When you come to a psychiatrist's office for the first time, you often do not know what to expect. Am I going to ask you to lie down on my couch? Are we going to talk about your childhood, your parents or your nightly dreams? Sometimes this unknown keeps those in need from getting help. There is a stigma that mental illnesses are somehow different from physical illnesses. I want to use this post to lift the veil on what going to a psychiatrist entails.
If you have never been to a psychiatrist, it may surprise you to find that the first visit in my office is a very similar experience to other medical professionals that you may have seen in the past. I 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 first discuss what brought them to my office and what we will be working 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.
When a patient comes to my clinic with a psychiatric/mental health concern, I always seek to rule out medical causes. Depression, mania, anxiety and thought disorders can all be caused by and may mimic medical problems such as thyroid disease, infections, medication side effects, hormone abnormalities and many other treatable medical conditions.
How We Formulate a Treatment Plan
When a patient presents with depression, there are a number of treatment options that I commonly utilize. Every patient is unique and comes with a history of treatment failures, treatment successes and treatment options that have not been tried in the past. I also must rule out conditions like bipolar disorder, ADHD, anxiety, psychosis and addiction, as these conditions influence which medications would be suitable for my patient. A proper diagnosis is imperative in order to develop an effective treatment plan.
I formulate a treatment plan based on the severity of the patient's symptoms, how much the depression is impacting their ability to function at work and/or home and their history of previous treatments.
Psychotherapy
Psychotherapy is the most common initial treatment tool that I employ with my patients who suffer from depression. There are numerous evidence-based types of therapy for depression. The type of therapy I employ is specific to what the patients discuss during their initial evaluation and subsequent follow up visits. I base the type and intensity of therapy on my patients' stressors, symptoms and preference for the frequency of follow up visits. All of my patients receive supportive therapy. At each appointment I provide an empathic environment in which they can discuss any number of concerns and stressors in a supportive, non-judgmental and non-critical atmosphere. I seek to help my patients make their own connections, discover insights and solutions, while working through difficult problems and situations.
There are other types of psychotherapy including: cognitive behavioral therapy (CBT), psychodynamic psychotherapy, interpersonal psychotherapy, eye movement desensitization and reprocessing (EMDR), dialectical behavioral therapy (DBT). There are also intensive outpatient programs (IOPs) for those who are most negatively impacted by depression and whose functioning is the most severely impaired.
The psychiatrist plays an instrumental role in making a formal diagnosis and formulating the treatment plan. Our role is similar to a primary care doctor, or general practitioner, who may need to refer a patient to a specialist. In some cases I perform therapy in my office. In other cases I refer my patients to another psychiatrist, a psychologist, or other therapist who specializes in a specific type of therapy. A psychiatrist can be instrumental in helping you determine what type of therapy will provide you with the most benefit.
Lifestyle Change and Behavioral Activation
Depression is associated with behavioral changes, as I mentioned in my previous article on the causes and signs of depression. Depression tends to lead to social isolation and a decreased interest in things like nutrition, exercise and enjoyable activities. Therefore, as difficult as it may be, I always encourage my patients to take an inventory of their current behaviors. These include attention to diet/nutrition, exercise/physical activity, recreational activities/hobbies, chores/bill paying and personal hygiene. More often than not, when patients evaluate these areas, they find that they have significant deficits as compared to their pre-depression behavior/levels of activity. This is because depression can keep us from having the motivation to do the very things that make us feel better.
I work with my patients to develop a plan that is tailored to their current motivation, functioning and abilities. Even small victories and accomplishments can lift your mood when depression has caused so much pain and struggle.
Psychopharmacology
Some patients come to my office looking for "a pill" to help. Others come and start off by saying "I do not believe in medication." Regardless of their preconceived beliefs about medication, I always educate my patients so that they can make a balanced decision about the risks, benefits and alternatives to every treatment option. I work with them to decide if a medication is right for them. It is especially important for us to be on the same page, because the patient makes the ultimate decision whether or not to take a medication after they leave my office.
There are a number of medications that have been proven to be of benefit in the treatment of depression. When assessing which medication may be right for any patient, I always consider their past history of medication successes and failures.
I then look at the patient's specific symptoms of depression. (You can read about these in my previous post, here.) These symptoms serve as our targets for treatment and align better with some medications and worse with others. I target the most severe and urgent symptoms, and also co-morbid symptoms like anxiety, thought distortions, obsessions and compulsions.
I work with my patients to pick a medication or combination of medication that best suit their personal and current needs. At each visit we evaluate the need to adjust the medication prescribed through changes in dosing (up or down) or augmenting with additional medications to achieve optimal outcomes.
Psychotherapy vs Medication
Medications for the treatment of depression can take a week or two to take effect and up to another six to eight weeks to have maximal effect. Therefore, it is important to simultaneously employ the other treatments options in our arsenal. That is specifically why I discussed psychotherapy and lifestyle changes and behavioral activation first. These treatment modalities can have significant positive effects on depression immediately and can serve as a bridge until medication can take full effect.
Conclusion
If you are suffering from depression, or know someone who is, my goal of writing these articles on depression is to spread a message of hope. Psychiatry is a field of medicine that specifically focuses on diseases of the mind including depression. Even a single consultation can help to clarify the diagnosis, treatment options and can begin the healing process. (You can access my article on depression and hope, here.) Know that you are not alone. Your symptoms, feelings and struggles are well understood and treatable by psychiatrists such as myself. I always advise my patients that coming to a psychiatrist is the most important step they can take to get help.
Dr. Goldenberg is a fourth-year psychiatry resident. He has written numerous articles about mental health and addiction topics. You can follow Dr. Goldenberg at docgoldenberg.com and on Twitter: @docgoldenberg
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