Full Answer Section

1. The questionnaire mentioned some things like feeling down, having trouble sleeping, or changes in appetite. Have you been experiencing any of those?” (Be prepared for her to say yes to many of them given the score.)

   I would also ask about the duration and severity of these symptoms.

2. Assess Safety: It’s crucial to assess for any immediate safety concerns. Directly, but gently, ask about thoughts of self-harm or suicide:

   “Kylie, sometimes when people are feeling this low, they have thoughts of hurting themselves. Have you had any thoughts like that?”

   This is a critical question, and it’s essential to be direct and non-judgmental. If she expresses suicidal ideation, I would follow established protocols for immediate intervention, which might include involving a mental health specialist or crisis team.

3. Inquire About Anxiety/Trauma: Given her easily startled demeanor and posture, I would gently explore the possibility of anxiety or past trauma:

   “I’ve also noticed you seem a little on edge. Have you been feeling more anxious or worried than usual? Or have there been any experiences recently that might have been particularly upsetting or difficult?”

   Again, sensitivity and empathy are paramount. I wouldn’t push if she’s unwilling to share, but I would make a note of my observations.

4. Address the Allergy Medication Refill: After addressing the more pressing concerns, I would acknowledge her initial reason for the visit:

   “I also wanted to take care of that allergy medication refill for you. Is the current medication working well for you?”

5. Collaborative Plan: Based on her responses, I would work with Kylie to develop a plan. This might include:

   • Referral to Mental Health Specialist: This is highly recommended given the PHQ-9 score. I would explain the benefits of therapy and/or medication for depression and offer referrals to mental health professionals in the area.
   • Further Evaluation: If there are concerns about anxiety or trauma, I might suggest further evaluation by a specialist.
   • Follow-up Appointment: Schedule a follow-up appointment to check in on her progress and ensure she’s connected with appropriate resources.
   • Safety Plan: If there are any safety concerns, we would collaboratively develop a safety plan, including coping strategies and emergency contacts.

6. Documentation: Thoroughly document all aspects of the interaction, including her PHQ-9 score, her reported symptoms, my observations, and the plan we developed together.

Important Considerations:

• Confidentiality: Maintain patient confidentiality while adhering to legal and ethical obligations regarding safety concerns.
• Empathy and Support: Approach the situation with empathy, compassion, and a genuine desire to help.
• Professional Boundaries: Maintain appropriate professional boundaries.
• Collaboration: Consult with other healthcare professionals, such as mental health specialists, as needed.

This situation requires a holistic approach, addressing both her physical and mental health needs. My goal is to provide Kylie with the support and resources she needs to manage her depression and improve her overall well-being.