Doctor Patient Relations

Guide Patients With Depression: Get Them the Help They Need

By Pamela Miller, OD, FAAO, JD, DPNAP

SYNOPSIS

Identify the signs of depression, and educate patients that they may need specialized mental health care. Guide them to the care they need.

ACTION POINTS

OPEN the conversation to how patients are doing in their lives

RECOGNIZE depression symptoms

BE AWARE of threat of depression in those losing sight

Clinical depression, which often impairs a person’s functioning in daily life, is a common mental health condition. According to the National Institute of Mental Health, major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the US population age 18 and older in a given year. Many of your patients suffer from such a depressive disorder and have no idea what ails them. As a healthcare provider, it is important for you to know the signs of depression and how to have a conversation about it with patients. You then can educate patients to let them know where they can find the help they need. Here are my key tips for interacting and speaking with patients who may have a case of clinical depression. As with all matters, it is best to consult with your attorney and local optometric board before taking any action.

Treating Depression Not Within Scope of Optometric Licensure, But Guide Patients to Treatment

It is important to remember that patients who are in need of treatment for depression, or who are currently in treatment for this condition, have a disease that is not within the scope of optometric licensure, but can certainly affect the patient’s overall health, well being and medication levels. A diagnosis of depression falls within the medical arena including treatment by psychologists and psychiatrists, but you can and should know the signs of depression and refer a patient to the appropriate healthcare practitioner, who can provide treatment.

OPEN
The Doctor Needs a Doctor:
Know the Signs that You Are Suffering from Depression

Like any person with a challenging work schedule and personal life, optometrists can struggle with depression. It’s important to know some of the signs of depression for your patients’ sake, but also for your own:

Recent traumatic life event. This could range from the loss of a close loved one or divorce to financial stress such as finding that your practice is deeply in debt or that you will have to close the second office you only recently opened due to financial need or insolvency.

Loss of interest in things that used to interest you. If you used to look forward to leaving early on Fridays in the summer to go fishing or do some other activity, and this past summer you had no interest in this pastime that usually gave you pleasure, you may be experiencing an early sign of depression.

Lack of energy. If you now struggle to see the same number of patients per day and find that you’re dragging through much of the day (and physical illness has been ruled out), depression may be to blame.

Change in appetite and weight. If you used to have little trouble maintaining a disciplined diet with healthy lunches, and now you find yourself compelled to have a double bacon cheese burger and large fries or some other fattening fare instead, or just the opposite, you can barely eat at all, a case of depression is a possibility.

Self-destructive thoughts. This includes feelings of guilt and negativity toward yourself, as well as thoughts about committing suicide or harming yourself or others. Self-destructive thoughts require immediate attention, and thoughts of harming others requires that as a doctor you remove yourself from contact with patients. The safety and care of our patients is our first responsibility.

An Open Conversation with Patients Can Point to Signs of Depression

I like to ask patients an open-ended question about their lives when they are in the exam room. Doing so often prompts a discussion of life circumstances and resulting health concerns. For example, I might simply ask: “How are you doing? Anything new this year?” Most patients, given an open door, will step through that door and will respond, on a positive note, that they recently got a new job or got married, etc., or on a negative note, that they just lost their job or recently went through a divorce, etc. If a serious negative situation like a job loss, divorce, diagnosis of a major illness or loss of a close loved one is mentioned, you can follow-up by asking the patient about the help they have gotten: “I’m so sorry to hear that! I can’t imagine how hard that must be. Are you taking any additional medications to help you through this time, or are you working with anyone like a psychologist or leader of your church?”

I would ask the question of possible need for extra help from a professional of any patient who recently experienced a known trigger of depression. Known triggers often involve major life changes like changes in health status (diagnosis of a major illness), wealth status (recent job loss or other financial misfortune), or change in family status (recent divorce or loss of a loved one, especially a spouse). A red flag might also go up for me if the patient casually mentions that his or her mother or father recently moved in them, or if a parent is experiencing a health crisis in their old age. The Baby Boomer generation, especially, is often dealing with an ailing parent while at the same time still caring for their own children. This creates multiple financial and emotional responsibilities many are not equipped to handle.

If you live in a northern part of the country, Seasonal Affective Disorder in which a patient becomes depressed during the winter months due to a lack of sunlight may also contribute to depression.

RECOGNIZE

Ask About Symptoms of Depression

Once a patient has opened up about a traumatic recent life event, see if they are experiencing any of the typical signs of clinical depression: “Are you having any trouble sleeping, have you experienced any major changes in weight (gain or loss), has your appetite changed, have you had any thoughts about harming yourself or others?” If a patient responds affirmatively to any of those questions, make sure they see their family doctor or appropriate specialist right away. If their insurance requires referral from their primary care practitioner, you may even want to have someone in your office call their family doctor’s office while the patient is still there to help the patient schedule an appointment as soon as possible. You might say: “I want you to go back to your primary doctor as soon as possible. I’m noticing some signs of what could be depression. This may be a short-term thing, but you may need some treatment from a specialist to get you over this hump.”

If a patient says they are seriously thinking about suicide or harming another person, call the police. The police have the authority to commit a person to a mental health facility for 48 hours so they can get immediately evaluated and treated by mental health specialists. The last thing you want to hear is that a patient who talked to you about committing suicide or harming others carried out his or her plans shortly after leaving your office.

BE AWARE

Be Aware of Threat of Depression in Patients Going Blind

It should be obvious, but you may not realize that a patient with significantly deteriorating vision may be highly susceptible to depression. Loss of vision represents a huge change in lifestyle and the loss of independence as they currently know it. Even if a patient in this situation appears to be doing fine, it’s a good idea to acknowledge the change in lifestyle the loss of their vision will result in, and discuss with them some ways of dealing with it, including, if necessary, working with a mental health therapist. Don’t dismiss a patient who uses humor to deflect concern about their loss of vision. Sometimes a patient will joke: “Ha-ha, well, I guess I better get a seeing eye dog and learn Braille.” Instead of laughing in return, you might say: “Yes, you might want to think about that, actually. It’s OK to feel anxiety about the loss of vision–it’s a huge deal. I’m here to help you any way I can, and I also can refer you to other specialists who can help you.”

Depressed Patients May Not Be Able to Follow Eye Treatment Regimens

In addition to getting patients the help they need, you should be aware that a clinically depressed patient will often have trouble following the treatment regimens you prescribe. It is hard for these patients to follow treatment routines because those with clinical depression tend to give up easily or forget. One of the signs of this condition is not only ongoing sadness, anxiety and feelings of helplessness, but lowered energy and difficulty concentrating. For that reason, try to streamline or make easy the treatment regimen, whenever possible.

For example, to avoid making a three-times-a-day eye drop regimen sound too overwhelming, you can just instruct them to administer the eye drops directly before breakfast, lunch and dinner. If your conversation with the patient reveals such lowered energy that you doubt they can even do that much, you might suggest to the patient that you speak with their family doctor so their PCP is alerted to the seriousness of the depression, and so specialized care can be given right away. In addition, you also could follow-up with the patient in the coming weeks by giving them a call to see if they are really following through on the treatment regimen. Let your patient know that you want to do everything you can to help them, including ensuring they receive the proper care for their eyes, as well as their other health needs.

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Pamela Miller, OD, FAAO, JD, DPNAP, has a solo optometric practice in Highland, Calif. She is an attorney at law, holds a therapeutic license, is California State Board-certified and glaucoma-certified to prescribe eye medications, and offers comprehensive vision care, contact lenses, visual therapy and low vision services. To contact her: drpam@omnivision.com.

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