms, we wouldn't want to miss that. Um so I think that's great. And then um the fact that the primary care doc was considering increasing the PROzac to 20 mg. That would make sense to me to maximize the ss ri um you know, before kind of considering alternative medication agents, I'd probably also think about the benzodiazepines and you know, utilizing one rather than two. And I'd probably ask her questions around that which the primary care doctor that you would do. So that's kind of my first thought, you know, in terms of medical and medications. Yeah, I say something. Please go ahead. All right, so I can only give the primary care point of view. I'm not a psychiatrist, but it sounds like this lady is out of control. She she doesn't really know what's wrong with her. And you don't know, nobody really knows she's out of control. So I don't know if I'm right, but I would usually give her the framework of what the primary care doctor can do is. So so we can have you come in regularly, we can rule out cardiac problems, uh neurologic problems problems, all the things she's having with the breathing and heart palpitations so that she can say, okay, I don't have this, I don't have this, I don't have this. And then along that time he said, well, you know, anxiety is playing a role in this as well, so let's control some of that with PROzac. So actually, whatever you're gonna use, so that she feels that she's got a progression to to some place. So that's one of the four components of happiness is control, progression, connectedness and being part of something bigger. So you can offer those things that okay, I'm working with my social worker and working with the primary doctor to rule out all these things, I have some control. I'm gonna do this in a progression. So I'm moving forward, I'm going to uh you know, reach out to my family maybe because maybe I need some connectedness and then I'm doing this all because I want to be part of the world. So she has a big picture that she has some place to go and you're gonna help her get get there along with the primary doctor. So that's where I would approach it because she got too many problems, you can't solve them all at once. That's gonna be a long a long road to get her someplace and you have to put her in that direction, that's what I would say, thank you doctor I just wanted to add. Um And in a way it goes along with what Dr Cheung is saying, Tyree that that that and you may have done this that part of it is what does she want, you know like what to sort of prioritize because there are so many issues. Um It does seem like that if the PCP has already yesterday increased the pros act so that's good because there will be some relief. It'll take some time but maybe she'll she'll see some relief. Um The only other thing I would say which is a very concrete kind of thing is you know for people with phobias around the dentist and it certainly sounds like she had a terrible experience. There are dentists who who are expert in, you know in treating people who are afraid to go to the dentist. And so that could, you know, if she's willing if she wants that, it could be something where you know you research and find a dentist who also she can afford obviously that's a problem as well. You know she certainly has a strength in if she's continuing to write somewhat that she's crochet and like there are things that she's doing that maybe distract her but give her some meaning, you know career wise work, thank you for the presentation Tyree thank you. Yeah, her primary the focus really is um getting her mental health under control. Um And so she she's definitely put that in the forefront because um as dr cheung put it she does feel out of control. Um and she she's aware that only a mental health provider can um you know kind of address that need. And so just you know, I was able to um reach out to some of my colleagues who there's a possible there might be a possibility that I might be able to connect her um to someone at Metropolitan. Um because I believe that they are opening up panel and no sign, eyes always um flooded and uh to the point where there isn't unfortunately availability in within the system. But um you know she even that was triggering because she lives in Brooklyn and her first response was is it gonna be close? And I kind of, you know they're my best to say well let's see how it works, right? We can talk about you know, possible barriers like transportation and and and and cost for certain things like that, but let's see if we can get you connected and see how it works. And you know, if it really becomes another stressor that we kind of explore somebody in proximity. Um I might also just suggest terry um if you haven't already the diff to the department for the aging have um some resources on their website. Um there may be sort of um psycho social groups and such that might help her, you know, to not, not directly address the concerns that she's having, but I'm, I'm just noting that she's not connected to anything right now and getting her connected to care is not going to be a quick thing, You know, even with Metropolitan, I mean, you've got, you've gotten something going, but she has to then be willing to get there. It's gonna be quite a trek. Um, so in addition to kind of, while you're getting her connected to care that she can sustain and maintain, there may be additional things that are more recreational that might help her given that she has interest like Crochet and writing and such that might help her, kind of just feel like she's part of a community because she has one friend that's basically her family right now. And it sounds like some of the estrangement from the family perhaps is related to the trauma that was from the family or not. I don't want to read too much into it. Just to give her a little bit of a support system that might be something you can look at. Um, and has this information on their website. Thank you for that. So, you know, I really appreciate you presenting this, I hope that some of the concrete as well as some of the kind of, uh more conceptual suggestions that you got are helpful. Um, you know, feel free to come back and give us an update on her and you know, if if something's kind of start to move and you have other questions that come up along the way, but I really appreciate you taking the time to present this case and appreciate everybody's feedback for Kyrie as well. Thank you appreciate it. Um so now I want to switch gears and turn it over to our speaker for the day for to present on screening for depression. Um Our speaker today is dr Mikhail Katz who is a licensed clinical psychologist and an assistant professor of psychiatry at the student training mental health program at icon with experience working with patients struggling with depression, anxiety and trauma. Dr Katz earned his PhD at the donor school of psychology at Adelphi University and he completed his pre doctoral internship at Mount Sinai Morningside and West and his post doctoral fellowship at the World Trade Center mental health program at Sinai, working with 9 11 1st responders. In addition to his clinical work, Dr Katz is a psychotherapy researcher and has published on topics such as mechanisms of change in psychodynamic therapy, therapist flexibility and crying in therapy. Um Dr Katz, thank you so much for being here today and for presenting on assessing for depression. Um and I'll turn it over to you. Thank you. Um dr Catherine. Hi, sorry about that, thank you so much. I'm very grateful to be here and looking forward to sharing some of these ideas with you all. Um I tried. Um so I'm aware that there are primary care providers here, psychiatrists, social workers, psychologists. It's a pretty diverse audience but um this presentation is mainly targeted to assist the primary care providers here and I try to to to take some ideas. I'm aware that the time that you may have working with the patient focusing on mental health is limited. Whereas um in comparison to a mental health session where we can dedicate a long session to many different questions about depression. So my hope is that the well you may not be able to not may not have the time to use all the things that go over in the presentation here that this could give you ideas for different questions or practical things to ask uh when you're meeting with the patient and you think they might be struggling with depression. Um can you can you change the slide or? Oh um so major depression is one of the most common dr Catherine mute seems to come back on by itself for somebody said oh I'm sorry we're good now. Okay I'm having trouble like with um with the slide is it oh you don't have to advance the slides when you're ready to have it move. You can just say next slide and we'll move it for you. Okay so can you get the next bullet point. Okay thank you. Uh Major depression is one of the most common mental disorders and as you may be aware, it may result in severe impairments and interference with major life activities and impact, ability to work, do school tasks, uh family obligations, whatever it is that's happening in the patient's life might be severely impaired because of it. And also with the correlation with the suicidality in some situations may even lead to loss of life next life. Can you add all the wood points? Um So in order to assess for major depression, we would want to see the presence for at least two weeks of at least five of the following symptoms here and the first for the first two on this list, we would want to see at least one of them, meaning that we would want to see the patient either reporting depressed mood for most days nearly every day, or we could refer to as an antonia, which is a lot of interest in activities or hobbies or things that used to be enjoyable or not enjoyable anymore. So we would want to see one of those things, either persistent low mood or difficulty enjoying things or sometimes both of them, and also at least five of the following other symptoms. Um So that would include changes in appetite. Um and and accordingly also changes in weight. Either weight loss or weight gain, uh disturbance in sleep, difficulty sleeping, for example, or oversleeping. Um Another thing that we might notice with people with depression and they might not even not might not necessarily notice that about themselves but other people in their lives might notice that they have kind of slowed down. Um They're thinking is slower. They move slower than than the usual. Um Feeling more tired than the usual loss of energy. Um excessive feelings of guilt or feelings of worth worthlessness. Uh This aspect might be um persistent beyond the p in an episode of depression but may get worse during an episode of depression for someone who struggles with self esteem. Um And then difficulty focusing. Often impacted in in depression as well. And uh for some patients also um return to suicidal thoughts. Uh Sometimes involving plan sometimes more passive thoughts. Just wishing that life was over wishing they wouldn't wake up the next day. Or in for some patients also suicide attempt as well. We'll talk about that more later on. And then in addition to all of that we would want to see like I said that that there is a significant impairment caused by these symptoms impacting things like uh the ability to socialize work or other areas of functioning next slide. Um So before going into question before going into questions you might ask during the session. I wanted to talk a little bit about some screening measures. So I I'm aware that the most the most commonly used one is the is the P. H. Q. Height Mount Sinai. So I listed here four of the common ones. Um And I thought I'd actually give examples from the G. D. I. To show a different kind of screening measure that is sometimes used the next slide. So the B. D. I. Has 21 questions it asks about the last week. Um Even though the D. S. M. Refers to the last two weeks. So sometimes there are nuances that are different between these questionnaires but they generally assess the similar things around the depression symptoms. In the case of the P. D. I. Each question has four possible responses. Next slide. Um So for example one of the items in the P. D. I. Referring to mood on a scale of 0 to 3 here with zero being I do not feel sad or have not felt sad at all in the last week. And three being I felt so sad or unhappy that I couldn't stand it. So that way patients reading the level of sentence that they felt. Um uh Moving on to the next slide. And another example is um item 15 on the P. D. I. Which were first to work with zero being I can work about as well as before and three being um I cannot do any work at all. And then ultimately you calculate the score and you get based on the score of the B. D. I. We can get a rough estimate. We wouldn't diagnosed depression just based on the B. D. I. Or or based on the P. H. Q. But based on the score that we get it can help us ah see whether the scores are consistent with what we saw and if they're not then um that will be an interesting thing to think about. But if they are consistent then it can give us more confidence in in our own assessment outside of the screening measure. Um the next slide. So uh some questions to ask in general when we're trying to assess depression. So I wanted to give some like some practical ideas here um that you can take for your own uh patients. So uh some of the questions I asked when I think someone may be experiencing depression or sometimes when a patient says that they feel depressed and I want to get a sense of um what's going on. I might actually start with the second question here of what does it look like for you when you're depressed? Depression is a big word and it may mean different things to different people. And I feel like starting with like an open ended question can really lead the way and see what patients report um uh initially and kind of also related to the case that was just presented. It can give us a sense of what are the things that are most pressing or whatever the things we may want to start with in thinking of treatment. Um And then some other questions we may ask related to the symptoms. So for example, have you been feeling more depressed than not on most days on the last week or weeks? This one is more similar to the kind of screening questions, but in addition to that asking the patient if they have had difficulty enjoying things that they used to enjoy if if so what kind of things? Um asking about appetite, asking about changes in appetite, asking about sleep when, when we get to sleep. Um I think if we have the time it's helpful to get very specific. Um Sometimes patients may say I have sleeping problems and it can feel kind of vague. Um So we can ask for example, how many hours of sleep or you're getting on average, Is it difficult to fall asleep to stay asleep or both? What wakes you up at night? Again related to the case presentation? We had, like the difference between waking up from a from a nightmare versus waking up all of a sudden and not knowing why. Um and potentially thinking of comorbidities such as anxiety disorders. Um Other questions we we could ask or if you notice yourself feeling more slow down than before, or if other people commented on it does it feel like it's it's difficult to do things in the same place that you used to do it than before asking the patient if they feel more tired than the usual, is it difficult to get things done? Um And also if they've been struggling with their self esteem or feelings of with regret about something? Like being preoccupied with something that they feel like they did wrong, which is often um part of that can come with depression as well and also asking the patients how the their focus has been and in terms of the cognitive overload, the depression can have um the next slide. Um So uh I thought we could talk about like different things like let's say we've come to the conclusion that this patient is struggling with depression. Um Then the next step we would we uh would want to know um different aspects of the of that depression and also what it's been like over the years. So um one question to keep in mind is is this a recurrent, is this the first time that the patient is experiencing depression or has it been something that's been going on for them? Is this a recurrent episode? So questions we could ask in this area would be for example, have you had previous um periods in the past where similar things like it felt similarly difficult to this one and and then if the answer is yes, took um I think this is again similar to talking about sleep. This is a place where it could be helpful to get very specific um like to ask the patient to tell you um about each episode, if you have the time to get into it of course. Um Like how did each of them start, How long did they last? Um whether was there a difference between the depressive episodes and if we're um from the if we if we are considering therapy and thinking about treatment options um I find it really helpful to ask patients what helped them get better. Um And do they have a sense of what got better? Did it feel like just like the depression um came and came and disappeared all of a sudden? Did it or did they feel like they do they feel like they did something that helped improve things and that can give us some indication of what might be also helpful to them this time. And it's also something we can use to help people have more hope about about the future, reflecting about previous periods of depression and how they ended or how at least they got better. Next slide. Um Oh and one more comment actually related to the previous slide is that um an important distinction between single versus recurrent depression is that the meaning for the patient might be um uh different. And if it's someone that's been struggling with depression for for for many years that can have a compounding impact on them and on their on on their hope. Um And also if if it's a single episode it's more likely that that there was a particular kind of shocking event that happened if someone has lived through their lives and then all of a sudden experiences depression, it's more likely that there was something really unusual that happened, Maybe a significant loss, maybe a breakup, maybe something would be a medical issue or something else. Whereas with recurrent depression, um there are also likely triggers, but it's more likely that there have been many triggers along the way as opposed to a significant shocking event that that led to the first episode of depression next slide. Um So another thing we would want to keep in mind is um does it feel like the depression is active right now? Or does it is if things started getting better, is it in remission or in partial remission? Um So questions we can ask, for example, is how long have you been struggling or feeling low or having difficulty? So getting a sense of how long, like a rough estimate of how long this period of depression has been going on. And then when you, when we get a sense, let's say, the patient says that it's been going on for two or three months, then the follow up question could be noticing any kind of shifts over time of certain things getting better or worse. Um and that can give us an indication of what the trajectory where things are going. Should we be more concerned or actually things getting better? And also um we can get even more specific about what kind of things have gotten better or worse. And that can also help us with the interventions later on, Like for example, if a patient says that there sleep there, sleep is getting better, their appetite is better, but there's still really struggling to get out of bed every day, then that could impact the kind of treatment would recommend based on the sort of the specific symptoms that have been persistent versus the ones that are maybe getting better next slide. So we would also want to think about the severity of depression and so some things to keep in mind that can get to help us get a sense of how severe the depression is. One would be the number of symptoms the symptoms. Another one would be the severity of each symptom and the impact on the patient's life. Um the impact on functioning. And we would also want to keep in mind the level of risky behavior with depression being associated with things like self harm. In some cases substance use as well, or aggressive behavior that uh might have depression underlying it next slide. Um so there's going to be a whole talk dedicated to suicide assessment later on, I think by Dr john dee Pierrot. Um there's a lot to say about this topic um, but just a few words on suicide assessment because it is really relevant with depression. Um I often like to think about it as a gradual step by step where we where we start with the lower risk and then gradually climb up to the high, higher and higher risk. So the first question to ask to just get a sense is two X. A patient. If they if they find themselves or ever found found themselves wishing they were no longer alive or going to bed wishing they wouldn't wake up the next day and then some patients might say um yes but never more than that. More just like passive suicide ideation. Some patients may say they've never had those kind of thoughts. Um If patients say yes, the next step would be to asking them um if they ever find themselves thinking about specific ways they might kill themselves. Um And then the answer here is important in terms of the determining risk um in terms of the feasibility, like for example if a patient says that they've had thoughts about um throwing themselves to the tracks in the subway, that's something that is um relatively doable versus if a patient talks about uh shooting themselves with uh with a weapon and they don't own an NFL weapon and no one in their household owns a firearm, then uh there's less visibility of them uh taking um that plan and then doing something with it. So that's something also to keep in mind in terms of the risk assessment and and then in addition to that if the patient says that they have a specific plan, we would want to get a sense of um what's the intent, asking specific questions about um intention of like taking that plan um and doing something with it to get a sense of how concerned should we be about the safety of the patient and and maybe the kind of recommendations we would make in terms of mental health. And also of course discussing past suicide attempts as well, if if the patient reports that as well next slide. Um so, to make things uh so while we are trying to make a GSM diagnosis here and determine whether someone has depression or not, and what kind of depression in order to make things more personalized. Um It is also important to get to get a sense of um what led to the depression. To get a more of a context about the patient's life and how this depression started. Um And sometimes patients have more awareness of how what led to their depression and sometimes it just feels like it came out of the blue. Um and then depending on that, that can impact the kind of questions we ask. Um So, for patients who have less insight into what led to the depression, we might ask if they have a sense of what kind of things tend to bring them down in general. And also talk chronologically, um asking about significant changes that happened in their life around that time and getting a sense of what kind of things were happening that maybe contributed to the current depressive episode. Um next slide. Um, so another important factor that we want to keep in mind, which might rule out depression and lead us lead us in the direction of potentially bipolar disorder diagnosis or at least to consider it is any kind of history of manic symptoms. Um, so questions we can ask, for example, about that is asking patients if they've ever find themselves experiencing a kind of natural euphoria for more than a few days feeling like naturally high. Um, other kind of questions that to help us assess for manic symptoms could be um if during that period, if they found myself feeling especially confident, like they were on the top of the world, ever feeling like you had special powers or feeling like special in in in any way. And of course we need to be cautious in the last question here. Um um exactly what just like feeling good about your yourself. Um wouldn't we wouldn't want to like miss label that, but just to get a sense of like whether the patient has ever had a period like that and and for many for it to be considered as for us to think about politics or that we would want to see this, um for at least more than a few days of consistent manic symptoms, uh next slide. So there are other conditions that wouldn't rule out the depression, like and again, like we saw in the presentation today, um anxiety and depression often come together. Um and sometimes even difficult to tell apart. Um So we want to we want to keep in mind other things that might be contributing to the patients suffering. Of course there's a lot to say about each of these conditions, but if we want to just like um ask some questions that wouldn't help us diagnose any of these conditions, but we'll just maybe give us a sense of whether we should open that door and consider additional diagnosis. So for anxiety we can ask the patient if they ever find themselves getting stuck in cycles of worry and what kind of things tend to make them worry so we can get a sense of whether we're going in the direction of or generalized versus social anxiety. Um for personality disorders, I find it useful to ask questions what are what things are like for them when they're not depressed. Often for patients struggling with personality disorders, there would be persistent um internal issues, internal turmoil, relationship issues or other or other kinds of issues that persist beyond the depressive episodes that come and go. Um And then for substance use, this could be a little complicated because sometimes substance use can lead to depression and sometimes it can be a result of depression. Um So I think chronology would be important, officials of substance use come up and generally we can ask questions, ask patients they've ever had any kind of negative negative consequences to the use of alcohol or drugs, emotional consequences, physical ones or behaviorally like doing things that you later regret under the influence and um anger management issues is something that's also important to talk about in general, but specifically with depression. Um as um for for some people it may be expressed that way as well. So asking patients if they tend to get irritable more than the usual or finding themselves doing things that they later regret out of anger next slide. Um for the one before. Um So this one could actually be in a segue to the next talk but a couple of words I wanted to say about what happens uh if we end up uh referring a patient to psychotherapy. So going back to actually thinking about the slide um for mild moderate versus severe, I think the recommendation is usually for mild to moderate depression. We would recommend psychotherapy and then for moderate to severe psychotherapy and medication which is considered the best combination for for depression. Um And then based on the modality, uh the kind of things that might happen in psychotherapy to kind of add to our understanding of depression. So under a cognitive behavioral therapy model the therapist would want to expand and try to understand the depression in terms of the patients trying identifying automatic thought that the patient has and then based on that. Trying to identify what is called core beliefs and this could be core beliefs about ourselves about others, about the world or about the future, and the idea here would be that these core beliefs shape the way we look at the world, shape the way we look at events that happened to us, and then ultimately also shape our feelings, our emotional responses and our behaviors and that way either lead to depression or perpetuated. So, and then the main focus and cognitive behavioral therapy for depression usually would be around challenging a lot of those core beliefs, or sometimes also in more kind of behavioral foc focus encouraging patients to behavioral activation to do things um even when it's hard to get out of bed to just like force themselves to do something, even if they don't have the money to do it, the motivation to do it. Um and that way gradually overcoming depression. And um in contrast psychodynamic therapy would often focus on um trying to understand childhood experiences for example, and how how might they relate to the depression that that occurred And also making the distinction between an eclectic versus introspective depression um with uh an eclectic depression being the kind of patient to um then that their depression is more focused on on fear of rejection and feelings of loneliness. Um and isolation. Uh we're in comparison to introspective depression, which is more about more inward focused and the feeling of self worth, low self worth and end doubting ourselves? Um So that's another psychodynamic perspective to trying to understand what the depression is about. Is it more about self self worth or is it more about um loneliness and feeling disconnection from others? Um Thank you. Great, thank you so much. Um Dr Katz, I really appreciate you. Um talking first of all about you know, a different measure for assessing depression than folks typically see and and use um and also about sort of providing a little bit of a teaser I suppose for your next talk next month on psychotherapy um for depression by talking a bit about psychodynamic therapy really, I know that's not something folks hear a lot about and happy to get that information out there. I wanted to open the floor up to see if there are any questions for Dr Katz. So what would you say is the sequence that you can take care of those people if you were in primary care office. Because what happens is primary doctors always time, like, you know, they never come in and say I'm depressed, they always come in, I got a headache, I got tired and I can't say there's always something else or it's just at their physical, they'll say oh by the way blah blah blah and I'm depressed. So you can't really take care of it at that time. So as long as they're not suicidal what would be the appropriate time frame to see those people to kind of get it taken care of like should you see them in a day a week should you see them every two weeks? And what should happen at those subsequent visits? And how long should it take you to say okay now we got this under control we're gonna move forward that way. So what what would be if if you were in a psychiatrist, your primary doctor what would be a good you know process for that? That's a good question. So just to make sure I understand uh dr chang so you're talking about a scenario where you're seeing someone um they're not seeing a mental health provider, you're their primary care provider and you're asking how often you should see them as you're trying to assess for depression. Well like here's an example. So today I saw a woman she's uh maybe 60 years old, 64 years old and she comes in for her physical and she has hypertension. She's a regular things and it's actually oh she's 65. This is her annual wellness exam for Medicare. And so really you're not supposed to do anything except assess them to make sure they can walk and talk and all this. And then of course she does P. H. Q. Two which is positive. So our staff does a P. H. Q. Nine which is 19 this is a high score. So there you are. She did we did her whole physical and then um of course I forgot to look at the P. H. U. Nine She says oh by the way remember your staff at the P. H. U. Nine? It was 19. So there it is I finished the physical there she is I got I got depression so how can I structure that? So she feels that we're addressing it as well as you know not not brushing it off. What do you do at that point? Um Well I think I think um so it sounds like in this case uh so you met with her and then after the session you you made a diagnosis and now you're trying to determine what to do next. And I think in that scenario first of all I think if if possible I would invite her to to another session or another appointment when you have the time to do it. And then I think if you're short on time I would give the priority first of all to ask her if she's ever received any kind of mental health care before whether medication or psychotherapy or both. Um And then if she's not if that's something she's interested in and and open open to. So I think that's the first thing and I might spend if you have more time I might also spend time on the what psychologists call psycho education um And getting a sense of um is she is she aware that she that she might have depression? It's and and sort of sort of like telling her about the different options that that could be helpful. Um Sometimes patients are not aware of of what can be done so that I think that in itself can increase the chances that she may follow up with a referral. Like if if you as our PCP tell her I think I think you may have depression and these are the kind of things that I think you might be helpful to. You maybe meet with a psych uh maybe meet with a psychiatrist maybe psychotherapy. Um And specifically for psychotherapy. I would also consider what the financial situation is. An insurance coverage psychotherapy is probably know it can be like expensive but depending on the coverage. So that's something I would also like try to keep in mind like is it something that's feasible with the kind of coverage that she has? Um Those are some things I have in mind. What do you think is that sort of like well more of a time frame. So she kind of lays it at the end of the visit and she said well I asked her you know how's your work so I can work fine and everything is fine. But my father died about four months ago and I haven't been feeling so well recently I said you don't have plans to you know hurt herself and she said no no no nothing like that. So that so I said well if we were to talk about medicine would you be interested in taking any kind of medicines? She said I would never take medicines for this. So I said well so it doesn't sound like we're in a hurry. Why don't we you know we'll do all your blood tests which she has to do for physical. And then if these symptoms continue, let me see you back in a couple of weeks. So that's that's how I left it. But I can see I can see that I could go deeper. I could I could be a lot more aggressive. I'd like to hear what other people would do in that situation. Dr brody. You have a thought. Okay. I wanted to meet myself so I have some concrete suggestions for you dr Cheung. The first thing I would do. The score of 19 on the PHP nine is pretty impressive. So first thing I would do is I would look at the ninth question. So if she has a score of even one let alone a two or three on item nine of the P. H. Q. Nine. That's a that's a suicide question correct. And that's you know um and or it's or it's a question about you know feelings of hopelessness and the idea that the person would be better off debt or has thoughts about hurting themselves. There is data. There is you know it's proven that if that question lights up the patient is clearly at increased risk for suicide or deliberate self harm or something like that. So that's the first thing I would do. So if if question, if item nine is zero, you can breathe a little easier. The other thing I would take a look at would be the, and you can quickly do this. Some of the other questions like appetite and sleep, is there any chance that any of the medications that you're prescribing for her physical health? Uh you know, problems are messing with her sleep or are screwing up her appetite or or make making her more fatigued or or something like that. You may not pay attention to that necessarily when you're doing just a regular physical exam, but if you see that, you know, it'll take you five seconds to think about what medication she's on and you know, hypothetically if she's on making this up a whopping dose of a beta block, you could say, you know, maybe that's why she's complaining, you know, a fatigue or something. Um in terms of, you know what you do at that point, I think you're very brave to have the question about about medication. I think at that point, I mean, unless you're willing to send the rest of your patients home for the afternoon, which I don't think you're willing to do. Um I think you have to ask her to come back and talk with someone else on your staff or if you have the time I can't imagine you do but someone else on your staff to really go into this in a bit a bit more detail and uh and see if there's any behavioral health treatment that you'd be open to. Um I think it's great that you're doing the P. H. Q. Two on on everyone. I think that's fantastic. And you know obviously you know having her do repeated measures have all all of your patients to repeated screenings is a way of sort of picking out those patients who were there may be a significant contribution of behavioral health disorders psychiatric disorder to their you know non psychiatric medical problems. Um Yeah great great great ideas. And uh one thing I would add is that um it doesn't if she's saying that she wouldn't take medication. Um I think depending on the time you have but I think there's a way to follow up that doesn't necessarily pressure her into taking medication but just like having an open conversation about what is a rationale is she afraid of side effects? Is she afraid of the stigma around psychiatric medication? Um Getting a sense of what's the reason maybe can wouldn't necessarily maybe change your mind but maybe over time things can change. Yeah. Oh sorry sorry sorry. Um No I just wanted to um just plug in um dr Cheung mentioned very briefly that the patient expressed a recent loss and I think um you know that that is something to seriously consider um you know she said it was a parent and um it's only been about four months and I think kind of ex I guess either as dr brody was saying you know having her come in um to to to see you know to assess a little bit more about that traumatic experience to see how that's been going on. And I know it's always a challenge because especially in the sm where they talk about grief there's a think a six month window before um you're starting to really um focus on whether it's depression or not related. You know if it's extensive or if it's just relating to the the experience but I think kind of finding out there any other I guess significant um events that happen of trauma that may be contributing to that thing, it would be important. But I think having her assessed um will be key in terms of figuring out really what the best option is. Yeah I was just gonna say you know concretely if you were to have availability you know within two weeks maybe bringing her back the next week or the week after to kind of delve more into the behavioral health concerns and discuss the options around that. I think that would be an appropriate time frame for sure. Um I think sorry if I could please um I have two things to say. One is a little bit off on a tangent but I think that it's sort of a red flag that someone is um has such a high P. H. Q. Nine and has no interest in getting help or going on medication. And um two things would cross my mind in there either. That person is truly suicidal because you know has almost given up doesn't want medication or anything and has a plan. So you know I think that the comment um from dr brody that you know you have to look at that that answer and see and if that person is resistant to treatment and has any number on that suicidal part of her questionnaire that you know you kind of have to take that a little bit more seriously that she seems to be in despair that she doesn't want any treatment or the other side of it is that this person is I don't want to say seeking attention because that may not be you know you I don't know her I just know the case presentation. But if somebody has such a high scale and doesn't want any help are they just looking to take up time and have somebody pay attention to them and have visit after visit. Um You know without looking for any open mindedness to help treat as opposed to uh Tyree's case where the person was so in touch with their issues that they really were open to all kinds of treatment and all kinds of help. And this person seems to be the opposite where they're so despondent yet aren't open to anything. And then the other thing I want to mention is that poly pharmacy and patients medications like dr brody mentioned is so important that we overlook and and sometimes we're not even sure that um you know that the medication is causing something. For instance today I had a patient on Parliament which is an injectable cholesterol medication and she's having frequent U. T. I. S. And you know she asked a question about the medicine and I just said well let me look up the side effects and it actually turned out that it causes frequent U. T. I. S. Which I didn't even know. So sometimes if you're having trouble with a patient and you can't can't treat something or not sure where it's coming from. Sometimes just even to look up the medications even though we we think we know the side effects sometimes one shows up and we didn't even know it sorry have all kinds of things running so that's it thank you um appreciate all that feedback. Um You know we're almost at the hour so I want to um you know just wrap us up here but I would just say you know connected to what dr brody said about that last question. Um I'm struck, first of all I appreciate the opportunity that annual wellness visits provide to kind of bring this into the conversation. Um Which is you know a huge step forward I think. But if I'm not mistaken dr cheung you said that um you were almost done with the session with the visit and the patient reminded you that the P. H. Q. Nine had been administered by your staff and were you going to review it? Is that right? Yeah of course she has lots of other issues as well. Yeah sure. I think that's striking right like the fact that she she wants to talk about it and and wants to bring it to your attention. Um But then kind of the I don't want any concrete help itself kind of underscores what dr Simon just said that like you know is it a cry for help? You know that she's sort of alerting you which is which is a positive thing and I underscore the instinct then to sort of want to see her more frequently than you would otherwise maybe the second time you know knowing that like you know if she talks to you about it you're not gonna put her in the hospital right away that you'll bring her back to have another conversation about it. Something like that might actually prompt her to be a little bit more forthcoming the next time. Um And maybe explore options for care. Um You know so I would just say sort of as dr Christopher said like bringing her back more frequently before the next visit might be a good thing. I was just thinking about the question about my own mental health. So so you're in a busy day, three o'clock and you and then if you say well I'll ask the question, tell me about your you know, your family member's death and what it means to you. Okay I'm putting number one on the Czech market number nine, that's hours and hours you're done you're done for. So I was just trying to find strategies so that you don't you don't kill yourself and you do something good for the patient at the same time. Yeah no that's extremely important. I really hope, you know others heard what you just said, I think you know um where many of us find ourselves in that situation and certainly what happens at the end of the day. Um So I appreciate you being honest about that and noting that um in september when dr Shapiro presents, we will talk a little bit about ways to take care of ourselves as well because health care providers are a very high risk, you know high burnout group. So um I want to wrap up the meeting just out of respect for everyone's time. You know folks who are here appreciate again everybody being here appreciate Tyree for you to present the case and dr Katz appreciate the didactic. Um you will have a post survey that comes out and um if folks please take a moment to complete it, um, it would help us kind of gauge how useful this session was. Thank you very much. And we'll be back again in june. So you are you well.