DR. EBER: The first step in identifying patients who may be suffering from mental health disorders is to notice warning signs and be aware of risk factors. Risk factors for mental health disorders include:
Exposure to trauma
A severe or chronic medical condition
Exposure to life stressors, such as job or financial loss
Prior history or family history of mental health disorders
And death or illness of a loved one
Some of these may be indicated in a patient’s history or physical exam, but others you may only discover by talking with the patient.
DR. RODGERS: And you mentioned some warning signs I should be aware of?
DR. EBER: Yes. Patients with mental health disorders may exhibit physical and behavioral warning signs. In fact, these patients’ physical complaints are often caused by, or exacerbated by, their mental health disorders. Let’s take a look at a few patients who were referred to me by primary care providers and note the warning signs they presented that prompted their referrals.
Alex:
Alex developed depression after losing his job. He went to his doctor for a loss of appetite and considerable weight gain. Alex showed up for his appointment looking exhausted and reported feeling lethargic, despite sleeping 10-12 hours per night. When questioned about his physical activities, Alex revealed that he recently quit his soccer league. He said he feels sad and stressed most of the time and doesn’t think he’ll ever feel better. His answers to the depression screening indicated high risk.
Warning signs of depression that Alex presented:
Excessive weight loss/gain
Exhaustion
Excessive sleeping/insomnia
Withdrawal from activities, friends, or family
Persistent sadness/stress
Hopelessness/helplessness
Here are some other signs of depression you might notice in your patients:
Visible tearfulness
Difficulty concentrating
Margot:
Margot presented with high-risk use of alcohol, as indicated on her substance-use screening form. She initially went to her primary care physician for an ankle injury sustained after tripping on her staircase while intoxicated. When asked about her drinking patterns, she explained that she’d been caring for her sick mother and had gotten in the habit of drinking several glasses of wine each night and a few wine spritzers in the morning to relax and take her mind off of things. She said she sometimes has trouble making it to work after drinking the night before.
Warning signs of depression that Margot presented:
Injuries Use of substances to manage difficult feelings
Difficulty meeting obligations
Here are some other signs you might notice in patients with risky substance use:
Poor hygiene
Frequent physical complaints
Insomnia
Drug-seeking behavior
Being under the influence
Phil:
Phil has Generalized Anxiety Disorder. He presented to his primary care doctor with difficulty falling asleep; he’d lay awake thinking about his day and worrying about the upcoming day . When questioned, he said he was constantly concerned that he’d be fired or evicted—though he said he was in good standing with his boss and his landlord—or that someone in his family would die of a terminal illness, though they were all currently in good health. During the exam, he was restless and fidgety, biting his nails and picking at his cuticles.
Warning signs of depression that Phil presented:
Insomnia/sleep disturbances
Excessive worry
Restlessness/fidgeting
Here are some other signs of Generalized Anxiety Disorder:
Digestive problems
Excessive sweating, chills, or shaking
Frequent appointments
Substance use to reduce anxiety
Nina:
Nina developed PTSD after she was mugged walking home from work one night. She went to her primary care doctor complaining of insomnia.
During the exam, she seemed on edge, distracted, and restless. When asked about her daily life, Nina reported that she had stopped going out with her friends, due to her fear of walking anywhere alone, which causes flashbacks of the mugging. She says she drinks more now to deal with heightened stress. At her appointment, she was irritable and easily agitated and even had an angry outburst at the nurse who took her vitals.
Warning signs of depression that Nina presented:
Exposure to trauma Insomnia/sleep disturbances
Hypervigilance
Distracted/restless/detached
Avoidance of social activities
Avoidance of trauma reminders
Use of drugs and alcohol to relax
Irritability/angry outbursts
DR. EBER: If you have prior relationships with patients, it’s also helpful to be aware of noticeable changes in their appearance or behavior since previous appointments.
DR. RODGERS: Right. Like, with Vanessa, I noticed that she seemed more anxious than I remembered and had lost a lot of weight since her last appointment, which was part of the reason I was concerned.
DR. EBER: Exactly. Dr. Rodgers, there’s a patient in your waiting room right now who you can meet with to practice what we’ve been discussing.
DR. RODGERS (looks down at his chart): Great. His name is Antoine, and this is his first appointment.
DR. EBER: (to the user) You’ll help Dr. Rodgers speak with Antoine. As you do, you may notice some of the warning signs we talked about. Your goal is to gather enough information to determine if Antoine is at-risk for a mental health disorder. You should be able to complete this conversation in about three to five minutes.
DR. EBER: As you’re interviewing patients, there are a few techniques you can use to gather more information and encourage them to open up to you within the short amount of time you have:
Sit at eye level with patients to put them at ease.
Ask open-ended questions (ones that can’t be answered with a simple yes or no) to get more info and save time.
Empathize with patients to promote open and honest dialogue.
Reflect patients’ statements in your own words to show that you’re listening and that you care.
Summarize what you discussed to clarify concerns and next steps.
DR. EBER: Antoine’s complete medical history has already been collected. Now, let’s get started.
Patient History & Physical:
Name: Antoine Randall
Age: 38 Chief
Complaint: Severe low back pain
History of Present Illness: Injured his back and diagnosed with herniated lumbar discs.
Prescribed percocet. Worsening pain making it hard for him at work.
Medical History: Appendicitis, herniated lumbar discs
Surgical History: Appendectomy
Family History: Family- parents alive and well. No siblings. Married. 1 daughter. Social- no tobacco, recreational drugs. Social alcohol use.
Allergies: None known
Medication: Percocet
You will hear an example of the talk with Antoine. At times, you’ll hear advice and feedback from your coach, Dr. Eber, commenting on what Dr. Rodgers said and guiding him to more effective techniques.