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Psychiatric Evaluation: Crisis Care of Depression

Updated on April 8, 2015

Depression can hit anyone at any time in their life. Simply put, a diagnosis will inevitably result in your depression being graded as mild, moderate or severe. We also hear words like mild to moderate or moderate to severe in terms of severity. If depression can be graded to this extent, is it so difficult to determine how much someone is clinically depressed?

We may be diagnosed by a general doctor or it might be a psychiatrist but if you reach the point of feeling suicidal the psychiatric crisis or intervention team may also be called upon to determine how urgent your depression care needs are. What if you don’t want them to know how bad you feel? What if a friend or relative has called upon the emergency services because they are so concerned about you and suddenly you find yourself being whisked down to the emergency department?

Your depression may be diagnosed as mild, moderate or severe
Your depression may be diagnosed as mild, moderate or severe | Source

Your general doctor is not specialized in psychiatry but will use diagnostic criteria to decide whether your severity of depression warrants being assessed by a psychiatrist. Most cases of depression are indeed dealt with by your usual doctor, and usually by a treatment of anti-depressants.

Depression can come and it can go with a few months treatment of anti-depressants and it can even pass without medication if therapy or self-help is applied. This particularly applies to mild to moderate depression. In this article I am going to talk about severe depression, when intervention is sought in a crisis and how it presents to a crisis worker. A crisis worker’s opinion counts for a lot when it comes to what happens to you next.

All about Depression

Symptoms of Severe Depression

There are many symptoms of severe depression but here are a few:

  • Difficulty concentrating
  • Irritable or impatient
  • General loss of energy - fatigue
  • Feeling numb and distant as if in a void
  • Feelings of guilt
  • Feeling helpless
  • Feeling angry
  • Heightened anxiety
  • Tearful
  • Not eating or eating too much (comfort eating)
  • Short memory span
  • Feeling unreal
  • Not caring for yourself or appearance as you usually would
  • Disturbed routine through lack of interest
  • Having thoughts of suicide

You may only have four or five of these symptoms or you may have them all and you could be considered to be severely depressed. I have suffered in the past with several bouts of severe depression and recognise those symptoms well. Of course when you become severely depressed you often don’t recognise the symptoms so clearly and it can be a case of feeling a sense of doom and gloom as if in a black hole. Feeling hopeless and helpless the downhill slide is obviously felt by a sufferer but friends and family can often see the picture of increasing depression too.

When you, a family member, friend or general doctor feels you are in a crisis and the depression has reached a critical level affecting every corner of your life, and especially when your negative thoughts include those of suicide, you may find yourself sat in front of a crisis worker.

Crisis workers may meet up with you in the A&E department
Crisis workers may meet up with you in the A&E department | Source

An obvious route for this to happen is to go to an emergency department in a general hospital where, after being seen by the triage nurse you will no doubt have to wait to see a psychiatric crisis worker. Being in an emergency department waiting room can truly be an awful experience when you are in a severe state of depression. You may be very anxious, confused and affected by the fact that you are expected to sit amongst other general medical patients. Some hospitals make provision for this but generally speaking the scenario is that you wait with everyone else until the crisis team member or members arrive. I personally have had to wait up to two hours and I can tell you that two hours seems like an eternity. By the time the crisis team arrives you often feel a lot worse than you did when you arrived!

You are called into the room to see the crisis team and believe it or not before you even sit down you are being observed or analysed.

  • On first glance it will be noted if you have come alone indicating a lack of support
  • Your state of dress will be noted - stains on clothes, dishevelled state
  • Your hair - is it combed or unkempt?
  • The way you walk - is it slow, are you hunched and tending to look down?
  • Do you appear anxious?
  • Facial expression - making eye contact

Note how many sufferers choose to relate their intentions

Source

Although why you are so depressed should be a natural first line question as that helps treatment, it often gets excluded. You are more likely to be asked questions such as:

  • How’s your appetite?
  • How is your sleeping pattern?
  • Have you lost weight or gained a lot of weight if so how much?
  • How are you coping at work or home?
  • Is your mood getting worse and if so how is it getting worse?
  • Are you tending to cry a lot?
  • Are you getting dressed every day, bathing and managing self-care ok?
  • How are your relationships with those around you?
  • Are you getting support from family or friends?
  • Are you feeling negative all the time?
  • Do you have suicidal thoughts?
  • Do you feel you would act on the suicidal thoughts - made any plans?

These are just a few off the top of my head, but you may be asked much more than this. You have walked into this room and you might not even actually want to be there. You may have had to wait a long time in a crowded waiting room but even if the workers were to visit you in your home you would still feel under pressure.

Your depression feels so bad that you feel unable to concentrate, you feel distant and very anxious. You may even be feeling rather unreal and yet the outcome of what you look like and say will determine the kind of help that follows…if any does. You may feel unable to rationalise what is being asked and even say the first thing that springs to mind which may not strictly be the truth. You may feel under pressure to say something even when you are not sure of the answer.

Avoiding eye contact can be one of the signs of severe depression
Avoiding eye contact can be one of the signs of severe depression | Source

Flaws in Assessing Depression

I remember being asked years ago if I was getting dressed every day. I said I wasn’t. My personal hygiene had also gone downhill but they failed to ask me that. I had lost interest in me. What the crisis team saw was a woman sat in freshly ironed jeans and a freshly ironed t-shirt with combed hair. The reason for this was that my husband had combed my hair, had been doing the ironing and had helped me get dressed to run me down to the emergency department. We couldn’t find a babysitter so he couldn’t stay with me and had to return home. They would have assumed by my appearance that it was likely I was coping in the self care respect.

Even when you are severely depressed you may make eye contact! I was taught by my parents that it is rude to not look someone in the face when you are speaking to them. You may find it a strain to do so but purely out of polite correctness you may find yourself looking in the worker’s face. Can this give the wrong impression? From the outcome of my meeting I know it did.

I was asked if I was eating OK. I said no. They asked if I had lost weight. I said yes. A worker then said that I couldn't have lost weight because my jeans fit me too well. I didn’t have the mental energy to pursue it but there was good reason for that. When I was prone to depression I would lose weight very quickly and so had two sizes of clothes in my closets. These were my smaller sized clothes. I was just too tired in my brain to explain it all.

Crisis workers will be interested in whether you have suicidal thoughts, but more so if you feel you would act on them. Now imagine if you feel so very depressed and are having these kinds of thoughts, how you may feel it would act against you to disclose the truth. So, you may lie. You may make up the first excuse that comes into your head about why you feel you wouldn’t act on them. You may be asked if you are making plans with these negative thoughts but what about those people who simply don’t plan? What if you are an impulsive person by nature or are secretly drinking alcohol to excess and therefore more at risk?

There is only so much a crisis team member can do to ascertain your level of severity with regards your depression and whether you are at risk or not. I know for sure a checklist of symptoms and observations cannot always determine the true facts because not everyone will be a textbook case. The best way to avoid a wrong diagnosis of severity and risk is to talk to the family or friends who have been around the depressed person and have seen them on a daily basis. Permission for this has to be given by the patient and in my past experience rarely happens.

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    • billybuc profile image

      Bill Holland 4 years ago from Olympia, WA

      Not a trivial matter at all and should be paid close attention to. I have had two friends commit suicide and it is devastating. Very useful and valuable hub.

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thanks. I agree. I have known people who committed suicide too and in several cases signs were missed. Sometimes it's not what people say, it's what they are not saying! I do know that if someone is intent on suicide it is extremely difficult to stop them unless urgent and intensive help is offered.

    • Om Paramapoonya profile image

      Om Paramapoonya 4 years ago

      This was such an interesting read, meloncauli. I agree that sometimes there can be serious flaws in depression assessment. Routine questions and superficial observation may not be enough in some cases. Back when I worked as a receptionist at a university's psych counseling center, I got to know a few very skilled crisis workers. Despite years of experience, they could still misdiagnose the severity of certain patients' depression sometimes. Being a crisis worker is incredibly hard.

    • thewritingowl profile image

      Mary Kelly Godley 4 years ago from Ireland

      Good article I voted it up. Been there too many times, here in Ireland it is hard to find help and the services are sparse. Thankfully I have turned to reading a lot of psychology to understand why I get depressed that has helped me a lot to cope with it. Also the only thing that can get me through when I feel a real downer coming on is to just be able to write and get some of the negative emotions out. Take care.

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thanks for your comment. It must be very difficult I agree as you can't ultimately read someone's mind. I don't know what's it is like over in U.S, but over here in the U.K there is often little involvement in the crucial early stage of crisis with regards family involvement.

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thank you. 'Prevention is better than cure' as the saying goes and you sound like you are on top of things. Understanding your own personal signs of decline in mood and addressing that before it reaches crisis level is the way forward for all those chronic depression sufferers. I find writing is a great escape actually. No one can think what they are writing about and think negatively all at the same time! I haven't suffered badly for a very long time now but I do remember depression well and how it affects not just the sufferer but those around them too. Take care

    • krillco profile image

      William E Krill Jr 4 years ago from Hollidaysburg, PA

      Nothing like the 'wounded healer' to voice difficult truths of illness and pain. Good job, as always, well crafted.

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thanks krillco! Flaws should be exposed and you are right it is usually only the voice of the sufferer who is willing to expose. We should always recognise too that whilst 'experts' are all we have, those 'experts' have personal understandings and opinions that can interfere with good diagnosis.

    • gsidley profile image

      Dr. Gary L. Sidley 4 years ago from Lancashire, England

      You clearly have insight from your own personal experience into what it is like to attend an Accident & Emergency Department in a psychiatric crisis.

      I have some sympathy for workers in Crisis Resolution teams. As well as being in a very demanding and stressful job, I think the role of a "crisis" worker is ambiguous and they commonly lose their way, unsure as to whether their remit is solely short-term risk assessment/reduction or whether they should be formulating a deeper understanding of a person's problems (given that a crisis can provide a unique window into gaining this understanding).

      Authentic and thought-provoking hub - as always!

      Best wishes

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thanks gsidley. The husband of a friend of mine was sent home from the doctor to await a visit from the crisis team because he was severely depressed. She actually thought he was mildly depressed but it turned out the doctor thought it severe. When the crisis team arrived she said she would wait in the kitchen and see them after they had finished talking to her husband. (At this point they didn't suggest she joined them with permission from her husband). The next thing she heard was them saying their good byes at the door to her husband.

      She was furious! Her husband wasn't well enough to fully take in what was going on and of course didn't mind her being involved at all , but they didn't even say goodbye to his wife never mind give her any advice etc. She called them back, asked her husband in front of them if he minded and asked them to return to her lounge to answer her questions. If you look at crisis protocols, carers are supposed to be involved. This was a case of completely ignoring that! She was actually scared having been told by her husband that the doctor thought him severely depressed. The crisis team visit emphasised that to her. Personally, wherever possible I believe that close loved ones of a depressed patient can be a vital tool in the process of diagnosis and recovery.

    • gsidley profile image

      Dr. Gary L. Sidley 4 years ago from Lancashire, England

      That sounds like poor practice; a thorough assessment should utilise a range of information sources. It also was crass manners to ignore his partner.

    • leahlefler profile image

      leahlefler 4 years ago from Western New York

      meloncauli, how terrible that the crisis care workers didn't fully question to determine that you were truly struggling with severe depression. It is so important for healthcare professionals to recognize the signs of depression and to listen to their patients, and to probe for things that might not be apparent initially. Asking the simple question, "how are you able to keep up with taking care of yourself?" would go a long way in showing whether someone has lost interest in themselves. Lots of hugs to you, and what a great hub full of wonderful advice!

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thanks Leah. If you feel you are not being listened to or evaluated adequately then it's easy to fall deeper into depression.

    • krsharp05 profile image

      krsharp05 4 years ago from 18th and Vine

      This is definitely an issue to be taken seriously. With the recent death of my sister, two people in my family have been hospitalized for suicidal reasons. I think it's a subject that a lot of people would prefer to sweep under the rug and often it does leave a stigma but it's serious, that's for sure. Great hub. Useful and up! -K

    • meloncauli profile image
      Author

      meloncauli 4 years ago from UK

      Thanks krsharp05. You're right that a lot of people would prefer to sweep it all under a rug. Clinical depression isn't always as obvious as the text books say either! Hard job for staff but a service is only ever going to be as good as the people giving out the service! Thanks again for your comment.

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