speaking the language of depression how to better communicate with patients with depression and...

Speaking The Language of Depression

How to better communicate with patients with depression and other mental health issues

At the conclusion of this session, participants will be able to:

1. Expand their understanding of clients’ mental health issues-as viewed from the perspective of the psychologist.

2. Develop techniques to work more effectively with your clients.

3. Implement a variety of communication strategies to work within the pharmacy environment and mental health community.

Speaking the Language of Depression

Welcome to a typical day in my office Today we are going to meet four “typical”

patients who have depression Newbie Just started On meds not working On meds working


Newbie-not diagnosed or recently diagnosed with depression and not on medication

Common themes: Am I really depressed? Maybe there is just something

wrong with me; Maybe there is nothing wrong with me and I am just complaining; Maybe I should just suck it up; why do I have to take meds? Why I can’t I fix it? Meds are addictive? When can I stop taking them? What are they going to do with me? See I am crazy, I should just stop asking all these questions? My doctor never explained how it works? Around and around we go, sometimes 2-3 sessions or months to get them convinced.


Just started- been diagnosed and have just started taking medication

Usually limited or no change Expect medical model: i.e. have an

infection , take meds, get better Now still feel awful-sometimes due to side

effects; and I am suppose to keep taking this because??


-getting them to track, over time, how their symptoms change- as they do not remember how they have felt; when feel awful, feel awful

Remind them takes time for the medication to “load” into their systems- takes 6-8 weeks and sometimes longer- that is a lot of patience – “waiting for something to work, when unsure if it will” ; people want to see for themselves – trust – how do others know it will work for me??? Maybe I am one of the ones; or alternatively may have to try another medication


Going to add our next “typical” client On meds not working These are difficult to keep on with

compliance As seeing or noticing no change and /or the

change is in small increments so very difficult to “notice”

Side-effects may be making it difficult to notice any changes


This is the time that suicide risk may present – for both “just on” and “on not working”

Another time of risk is when the Antidepressant medication ( ADM) starts working, especially for vegetative clients, as they often don’t have the energy to commit suicide and when they start feeling better they can then act on their suicidal thoughts


80% suicides carried out by people who are depressed (CANMAT, 2015)

15% people who are hospitalized for major depression eventually commit suicide (CANMAT, 2015)

4 times as many men than women die by suicide (more lethal methods); women attempt suicide twice as often as men ( all about Depression.com, 2015)


Depression is very treatable Up to 80% of people with depression do get

better with the right medication (CANMAT, 2015) However efficacy studies indicate that over 60%

of depressed clients improve with ADM, which means 40% do not (Academic Review, 2014)

Risk depression will return is high: 50% after one depressive episode, 70% after two, and 90% after 3- therefore compliance and treatment is important


ADMs- symptom suppressive vs curative (DeRubeis, Siegle, Hollon; 2008)

This when patients to point of remission should continue to be treated for at least 6 mos (DeRubeis, Siegle, Hollon; 2008)

Reminder 6-9 months for one occurrence; over 12 months for 2 occurrences


Depressionmov.com – YouTube I explain at the start of therapy and

throughout therapy how ADMs work with the brain

I often use this short video to demo to a client how the neurology of their brain and pharmacology interact


In conjunction with medication some type of therapy should be undertaken to assist in reducing depressive symptoms

Cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) have been found to be effective in reducing depressive symptoms (Academic Review, 2014)


Often others notice difference in them before they do-ask others “ what changes do you notice in me?”

Support them by reminded them of risk to reoccur – therefore most treatment should be for 6-9 months to prevent relapse and for greater than 12 months if someone being treated for recurrent episode

Optimal dosage of medication – gives desired effect with minimum side effect – note see a fair amount of clients that are not at optimal dosage – if notice this perhaps flag physician and/or psychologist/ and/or client


On meds – working These are the “poster clients” for ADMs They really notice a difference and find it

very easy to see how they were compared to how they are

It is a joy to see them improve and they also need encouragement to keep taking their meds


Let’s add one more piece of joy/joy into the mix

People who suffer with depression do not sleep as well

For the past half-century, Rosalind D. Cartwright, has been researching sleep

one aspect of her research examines dreaming as a mechanism for regulating negative emotion and the relationship between REM sleep and depression


More severe depression-earlier first REM begins

Starts about 45 min into sleep cycle Equates to these sleeper’s 1st cycle of NREM

sleep amounts to about ½ usual length of time

Early REM replaces initial deep sleep-not fully recovered later in the night

This displacement accompanied by absence of human growth hormone (HGH)


Timing of greatest release of HGH is in the 1st deep sleep cycle

Depressed have very little SWS (slow-wave sleep), no big pulse of HGH-related to growth and physical repair

If do not get enough deep sleep our bodies take longer to grow and heal

Absence of HGH during 1st deep sleep continues in many depressed patients even when in remission


Not only does the first REM period begin too early in the night in people who are clinically depressed, it also is often abnormally long

Rather than usual 10 minutes, often twice as long and eye movements are abnormal-too sparse or too dense-sometimes so frequent called eye movement storms


Neuro imaging technology has found that people who have depression have a higher activity in the limbic and paralimbic systems which translates into higher activity in the executive cortex areas (rational thought/decision making) than healthy individuals

This finding has been tentatively interpreted as a response to the excessive activity in the areas responsible for emotion


What was further connected was the ADMs suppress REM sleep and it is suggested that this very suppression of REM might be responsible for reinvigorating people who have depression (Cartwright, 2010)

SSRIs –often decrease REM sleep, however can have the opposite effect on others (Hobson, 2002)

So explaining this to clients helps them to understand one more reason why and how ADMs help


Giving clients different models of “what” causes depression and how it is “helped” assist the client in accepting and understanding – they are looking for a “why” the above information helps to fill that “why”

Psychological explanations also help to fill that “why”


Beck’s cognitive model: negative view of the future, world, and self

Cognitive distortions –faulty information processing

Core irrational beliefs –create psychological vulnerability to depression


Seligman’s Attribution Model Meaning giving to negative events will

determine risk of depression 3 attributional dimensions: Internal vs external, global vs specific, stable

vs unstable


If negative events interpreted as internal, global, and stable then clinical depression becomes significant probability vs.

View events due to circumstances beyond their control (external), event unique to situation (specific), does not represent future pattern (unstable) client handle this more healthy emotionally

Therefore assisting clients to monitor and develop more healthy cognitive patterns are important part of recovery


Selge – Learned helplessness Wolpe – believed cause of maladaptive anxiety was

social anxiety; depression secondary to maladaptive anxiety due to: severe and prolonged conditioned anxiety, consequence of cognitively based anxiety, secondary to social anxiety or feeling of interpersonal intimidation, result of unresolved bereavement and once focus of maladaptive anxiety identified – should be treated as anxiety problem which should also resolve depression


What to take from here: Clients are at different stages with their

disorders want to know they are not broken and there

is hope Want to understand how ADMs work /not

traditional medical model and build understanding of optimal dosage

Need various “why” explanation to help them accept, understand and comply


2. Develop techniques to work more effectively with your clients


Support yourself firstNo one can effectively communicate, especially in a hectic environment, if they are not well preparedThat starts with the basics: what do you do to a) exercise b) relax c) be creative d) destress e) eat appropriately f) get enough water g) connect? Reality Therapy: meet your own basic needs –fun, freedom, love and belonging, and power


Make sure you plan your day –from the start Line yourself up to take away as much stress

from the day as possible Successful people line up their cloths for the

next day –just like 1st day of school; have their lunches made, ensure the vehicle has gas, stop cramming everything into the day – prioritize : do you really need to make that personal call now?


Think about what you know the day is going to be like and plan backwards

If exercise is important then plan to do that but the key word is plan

Too many people I know are constantly on the go and do not “plan” how to manage their days-take the shoulds , have tos and musts out of your day


Learn to say no and again prioritize, prioritize, prioritize –once you have figured out how to handle something –let it go –stop regurgitating !

Your inner being is like a gas tank –it has to be filled up- that means make sure you get food and water throughout the day

Find a practice to slow your mind down and be more in the present , so you can deal with the present –i.e. mindfulness meditation


The most effective strategy for managing hectic days are being mentally prepared and taking it one step at a time; being gentle and compassionate with yourself and others

You can only get done what you can only get done –no more


Takes two to tango So the reality is there are two sides or more

to the equation; you plus your client – and maybe their family, the doctor, and other professionals in the background

Once you have “supported” yourself then its time to take a “look” at the other part of the equation

….the client


How do people understand their world? Remember what we learned in the last part

about how people might be entering your pharmacy –newbie, just on, not working, working; plus maybe scared, confused, embarrassed, intimidated –after all you are the “professional” – how will you view them, may be a concern for them


Schemas – these are representations that people build about everything in the world; what to expect in a library, pharmacist, how drugs work, what doctors do

2 processes assimilate and accommodate – horsey with stripes - zebra

Schemas contain beliefs, attitudes which lead to emotional responses


Discovering your clients schemas: 93% of all communication is non-verbal – so

what are their non-verbal's telling you – how do they approach the counter, do they ask questions, what for you to take the lead, look at you, look away from you, speak softly/loudly – not that you will know for sure and one can start to guess –what might this be telling me


If the conversation seems to be going along just fine and them blip – something is very different – what changed – what was said – what might they be reacting to?

Keep detached – in other words not reacting but responding and gently probe or offer your communication in a different manner


Manage for all the “unknowns” that you can Turn your attention to them first; all of us

want to be heard and if someone feels you are listening they will respond better

Great them professionally and kindly Give them your undivided attention – even if

it is only for a few minutes Speak clearly and slowly; ask if what you

Learning the Language of Depression

Ensure they have some type of privacy – if needed and have a consultation room you could use that, or ask people to step back

If they are here for a first fill – do a check in as to how they understand depression and what might be some of their fears/concerns

If they are here for a refill – how are they doing? I get clients in for a first visit that have been on the same medication for 2-3 years, struggling, and same dosage- all of us need to have some “eyes” to support our clients in advocating for themselves –when needed


When people feel they are supported they actually function better in their recovery – therefore ensuring the professionals around them support them – 2-5 minutes can go a long way

There are two sides to communication – receiver and sender ; when people are depressed they may not follow a conversation at the same speed that we do; if need be slow down, use easier to understand language and double-check as to their comprehension


Sometimes using clarifications –tell them what to expect ; I’m just going to go over your medication now, if you have questions please feel free to ask ; then you are going to take it home and start your medication – ask them when and how specifically they intend to do this; by getting some form of agreement and commitment to the next behavioral step it potentially fosters more probability of this occurring


Those clients we all “love” Every person can have times when they are

less than wonderful and sometimes our clients can come across that way

They may be confrontational, grumpy, upset Most of these behavioral displays infer fear,

insecurity, confronting the unknown


Questions are your friend Let people talk – listen –what are they telling

you They will give you the keys to their issues By repeating back to them , so let me get

this straight, these seem to be your concerns and frustrations….

A key strategy to defusing anger, fear, and frustration is empathic listening


This gives their brain time to defuse out of the amygdala – which is busily assigning emotional responses to the situation – and re-engage their prefrontal cortex –thinking/logic/reasoning

Don’t let your amygdala jump into the soup with theirs –maintain your rational /logical thinking

Try to discern what are their key important needs that they are trying to resolve


I’m tired of waiting and I just want to go home

Listen, acknowledge the feelings, redirect what to what you can change : i.e. I appreciate you are tired and of course you want to go home, I appreciate you waiting, I promise I will get this filled as soon as I can in order to get you home as soon as we can

If client recycles to what can’t change , i.e. Yah well here we go again in the waiting game


Then acknowledge and redirect I understand this is very trying for you, I am going

to get this done as soon as possible to get you on your way

Broken record: stay out of what you can’t change and focus only on what you can

Well you promised this before I am going to get this done as quickly as I can

(remain calm, professional, and remain detached)


Ensure you are speaking supportive thoughts in your own mind, rather than cycling about how annoying they are, how unappreciative they are, focus on what you can change, leave the rest

Effective cognitive thoughts keep your brain unfrozen so that you can be more productive and think more clearly and thus more effectively solution solve


What we have learned: Take care of you Prioritize Stop Regurgitating Attempt to understand where your client is

coming from –assimilate, accommodate, emotional reactions

Listen Conflict resolution skills


3. Implement a variety of communication strategies to work within the pharmacist environment and mental health community


A good approach to establishing more effective communication is to start with an examination of :

Identify all the players. Where are you now and where do you want

to be? Develop a communication plan. Develop communication strategies.


Identify all the players Think of your professional

relationships/teams like circles


self


Identify all the players in each circle Ask yourself – How do I communicate with each of those

players? How do those players communicate with

me? What types of information do I communicate

and receive from those players? Are each of these processes handled in the

most effective manner?


Asking questions about how you see yourself interacting with each of those environment begins to build awareness of where you are now

How do I interact with these areas? What am I doing well? What would I like to improve? What do I want to keep? What would I like to change? How am I going to proceed?


Role and boundary clarification: What do I view my role in each of these

areas? What do I view the others roles in each of

these areas?


One can mange change from the front – managerial/owner

From the rear – from within the ranks, pharmacists, assistants and non medical team

Foster ways to build within your own team – how do you support your team? How does your team support you?

Are we in agreement as to the types of information and strategies we utilize to communicate with our clients?

Do you have consistent workplace and communication strategies – if not work on building these


Steps to developing a communication strategy:

1. Identify what needs to be communicated – gather all the content and ensure all parties are aware and are communicating the same content, i.e. decide what gets communicating at first visit, refills

2. Identify what communication skills are required – professional, detached, conflict resolution, clear, concise, non-judgmental, empathetic


3. Decide how and who will be responsible for ensuring people are trained on communication strategies-there are lots of videos and books that are cheaper and provide excellent guidance

4. Draw from the team – learn from each other –share your knowledge


Look for ways to foster more communication and teamwork with physicians, psychologists and psychiatrists

When in contact with these health professionals ask them for their ideas on how to improve the team approach

Encourage your clients to build team by asking for their medical professionals to speak with each other –need a release form

This would foster a broader team approach, improved client care and potential improved medication compliance and treatment –these could be quick phone calls/letters to ensure agreement with treatment


Approaches to working with professionals: Remember we are all busy Be clear on the intent of your communication Be concise Remove any judgement If conflict arises, drop back to the area where you

have agreement and then proceed to move forward Build relationship by using first names or

professional designations if the professional prefers


Determine next steps and agree on next steps – if appropriate; ensure each knows who is doing what

Show appreciation


Questions Handout of references and resources for your

clients to build more understanding re depression

Thank you for your time and attention


speaking the language of depression how to better communicate with patients with depression and...

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