For Clinicians: A Guide to the Clinical Interview of Patients with Mood Disorders
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Essential Concepts
1. Here is Ghaemi's rule: Psychopharmacology
is first and foremost diagnosis; after
diagnosis,treatment follows.
(→Psychopharmacological diagnosis
is first and foremost diagnosis; after
Psychopharmacological diagnosis,the programe of Psychopharmacological treatment and
Psychosocial treatment logically follows.)
Thus the clinical interview revolves around getting data
to make a Psychopharmacological diagnosis and then discussing
the rationale for Psychopharmacological and Psychosocial treatment based on the
Psychopharmacological diagnosis.
2. Always seek to obtain history from family
members or friends. Do not rely on the
patient's self-report. Other clinicians are
also often a biased source of information.
3. Once depression is identified, shift the
interview to obtaining history on the course
of illness.
4. Spend as much time as possible on examining
possible past mania or hypomania.
5. Assess secondary causes, but do not overinterpret
psychosocial factors as being causative.
6. After the mania aspect of the interview,the
next largest amount of time should be
spent on detailed treatment history, especially
concomitant medication(併用薬) use and
duration of treatment trials.
7. Tell the patient the diagnosis, why it is
made, and why others are not made.
8. Once the diagnosis is made,the treatment
recommendations should follow simply.
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It is my experience that the clinical process of assessing
depression and mania is not sufficiently appreciated by many
clinicians. In this chapter I will walk readers through how I
approach the clinical interview in patients with mood disorders.
Table 25.1 summarizes the steps I take in the clinical
interview. Please refer to Appendix B for a complete clinical
evaluation form I use in my practice.
Table 25.1 ————————————————————-
1. Identify a current major depressive episode (5 minutes).
2. Assess the course of depressive illness (5 minutes).
3. Spend the bulk of the interview assessing past mania or hypomania (10-15 minutes).
4. Examine causes of secondary depression (5 minutes).
5. Obtain past treatment history (5-15 minutes).
6. Discuss the rationale for the diagnosis (5 minutes).
7. Discuss treatment options (5-10 minutes).
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BEFORE THE INTERVIEW :ASK FOR FAMILY AND FRIENDS TO BE PRESENT
Usually, when I go to the waiting room to find my patient,
someone else is there, a family member or a friend. About half
the time,that other person remains seated. Most psychiatrists
do not invite that person to join the interview. I always do. Not
only that,I inform my patients before their first interview that
they should seek to bring a family member or friend along with
them. This is for two reasons: First,family members and
friends can corroborate the history or,in the case of mania,
actually provide accurate history, whereas patients, owing to
lack of insight, often invalidly deny the presence of manic
episodes in their personal history. Second, when discussing
treatment options,the presence of others in the office improves
the likelihood that the treatment plan will be understood and
implemented;frequently, patients are depressed and cannot
clearly understand the complex treatment options being
described—family members can hear and repeat what was said
later to the patient. Further,if family members are not present,
the patient will later have to explain what I said to them;it is
better for the family to hear what I have to say directly from me
rather than secondhand.
If there are concerns about certain confidential topics
(which usually do not have a direct impact on the diagnostic
interview anyway),family can be asked to leave the room for
a few minutes in the middle of the interview and then be
invited to return toward the end, where I provide my diagnostic
impressions and treatment recommendations.
Tip———————————————————————
Avoid interviewing patients alone.Ask for a family member or
a friend to be present at the first diagnostic interview.
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BEGIN BY ASKING ABOUT DEPRESSION
KEY POINT————————————————————
After you have identified a current major depression, change
the subject to the depressive course of illness or past mania.
Detailed evaluation of current major depressive symptoms is
not diagnostically valuable.
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Usually,the presenting complaint is depression. As the psychotherapeutic
saying goes,it is best to meet patients where they are,
so I usually start with the noncontroversial and
straightforward determination of the presence of clinical
depression.
At one level, one simply identifies major depression to get
beyond it. In other words,it often is relatively easy to know
that a patient has a current major depression—it may take
only 5 minutes to quickly review current neurovegetative
symptoms—but this is not the end of the evaluation, only the
beginning. This is so because, as discussed in Chapter1,
depression is not a diagnosis but only a constellation of signs
and symptoms. Diagnoses are bipolar depression, or sec-
ondary depression, or unipolar depression—with unipolar
depression signifying that the bipolar and secondary diag-
noses have been ruled out. Thus, as soon as a major depres-
sive episode is identified, especially currently,the clinician
should stop talking about depression and shift the focus to
identifying past mania or hypomania and assessing possible
secondary causes (mainly medical).
It is irrelevant(見当違い),for instance,to spend much time assessing
how depressed the patientis, whether he or she is hopeless or
helpless, whether his or her symptoms are atypi
cal or typical,
cal or typical,
and so on. All these features are important perhaps prognos-
tically and therapeutically, but they are unimportant diagnos-
tically. They do not differentially diagnose bipolar as opposed
to secondary or unipolar depression.(鑑別診断に役立つのは経過と躁状態/軽躁状態の有無である。)
QUICKLY MOVE TO ASSESSING THE COURSE OF DEPRESSIVE ILLNESS
I emphasize something that is rarely done: Evaluate the course
of the depressive illness. The reader will recall that the course
of depression, unlike the details of current depressive symp-
toms, can differentiate between bipolar and unipolar condi-
tions, as well as help to identify secondary depression. Too
often clinicians simply say, "The patient has depression," as if
this is enough to make a diagnosis. They have no idea when
the depressive episodes began, how many there have been,
how long they have lasted, precipitating factors,interepisode
symptoms, and so on.
So here is what is diagnostically important: age of onset,
number of episodes, duration of major depressive episodes, and
interepisode status. Ask patients how far back they can
remember depression for the first time,refreshing their mem-
ory as to the definition of a major depressive episode (daily
depressed mood or anhedonia with multiple neurovegetative
symptoms, day in and day out(明けても暮れても), most of the day nearly every
day,for weeks on end, or more).
Then ask how long their depressive episodes have lasted in
the past. Here patients usually throw up their hands and claim
ignorance. I usually say, "I could make it up, but your guess is
better than mine." Patients need to know that this is impor-
tant;force them to think about it. Usually they can give an
average duration;it need not be precise—if they are especially
exasperated, give them options(うまく答えられなくて困っているようなら、選択肢を提示する)
: more than a month less than
a month, about 6 months, over a year. These are the time
frames that are diagnostically relevant because unipolar
depression lasts 6 months to a year or longer, whereas bipolar
depression is shorter, usually 3 to 6 months or less. Also,ide-
ally assess the durations in untreated periods to understand
the natural unmedicated history,if a patient has been nonre-
sponsive to medications,then treated periods also reflect the
natural history of the illness.
Then ask how many episodes the patient has had: "How
many times in your life have you felt very depressed like that?"
Usually,if currently depressed, patients overestimate their past
depression: "Forever" is the common desperate answer. "Really?"
I reply, "All your life, every day, day in and day out, without
every having one day of being different,forever?" Usually they
back off at that point. "So how many times?" "I don't know,
doc." Again one can offer multiple-choice answers: "Just once?
A few times? More than 5 times? More than 10 or 20 times?"
Sometimes it is obvious in the history that the patient has had
many episodes, more than 10 or 20;in this case, the exact num-
ber matters little. What does matter diagnostically is that if a
patient has one or two or three episodes, this is common in
unipolar depression and uncommon in bipolar disorder. Many
episodes are more common in bipolar illness, especially if they
are brief(less than 3 months in duration).
Finally, once you have identified the ballpark(おおよその) number of
episodes, determine if there are periods of wellness between
episodes. This is usually not difficult; either patients will claim
that they are always depressed, which may reflect interepisode
dysthymia or subclinical depression, or they have periods of
euthymia, which they or their family can clearly describe:
"Were there evertimes when you were not depressed and were
your normal self or normal like everyone else in your mood
energy for weeks or months on end or longer?".If such peri-
ods are present,then past mania can be more easily assessed
compared to that enthymic baseline.
SPEND THE BULK OF THE INTERVIEW ASSESSING PAST MANIA OR HYPOMANIA
In the typical interview,it might have taken 5 minutes to
establish that the patient has a current major depressive
episode. Another 5 to 10 minutes should establish the depres-
sive course of illness. Next, one should take as much time as
needed (up to 15 minutes or more)to examine the ins and
outs(一部始終) of possible past mania or hypomania. Unfortunately,this
part of the interview,the most important clinical aspect diag-
nostically and therapeutically,is often conducted with only a
single question or hurriedly. The clinician should take his or
her time and come at the question slowly and in a round-
about(回り道の) fashion so as to avoid patients' natural defensiveness
about the stigma of bipolar disorder.
I usually begin with an open-ended question, especially if
I have established a period of normal or euthymic mood in
the past in the assessment of the course of depressive illness:
"Did you ever feel the opposite of depressed, where you were
not sad and down and depressed, but you also weren't just
your normal self?" With equivocal(あいまいな) responses,I might get
more specific: "Did you ever have times where you were more
energetic than normal compared with when you were not
depressed or more energetic than most people around you so
that you were doing lots of things or not sleeping much and
not feeling tired?" Or perhaps: "Did you ever have periods
where you were angry and irritable but not depressed and full
of energy, doing lots of things?"![[猫]](https://i0.wp.com/blog.ss-blog.jp/_images_e/101.gif?resize=15%2C15&ssl=1)
If a somewhat positive response is elicited(ひきだされた), or if the patient
comes to the appointment with possible past mania as a clin-
ical question,I ask an open-ended question of the patient
so as not to direct the patient toward manic criteria but seeking
to get his or her own words about it: "Tell me about how you
felt and how you behaved, or what people told you about
how you were, during that time (when you felt hyper or more
energetic than usual or when you or your doctor or others
said you might be manic or hypomanic)?"
Then,importantly,I write down what the patient says verbatim(逐語的に).
It is very important to do this. Bipolar disorder is such a
controversial topic, with patients getting different opinions
from different doctors,that it is important to avoid miscom-
munication by letting the patients speak for themselves. Con-
sider if I write: "The patient had elevated mood, with
decreased need for sleeping,flight of ideas, distractibility, and
increased goal-directed activity for 5 days." The patient may
disagree and go to another clinician, who is skeptical about
the bipolar diagnosis, and that clinician simply may disbe-
lieve my interpretation of what the patient had said. But no
one could deny mania if I write: "The patient stated that he
would feel 'hyped up(興奮して) and like I could do anything;I was a
tyrant,felt I was smarter than everyone else,like there was
nothing I couldn't do;I didn't need to sleep for days on end(連日),
yet I was full of energy;I was giddy(軽薄な) at times; my thoughts
were all over the place;I couldn't keep up with them;I would
wake up in the middle of the night and clean the house five
times over;then the next day I would paint the house inside
and outside, even though it was perfectly fine; and a week
later I would do it again with a different paint color.'"
Tip———————————————————————
Write down the patient's description of manic symptoms verbatim.
Let patients speak for themselves. Since clinicians
tend to disbelieve each other's descriptions of mania, avoid
translating patients' descriptions into clinical lingo(臨床医学専門用語).
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Once a manic or hypomanic episode is identified,the diag-
nostic process is over: The diagnosis of bipolar disorder has
been made.If mania or hypomania cannot be identified,the
interview is still not over;then the absence of mania/hypo-
mania needs to be confirmed by third parties(第三者). This is done
most efficiently if family or friends are present at the inter-
view;if they are not present,the clinician should call, or ask
the family to call,to quickly review mania criteria over the
phone. Sometimes I make this phone call during the patient
interview, sometimes later.
EXAMINE CAUSES OF SECONDARY DEPRESSION
These causes are most often medical, although they also can
be psychosocial. It is important to distinguish between a trig-
ger and a cause. A trigger is the final event that leads to the
episode, but it is not the sole or even the main cause of the
episode. This is similar to what Aristotle called the efficient
cause. Sometimes there is a certain trigger, sometimes another
trigger, and sometimes no trigger. Don't focus on triggers.
Although they may be somewhat relevant (妥当である)later, especially in
psychotherapy,they are diagnostically irrelevant.
Unfortunately, most patients, and many clinicians,focus
on the most recent psychosocial triggers as if they were
absolute causes of episodes. This is a big mistake. The best
way to think about this problem,in my opinion,is to recog-
nize that the brain is a rationalizing machine. The classic split
brain experiments in epilepsy show us how:In patients with
intractable seizures requiring corpus callectomy (severing the
two hemispheres of the brain from each other), one creates a
circumstance where the right hemisphere might note some-
thing and yet not be able to transfer that information to the
left hemisphere, where verbal control is located. Since the left
visual field is transmitted to the right hemisphere,researchers
can place the right visual field behind a blindfold and show
pictures in the left visual field, such as violent and anxiety-
provoking images. The right hemisphere sees these pictures,
and the patient feels scared and nervous. When asked why
the patient says: "Well, my neighbor had a car accident last
week, and I was thinking about that" or "I was thinking about
the recent war in the Middle East." In other words,the
patient cannot verbalize why he or she suddenly feels anxious
or scared, yet he or she comes up with an explanation, any
explanation, as long as it is plausible, even though it is wrong.
We do this all the time, so when patients say that there are
depressed because of x, y, and z happening in their lives,they
may be right, or they may be wrong. We can not take those
explanations as true at face value.
Tip———————————————————————–
The brain is a rationalizing machine. As the clinician, do not
accept at face value the patient's explanation for mood
episodes, nor should you as a clinician simply ascribe(Bto A :AにBの原因を帰する) mood
episodes in a common-sense manner to apparent psychosocial factors.
————————————————————————–
True psychosocial causation, secondary depression owing
to a psychosocial cause, should be relatively obvious and
should be placed in the context of a nonrecurrent course of
illness: The patient may have one episode after a horrible psy-
chosocial trauma or maybe two episodes after two horrible
psychosocial traumas, but most people,fortunately, do not
have many isolated psychosocial traumas (or if they are the
victim of recurrent abuse,they usually experience prominent
post traumatic symptoms rather than simply major depressive
episodes alternating with euthymia).If recurrent major
depressive episodes occur,the psychosocial factors should b
e
e
seen as triggers, not causes.
The same is the case with medical factors. One might have
no past depression,then have a stroke, and then experience
a major depressive episode. This is poststroke depression.
Most individuals do not experience repeated strokes (since
most persons get treated)followed by depressive episodes
after every stroke. On the other hand, mild hypothyroidism
may be a factor in contributing to recurrent depressive
episodes.
KEY POINT——————————————————–
Unless a secondary factor is a clear and indisputable cause,
preferably of a single,isolated episode with no recurrent
course, view secondary factors as contributors but not as
causes. In general,focus on the description of the syndrome
rather than an explanation of causes. Be humble about etiol-
ogy: We know far less than we think.
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The role of substance abuse should be seen in this way too.
If I've never had mania,take cocaine for the first time in my
life, and then have a manic episode, one can call that condi-
tion cocaine-induced mania. However,if I have experienced
many manic episodes and many periods of cocaine use,it
would seem difficult to demonstrate a one-to-one correlation
so as to justify the diagnosis of mood disorder secondary to
cocaine use. Often the situation is the reverse: Cocaine use
frequently occurs in those settings as the result,rather than
the cause, of manic episodes.
OBTAIN PAST TREATMENT HISTORY
This step is often conducted quite superficially: "The patient
has taken venlaxine, sertraline,fluoxetine, paroxetine,lithium,
and olanzapine." This description tells me nothing.It is impor-
tant to get some detail with each medication taken. I ask
patients to provide this history in written form and bring that
information to the interview; otherwise, much interview time
can be lost in fleshing out(肉付けする、詳しくする) the medication history. Even when
an initial written version is provided,it is important to confirm
and extend the written history provided by the patient because
usually such history is only partially complete.
As shown in Table 25.2.the relevant factors needed are not
only the names of the medications but also the durations of
treatment, doses if available, and concomitant medications
used. For each medication, one should assess efficacy and
side effects and the reason for discontinuation.
TABLE 25.2. Medication History Chart————————-
Past Medication Trials
Name
Duration(Weeks)
Main Dose(mg/day)
Benefit
Side Effects
Reason Stopped
Other Agents in Same Trial
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Clinicians may be rolling their eyes, knowing that most
patients cannot provide this information, especially in complex
cases with decades of prior treatment. Yet again, my view is that
any history is better than no history and I feel that most of the
fault lies with clinicians who do not take the time to bother
eliciting(めんどうだけど聞き出す) this history rather than with patients who, understandably,
will not recall many details.
I find that patients who claim that they cannot remember
details are often overconcerned with being exact. For
instance, when I ask how long they took a certain drug,they
become exasperated(いらだつ) because they cannot remember if it was
2 months or 3.5 months or 4.25 months. Since they can't be
precise,they will just say they don't remember,I then give
them multiple-choice options: "Was it less than 1 month,
more than 1 month, more than 1 year, more than 10 years?"'
Obviously,this forces them to say something, and we can get
some valuable data, such as the idea that they took the drug
somewhere between 1 and 6 months.
TIP——————————————————————–
Detailed treatment history can be obtained from almost all
patients. Use the multiple-choice method to get the relevant
level of detail.
————————————————————————
Hence,if, as is commonly the case,the patient is a vague
historian on these details,I direct the history as a multiple-
choice test: Dosing is the least important fact, especially with
modern antidepressants, because most of them can be dosed
easily to a therapeutic amount. Duration is much more
important because no trial is therapeutic if it has lasted less
than 1 month. I ask about more than 1 month or less than 1
month duration;if less,the trial was automatically not therapeutic,
and usually it was stopped owing to side effects, about
which I then inquire. If more than 1 month,I then get a sense
if it was more than 6 months, more than 1 year, or longer still.
However long it was used,I always ask about whether other
medications were taken with it. Often patients can say that
other medications were taken, but they do not remember
which ones. It is just as important to know that they did not
have monotherapy trials, especially with mood stabilizers in
bipolar disorder, as it is to know the details of the other med-
ications they received. I then ask whether they thought the
medication trial was effective or not and whether they had
side effects. People usually remember side effects more
clearly than efficacy, although sometimes they can be clear
when a drug was either definitely not effective or definitely
extremely effective. It is still very useful clinically to see if one
can elicit either extreme response, marked efficacy or marked
inefficacy, or the absence of ever having such clear good or
bad effects. Sometimes,if a patient has taken many drugs
from the same class (such as ten different antidepressants),I
will simplify the efficacy assessment by asking, "Was there
any one of these that worked very well for you,that stands
out as especially effective?" Also,if efficacy is reported, one
should ask about whether the drug maintained its benefits if
used long term (to assess tolerance or "poop out(疲れてやめる)").
The assessment of concomitant medication use is esp
ecially
ecially
important when assessing bipolar disorder or treatment-refrac-
tory depression (TRD:治療抵抗性うつ病).In the case of bipolar disorder,the rel-
evant issue often is constant and chronic antidepressant use
concomitantly with multiple failed mood stabilizer trials. The
importance of the mood-destabilizing effect of the concomitant
antidepressant in accounting for failure of mood stabilizers is
discussed in Chapter19. In the case of TRD,it is important to
know if antidepressants are used together or singly or with
other adjuncts so as to determine the extent of adequate com-
bination therapy, especially since the Sequenced Treatment
Alternatives to Relieve Depression (STAR-D) study identified
somewhat more efficacy with combination therapy as opposed
to switching antidepressants in TRD (see Chapter12).
KEY POINT—————————————————————
The most important part of the treatment history, often ignored
is concomitant medications(併用薬).
—————————————————————————-
DISCUSS THE RATIONALE FOR THE DIAGNOSIS
Here I enact Osier's rule (see Chapter 5): We treat at diseases, not
symptoms. Thus the diagnosis, above all,is the most important
fact that needs to emerge from the interview. If there is
no diagnosis or a highly uncertain state in which no diagnosis
can be made,then no treatment should be given (at least
with medications,in most cases).If the diagnosis is made,the
treatment options then follow clearly.
Many times clinicians jump at this point to discussion of
treatment recommendations, skipping diagnosis altogether or
addressing it only briefly I am not sure why this is the case.
Sometimes it probably has to do with time constraints(時間の制約); sometimes
I think clinicians do not value diagnosis as important
and rationalize their approach as simply treating symptoms
anyway. The latter view goes against Osler's rule and a Hippocratic
approach to psychopharmacological however(see
Chapter 5).
Hence, at this point in the interview, one should stop, ask
the patient if there is anything else the clinician should know
or has overlooked that is important, and then the rest of the
time should be spent discussing the working diagnosis and
then treatment recommendations. Since treatment relies
completely on the diagnosis, at least in the Hippocratic
approach,then a great deal of effort and time should be put
into identifying the diagnosis, explaining the rationale for the
working diagnosis chosen,reviewing the differential diagnosis,
and explaining why other conditions are less likely and
soliciting the patient's reactions and responses and input.
I am surprised at how frequently patients tell me that they
received medications (often antidepressants) for lengthy periods
of time (often years) without ever formally being told:
"You have diagnosis X, and you do not have diagnoses Y and
Z, and these are the reasons why."
It is important, respectful, and humane to state the diagnosis
explicitly to the patient before discussing treatments in
any way and further to elicit a two-way dialogue about the
patient's feelings about the diagnosis.
KEY POINT————————————————————–
Make a diagnosis and be explicit about it, soliciting the
patient's feedback and reaction. It is disrespectful of patients
to avoid clear discussions of the working diagnosis and the
rationale for it as opposed to other conditions.
—————————————————————————
The clinician should keep in mind, and the patient should be
told,that working diagnoses are just that—working—so they
are liable to change. In psychiatry,the course of the illness is the
final arbiter(決定要因) of diagnosis: "Time will tell whether this diagnosis
is right, or whether another one turns out to be the case," I tell
my patients. Time will tell; both clinicians and patients need to
be open-minded and revisit the diagnosis overtime. A major
mistake, often seen in public mental health settings,is that a
diagnosis (often schizophrenia or "depression")is parroted(オウムのように機械的に繰り返して言う) over
years, often from clinician to clinician, without ever being reevaluated,
even though the course of illness often clearly proves
it wrong.
DISCUSS TREATMENT OPTIONS
Here I enact(ルールを適用する) Holmes' rule (see Chapter 5): All drugs are guilty
until proven innocent. Thus our presumption will be to avoid
using medications and to look for evidence to use them rather
than evidence not to use them. This means looking at evidence
of efficacy before thinking about side effects.
This is the practical conclusion of the interview. The
process at this point should be easy,if all the previous steps
were taken with care. This is so because the hardest part of
psychopharmacology practice,in my view,is establishing the
diagnosis; once the diagnosis is established,treatment choices
should be simple.
KEY POINT—————————————————————
Here is Ghaemi's rule: Psychopharmacology is first and fore-
most, diagnosis; after diagnosis treatment follows. In other
words,the key to successful psychopharmacology practice
is to get the diagnosis right. This is the hard part of psy-
chopharmacology; treatment decisions are easy once the
diagnosis is correct.
—————————————————————————–
Here, after restating the diagnosis,the clinician should be
able to turn to the scientific evidence base to offer treatment
options. Invoking Holmes' rule, we first turn to evidence of
efficacy to limit our universe of options. The patient is not
allowed to choose from all the psychotropic drugs that exist,
but only from the ones proven effective for his or her diagnosis.
Thus,if the diagnosis is bipolar disorder type I, the options
given are the four proven mood stabilizers (see Chapter 7);if
the diagnosis is recurrent unipolar major depressive disorder,
the options given are proven standard antidepressants. Within
those proven treatments,the patient and clinician then can
discuss side-effect risks and patient preferences.
It is key,though,to minimize polypharmacy and to maximize
efficacy (i.e.,to practice Hippocratic psychopharmacology),to
always begin by limiting the initial medication options based on
efficacy data and only then turn to side-effect co
ncerns. If the
ncerns. If the
approach is the reverse, as patients and many clinicians often do
it,then patients end up on many inefficacious (although purportedly(そう信じられている)
safer) drugs (i.e., gabapentin syndrome(！)). As a result,
the illness will continue to wreak havoc(大きな害をおよぼす).
KEY POINT————————————————–
Treatment decisions begin with efficacy, not safety.
—————————————————————
HIPPOCRATIC PSYCHOPHARMACOLOGY
Putting it altogether(まとめると),the clinical interview aims primarily at
getting the diagnosis right , which allows the implementation(実行)
of Osler's rule—-to identify a disease that can be treated. It then
requires a conservative and efficacy-oriented approach to
treatment,implementing Holmes' rule,which,with a correct
diagnosis,leads the clinician toward that ultimate Hippocratic
goal:To cure sometimes,to heal often,and to console always.