How to address a patient's external stressors?

[DrFrasierCrane]

Throughout third year, I've seen numerous patients who meet the required DSM criteria for depression. Nearly all of these patients point to difficult external factors as the cause, such as losing their significant other or job. They rarely say they feel depressed despite a wonderful life. Beyond empathy, I'm not exactly sure what to say, I mean we can't exactly fix their issues but I also want to do more than say "here, try an SSRI."

This is one of the many reasons I look forward to a psychiatry residency, to learn how to approach problems such as these.

But in the mean time, I'd love to hear what your strategies are for helping these patients? What can you say/do in a non-psych based outpatient visit, since the majority of my rotations left in med school won't be psychiatry?

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[zenman]

Have them contact their congressman.

 

[strangeglove]

This is not something that can easily be addressed in a single thread. What you are asking is how to do psychotherapy, right? This is a process that takes a while to learn, and hopefully you will enter a residency that teaches you how to do this. For starters, however, you might want to read about Interpersonal Psychotherapy for Depression. This form of psychotherapy is evidence-based (i.e. has been studied in randomized, controlled trials), and has been shown to be effective for treatment of depression. It works by addressing life changes (losses, relationships, etc.) that commonly trigger depressive episodes.

 

[erg923]

In this position/situation, empathy (don't underestimate it either) is about all you can do. You are not this persons therapist and are not trained for such as this time.

Giving them a standard psychoeduational spiel about what we know about the power of therapy and how it might be useful for them might be in order. Provide them with resources and referrals, even it just a suicide hotline number or the numbers of a few local therapists, community mental health centers, etc. if they are interested.

 

[masterofmonkeys]

In this position/situation, empathy (don't underestimate it either) is about all you can do. You are not this persons therapist and are not trained for such as this time.

Giving them a standard psychoeduational spiel about what we know about the power of therapy and how it might be useful for them might be in order. Provide them with resources and referrals, even it just a suicide hotline number or the numbers of a few local therapists, community mental health centers, etc. if they are interested.

While that's true, I think there's no problem with introducing patients to basic stress reduction techniques, and maybe doing a pinch of cognitive reframing with them.

 

[OldPsychDoc]

Agree with above. My standard set of questions is "What can you do do feel better?" and "Who's got your back?" (or some culturally appropriate variation of above.) The key issue is to help them identify and access the resources in their life in a healthy way. I want them to leave knowing that isolation is the enemy, and to have a couple of people or groups they are going to connect with. For some of them, that's a tall order, but we work on it, and well, in the meantime, they've found out they've got me...

 

[masterofmonkeys]

Agree with above. My standard set of questions is "What can you do do feel better?" and "Who's got your back?" (or some culturally appropriate variation of above.) The key issue is to help them identify and access the resources in their life in a healthy way. I want them to leave knowing that isolation is the enemy, and to have a couple of people or groups they are going to connect with. For some of them, that's a tall order, but we work on it, and well, in the meantime, they've found out they've got me...

Agree with above. lol. I know you are an attending, but you are not my attending.

Seriously though, I remember a frequent flyer who dx schizoaffective d/o-bipolar type (i.e. Bipolar I lol). Who also was massively borderline. It turned out that art was a pretty effective replacement for cutting behavior for her. We hooked her up with the activity center that the local outpatient community psych group has and she hasn't been admitted for cutting in quite a while.

I've had med students do quite impressive things along these lines to improve a patient's quality of life and reduce the morbidity of several psych patients.

 

[kugel]

many yrs ago, kept a young lady from being admitted over a really bad weekend by suggesting she go down to the humane society and play with the puppies. I regularly recommend that the pt get involved in a church/synagogue/mosque or some other worship group - connection to a community of people who support each other in their belief in something larger often helps. Plus, many have access to low-cost counseling and have info/access for help with food, clothing, utility bills, etc.

But I agree with the point that you should not underestimate sympathy/empathy. Even in your Board Exam, they expect you to RESPOND to the pt. Never forget you are two PEOPLE.

 

[billypilgrim37]

many yrs ago, kept a young lady from being admitted over a really bad weekend by suggesting she go down to the humane society and play with the puppies.

My wife is actually an adoptions counselor (i.e., that's her full time job, not a volunteer) at the city humane society. She would like to beat you for such recommendations.

Jokes aside, the humane society is actually very close to one of the methadone clinics, and there are plenty of clinic pts who are wonderful volunteers there. The overlap between our psych emergency room and the humane society is very high, and I'm finding myself trying to become a bit of a liason between pt's and their animals when they are involuntary committed by police (which is a frequent occurrence).

So yes, send your pts to volunteer with the pit bulls. But please only send your stable pts!

 

[nancysinatra]

Agree with above. My standard set of questions is "What can you do do feel better?" and "Who's got your back?" (or some culturally appropriate variation of above.) The key issue is to help them identify and access the resources in their life in a healthy way. I want them to leave knowing that isolation is the enemy, and to have a couple of people or groups they are going to connect with. For some of them, that's a tall order, but we work on it, and well, in the meantime, they've found out they've got me...

"in a healthy way" being the key, I would think... Any suggestions about what to say to patients who are overly enmeshed, dependent on others, or dependent on the system? I feel like there are some patients where they are already perpetually in a state of crisis and perpetually activating their "support system" or utilizing "services," where what they really need to start doing is relying on themselves. I feel like I've seen a lot of these cases... (Or maybe I've just been on call too many nights at the VA with too many people pestering me to be admitted!)

 

[OldPsychDoc]

"in a healthy way" being the key, I would think... Any suggestions about what to say to patients who are overly enmeshed, dependent on others, or dependent on the system? I feel like there are some patients where they are already perpetually in a state of crisis and perpetually activating their "support system" or utilizing "services," where what they really need to start doing is relying on themselves. I feel like I've seen a lot of these cases... (Or maybe I've just been on call too many nights at the VA with too many people pestering me to be admitted!)

Yeah, the VAs can be like that--they think they've "paid their dues" so any mention of doing something for others or giving back to the system goes over like a lead dirigable...

I usually try to reinforce what they are doing that's healthy, and suggest widening their networks wherever possible. It really helps to try to get a picture of how they spend their days, what's important to them, etc. Of course, most of them, if they had healthy support systems they wouldn't be in our office in the first place....