Even student doctors who have not yet completed all of their medical training have probably realized that awkward, difficult or delicate conversations are part and parcel of a physician’s practice, and for a number of different reasons. Few conversations you will likely to have with your patients can feel more uncomfortable–for patient and doctor both–than those involving a patient’s mental health. Despite energetic advocacy for the mentally ill in recent decades, the stigma of mental illness remains and many patients may feel embarrassed, upset, or ashamed to discuss these issues with their healthcare providers. A doctor who is comfortable with this topic and can put their patient as ease, however, can more easily screen patients for mental health disorders and, more importantly, get them referrals and contact with community resources that many of them so desperately need.
But how do you start this conversation?
Begin the Dialogue
According to the United States Department of Health and Human Services, an excellent resource for educating doctors and other healthcare workers on mental illness, the topic of mental health issues should come up early in the doctor-patient relationship, if possible on the patient’s initial visit, even if the patient is seeing the doctor for another reason.
One method which can help send the message to the patient that mental wellness is part of a holistic view of health is to screen for it in the same manner that you would screen, for example, cardiac disorders. Questions about mental and emotional health should be asked in the same manner as other questions about a patient’s personal and medical history during the initial evaluation. Such questions can include those such as:
● How often a patient has felt depressed, down, or hopeless recently
● If a patient has lost interest in activities that they once enjoyed
● If a patient has experienced sleep disturbances such as insomnia, bad dreams, problems with early waking or other obstacles to a good night’s sleep
● If a patient has had an unexplained increase or decrease in their appetite recently
● If a patient finds it difficult to focus in on tasks or finds that they have scattered or muddled thoughts
● If a patient has had thoughts of suicide or self-harm recently
● If a patient has any major stressors in their lives
Questions such as these can open a discussion with the patient about any mental health challenges that a patient may be facing–and a doctor that is open, attentive and at ease with these discussions can make it easier for a patient to be open in turn.
The first contact with the patient and the quality of the initial screening are vital, for this will set the tone of care and professionalism that a patient needs in order to open up about depression, anxiety or other mental health issues. Once the barrier of actually talking about these problems has been overcome, assessments can be made and actions taken. A good way for doctors to wrap up this part of the conversation with patients is to let them know that identifying problems and starting a conversation about them is an important first step in restoring them to full health and helping them realize their full potential.
A clinical study out of Poland, where researchers estimate that approximately 25% of the population suffers from or has suffered from a mental disorder, found that doctor understanding of the basic symptoms of and treatment for mental health disorder and the ability to communicate effectively with the patient “determines the success of the healthcare system” in regards to this vulnerable population. Furthermore, the authors of the study note the importance of “simple yet exact messages and the ability to adapt them to the patient and the problems reported by him” and that “good communication with the patient is aided by patience, empathy, understanding and competence”.
Be Sensitive to Patient Presentation
While every patient should be screened for mental health issues, doctors should be sensitive to particular patient presentations which can constitute “red flags” for a potential mental illness, even before the discussion of these problems begins. Physicians should be aware of patients who present with:
● Unexplained chronic pain or fatigue
● Changes in eating or sleeping patterns
● High rates of infections
● Signs of impairment in work, school or home life
● Signs of past or present use of alcohol or drugs
If a doctor’s patient presents with these or similar symptoms, this should prompt a clear focus on and evaluation of a person’s mental health.
Conduct Yourself Carefully
Doctors need to also be aware of how they conduct themselves when speaking with a patient about mental health issues. While these conversations are difficult, they can be made somewhat easier if a doctor:
● Practices active listening skills and really takes in what their patient is telling them; this is not a conversation you can have with your head stuck in your computer: good eye contact and focus on the patient is essential.
● Communicates “person to person” and not “expert to victim”–in other words, treats the patient as an equal partner in the process of achieving good health.
● Avoids the use of highly technical medical language or jargon and communicates with patient according to the patient’s level of knowledge.
● Builds a relationship of trust with the patient; if a patient does not feel this basic trust, it is unlikely that they will share issues or thoughts related to their mental health.
● Maintains an air of being nonjudgmental, no matter what the patient is confiding in you.
● Validates the feelings of the patients.
The importance of good communication skills when dealing with mentally ill patients cannot be overstressed. A recent study, for instance, looked at the perceptions of mental health patients who go for help to the emergency room which, authors note, evidence shows is not associated with good psychiatric patients outcomes. The purpose of these interviews was to find similarities in the retelling of these patient experiences and the researchers found three basic themes: “The emergency room is cold and clinical”, “They talk to you like you are a crazy person”, and “They put you away against your will”. What authors also noticed was the positive–or negative–impact that staff communication had on these patients coming into the ER during an emotionally vulnerable time. A doctor who is able to use his communication skills to reach out to the patient can make a vital difference in the patient experience and perception of care.
Know What to Do Next
Once a patient has opened up and discussed the challenges they are facing with their mental health, it is also good to not just listen attentively but to also know what actions needs to be taken next. Does the patient need a referral to a specialist such as a psychiatrist or therapist? Is it appropriate to begin a patient on medications such as antidepressants? What support groups are in the area which the patient may benefit from? These answers will vary radically depending on the patient, of course, but having these questions in mind ahead of time can make it easier for you to answer them when the time comes. The researchers from the Polish study previously mentioned point out the importance of physician knowledge of both the symptoms of and treatment for mental illness and that this clinical competence is vital in order to get mentally ill patients the treatment that they need.
Take Care of Yourself to Take Care of Your Patient
Any healthcare professional knows that dealing with issues of mental illness or patient trauma can be emotionally difficult for the provider him- or herself. It is, in fact, easy, for physicians to be emotionally affected when patients confide in them about, for instance, a history of sexual abuse. Physicians, especially those at the beginning of their professional career, should be aware of this danger and learn to take care of themselves in order to better take care of their patients. That is why organizations like the World Health Organization encourage healthcare professionals working with mentally ill patients to:
● Set limits and not try to do everything; realize that you can only do so much when it comes to helping your patients.
● Make time when you are not working to relax and get away from the pressures of your professional duties.
● Don’t let the stress build up but find some sort of healthy outlet for it, such as exercise or particular hobby or pursuit.
● Continue to educate yourself about new breakthroughs or knowledge in the field of mental health through continuing training/education so that you will be aware of new advances–such as a new treatment or medication–and be able to communicate these to your patients.
● Work closely with other members of your health care team and find a co-worker whom you trust and whom you can confide in when it comes to the emotional difficulties you are facing in your professional life.
Following these suggestions for self-care can make it easier to deal with the emotional rigors of working with mentally ill patients and can leave you feeling able to give your patients what they need.
To conclude, beginning a conversation with your patients about their mental health status can feel like a daunting task because of the very personal nature of the questions and because of the stigma which unfortunately remains around issues of mental illness. However, a doctor who presents himself as open and caring and appears comfortable discussing matters of mental health can set a patient at ease and open up that preliminary conversation which must take place before a problem can be identified and a course of action set.
Blaszcyyk, J. et. al. General Principles of Effective Communication Between Physicians and
Patients with Selected Mental Health Disorders. Polish Medical Journal. 2015. 38(226)
Harris, B. et. al. Patients’ Experiences of Psychiatric Care in Emergency Departments: A
Secondary Analysis. International Emergency Nursing. 2015.
Talking to Mental Health Patients/Clients. BJC Healthcare. 2015
Talking to Your Patients About Alcohol, Drug and Mental Health Problems. United States
Department of Health and Human Services. 2014.
What Workers Need to Know About Mental Health and HIV/AIDS. World Health Organization.
Brian Wu, MD, Ph.D., MNM, graduated from the University of Maryland with a Bachelor’s of Science in Physiology and Neurobiology, and graduated from the Keck School of Medicine (University of Southern California) with an MD with a focus on holistic care and treatment. He currently holds a Ph.D. in integrative biology and disease for his research in exercise physiology and rehabilitation.