Vignette 3: Asking about Depression in a Preventive Services Visit
Tony is a 15 year old boy who has come to an outpatient clinic for a routine preventive services visit and physical exam. In this vignette, he is being screened for depression. Screening questions for depression are more oriented toward a female experience of depression, as are the DSM–V criteria for depression. Girls have a higher prevalence of standard depressive symptoms. However, depression in young men is often overlooked, and may be experienced and reported differently by males. Adolescent boys often report symptoms that are more compatible with fatigue, anger, and anxiety. It is crucial for the provider to be alert to signs of depression in adolescent boys, as the completed suicide rate for adolescent boys is 5.3 times higher than that of adolescent girls.
In this vignette:
The provider asks a general question about any problems the patient might be having, and patient answers that he is not having problems. This would be a likely answer for a boy who does not know how to introduce his concerns about talking to the provider and about the possibility that there is something wrong with him.
The provider asks about self–harm. This is an important question, but is asked before the groundwork has been laid for this line of questioning. The patient is startled and does not know how to answer. He hesitates and avoids eye contact, indicating his distress.
The provider catches his error and asks more general questions about mood. However, he asks about too many emotions at once. The patient, trying to be cooperative, endorses most of these feelings, but does not give any specific information. He does not endorse sadness, an emotion that may be difficult for an adolescent boy to acknowledge.
When the patient talks about fighting at home with his younger sister, the provider casually empathizes with him. This is a warm moment between the provider and patient. The patient responds genuinely with a smile.
The provider eases back into questioning about depressive symptoms. He asks again about sadness and depression. Again, the patient does not relate to these symptoms and denies having them.
When the provider asks about energy, he has found something the patient can relate to. This enables the patient to talk about his fatigue, health concerns, and anxiety symptoms. The provider takes the patient’s health concern seriously, but also recognizes the symptoms of anxiety. This allows the patient to elaborate on his anxiety and how worried he is. He says that he doesn’t know how to make it go away; a subtle way of asking for help.
The provider, having established rapport and understanding of the patient’s way of expressing his feelings, asks again about suicidality in a way that is connected to the boy’s experience of emotional pain. This helps the patient feel comfortable enough to reveal his suicidal thoughts. The provider gently and appropriately refers the patient for further mental health assessment.
The positive elements of this interview are:
The provider is friendly and warm.
The provider catches himself asking about suicidality too soon and returns to it later.
The provider makes a connection with the patient about his sister, putting the patient at ease and helping him relax.
The provider thinks to ask about lack of energy and fatigue as possible symptom of depression.
The provider appropriately accesses mental health support.
The negative elements of this interview are:
The provider asks about suicidal thoughts too soon, confusing and intimidating the patient.
The provider asks about too many emotions at once, making it difficult to gather information.
The provider asks about depressive symptoms that many adolescent male patients do not endorse. This patient does not relate to those symptoms or is reluctant to admit to them.
The provider doesn’t ask about who else the patient has talked to, the patient’s connections and relationships with other adults, and does not discuss how to include the patient’s parents in the evaluation. (see handout 4)