What to Expect When You Visit the Psychiatrist: Part One

The initial psychiatric interview is the beginning of an important relationship. Many things will be determined in the first encounter by both the patient and the psychiatrist. At times this can feel overwhelming. A large amount of information must be gathered, processed, and incorporated into a cohesive treatment plan. This series of posts is designed to shed some light on the process, and reduce the anxiety associated with undergoing a psychiatric evaluation. 

The interview consists of five key parts: (1) introduction, (2) opening, (3) the body, (4) closing, and (5) termination. A good psychiatrist will blend these sections into each other, so it feels more like a conversation than a formally structured interview. 

Part 1: The Introduction

This is an important phase and begins as soon as the psychiatrist and patient see each other. The primary goal is to engage the patient and get them comfortable before asking sensitive questions. Like other first encounters the patient will form an impression of the psychiatrist which will shape the rest of the interview and treatment process. 

One way to ensure patient comfort is to address anything in the office setting that can be altered prior to starting the evaluation. For example, closing a shade due to light from the window shining directly on the patient’s seat. Another example would be offering a drink of water or tea before starting. A simple gesture of kindness goes a long way in helping the patient feel comfortable in the setting. 

The psychiatrist should then proceed with a formal introduction and offer a few details about himself or herself. One fear many patients have is a friend or family member finding out that they are under the care of a psychiatrist. It’s always a good idea to clarify and ensure confidentiality. Confidentiality is strictly maintained with the exception two primary scenarios (may vary by state). If a patient informs the psychiatrist of a plan to kill themselves or someone else, there is a duty to warn and protect the patient. 

Once these parts are complete a brief description of how the interview process works is in order. 

An example of this interaction may occur as follows:

The purpose of today’s interview is to learn about your concerns and the types of stressors you are dealing with. As the interview progresses, I will get a better idea of the primary concerns. We will then transition to some background questions about your family, medical health, schooling, and any previous psychiatric care you received. At the end of the discussion we can work together on a treatment plan. This process will take approximately one hour. Do you have any questions before we get started?

We want to convey two things to the patient, (1) a sense of understanding about the interview process to reduce fear, and (2) altering the patient to the fact that many questions will be asked, and it will take a fair amount of time. 

The structure of the introduction is not set in stone and may be modified. It should take around five to seven minutes to complete. 

In the next post we will tackle the opening of the interview process. 

 

Diagnosis Depression: Sleep Dysregulation

One of the most common symptoms found in multiple psychiatric disorders is sleep disturbance. In fact, sleep disturbance is one of the criteria for the diagnosis of major depression. This post will offer an explanation of some of the changes observed in the sleep patterns of depressed patients.

Much of this information comes from sleep studies in patients who have a diagnosis of major depressive disorder. Without getting too technical there are two primary types of sleep, non-rapid eye movement sleep (NREM) and rapid eye movement sleep (REM). The NREM sleep can be broken down further but for the sake of simplicity we will consider these two categories. 

What we notice in sleep studies of patients who suffer from major depression is a much faster onset of REM sleep. The body usually cycles through these stages 4-6 times throughout the night, averaging 90 minutes in each stage. As the night progress NREM sleep decreases and REM sleep increases. A person with normal sleep architecture will enter REM after 90 minutes, in patients with depression this time period is shorter and can be observed on the sleep study results.

Other changes include decrease NREM sleep which can be thought of as restorative sleep. Increased REM density reduced total sleep time, and decreased sleep continuity are also present. 

Any single change in sleep architecture is not diagnostic of major depression. However, taken together decreased onset to REM, increased REM density, and decrease sleep efficiency can separate patients with major depression from a control group. 

Given all of this information, routine sleep studies are not diagnostic for major depression and are not routinely ordered unless you suspect another sleep disorder. 

Hopefully this provides a basis for why questions about sleep in depressed patients are important. The sleep changes also provide some objective evidence of altered sleeping patterns in patients with depression. 

The Biochemical Theory of Depression

Introduction

How many times in a casual conversation about depression have you heard someone use the term chemical imbalance? Have you ever asked yourself where that idea comes from?  

This is the way many people think about depression, as a “chemical imbalance.” It all seems so intuitive. If there is a chemical missing from the body, you should theoretically be able to replace that chemical and solve the problem. However, the question remains, how did we come up with this idea in first place? This post will attempt to explain how the biological basis of depression was formed. If you can understand these concepts, it lays the groundwork for understanding how many medications for depression work.

Biogenic Amine Hypothesis

The current prevailing biochemical theory of depression is called the biogenic amine hypothesis. The name is a little complex so we can use serotonin as our example. It’s the neurotransmitter most commonly associated with depression and it happens to be a biogenic amine. This was the first attempt to explain the biological basis for depression and evolved from observations that certain medication had either a positive or negative effect on mood. 

Mood & Neurotransmitters 

One early observation of medication effecting mood was with the drug iproniazid which was designed to treat tuberculosis. The researchers observed that it wasn’t very effective for tuberculosis, but it did enhance the mood of some patients. The researchers hypothesized that it was the medications ability to inhibit metabolism of norepinephrine, serotonin and dopamine thus increasing these levels in the brain that provided the antidepressant effect. Iproniazid is what you would call a monoamine oxidase inhibitor (MAOI) which is an older class of medication for depression. It’s rarely used today due to the side effect profile, but hopeful this illustrates the concept. 

Further support for the theory comes from animal studies with the antidepressant medications in the tricyclic antidepressant (TCA) family. These medications block the reuptake of serotonin and norepinephrine thus increasing the levels in the brain. This illustrates the same concept as the (MAOI) discussed above, increase serotonin and norepinephrine in the brain and mood improves. 

Problems with the Theory

One issue with the theory was these medications begin blocking reuptake within minutes, but the antidepressant effects take several weeks to occur. More recent research has shown that these medications down regulate certain receptors, but even with this it’s unlikely to fully explain the antidepressant effects of the medication. While this remains the prevailing theory, it’s clear that there is more to learn about the way these neurotransmitters interact with receptors. Some of the newer medications for depression do not function in the manner as those listed above, but still provide antidepressant effects.

Final Points

  • The biogenic amine hypothesis, is just that it’s a hypothesis about how these medications work on depression 
  • Most of the early evidence was observational, and with medications initially designed to address other disorders. 
  • While the biogenic amine hypothesis is incomplete and does not fully explain depression, It provides a useful framework for future study and drug design 

Is Depression A Genetic Disorder?

Introduction:

This is a common and difficult question I get asked. Like everything in psychiatry, the answer is not clear.

When people think about genetic disorders, they tend to think about classic genetic diseases. Some examples would be sickle cell anemia or cystic fibrosis. There is a clear pattern of inheritance with a single gene involved in these diseases

The human genome project set out to sequence the entire human genome. While it accomplished the goal it did not offer the personalized medicine and targeted interventions initially promised. What it did reveal was a more complicated interplay of genetics and environmental factors. Depression is a multifactorial disease and does not have a single gene involved in the disorder. 

Let’s look at some the evidence supporting the genetic influence on the development of depression.

What Can Family studies tell us ?

The first place to look for a genetic link is family studies. This is one reason we obtain a family history in a psychiatric interview.

MDD is common in families. It’s found 2 to 3 times more often in first-degree biological relatives (e.g. mother or father) of individuals with the disorder than the general population. It’s important to note that the influence of genetics on the development of depression depends on the percent of the genome shared by the individuals. For example, first-degree relatives who share 50% of their genome will have a much greater influence than a second-degree relative who shares 25% of the genome.

What can twin studies tell us ?

The second area of evidence that supports the influence of genetics on depression comes from twin studies.

From the data we know for monozygotic twins (identical twins), there is a 50% chance that one twin will develop the trait (e.g. depression) if the other twin has depression. This number decreases to 20% for fraternal twins who only share 50% of their genome. One flaw in many of these studies is the twins were often raised together in the same environment. There is clearly something to be said for the influence of environment. Some researchers believe twins will influence each other’s behavior when raised together. Identical twins have been known to be treated more similar by their parents than fraternal twins. Taken at face value, when a twin with 100% of the same genetics (identical twins) develops depression the other twin is more likely to also develop depression. Keep in mind, they do not always develop depression even if they share 100% of the genome. 

What do adoption studies add?

Adoption studies make an attempt to differentiate the influence of genetics from environmental factors. These studies examine differences in rates of illness among biological relatives as opposed to adoptive relatives. The studies show higher rates of illness among biological parents rather than adoptive parents. This provides some additional evidence to support a genetic influence. 

Conclusion

There is clearly a genetic component to depression. However, it’s a complicated process that involves multiple genes interacting with the environment. This makes identifying a single causal gene difficult and likely impossible. There are people biologically predisposed to developing depression, but not everyone with biological predisposition will go on to develop depression. 

If you found this helpful please like, comment and share your thoughts for future posts on genetics.

Diagnosis Depression: Major Depressive Disorder (MDD) with Seasonal Pattern

With this specifier, the name provides most of the information. There has to be a clearly defined relationship between the onset and remission of depression with the changing of the seasons. For example, a patient becomes depressed in the late fall or winter and their depression remits once spring arrives. This is the most common pattern in clinical practice.

The relationship between the depressive episodes and season is present for at least the prior two years. Furthermore, the number of seasonal episodes is significantly more than nonseasonal episodes. Basically, what this means is there must be an established pattern related to the changing of the seasons for two years.

If the depressive episode is clearly related to another factor (e.g. start of school or change in work stats) the specifier does not apply. 

In the two-year period where the pattern is established there cannot be any nonseasonal episodes. 

For this specifier to apply, the person must clearly become depressed in the months where day light is reduced (possible mechanism for these episodes), and have remission of symptoms once the days become longer. (this is one example, there are others)

Like, Share, and leave a comment below if you ever felt depressed during the winter months

Diagnosis Depression: Major Depressive Disorder (MDD) with Melancholic Features

I wanted to finish the discussion on the various specifiers for major depressive disorder. In this post I will discuss melancholic features. 

The most distinct feature in MDD with melancholic features is profound loss of interest (anhedonia) in all or almost all activities. This is a common feature in MDD as well, but the loss of pleasure in activities is far more severe. There is also a complete lack of reactivity to anything that would usually be considered by the person as pleasurable. 

In addition, at least three of the following are required: 

  1. Depressed mood that is experienced as qualitatively different from the feeling experienced after a loss. 
  2. Depression that is worse in the morning. 
  3. Awakening at least two hours prior to the usual wake time 
  4. Marked psychomotor retardation (slow movement) or agitation 
  5. Significant anorexia or weight loss 
  6. Excessive or inappropriate guilt 

I think of this specifier as a more profound form of MDD. 

One thing we try to do with modern pharmacology is treat specific symptoms with classes of medication that match the neurotransmitter profile. The medication selection or augmentation strategy may change depending on the symptoms we want to target. For example, fatigue and concentration are largely regulated by norepinephrine and dopamine, so we may choose a medication that targets these neurotransmitters. In this example of melancholic depression sleep and appetite may be the primary issues, we may select a more sedating medication like mirtazapine. I will provide more details on the symptom-based selection of medication for depression in future posts. 

Diagnosis Depression: Major Depressive Disorder (MDD) With Atypical features

I like the DSM-5 and I think it provides us with a conceptual framework for evaluating patients. In clinical practice it’s rare to find patients that fit all diagnostic criteria perfectly. When that does occur it’s nice and makes life easy. 

Major depressive disorder with atypical features is one of those situations. Many patients have some of the symptoms but not enough to clearly make the distinction. Nonetheless, some of these symptoms are common and need to be discussed.

What makes this type of depression atypical?

I like to think of the symptoms as the opposite or reverse of major depression discussed in previous posts. 

A key distinction to look for is mood reactivity in response to positive events. In major depressive disorder nothing usually makes the patient feel happy. They may even present with a restricted, constricted or blunted affect. In the atypical case, these patients can react and show emotion when positive events occur. 

Along with mood reactivity, they must have two of the following features

  • Increased appetite or significant weight gain 
  • Hypersomnia (excessive sleep) 
  • Leaden paralysis often described as a heaviness of the arms and legs 
  • A longstanding pattern of sensitivity to interpersonal rejection 
  • It must be impairing social and occupational function 

When you look at the list above you see why we can think of these symptoms as the opposite of typical major depression.

Hope this post helps to clear up some question about atypical depression. Please like, share and comment. 

Diagnosis Depression: Major Depressive Disorder (MDD) With Psychotic features

In the last post we covered MDD and we introduced the specifiers. In this post I will talk about MDD with psychotic features. 

You may have guessed already, but what separates this disorder from MDD is the presence of delusions, and hallucinations along with symptoms of major depression. Fairly simple, right?

First, we need to define psychotic symptoms. 

In general, we can think about the following symptoms: 

  1. Delusions: which can be defined as fixed false beliefs. Something that the person believes despite evidence to the contrary. 
  2. Hallucinations: A hallucination is a sensory perception in the absence of external stimuli. There are several types including auditory (most common, consists of hearing a voice or several voices), visual, olfactory (smell), tactile (touch), and gustatory (taste). 
  3. Disorganized speech or behavior: This is an indication of the persons thought process. If the person is not thinking in a clear logical manner their though process may be difficult or impossible to follow for an outside observer.  

These psychotic symptoms can be congruent with the depressed mood (content is consistent with depressive thoughts) or mood incongruent (content is not consistent with typical depressive thoughts). Mood congruent psychotic symptoms will consist of depressive themes such as guilt, death, poor self-worth, and punishment. Mood incongruent symptoms include things such as delusions of control, thought broadcasting, or thought insertion. Both mood congruent and incongruent themes can occur in the same episode.  

Another key point is the psychotic symptoms only occur during a depressive episode. They are not present when the patient is not depressed. Once psychotic symptoms appear with an episode of depression, they tend to be present on subsequent episodes. 

In the next post we will cover atypical features of depression. Please like, comment, and share the content. Feel free to offer suggestions for future posts. 

Do You Love Your Shampoo?

Good morning! Happy Monday. Generating content the way I’ve wanted to has been difficult being home with a little one, working, or working while being home with a little one. I have chosen to take my own advice and be kind to myself, realizing these are unique times and congratulating myself for small victories.

So why am I asking you about shampoo?

There are four shampoos in my shower.

This morning was a tough Monday after a tough weekend. Feels a little bit groundhog day and the gray weather is definitely affecting my mood. But as I engaged my glutes in some old-school leg lifts while jazzercising on Facebook, I had a moment of clarity. It’s wild how the mind clears with increased blood flow from exercise. I promise I’m getting to the shampoo.

In other areas on the site, you may have read about depression. We work with people with depressive disorders every day and there are some common themes. One of the questions I frequently ask my patients is, “What brings you joy?” Why do I ask this? It can answer many questions. Not least of all, assessing for anhedonia. If nothing brings you joy, you may be experiencing anhedonia and should check out Dr. G’s series on depression.

I’ve been thinking about the things that bring me joy and have come to the conclusion that I am unable to do many of them right now. Among those include spending time with friends and family, enjoying new restaurants, taking live workout classes, and perhaps the most missed activity, traveling. What that means is that I need to fill the joy bank with other things in order to prevent anxiety and depression. Preventive medicine is the best medicine after all.

Finally, the shampoo.

I shampoo my hair probably every other day. That means I’m spending a decent amount of time engaging with my shampoo. Recently, I determined that I don’t really like my shampoo. It was simply shampoo, got the job done, nothing special. Then, one evening at approximately 1AM, I made the bold decision to try to love my shampoo. (Side bar: the mind readers on Facebook advertising may have nudged this decision ever-so-slightly. Thanks omniscient overlords of Facebook.) While it took three tries, and a few dollars from my pocket, I now love my shampoo. I like the smell, how it feels in my hair, and the overall results. Best part? Creating a little bit of joy. A little bit of joy every day as a result of a small change adds up to serious improvements in mood.

Below I will make some suggestions for ways to increase joy in your daily life. Who knows when I will take my next trip to Key West or participate in my next 10k? It is time to create some joy and prevent dips in my mood that might contribute to the development of depression or anxiety.

  1. Food

If you are like me, social distancing might have you realizing how frequently you were eating out. Cooking and eating-in are definitely increased in my household. When we do order out, it requires more thought and intention about how to acquire the food and if it will be worth the effort involved.

Honest moment: I’m still not that into cooking. If you love to cook, yay you! Keep cooking and generate some joy. Just learning? Even better! America’s Test Kitchen is a tried and true resource and they are having some excellent promotions right now.

As for me, the answer is avocados. Prior to life in social distancing, I never purchased avocados. They either taunt me while being completely unripe at the exact moment I crave guacamole or slowly disintegrate into a pile of mush in the corner of my counter. Now, I have the time to commit to avocados. Each week, I splurge on delicious avocados and excitedly anticipate the moment my thumb gently indents the skin of the avocado easily, indicating nature’s mayonnaise is ready for consumption. I’m currently at a pace of half of an avocado per day. Sliced up with salt, pepper, and parsley on top of toast – maybe with some tomatoes? Go wild. Breakfast is elevated and I am happy. Every time I have this breakfast (which is quite frequently now) I am tempted to document my elegant meal.

Are there any foods that bring you joy? (I’m not referring to in-the-moment joy that leaves you feeling tired and unmotivated afterwards – although of course there is a time and place for that.) Just think, if you could be excited by your breakfast, that would add some serious coin to your joy bank.

2. Bathing

Most people I know bathe every day. (This is a judgment free zone, and you may not have left the house in several days, so please continue to do you. Unless the people around you complain. In that case, please take a shower.) For this article, let’s assume you bathe every day for about ten minutes. Why not make those 70 minutes per week joyful? What type of soap do you use? Do you love it? (I love my soap, check out Little Egg Harbor soaps online, loving Citrus Twist right now.) I already addressed the shampoo situation. What about a loofah or new set of plush washcloths? Doesn’t have to be expensive, I am very happy with my set of purple Amazon Basics washcloths. Take the time to assess your shower routine. Are there any ways you can make it better, specifically in a way that increases your happiness?

3. Clothes

This category will be different for everyone depending on how you are most comfortable. Are you someone who loves getting dressed up for work every day and now you never change out of sweatpants? That probably isn’t going to add any joy to your life. I’ve spoken to some friends who feel much happier putting on jeans and a cute top, and this simple action of putting on clothes that make you feel good can improve your self esteem and help prevent problems with your mental health.

As for me… if one more person on social media suggests putting on pants with buttons to keep myself in check, I might yell at the computer. Why on earth would I put on pants with a button if that is unnecessary at this time? What an absurd notion. So how has clothing brought me joy? Glorious sweatpants and leggings. Soft flowy tops. Buttery wire-free sports bras.

I have two pairs of sweatpants that I love. One pair has dinosaurs on them and the other I purchased at a brewery a few months back. I also treated myself to a pair of overpriced camo print leggings. Every time I slide them on, I take a moment to deep squat and stretch it all out and bask in the sensation of unrestricted leg movement.

4. Sleep

Good sleep is integral to your mental health and I would like to devote a post in the future exclusively to sleep. For the purpose of this post, I’m suggesting improvements to your sleep routine that might make you smile. Do you sleep with an eye mask? These can be wonderful, especially for city living. What about aromatherapy? A touch of lavender on your pillow prior to bed time might trick your senses into thinking you are at an upscale spa hotel. Some other suggestions: update your pajamas, sheets, or pillows.

5. Self Care

Self care means different things to different people. For me, one of the things I think of is makeup. I love makeup, but my relationship with makeup has evolved over the years. In the past, I loved a full face. Bring on the bronzer! When I started my residency training, I wore full makeup (and heels… what was I thinking?) every day. I think it was almost like wearing armor. As I’ve grown more comfortable over the past few years in my role as a resident physician, I feel perfectly comfortable going to work with no makeup.

For me, playing with a new eye palette in preparation for an upcoming wedding or watching a YouTube tutorial on liquid eyeliner or DIY lashes is fun and makes me happy while applying makeup daily does not. I treasure the extra fifteen minutes in the morning to eat my fancy avocado toast with my family (see above.)

I also no longer feel like I need makeup to be attractive. I have my daughter to thank for that… I see her tiny face sprinkled with my features and I never want her to feel anything less than beautiful. If I think I need makeup and her face looks like mine, that would suggest her perfect face needs makeup too – which it most certainly does not.

I’ve also become comfortable with the mascara and lip only makeup which takes exactly one minute. You’ll find me wearing that makeup look in the photo above posing with shampoo. This applies to hair, waxing, nails, and skin care. As much or as little as makes you happy. Does being home and not needing to do your hair feel amazing? Time to harness that and include it as added happiness to your day. Have you perfected the at-home gel manicure? Color me impressed by both your artistic ability and commitment to nail care. It might even save you money in the future.

6. Sexual health

Sexual health is part of your health. This might mean a celibate hiatus due to a lack of interest at this time. Prefer the Netflix portion of Netflix and chill? That’s just fine. Despite what the internet might have you believe, global pandemics and social distancing aren’t an absolute aphrodisiac for most people.

If the mood does strike you, this might present an opportunity to get to know your needs more, with or without assistance from a device or adult entertainment. Or maybe now is the time to revisit your sexual health needs with your partner.

Pro-tip: Continue to use contraception while engaging in partnered sexual activity if you do not wish to grow your family.

I’m sure there are other ways to add joy into your day. We would love to hear suggestions in the comments! Whatever you choose, take time to assess your piggy bank of joy. Don’t let the balance get too low or you may risk experiencing depressed moods or feelings of anxiety.

One further comment on this subject, and I alluded to it above: you don’t actually NEED to do anything. We are in an uncharted time of global pandemic. If you are alive and keeping any persons that depend on you alive, you are doing a fabulous job! This post seeks to protect the integrity of your mental health by way of experiencing happiness in your daily life.

Sincerely,

Kris @shrinksinsneakers

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