Vignette 5: Assessing for Depression in a Mental Health Appointment

In Vignette 3, Tony has been referred to a mental health provider to assess for depression. This vignette (5) shows a mental health provider assessing Tony for depression and suicidality. The provider must find a way to get beyond female–oriented ways of asking about depression to help Tony talk about his feelings. Adolescent males often do not endorse sadness, depression, crying, or hopelessness. They may experience frustration, anxiety, irritability, and anger, and may have somatic concerns. Asking about these symptoms often provides a pathway for boys to talk more about their feelings, or to at least indicate their level of distress. Being able to assess adolescent boys for depression and suicidality is vital, given the rate of completed suicides among males.

In this vignette:

  • The provider asks the patient why he has come to the clinic. This is a standard opening mental health assessment question. As in this case, adolescent boys often present at mental health appointments because someone else has told them to come.
  • The provider asks the patient standard mental health assessment questions such as what his mood is like, and if he is feeling sad or depressed. These are questions that adolescent boys often do not relate to. Even if they are experiencing these feelings, they may not be able to identify them, or they may not want others to know they are experiencing them. The patient is confused about the mood question and denies feeling sad or depressed. The provider moves ahead with a question about crying. The patient stops this line of questioning by disengaging and saying he doesn’t cry. He cannot discuss his sadness, even though he looks very sad. The provider persists with questions about hopelessness. Even though the provider asks the wrong questions, her demeanor is caring, gentle, and reassuring. She conveys that she is paying attention and listening carefully.
  • The provider asks about anger, and the patient relates to this. Boys often experience sadness and depression as irritability and anger. He endorses this symptom and elaborates on his affective experience. The patient clearly becomes more engaged when he feels that the provider is asking him questions about the feelings he experiences. The provider indicates that she understands that angry feelings are a problem for him and will give him an opportunity to discuss it further.
  • The provider asks about the patient’s energy level. He endorses this symptom, as he did in his medical appointment. He is more comfortable with a somatic presentation of his distress.
  • The provider asks about school. The patient says his grades have dropped. The provider misses this opportunity to pick up on this possible symptom of depression and asks about drugs and alcohol use out of context. The provider is wondering if the patient is using substances that might contribute to his declining school performance. However, the timing of her question is awkward, and she alienates the patient. He answers, but is withdrawn.
  • The provider sums up what the patient has said, indicating that she has been listening closely and understands his concerns. When the provider asks how long the patient has been feeling this way, he feels connected enough to elaborate on what is bothering him, using his own words to describe his feelings. The patient talks about anger, but looks very sad and discloses suicidal feelings.

The positive elements in this vignette are:

  • The provider is interested, relaxed, and non–confrontational throughout the interview. She sets a comfortable tone by engaging in attentive conversation and expressing her wish to be helpful.
  • The provider discovers that the patient’s way of expressing distress is through angry feelings.
  • The provider sums up what the patient has said, indicating that she has been listening closely. This invites the patient to reveal more.
  • The provider looks calm when hearing about how much pain the patient is in, and this makes the conversation feel safe for the patient.

The negative elements in this vignette are:

  • The provider asks a number of female–oriented questions, and persists even when they do not elicit a response from the patient. She eventually asks about an expression of depression that is more likely male–oriented.
  • The provider asks about drug and alcohol use – a useful question – but it is out of place, alienates the patient, and disrupts the flow of the conversation.
Boston Children's Hospital © 2013