15-Minute interview for serious mental disorders.
But before you begin to ask some important questions, you need to set the stare. Use body language and alter the physical environment in your office that typically serves for medical rather than psychological issues. You want to create an atmosphere that indicates this is a different kind of clinical interaction, and although you have only 15 minutes, you are not in a hurry. Take a breath, relax, and sit comfortably rather than in a posture that you use when you have to get all over the room. You want to establish a sense of focus, communication, and trust.
Pediatricians today are under a lot of time pressure. A good 15 minutes, however, is enough to assess the severity of a mental health concern. That is the goal. You are not trying to know every problem or to make a definitive, comprehensive diagnosis.
In contrast to a well-child visit or assessment of a minor injury, you change sets. You see this in the movies where interviews with patients are much shorter. The doctor gets up from behind the desk, takes off their glasses, and leans forward. Actors use body language that says, "I'm about to ask a different kind of question."
You want talk to the child or adolescent directly If they are on the exam table, move your stool closer and talk from a comfortable distance. You may want to put your pen away or sit more comfortably Avoid any physical barriers, if possible. For example, if the patient is sitting in an office chair, come out from behind your desk and sit in the chair next to them. You don't want to face them head-on--that can be confrontational--but at a slight angle.
Once you've set the stage appropriately, I recommend asking information-gathering questions in an order from easy to more challenging (for example, What school do you go to? What grade? What is your favorite activity?). This facilitates trust and strengthens your relationship with the patient, even if you've been seeing the child or adolescent for many years already. A relationship is probably what keeps a teenager going through rough times. What you're doing is intrinsically therapeutic. You're letting them know someone cares and someone is going to work with them on their behalf. That, in and of itself, is a powerful message.
After some informational questions, you can start the interview by stating, "It sounds like you're having some serious difficulties. Let's talk for the next 15 minutes or so about what you're facing." This lets the patient know you're ready to listen and gives them the time frame. This works well for older school-age children and adolescents. Younger children will not understand how long 15 minutes is, and in most cases you'll be interacting with their parents more anyway.
The first questions can be general. Ask how things are going in different areas of their life. An easy question to start is: "How are things going in school?" Ask two or three questions to find out about attendance (missing a lot of school is a warning sign), grades, their ability to concentrate, and school performance. Don't dwell--once you're satisfied school is going well, move on.
Ask about activities. Is their involvement stable and ongoing? Do the activities make them feel good? Do they care about what they are doing? When they give a sense of being connected to an activity that matters to them, it's usually a good sign.
Ask about friends as well. Do they do things with friends and if so, how often? Do they have a best friend? Are all their friendships age-appropriate?
Next, ask about family, which is often a more difficult area. "How are things going at home?" is a good opener. Find out if there is any ongoing discord or tension, and find out more if they answer yes.
Dysfunction in any of these areas can be an important clue. In general, a milder mental health concern impacts only one area of their life. More serious disorders, in contrast, often cause dysfunction across multiple areas.
The most difficult area, and the one I often leave for last, concerns mood. Hopefully how you've asked and responded to the previous questions set a tone that built trust at this point. Specifically assess for depression, particularly in adolescents. Serious depression is one of the more common and most concerning issues identified through this interview process. ASk how they've been feeling lately or what kind of mood they are typically in. Watch for answers such as "sad," "angry,," or "irritable."
Again, ask about dysfunction. "Has your mood been so bad that it has interfered with school, your friendships, or your family?" If they answer yes, you have to ask questions such as: "Have you ever thought that life is not worth living because you feel so badly?", "Have you ever felt there is no hope?", or "Have you ever felt that there is no way out of the way you're feeling and the problems you're facing?" If they respond yes to any of these questions, you're now doing a suicide evaluation. Follow up with: "Have you ever thought about hurting yourself or tried to hurt yourself?" At this point, you may need to get this teenager to see a mental health colleague urgently or send them straight to the emergency room.
In contrast, if their issue is not too serious, and you feel competent to do more, there is no reason not to ask the patient to return for further discussion over two, three, or four 15-minute subsequent consultations with you.
Standardized screening instruments are helpful, but they are supplemental. The Pediatric Symptom Checklist, which I developed, is probably the most widely used screen for emotional problems (www2.massgeneral.org/ allpsych/psc/psc_forms.htm). It can alert you to which 5 or 10 of the 100 kids you see in a week potentially need a mental health interview. Some you will be aware of and need little time; others will come as a surprise.
The Hamilton Rating Scale for Depression is a more specific screen (www.medafile.com/cln/HDRS.html). Also, if they have depression, it can give you a sense of the severity.
However, I'm not completely comfortable relying on what patients--particularly teenagers--check off or do not check off on a piece of paper. Face-to-face interaction in a trusted environment remains critical and potentially the beginning of a therapeutic intervention.
MICHAEL S. JELLINEK, M.D.
DR. JELLINEK is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. He is also president of Newton (Mass.) Wellesley Hospital. He said he had no relevant disclosures. E-mail him at firstname.lastname@example.org.
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|Title Annotation:||BEHAVIORAL CONSULT|
|Author:||Jellinek, Michael S.|
|Date:||Dec 1, 2011|
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