Most people with depression consult a professional willingly but some, particularly adolescents, may have to be forcefully encouraged or even coerced by others. People who are in this position should inform the professional that they are presenting ‘under sufferance’ and then establish the ‘rules’ that will apply to the relationship. Minors may be concerned that the assessment procedure will result in information being passed on to their parents, and adults may worry that their case will be discussed with their spouse.
Professionals have an obligation to respect confidences. Any concerns about how the interview data will be recorded, or who will have access to it, should be raised at the start of the interview. If the professional is able to provide reassurance about patient confidentiality, the patient should try to face the assessment with an open mind.
It is becoming more common for patients to bring a family member or friend to an assessment interview. In this case, the professional must establish whether the patient wants to be interviewed alone or with the other person present. It is usually the patient’s call; rarely will the professional make the decision.
It may be best to start the assessment alone, as this gives the patient more control over private issues. A family member or friend can be invited to join at a later stage, to give their own observations and to be involved in the development of the patient’s management plan.
If, however, you are a relative or a friend of someone with depression, the rules are less clear and guidelines are more difficult to draw up. If you are encouraging someone to see a psychiatrist, do not disguise the issue. Do not wait until the day of the appointment before telling them about it. Do not tell them that the appointment is with a ‘doctor’ or a ‘counsellor’ if it is with a psychiatrist.
If it is unlikely that your relative will tell the doctor or counsellor of any risks their disorder may pose, such as self-harm, inform the professional or their secretary/receptionist directly of your concerns. If your relative or friend has a very severe disorder such as psychotic depression or mania, try to accompany them to the appointment. If you are not requested to be present during the initial assessment, ask that you are at least briefed about the management plan. Ideally, however, you should be present while the management plan is being discussed as this will prevent or limit miscommunication, and you may have valuable contributions to make to its development.
✰ What a detailed assessment might cover
At the initial assessment the following questions might be expected to be asked:
- Is depression the principal disorder, or is it secondary to some other condition (for example, anxiety or substance abuse) that should be assessed and treated?
- If depression is the principal disorder, what are its key features (in order to determine the depressive sub-type)?
- What is the risk, if any, to the patient of self-harm, harm to reputation, or even harm to others?
- What is the level of current disability?
- Were there any triggers (for example, stressful events) to the episode?
- If there were triggers, did they entirely cause the depressive state, did they activate or worsen it, or were they merely coincidental?
- How did the patient interpret the triggers, and what thoughts did they activate?
- Is the patient part of a family network and, if so, what is the quality of the relationships?
- What can the patient remember about their childhood, including the level of parenting received, their interactions with other children and their experiences at school?
- Is there any family history of depression or other relevant medical problems?
- How many and what types of jobs has the patient had and what level of satisfaction, if any, was there?
- What is the quality of the patient’s relationships with intimates, peers, work mates? Have those relationships been sustained over time?
The professional should also seek to establish:
- the patient’s personality style and repertoire of coping responses, identifying particularly any cognitive style that may increase the patient’s vulnerability;
- a drug and alcohol history;
- any medical/surgical problems, in particular any that may have contributed to the depression;
- whether or not the patient suffers from any allergies, especially to medication;
- any cognitive limitations affecting concentration, memory and intellectual functioning;
- the patient’s life history of depressive episodes, previous treatments and perceived effectiveness or ineffectiveness of these treatments;
- any current ‘sustaining’ factors to the depression—for example, ongoing work problems or dysfunctional relationships; and
- the patient’s own views about the reasons for their depression, and their preferred treatments.
✰ What the patient should be told
If the outcome of the assessment is that the patient is depressed, then the professional should inform the patient of the diagnosis and identify the likely depressive sub-type. If the patient is suffering from another disorder, for example, anxiety or bipolar disorder, then this should be formally acknowledged. It is important that the professional establish confidence in the diagnosis with the patient.
The professional should also identify to the patient any other problems of significance, as well as any medical or emotional conditions that require investigation and/or treatment. It is important to provide the patient with a pluralistic explanation of why the disorder developed at this particular time. This involves integrating past environmental and developmental factors with genetic influences, stress levels and personality interactions.
The professional should also recommend a management strategy and outline the lines of responsibility for those involved in the case. For example, the general practitioner is to handle X and the non-medical professional to handle Y. The professional should always give the patient an accurate assessment of any costs involved and the likely advantages of the management plan.
Different professionals (psychiatrists, psychologists, general practitioners, nurses, social workers, occupational therapists, counsellors) have different training backgrounds and therapeutic orientations. Their therapeutic approaches may range from the very narrow to the very broad, each having advantages and disadvantages for the management plan.
(extracted from) Dealing with Depression: A Commonsense Approach to Mood Disorders by Gordon Parker, published by Allen & Unwin