DR. RODGERS: Hi, Judith. It’s been six weeks since I last saw you. How have you been doing?
JUDITH: Oh, not so good, Doctor.
DR. RODGERS: What’s going on?
JUDITH: Well, my wrist has really been hurting lately from the arthritis. And I’ve been having some headaches.
DR. RODGERS: Okay. Last time you were here we talked about you taking Ibuprofen and trying some physical therapy. Has that helped at all?
JUDITH: No, not really. My wrist is still bothering me.
DR. RODGERS: And what about the physical therapy?
JUDITH: No, that didn’t help. I went a couple times, but… I don’t know …
DR. RODGERS: Judith, a couple times isn’t really giving the physical therapy a chance. You need to try it again. It can really help with arthritis pain.
JUDITH: Oh, okay. (Judith lowers her head and becomes more withdrawn)
COACH FEEDBACK: This sounded like criticism and shut Judith down. You know she screened positive for depression; her reasons for not going to physical therapy may be related. Let’s come back to the topic of physical therapy a little later on in the conversation…
DR. RODGERS: Okay, Judith, before we talk more about your pain and headaches, I’d like to talk about the forms you filled out in the waiting room. You… are suffering from depression.
JUDITH: Depression? What about my wrist and headaches?
COACH FEEDBACK: Try to ease into this conversation. Ask Judith about her chief complaint and then about her mood before jumping into the results of the screening.
DR. RODGERS: Tell me more about your pain. How are your arthritis and headaches affecting your ability to get around and do things?
JUDITH: It’s not easy. I don’t move around much.
DR. RODGERS: How often are you getting out of the house?
JUDITH: Not often. This is the first time in a while, actually.
DR. RODGERS: What about work, or seeing family or friends?
JUDITH: I retired last year… and, I don’t (pauses)… I don’t have any immediate family. I had a lot of friends at work, but… I haven’t really seen them since I retired. It’s just really hard with my pain.
JUDITH THOUGHT: It’s just me now… me and Rosie.
DR. RODGERS: So the pain and headaches are keeping you a bit isolated.
JUDITH: Yeah, I have a cat to keep me company, but besides her I never see anybody anymore. My friends from work, they still invite me places… they don’t understand how hard it is.
COACH FEEDBACK: Good job summarizing how you think Judith is feeling. It’s okay if you don’t get the summary perfectly right; just try to imagine how her situation might make her feel. She’ll correct you if you’re wrong. And, either way, it encourages her to open up.
DR. RODGERS: Judith, would it be alright to talk about the forms you filled out in the waiting room?
JUDITH: Sure.
DR. RODGERS: You indicated that you’ve been feeling kind of down lately and that you’ve been having trouble sleeping, feeling tired, and there are some changes in your appetite. What’s your mood been like?
JUDITH: Not great, I guess. I just wake up, feed my cat, Rosie, watch a little TV, take a nap... Just kind of go through the motions… I really don’t feel good. And my arthritis and headaches just make me feel even worse.
COACH FEEDBACK: Great approach. By asking Judith’s permission to discuss the forms, you made her more of an equal in this conversation, which encouraged her to open up.
DR. RODGERS: What have you been doing to make yourself feel better?
JUDITH: Well…nothing, really…Sometimes I think about calling one of my friends, but…I don’t want to bother them. DR. RODGERS: How long have you felt this way?
JUDITH: (thinking) On and off. Worse since I retired.
DR. RODGERS: So it sounds like it’s been going on for a while now.
JUDITH: Well, since I retired and- and not working, not having something to occupy my mind, it’s easier for me to think about things I- I don’t want to think about.
DR. RODGERS: Do you mind if I ask… what kind of things do you think about?
JUDITH: I just miss my family, I guess.
DR. RODGERS: You lost them.
JUDITH: (sigh) Lost my husband to cancer a while back. Then my daughter… she died too.
DR. RODGERS: Oh. I didn’t know. I’m so sorry to hear that.
JUDITH: Thank you.
COACH FEEDBACK: Death or illness of a loved one is a significant risk factor for developing a mental health disorder. Even if Judith had not already screened positive for depression, hearing this would clue you in that she may be suffering from emotional distress.
DR. RODGERS: You know, I’d… I’d hate for anything bad to happen to you, Judith.
JUDITH: (looks confused; nods)
DR. RODGERS: I mean, I hope you’re… doing alright.
JUDITH: (remains confused) Uh, thank you.
DR. RODGERS: You wouldn’t do anything drastic, I’m sure.
JUDITH: Drastic? I’m sorry; I don’t really follow…
COACH FEEDBACK: By phrasing the question about suicide in this way, you’re presenting a very clear “right” and “wrong” answer to the patient, which might prompt her to conceal her thinking. Instead, when asking about suicide, it’s best to be direct, which shows the patient that you’re nonjudgmental and comfortable having this type of conversation.
DR. RODGERS: Sometimes when people are in a lot of pain and coping with the loss of loved ones, they may think about hurting themselves or that they’d rather not still be here. I noticed on your form you said you’ve had thoughts like this from time to time—can you tell me a little about that?
JUDITH: Oh, Well, I’ve thought about it here or there. I’m not working . I don’t have a family to take care of.… I’m not much use to anybody anymore… And I’d get to be with my daughter and my husband again. But, honestly, I’d never actually do anything…
COACH FEEDBACK: Good job asking Judith about suicide. She seems to be low-risk for suicide, but we need to ask a few more questions to better assess her risk level.
DR. RODGERS: It sounds like you’ve had thoughts of hurting yourself in the past. At the same time, you don’t think you’d actually do anything like that.
JUDITH: Right. It’s more like a… a fantasy maybe.
DR. RODGERS: What are some things that keep you from ending your life?
JUDITH: Well, you know, there’s Rosie. If I were gone, there’d be nobody to take care of her. She’d probably die, too, and she doesn’t deserve that.
DR. RODGERS: Sounds like Rosie’s really important to you.
JUDITH: I adopted her from a shelter and… She was all alone… We’re the only family we have.
DR. RODGERS: What else keeps you from acting on those thoughts when they pop into your head?
JUDITH: I guess I think about my daughter and how disappointed she’d be in me. If she were here… she’d say, “Come on, Mom. Snap out of it.” And I couldn’t do that to her. She didn’t want to die; she didn’t have a choice… And here I’d be, choosing to die? That’s not right.
JUDITH THOUGHT: She’d never forgive me if I killed myself.