Try, Try, Try

What can I do as an emergency physician?

In the emergency department, many patients who might have depression come seeking for help but for other conditions, like a chronic headache or chest pain, or a plethora of symptoms that don’t add up to any specific identifiable physical cause. Mostly I think doctors are relieved for the patient’s sake that his symptoms are not due to a life or limb-threatening condition, but then we fail to address to underlying issue which may be psychological. Truthfully, most of us don’t remember too many details from our psychiatric training in medical school, including how to pick up clinical depression and the tools used by qualified psychiatrists are too complex. Yet we must try.

How do I diagnose depression?

Dr Doug Rund, an emergency physician, developed a bedside depression screening tool, “In SAD CAGES“, which stands for:

Loss of Interest in activities, Sleep disturbance, Appetite change, Depressed mood, Difficulty in Concentrating, Activity level change, Excessive Guilt, Loss of Energy, Suicidal thoughts, plans or attempt.

To screen positive for depression, the patient must have at least 5 out of the above 9 criteria on a daily basis for at least 2 weeks, including either loss of interest in activities or depressed mood. Several studies, including one done by Dr David Hoyer, show that the prevalence rates of depression in ED patients range from 20-30%.

How do I treat depression?

So the next challenge to emergency physicians is, what do we do with patients whom we have diagnosed with possible depression? Dr Hoyer believes in starting treatment with antidepressants from the ED. However many emergency physicians would prefer to refer such patients to a psychiatrist for initiation of treatment as some antidepressants have side effects. I think we can still try to help our patients, maybe with non-pharmacological methods while awaiting follow-up or even admission, to expedite team-based treatment especially if the patient has active suicidal ideation.

Infinite Sadness

When the doctor is unwell.

Hang on a minute. Based on the In Sad Cages screening tool, I myself might have skated on the edge of depression once or twice. Recently in the aftermath of some drama, I was beyond blue for a couple of weeks and checked enough boxes to be considered someone with possible depression. Even my nurses noticed and one left a coffee on my desk with the words, “Cheer up, okay? Smile, Dr Jade!”

What not to say.

While I have since bounced back, I’ll share with you what made me feel worse and held me back when I was trying to recover. Quite frankly, sometimes I regretted sharing about what I was sad about, because I might get a response like, “But, I think you allow yourself to feel sad,” or “You know, I think you’re making yourself feeling victimised, so don’t.” At that time, I found these remarks quite upsetting, and now as I recall them, I still find them quite patronising, if not damaging. Instead I found that when friends acknowledged that I was upset by certain circumstances, even if they didn’t take sides on the matter, I felt that I had been heard and believed. And that cleared my mind to pivot and come up with constructive solutions.