Ten key skills in diagnosis and treatment of anxiety and depressive disorder
Bo Zhou1, Aiqin Wu2
1Psychosomatic Medicine Center, Sichuan Academy of Medical Sciences×Sichuan Provincial People’s Hospital, Chengdu, Sichuan 610072, China. 2Department of Psychiatry, The First Affiliated Hospital of Soochow University, Suzhou, Zhejiang 215006, China.
Abstract Anxiety and depressive disorder have a high prevalence around the world. Patients suffering from these diseases often go to a doctor with physical symptoms as the main complaint. Doctors not specialized in psychiatry may have difficulty in disease recognition and doctor-patient communication. Furthermore, patients with such diseases usually have poor compliance, limited efficacy, and low satisfaction, causing much confusion to attending doctors. Based on the characteristics above, this article summarized 10 key clinical skills to provide non-psychiatric doctors with a reference for the diagnosis and treatment of anxiety and depressive disorder, which includes consultation skill, listening skill, topic-switching skill, empathy skill, employment of questionnaires, secondary attribution of physical symptoms, diagnosis names fitting patients' cultural background, medication skill, fast and effective psychotherapy skill, and referral.
Anxiety and depressive disorder are quite common in China. The prevalence of depressive disorder, anxiety disorder, comorbidity of depression and anxiety is 12.0%, 8.6% and 4.1% respectively, and the total prevalence rate is 16.5% [1]. Patients are mainly characterized by physical symptoms [2], with complex and changeable clinical manifestations. They repeatedly seek medical treatment in multiple departments due to unsuccessful examinations, forming a special medical seeking treatment, "doctor-shopping" [3], which not only wastes a lot of medical resources but also makes themselves a high-risk group of medical disputes.
Patients often have some defects or obstacles in social psychological factors and personality in the onset of illness, so clinicians often feel confused and difficult in the diagnosis and treatment. For example, patients often present physical symptoms as the main complaint, resulting in a low rate of recognition and recovery. Even if the mood disorder is identified, patients often refuse to accept the diagnosis of anxiety and depression. Even if patients accept the diagnosis, they are often unwilling to take medicine for adverse reactions on the drug instructions. Even if they take medicine, the disease often relapses or recrudesces because patients go off the drugs spontaneously after feeling better. In a word, such patients are not easy to identify or communicate, and they often have poor compliance with treatment and have difficulty in recovery or complete cure. Based on years of clinical experience, the author summarized some skills in the diagnosis and treatment of anxiety and depression for general doctors.
1. To establish a therapeutic alliance is the key to successful treatment
The key to successfully curing anxiety and depressive disorder is not the accurate diagnosis of disease, nor the accurate employment of drugs, but the establishment of a therapeutic alliance, which helps guarantee patients' good compliance. The American Psychiatric Association (APA) pointed out in the 2010 "Practice Guideline For The Treatment of Patients With Major Depressive Disorder, Third Edition" that no matter which treatment plan the patient chooses, the establishment of a therapeutic alliance based on the mental assessment was the primary active treatment method and the key to working together to formulate an effective treatment plan. A treatment alliance of power can enhance patients' treatment compliance [4].
2. 10 key skills in diagnosis and treatment
2.1 Consultation Skill
Most patients with anxiety and depression go to a doctor due to physical discomfort, and they often refuse to attribute their physical symptoms to emotional disorders. Therefore, even if the doctor finds some problems in their mood, it’s better not to ask about emotional discomfort immediately, otherwise, patients will reject or deny your questions and tell you "If my physical symptoms disappear, I won't have these bad emotions." Therefore, it is recommended to follow the following order and content to carry out a medical consultation. Firstly, ask about what physical discomfort the patient has, and then inquire about factors that aggravate and relieve it, leaving him a belief that the doctor pays attention to his physical problems. Secondly, ask about what examinations and treatments have been done and how the effect is, which helps a doctor to make differential diagnoses. It should be emphasized that the identification and elimination of organic diseases are of much importance, too. Thirdly, ask about his sleep conditions, and then, emotional state. Because most patients don’t hide their sleep problems, such a procedure gives them a period of buffer time, making it easy to gradually transition to emotional problems. Fourthly, ask about whether they have negative life events such as strong work pressure, poor financial condition, tight interpersonal relationship, serious illness or death of relatives, etc. Then inquire about personality characteristics and growth experience. This kind of consultation mode fully embodies ＂bio-psycho-social＂ medical model. In a word, clinicians should keep the consultation skill that ask more and talk less; Listen first and speak later.
2.2 Listening Skill
Patients with anxiety and depression often have a large number of main complaints, have a strong desire to talk, worry about missing any point, afraid to be misdiagnosed. They often turn back to reconfirm their doubts or put new questions several times after leaving the consulting room, hoping the doctor will listen to them carefully. At the outpatient clinic, patients often complain, "I haven’t finished discussing my illness, the doctor has prescribed all the medicine. It’s too irresponsible." Even if they receive the medicine, they don’t take it. So, even though the diagnosis and treatment plan are correct, the treatment fails in the end, just because patients don’t adhere to it. Therefore, clinicians should listen to patients carefully, and respond with signals such as nodding, "um" or repeating their words, but not with an attitude of irritability or contempt in that these patients are always sensitive to doctors' attitude. In short, listen with eyes, heart, and brain, so that patients can feel the doctor’s seriousness and concentration.
2.3 Topic-switching skill
Some patients with anxiety and depression have a strong desire to pour out their feelings. They often talk for a long time and even emphasize repeatedly in case the doctor doesn't hear clearly. Therefore, we must learn to interrupt, but can't interrupt it roughly, or it will cause dissatisfaction in patients and induce the failure of a doctor-patient alliance. There are three ways commonly used to change the topic: (1) When a patient strays off the topic, we can remind him and return to the previous subject；(2) Summarize what the patient just said, and then introduce another topic. For example, "You just said you had a stomachache, a headache, a tight chest, dizziness, and heart palpitations. I got all of them. Then, tell me about the examinations you have done and the results? "(3) Help the patient to express his unclear feelings. For example, some patients are unorganized, babbled, and unable to enter the subject. Then, the doctor could say, "let me describe it for you, ok? You feel uncomfortable in many areas of your body, and it seems that no part is right. Meanwhile, you don't sleep well and stay in a bad mood. Isn’t it like this? " Patients often answer, " Yes, yes, that’s it. " Changing the subject can not only help patients understand that the doctor fully understands their condition, but also help save time for consultation.
2.4 Empathy skill
Empathy is extremely important for patients with anxiety and depressive disorders. These patients often seek medical advice and have examinations repeatedly due to a large amount of physical discomfort, bringing great economic and psychological burdens to their families. Because the tests often fail to give a positive result, some doctors may say the patient is "not sick", and then, family members may blame the patient for pretending to be sick, which makes him feel aggrieved. Some of the patients even told the doctor that this was his last visit to a doctor, if this doctor still said that he was not sick, he was prepared to give up treatment or even exhibit negative behaviors to prove to their families that he was not pretending. Therefore, doctors' understanding of patients’ inner pain and grievance is great support for them. At this time, the doctor needs to tell the patient, "I know you are wronged. You are not pretending to be sick, but actually having an illness. Family members cannot understand this kind of illness, and even some doctors don’t know it. But I can feel your pain and help you to defeat it. So, don't worry.” Hearing the news, some patients often excited to say: “It's a surprise to find a doctor who can treat my illness."
2.5 Employment of questionnaires
APA advocated assessment-based treatments in the "Practice Guideline For The Treatment of Patients With Major Depressive Disorder, Third Edition" [4]. One of the important assessments is the evaluation of the severity of mood disorders. There are many tools for the evaluation, including nurse-administered rating scales, such as Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD), and self-rating scales，such as Self-rating Anxiety Scale by W.K.Zung (SAS), Self-rating Depression Scale by W.K.Zung (SDS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder (GAD-7), Patient Health Questionnaire-15(PHQ15), Symptom Checklist-90 (SCL-90), Hospital Anxiety and Depression Scale ( HADS), etc., among which PHQ-9, GAD-7, PHQ-15, SCL-90 are more simple and practical for non-psychiatric doctors. Rating scales not only help doctors understand the severity of a patient’s emotional disorder, but also make the patient aware of their problems in mood, laying a foundation for the next diagnosis and treatment. The result interpretation of scales also requires some skills. Some patients often exaggerate their emotional experience, leading scales to indicate severe anxiety and/or depression. If the doctor finds it inconsistent with patients' real situation after consultation, informing them of their actual condition can make them feel relaxed and also increase their trust in the doctor. Another kind of patients have obvious anxiety and depression emotion, but the self-rating scale results indicate little, leaving non-psychiatric doctors embarrassed. The solution is to tell the patient that he may have alexithymia, that is, his negative emotions often present as physical discomfort, but not language and behavior when he encounters conflicts.
2.6 Secondary attribution of physical symptoms
Patients with anxiety and depression are often confused at one or several physical symptoms, but the cause cannot be found, forcing them to place their hopes on more advanced examinations and better doctors. Here, we should stop their pursuit and give them a reasonable explanation with mind-body dualism, in other words, the secondary attribution of physical symptoms. We can explain the complex pathological psychology and pathophysiological mechanism through some easy-to-understand examples to help patients understand the root cause. For example, "You have been flustered, tired, chest pained for such a long time, and repeatedly checked the electrocardiography, Doppler echocardiography, and even coronary angiography, but did not find any problem. Do you want to know where the problem is? Let me show you. Your problem lies in the heart, but the cause of it is not in the heart, but in the brain. Why is it in the brain? The brain is the headquarters of our whole body, so if there is a problem in the headquarters, there may be problems everywhere in the body. Scientific researches have found that there are some neurotransmitters in the brain, and they may be out of balance. It's like an electric lamp is out of order. The problem lies in the switch, not in the bulb or lamp holder, so repeated checks of the bulb and lamp holder show nothing wrong. If the switch is repaired, the light turns on naturally." Most patients can accept such an explanation. Once they approve the doctor's explanation, they will lay a solid foundation for the next treatment.
2.7 Diagnosis names fitting patients' cultural background
Many patients with anxiety and depressive disorder dislike the diagnosis of "anxiety" or "depression". On the one hand, they think it means that they are psychopaths, and will be despised or ridiculed by others. Furthermore, their brains can be controlled by themselves, so the probability of these diseases is very low. On the other hand, they think they have good material conditions, have no worry about making a living, so there is no reason for them to get anxiety or depression. Moreover, they believe that even if there are negative emotions, they are caused by long-term physical discomfort and ineffective treatment. As long as the body discomfort disappears, the bad emotions will not exist. They are unwilling to accept such a diagnosis, refuse to take anti-anxiety and depression medications, and reject to be referred to the department of psychosomatic medicine or psychiatric for further treatment. Facing the situation above, it is more important to give a diagnosis name that fits the patient’s cultural background than the correct diagnosis considered by the doctor, such as "vegetative system dysfunction", "neurasthenia", "neurosis", etc. The most important is to make the patient receive reasonable treatment, and then gradually let him receive the correct diagnosis after his condition improving.
2.8 Medication skill
With the development of technology, there are more and more anti-anxiety and depression drugs. Although the drugs have their own characteristics, it is difficult for non-psychiatric doctors to fully understand the differences between drugs. Meanwhile, the choice of drugs is limited in primary hospitals. But in fact, it does not hinder the treatment of these patients, because the various antidepressants currently on the market are both antidepressant and anxiolytic, and the overall efficacy is roughly equivalent. Therefore, it is important to master the basic medication skills: (1) The starting dose should be low, increasing gradually and slowly. Because these patients have prominent physical symptoms, their bodies are in a highly sensitive state, and also particularly sensitive to adverse drug reactions. Therefore, the initial dose should be small and gradually and slowly increase to the target dose. For example, start it from half a tablet or even 1/4 tablet, and gradually increase the amount. The rate of increase depends on the patient's tolerance; (2) The drug is slow to work, so wait patiently. Due to repeated visits to a doctor, these patients often accumulate a lot of ineffective drugs at home. They often warn the doctor to prescribe the drugs for only a few days. If the medications are effective after they try, they will continue to take them, or they will not take them again to avoid waste. It seems reasonable, but the doctor must explain it patiently that if the medication time is less than 2 weeks, the effect is not significant; (3) It is still necessary to continue taking the medicine after the symptoms improve. Symptoms often relapse due to discontinuation of medication after improvement. So they should be told that regular follow-up visits are required even if their symptoms improve; (4) Improve the condition and strive for clinical recovery. The clinical recovery of anxiety and depressive disorder must be treated with a full dose and full course of systemic treatment, otherwise, there will be many residual symptoms and the risk of recurrence after stopping the drug will increase; (5) Improve the quality of life and restore social functions. This is the goal of treatment for all chronic diseases and is particularly important for patients with anxiety and depressive disorder. There are often some young and strong anxiety patients in clinical work, especially panic disorder patients, feeling afraid to go to work and even reluctant to go to any place far away from home, worrying about getting sick again, and only recuperating at home after their symptoms have completely disappeared through treatment. Therefore, it is very important to cooperate with psychotherapy, especially cognitive behavioral therapy, to increase the patient's understanding of the disease and to change unreasonable cognition. Through behavioral training, increase patients’ sense of self-control, gradually adapt them to the environment, and restore their social function.
2.9 Fast and effective psychotherapy technology
Many non-psychiatric doctors worry that they have not learned through standardized psychotherapy and cannot provide psychotherapy services to patients. It is not the case. Professor Mei Qiyi in the field of Psychiatry believes that explanatory and supportive psychotherapy is a fast and effective method of psychotherapy [5]. Every clinician can use his professional knowledge to provide mental health services to patients. For example, a cardiologist used his authority in heart disease, combined with the negative results of heart examinations and the mind-body dualism, that is the secondary attribution technique mentioned above, to eliminate patients’ doubts about heart disease and make patients understand the cause of their cardiac symptoms was not the problem of the heart itself, but related to the dysfunction of the brain and autonomic nerves, eliminating the patients’ misunderstandings and proposing solutions at the same time. We can also use the example of others who have improved after treatment to increase patients' confidence. Through understanding and empathy, we can provide patients with psychological support, give health knowledge propaganda to family members and increase their understanding and support for patients, relieve patients’ psychological pressure, and enhance their confidence in overcoming the disease. Patients who like to ＂sit in the right seat" should be warned that don’t talk about diseases, don’t search in Baidu for symptoms, don’t read drug instructions, and communicate with others more.
2.10 Referral
The condition of anxiety and depression disorders can be simple or complex. For the occupational safety of non-psychiatrists, it is recommended to refer to the psychosomatic medicine or psychiatric department for treatment in the following situations: (1) Those who show a risk of suicide during medical history inquiry or scale test; (2) Those who have a family history of psychosis or suspected presence of psychotic symptoms; (3) Those who have a history of bipolar disorder or have (hypo)manic symptoms; (4) Those who have persistent intolerance to drug adverse reactions; (5) Those who are still ineffective after two stages of adequate and full courses of antidepressant drugs; (6) Those who have complicated physical comorbidities that affect the choice of drugs; (7) Those who have other psychiatric comorbidities or substance dependence problems; (8) Those who have personality disorders and are at greater risk of medical disputes.
3. Summary
Due to differences in personality characteristics, growth environment, education level, etc., the clinical manifestations of patients with anxiety and depression disorders are also various, and patients in different departments have their own features. For the author's limited experience, these 10 key skills of diagnosis and treatment are only a glimpse of the clinical work. Through individual experience, clinicians could explore a set of methods and skills fitting themselves to enhance patients' trust and compliance, and consolidate the treatment alliance.
Acknowledgments
This work was financially supported by The National Key Research and Development Plan (2017YFC0113907).
Author Contribution
Bo Zhou was responsible for the article, in charge of supervision and management. He conceived the article, drafted the copywriting, collected and organized the intellectual content of the article, revised the article，and wrote the English version; Aiqin Wu was responsible for the quality control and review of the article, reviewed the intellectual content of the article
Author Disclosure Statement
This article has no conflict of interest.
Reference
1. HE Y L, MA H, ZHANG L, et al. A cross-sectional survey of the prevalence of depressive-anxiety disorders among general hospital outpatients in five cities in China［J］．Chin J Intern Med, 2009, 48（9）：748-751. DOI：10.3760/cma.j.issn.0578-1426.2009.09.010.
2. ZHAI X Y, LYU P Y. The clinical diagnosis and treatment of depression in general hospital［J］．Chin J Behav Med & Brain Sci，2015，24（4）: 301-303．DOI: 10.3760/cma. j.issn.1674-6554.2015.04.006.
3. LIN M H, CHANG H T, TU C Y, et al．Doctor-shopping behaviors among traditional Chinese medicine users in Taiwan［J］. Int J Environ Res Public Health, 2015, 12（8）：9237-9247. DOI：10.3390/ijerph120809237.
4. GELENBERG A J, FREEMAN M, MARKOWITZ J C. Practice guideline for the treatment of patients with major depressive disorder, third edition［G］. American Psychiatric Association，2010.
5. MEI Q Y, The best-qualified psychotherapists are psychiatric doctors and nurses［J］. Psychological Communications，2018，1（2）： 100-104．DOI：10.12100/j.issn.2096-5494.218049.
