A Guide to Treating Depression

Introduction

When a patient is referred to a psychiatrist's office for the first time, they often do not know what to expect. Am I going to ask them to lie down on my couch? Are we going to talk about their childhood, their parents, or their nightly dreams? This unknown can keep patients suffering from depression from seeking help.

In this article, I will lay out how I evaluate and develop a treatment plan for a patient with depression who presents to my outpatient psychiatry clinic. I hope this article can lift the veil on what an initial evaluation with a psychiatrist entails. As a primary care physician, what follows can help you to better assist patients with depression in your office and also to help you understand the important role a psychiatrist can play in evaluating and treating a patient suffering from depression.

The Initial Psychiatric Evaluation

If your patient has never been to a psychiatrist, it may surprise them to find that the first visit in my office is very similar to what they experience in yours. One difference is that I always start off by reminding my patients that everything we discuss is confidential, unless what they discuss is dangerous to themselves or someone else.

I then explain that we will use the first visit as a consultation. During this hour, we both will get to know each other. I prompt the patient to discuss what brought them to my office and what they would like to work on together.

Next, I ask the patient a series of questions that help me get up to speed regarding their mental health, general health, and family history. This evaluation interview follows the standard history and physical exam format that most specialties use in their initial appointment. It may comfort your patients to be reminded that psychiatrists are medical doctors who specialize in diseases of the mind and spirit.

During the initial evaluation of a patient with depression, I always seek to rule out medical causes. Depression (and also mania, anxiety, and thought disorders) can be caused by medical problems, such as thyroid disease, infections, medication side effects, hormonal abnormalities, and many other treatable medical conditions.

One tool that I use to rule out medical causes of depression is laboratory testing. Some patients will present to my office with lab results. However, I usually order them during the initial visit.

The most common tests that I order to rule out medical causes of depression include a complete blood count, a comprehensive metabolic panel, thyroid-stimulating hormone, thyroxine, vitamin D, and urinalysis. Other lab tests I may consider include vitamin B₁₂, folate, testosterone (free and total), a pregnancy test, rapid plasma reagin, a urine drug screen, and fasting lipids. This is by no means an exhaustive list, but it should give you a place to start if you have a patient in your office who presents with depression.

If a medical explanation exists for their symptoms, I always enlist the patient's primary care doctor or a specialist. However, if medical causes are ruled out, then I focus on the psychiatric causes and treatment of their symptoms.

Formulation of the Treatment Plan

When a patient presents with depression, there are several treatment options. As such, a thorough history needs to be collected during this initial evaluation to guide your decision-making. Every patient is unique, and it is important to discuss their history of treatment failures, treatment successes, and treatment options that have not been tried in the past. Obtaining that history, to inform your future prescribing, can help to improve outcomes.

In addition, it is important to rule out such conditions as bipolar disorder, attention-deficit/hyperactivity disorder, anxiety, psychosis, and addiction. The presence of these conditions influences which medications are suitable for use in a patient who presents with depression. A proper diagnosis is imperative in order to develop an effective treatment plan.

Once I collect the patient's history, I formulate a treatment plan based on the severity of the patient's symptoms, how much the depression is affecting their ability to function at work or home, and their history of response to previous treatments. If a patient has minimal symptoms and the depression is having a minimal impact on their ability to function, accordingly I take a more conservative treatment approach. However, if the patient presents with a history of several treatment failures, severe depression, and an inability to work or function at home, then it is prudent to be more aggressive and use several treatment modalities from the onset.

Regardless of the severity of the patient's depression, treatment history, or current ability to function, I always support their decision to come for a consultation. Whether to seek assistance can be a very difficult decision, and one that your patient may have put off for a long time. I strongly believe that a referral to a psychiatrist can be the most important step to help for depression. Even a single consultation can help to clarify the diagnosis, rule out medical or psychiatric comorbidities, define treatment options, and begin the healing process.

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