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It may seem like an exaggeration to say that everything flows from the consultation but, when treating major depression, that is most often the case.
From the physician’s perspective, the psychiatric consultation is key to gleaning as much information as possible in order to diagnose the problem, determine the best treatment, and outline what you can expect to feel and when during the treatment process.
It is so essential to the ultimate success of treatment that there is an 800+-page tome for professionals devoted to the topic. (It’s called Psychiatric Interviewing: The Art of Understanding—A Practical Guide for Psychiatrists, Psychologists, Counselors, Social Workers, Nurses, and Other Mental Health Professionals by Shawn Christopher Shea, MD)
Yet if someone were to hear me chat with a new patient at the start of a session, it might sound as though we were just having a casual conversation—”How are you feeling?” “How long have you been feeling this way?” “Has anyone in your family suffered from a similar problem?”
But I am not just shooting the breeze when I ask these patients questions. I am using the time-tested diagnostic procedure taught to us in medical school, which is as laser-focused as an X-ray, blood pressure monitor, stethoscope, or any other medical screening device.
It is an information-gathering tool commonly referred to in the medical community by the acronym SOAP for subjective, objective assessment, and plan.
The SOAP process is broken down into four parts:
1. Subjective: You, as the Expert
The key to the consultation is you. You, the patient, are the expert on how you feel. You hold the clues to what will eventually be the solving of the medical mystery: your diagnosis. The more you share about your symptoms, how they impact your life, and your family, medical, and medication history, the easier it will be for your health provider to determine your diagnosis.
While some people come into my office bursting to unload their feelings, others are more reticent and need to be prompted. I prefer to gather information myself, but the medical office you visit may require patients to fill out symptom checklists and medical, medication, and family history forms before seeing the doctor.
Whatever consultation format your health provider uses, be sure to bring to your appointment notes about what has been bothering you and any recent health test results, so your physician has the necessary information to determine an accurate diagnosis.
Depression disrupts sleep, increases memory loss, and heightens anxiety and cloud thinking. By jotting down your symptoms and questions in advance of your medical visit and taking notes during it, you’ll be sure to cover what is on your mind during your medical appointment and be able to go back and reread the doctor’s recommendations after it.
2. Objective: The Doctor as Observer
The objective part of the psychiatric consultation begins the moment you walk into your doctor’s office, log on to a telehealth appointment, or call to schedule an appointment. There is so much to be learned from listening to, looking at, and being sensitive to the mood and physicality of someone.
The tone of voice, appearance, posture, demeanor, attitude, hygiene, grooming, emotional expression, the pacing and patterns of speech, eye contact or lack of eye contact, and thought processes all contain clues to a person’s state of mind.
A patient’s capacity for judgment, insight into their condition, and empathy for others (which usually drops severely in depression and may barely be present in schizophrenia) are also key qualities to observe. If someone has thoughts of or plans for suicide or harming others, the doctor has an obligation to act and may contact a family member or respond in some other way.
Your doctor may also request to send reports of your bloodwork and physical exam, as lab findings and screenings can influence the treatment of choice.
3. Assessment: Diagnosing Depression
Once your health provider has pulled together all relevant information, it’s time for an assessment. People who are diagnosed with depression are often surprised. The fact is, depression is a misleading name for a condition that has so many varied and seemingly unrelated symptoms.
Depression and anxiety are linked, and many people with depression may find their mood more anxious than depressed. There is also a strong cognitive component to depression. Ruminating thoughts concentration and focus. Constructive problem solving suffers. Decisions are difficult to make.
A tendency to see everything in a negative light is often more prominent than sadness or irritability. Obsessional thoughts, dreams, anxieties, and regrets leaving no room for believing that relief is possible. A feeling of remorse for all you’ve done wrong or not accomplished and a sense that nothing will work out in the future are manifestations of a hyper-focus on the negative.
In addition to mood and cognitive symptoms, there are somatic signs of depression, including problems with eating, sleeping, sexual interest, and body pain. When I explain to patients that their constellation of symptoms leads me to believe they are suffering from depression, some are shocked.
“What do you mean I’m depressed? I don’t cry all day. I’m just anxious,” is a typical response.
Another common reaction: “Of course I’m depressed. Wouldn’t you be if you had my problems?”
Frequently, there is also relief. Finally, my patients understand that seemingly unrelated physical, emotional, and cognitive symptoms are tied up in one condition.
4. Plan–Outlining the Route to Recovery
Being prepared for what the road to recovery will look and feel like can be supremely helpful in attaining a successful treatment outcome. Depression is anxiety-provoking, and knowing what to expect—and when—is key to staying calm. Unfortunately, many people begin panicking if treatment doesn’t start working right away and stop taking their medication before it takes effect.
Anxiety is relieved when a treatment plan is laid out properly and reassuringly. After a psychiatric consultation, you should feel like you are embarking on a journey and have been given good directions, are prepared for the signposts and detours you may encounter, and feel confident that you’ll get to where you want to go.