Responding to a positive depression screening in a primary care setting.
Responding to a positive depression screening in a primary care setting.
Harper is a 38-year-old Black cisgender woman who makes an appointment with her primary care provider because she has been experiencing insomnia and decreased libido in recent months. Harper is also an oncologist at a well-known hospital. She is currently experiencing racial discrimination at work. She mentions during her appointment that although she is exceeding performance metrics (e.g., high number of patients seen per day, excellent TaT and patient outcomes, etc.), she contributes often to research initiatives, and has developed a strong rapport with patients, her clinical judgment is often questioned, her contributions to the team are often minimized, and she is often excluded from meetings. She also mentions that she recently applied for a senior-level position but was denied due to goodness of fit. She blames herself for not working hard enough. Her primary care provider commends her for her strength in being able to withstand the difficulties at her job and advises her that her symptoms of insomnia and decreased libido are most likely due to a transient adjustment period at work. Her primary care provider quickly ends the appointment and encourages her to consider exploring weekend hobbies. Harper feels gaslit and dismissed by this experience, so decides to schedule an appointment with another provider for a second opinion. She meets with a provider who was recommended by a close friend. During this appointment, she was given the PHQ-2 ([in which she scored a 5 out of 6), followed by the PHQ-9, in which she scored a 14 out of 27.
Good morning, I am Dr. Yaara Wolfe and my pronouns are she/they. How would you like me to address you during our conversation?
Harper works, and my pronouns are she/her.
I appreciate you sharing that with me, and it is a pleasure to meet you. I reviewed your screening responses, thank you so much for your willingness to be vulnerable.
Of course. I have been dealing with a lot and I tried to talk to another provider about it, but I just felt so dismissed by the conversation.
I am so sorry that you had that experience. I am sure that it was difficult for you to even have that conversation. Do you feel comfortable telling me more about what you have been experiencing?
I have been struggling with a lot, and I have not felt safe talking about it. In recent months, I have been having trouble sleeping and I no longer have the desire to be intimate with my partner—and that used to be one of the highlights of our relationship. Colleagues often question my clinical judgment despite my experience and track record, and because of this, I now question myself often. I hesitate before making decisions that used to come so easily for me. In the last couple of years, I have worked super hard with the hope of securing a leadership position. I recently applied for the position with confidence because I was overqualified. I found out that I was not offered the position due to goodness of fit. It is not difficult for me to understand what goodness of fit means when the entire leadership team is white, but I still question myself. I have always been able to roll with the punches, but this…this is too much.
I am so sorry that you are going through this. For lack of better words, it sucks. I have battled bias and discrimination throughout my career, so I know what this feels like. We, as in folx whose marginalized identities intersect on the lines of race and gender or sexuality, often end up questioning ourselves when we are a part of systems that have cultivated environments of discrimination and exclusion. We question ourselves instead of questioning the system. I want you to know that your feelings are valid and what you are going through is real. I know that this is a larger conversation that needs to be had, but at this moment, how can I support you?
I appreciate you genuinely listening to me. I don't even know where to even start.
Of course. Sometimes bias and discrimination can impact us on an internal level, too. Based on the screenings that were completed earlier, it is possible that you have also been experiencing symptoms of depression.
Depression? How? I am not stuck in bed all day—I have a full life, and I have done well for myself.
I agree with you, but sometimes depression shows up differently, especially in Black women and folx who function at a high level.
Oh.
I know that this is a lot to digest and although this is just a screening, not a diagnosis, I want to connect you with people who specialize in this area and can dive into this further. Is it ok if I connect you with resources that will support you in the way that you need?
I would like that, thank you.
Things to consider.
It is important not to assume that all symptoms are linked to depression, although there might be some overlap. Similar to abdominal pain or any other health condition, explore all potential etiologies and differentials.
It is also important, as much as possible, to make trusted referrals. Individuals can easily get lost in the health care system or become retraumatized. Take the time to close the loop and ensure that the patient has all the support needed to show up in the world as their best selves.
Even if you cannot relate to a patient’s experience, how can you demonstrate openness and offer an empathetic ear in a way that allows them to feel safe, seen, and supported?
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