I thought I’d share with you my experience with a particular new patient I saw for an initial assessment this week. At my musculo OP placement, we always discuss our patients for the day at a morning meeting. Literally all I knew about this patient was that she had LBP, and a fairly extensive list of medical problems that included alcohol-induced liver cirrhosis and manic depression from the referral letter. Discussion that morning focused a little on some difficulties I may encounter with such a patient with manic depression, depending on how well-controlled it was. I think in general, it’s fair to say that this patient caused some apprehension in all of us involved in that discussion.
The obvious issue to me was, How much can I discuss this condition with her? Would such a person prefer that I openly ask her questions about her condition and ask questions about how it may affect physiotherapy? Do I risk offending her? I didn’t feel right just ignoring the topic. I thought I’d share my reasons why… and then leave it to you guys to share your opinions.
I think depression is so largely misunderstood. The “down” mood, low motivation, lack of interest, poor concentration, cloudy mind, and irritation is so out of the person’s control. A lot of frustration arises from that, because these ppl are often afraid of being perceived as too lazy “to snap out of it”. I thought it was important to make it clear to the patient that I understood that, that I wasn’t intimidated or afraid to talk about it.
I asked questions and said things that indicated to her that I understood that She was separate from The Condition. I started off conversation with “I’ve been left some very good notes in a referral letter from your doctor. I understand you suffer from manic depression.” I asked questions like, “I’m asking because I’d like to know how it may affect your ability to deal with your back problem, and how I can help.” Instead of saying “on a day that you are particularly down”, I’d say “on a particularly down day when it’s affecting you”. I felt this forthright approach worked well with this patient. The patient was comfortable talking to me about her condition. I feel like I’ve built good rapport with her. She tells me honestly that sometimes she doesn’t do her HEP because “she can’t be bothered”. Not something you’d like to hear, but there’s something to be said about the honesty there, right?
I think it’s important to develop a fine-tuned ability to detect who you talk to in this way, and who you don’t. This frank approach may not be suitable for a patient who is very introverted, cut-off and non-talkative. What do you guys recommend as your approach in this situation?
1 comment:
I think you handled this situation very well, in that you were able to guage the extent to which the patient was willing to talk about their mental illness.
Bipolar disorder (often written in notes as BAD - bipolar affective disorder,)as you say involves the cycling between 'manic' and 'depressive' episodes, however there can be long periods of stability between these. An episode generally lasts between 3 and 6 months, there can be long periods in between episodes where the person is 'stable,' and the episodes do not necessarily alternate between the two. The exception to this is rapid-cycling BAD, which is were at least 4 major episodes occur within 12 months. Extremely rapid-cycling BAD which is very uncommon is where the is distinct mood shifts within a 48 hr period.
Patients who are compliant with their medication can in many situations minimise or almost eliminate the effects of BAD, depending on the severity. Severe manic episodes can present with elements of psychosis, not too dissimilar to episodes of mania in schizophrenia. Drugs used are mood stabilisers (lithium etc) and either antidepressants or antipsychotics.
The way you approach the person will be very much dependant on how they at the time. Most people with BAD have their symptoms well controlled with medications and lead a relatively normal life (at least most of the time). But as you say it can have a significant affect on their recovery. The question you asked 'do you think it may have an effect on us trying to get you back better?' is a great beginning question - from here the patient may then either discuss their condition with you openly, but it also gives them an avenue to back out - leave it until next time when you can make a judgement as to whether they have been compliant with HEPs and postural changes etc.
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