Patient counselling is defined as providing medication information orally or in written form to the patients or their representatives on direction of use, advice on side effects, precautions, storage, diet and life style modifications.

Objective of patient counselling:

1. Patient should recognize the important of medication for his well-being.
2. A working relationship and a foundation for continuous interaction and consultation should be established.
3. Patient under stand of strategies to deal with medication side effects and drug interaction should be improved.
4. Should ensure better patient compliance.
5. Patient becomes an informed, efficient and active participant in disease treatment and self-care management.
6.  The pharmacist should be perceived as a professional who offers pharmaceutical care.
7.  Drug interaction and adverse drug reaction should be prevented.

Patient counselling consist of three stages:

1. Introduction
2. process content and issue regarding manner
3. Conclusion

1. Introduction

• Review the patient’s records, introduce yourself and explain purpose of counselling.
• Obtain drug related information such as allergies, use of herbals etc.
• Assess the patient understanding of the reason for therapy.
• Assess any actual and potential concerns or problems of  importance to the  patients.

2. Process content and issues regarding manner

• The medicine’s generic and brand name
• How it helps the patient
• How it makes him /her feel

• How long it takes to being working
• How much to take at one time
• How often to take the medicine
• How long it will be necessary to take the medicine

• When to take it: before, during, after meals? At bed time? At any other special times?
• How to take it? With water?  With fruit juice? How much?
• What to do if you forget to take it (miss the dose)
• Foods, drinks or other medicines that you should not take while taking the medicines
• Restrictions on activities while taking the medicines
• Possible side effects. What to do if they appear. How to minimize the side effects. How soon they will go away
• When to seek help if they are problems
• How long to wait before reporting no change in symptoms
• How to store the medicine and its expiration date
• The cost of the medicine
• How to have your prescription refilled, if necessary
• Necessity to complete the course
• Drug-Drug, Drug-Food interactions
• Supply medication remainder chart

Issues regarding Manner:

• Use language that the patient understands
• Use appropriate counselling aids
• Present facts and concepts in simple words and in logical order
• Use open ended questions.

3. Conclusion

• Verify the patient’s  understanding by means of feedback.
• Summarise by emphasizing key points.
• Give an opportunity to the patients to put forward any concerns.
• Help the patient to plain follow-up. [1]

Patient counselling for depression :

Depression, or major depressive disorder, is a prevalent and severe medical condition that adversely affects how you feel, think, and act. It often manifests as persistent feelings of sadness and a marked loss of interest in activities you once enjoyed. This condition can lead to a range of emotional and physical issues, significantly impairing your ability to perform at work and home. Depression is characterized by various symptoms, which can fluctuate in intensity. One of the challenges in dealing with depression is that the very nature of the disorder can delay the decision to seek help. However, it is important to note that depression is treatable, and with the right interventions, individuals can manage their symptoms and improve their quality of life.[2]

Types of Depression:                                              

1. Major Depressive Disorder (MDD): Characterized by persistent and intense feelings of   sadness and loss of interest in activities.
2. Persistent Depressive Disorder (PDD): A chronic form of depression with symptoms lasting for at least two years, often less severe than MDD but more enduring.
3. Bipolar Disorder: Involves episodes of depression alternating with periods of mania or hypomania.
4. Postpartum Depression (PPD): Depression that occurs after childbirth, affecting a mother's ability to care for her new-born.
5. Premenstrual Dysphoric Disorder (PMDD): Severe depression symptoms, irritability, and tension before menstruation.
6. Seasonal Affective Disorder (SAD): Depression related to seasonal changes, typically worsening in the winter months.
7. Atypical Depression: Characterized by mood reactivity, significant weight gain or increased appetite, excessive sleep, and a heavy feeling in the limbs.[3]

Symptoms of Depression:

Depression can occur multiple times throughout life, with episodes characterized by symptoms experienced most of the day, nearly every day. These symptoms may include:

• Feelings of sadness, tearfulness, emptiness, or hopelessness
• Angry outbursts, irritability, or frustration, even over small matters
• Loss of interest or pleasure in most or all normal activities, such as sex, hobbies, or sports
• Sleep disturbances, including insomnia or sleeping too much
• Tiredness and lack of energy, making even small tasks challenging
• Reduced appetite and weight loss or increased cravings for food and weight gain
• Anxiety, agitation, or restlessness
• Slowed thinking, speaking, or body movements
• Feelings of worthlessness or guilt, fixating on past failures or self-blame
• Trouble thinking, concentrating, making decisions, and remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts, or suicide
• Unexplained physical problems, such as back pain or headaches [4]

Depression Symptoms By Age Group:

Children: Although depression is rare in children under 12, it can still occur. Symptoms include sadness, school difficulties, loss of interest in activities, changes in eating habits, anxiety, and avoiding social interactions. Causes may include family stress, abuse, or the loss of a pet or loved one. Early therapy can be helpful, and parents should seek referrals from a paediatrician or school counselor if needed.

Teens: While mood swings are common in teens, persistent changes in mood, irritability, feelings of worthlessness, or self-harm behaviours may signal depression. Factors such as peer pressure, hormonal changes, sleep issues, and social rejection can contribute. Parents should approach the topic gently and seek medical advice to rule out physical causes and possibly consult a mental health professional.

Young Adults( 19-29): Depression in individuals aged 19 to 29 can stem from major life transitions, relationship problems, or a lack of support. Encouraging them to build a support network and seek therapy is important. They should also be encouraged to discuss symptoms with a healthcare provider.

Midlife Adults (30-69): People aged 30 to 60 may experience depression due to stressors like caring for children and aging parents, financial issues, or health concerns. Symptoms might include substance abuse, anger, or risky behaviour. It's important to encourage them to talk about their concerns, practice self-care, and consult a doctor for evaluation and treatment.

Senior Adults(70+): Depression in older adults is common but often goes unnoticed. Symptoms include sleep problems, fatigue, persistent sadness, and mood changes. Factors like social isolation, loss of a spouse, and health issues can contribute. Encouraging social engagement and a discussion with a doctor can help, as treatment can improve their well-being.[5]

Causes Of Depression:

Several factors are believed to contribute to the development of depression:

• Brain chemistry: Imbalances in neurotransmitters like serotonin and dopamine play a role in depression.
• Genetics: Having a first-degree relative with depression increases your risk by about three times, though it can occur without a family history.
• Stressful life events: Experiences such as losing a loved one, trauma, divorce, or isolation can trigger depression.
• Medical conditions: Chronic pain and illnesses like diabetes are linked to depression.
• Medications: Some drugs and substance use, including alcohol, can cause or worsen depression.
• Biological differences: Individuals with depression often show physical changes in their brains. While the exact significance of these changes is not yet fully understood, they may eventually help identify the causes of depression.
• Hormones: Shifts in the body's hormone balance can contribute to the onset or triggering of depression. These changes may occur during pregnancy, after childbirth (postpartum), or due to conditions such as thyroid issues, menopause, and other health factors.[6]

Need For Patient Counselling:

Patient counselling for depression is crucial as it significantly enhances treatment effectiveness, improves symptom management, and empowers individuals. The integration of counselling with medication can lead to better outcomes and increased compliance with treatment. Notably, cognitive-behavioural therapy (CBT) effectively reduces depressive symptoms and prevents relapses. Counselling also fosters emotional resilience and equips patients with coping strategies, enabling them to recognize early warning signs of depression and implement effective strategies promptly. Counselling emphasizes the importance of a collaborative and supportive therapeutic alliance between the patient and the counsellor. This relationship is foundational to achieving success in therapy, as a trusting environment allows individuals to express their thoughts and feelings freely. The process not only draws on the expertise of mental health professionals but also actively involves patients, facilitating their personal growth and self-awareness. Moreover, it helps improve overall quality of life by addressing personal issues and enhancing support systems. ?Overall, patient counselling plays a vital role in managing depression and supports individuals towards long-term recovery.[7]

Strategies To Improve Patient Counselling:

Consider a broad psychiatric diagnosis when assessing a patient with depressed or anxious mood, as misdiagnosis is frequent and negatively affects outcomes. Make specific and appropriate referrals to specific form psychotherapy, such asInter personal therapy(IPT),cognitive-behaviour therapy (CBT) andproblem solving therapy(PST). Providing key educational messages at the beginning of treatment can enhance treatment adherence, particularly with regard to antidepressant medication use. Early monitoring for adherence, treatment response and side effects can improve adherence and outcomes. Treat depression until remission in order to decrease relapse rate. Change treatment after 6 weeks, if there is no or very minimal response to initial medication. Evaluate every anxious or depressed patient for alcohol or drug abuse.[8]

Make specific and appropriate referrals for psychotherapy:

Just as there are specific medications, there are specific forms of psychotherapy. Patients with anxiety disorders in particular, benefit from cognitive behavioural therapy (CBT), in which they undergo exposure to their fears and gain mastery over them. There are several forms of effective psychotherapy for depression, including CBT and interpersonal therapy. Non-specific ‘supportive’ therapy can help people in times of crisis or stress but is typically not efficacious for serious mental health disorders. Family therapy or behavioural marital therapy can be effective when dysfunction in families or couples is a primary driver of the patient's depressive symptoms. Providers should be aware of local therapists who practice evidence-based forms of treatment.

Counselling Strategies

Education and negotiation

When managing depression, it's crucial to educate patients about the nature of their condition. They should be informed that depression is a common illness, producing genuine symptoms, and that these symptoms are not due to personal failure or "craziness." It’s helpful to explain that depression often stems from a biological predisposition, which can be triggered by life stress. With appropriate treatment, depression typically improves, though patients should be aware that relapse can occur if treatment is stopped, necessitating long-term management or follow-up. After providing this information, it’s important to gauge the patient's willingness to accept a diagnosis of depression. If there is any resistance, healthcare providers should explore the patient's concerns or other potential health conditions they might be worried about. Some patients might not readily accept a depression diagnosis without ruling out other medical issues. Once the diagnosis is accepted, the patient should be informed about the various treatment options available. They should be involved in deciding on the treatment plan and the goals they hope to achieve. This collaborative approach helps in clearly defining the treatment process, which can otherwise be vague and frustrating. Engaging patients in their care can improve disease management, functional health, and the relationship between patient and physician. Research shows that when psychiatrists work with patients to identify specific treatment goals, it leads to better symptom management, higher compliance with follow-up visits, and greater patient satisfaction.

Increasing pleasurable activities

Encouraging patients with depression to participate in enjoyable and rewarding activities is a crucial part of treatment. These activities can help reduce symptoms by providing a break from negative feelings and giving patients something positive to anticipate. Engaging in pleasurable activities can also help shift their perspective to view themselves and their lives more positively. To identify activities that might be beneficial, physicians can ask questions like, "Have you recently experienced anything that made you feel even a little better?" Based on the patient's responses, doctors can then collaborate with them to increase their involvement in these positive experiences. Recommendations might include pursuing hobbies, spending more time with family and friends, or taking a vacation. These simple steps can complement other treatments and support overall well-being.

Supportive listening

Supportive listening involves empathically hearing patients describe their issues and concerns, which can be beneficial in itself. When physicians use phrases like "I understand why you might feel that way" or "You seem to be managing as well as can be expected," they provide validation and reassurance. These supportive comments can help counteract negative self-thoughts and improve the patient's self-esteem by demonstrating genuine concern. Furthermore, through attentive listening, physicians can evaluate several key aspects: how much of the stressful situation can be addressed, the significance of the patient's thoughts and feelings about it, and the accuracy of those thoughts and feelings. This approach not only supports the patient emotionally but also aids in developing a deeper understanding of their situation.

Problem solving

Helping patients solve problems can reduce their distress and enhance their feelings of control and effectiveness. For individuals with depression, successfully resolving even small issues can improve their sense of competence and hope. This, in turn, may make them more willing to address other challenges and contribute positively to their overall well-being.

Adjusting Expectation

When patients face issues that can’t be altered, physicians can guide them in adjusting their expectations. This might involve helping patients recognize that perfection is unattainable or that things could be worse. The gap between what patients expect and what they actually experience often causes distress. By helping patients align their expectations with reality, physicians can reduce their emotional discomfort.

Modifying Negative thoughts

Addressing negative thoughts is vital for managing depression. Patients often have distorted beliefs about themselves or their situations that can increase distress. Using a log to track moods, triggers, and thoughts helps patients see that negative thoughts, rather than events, influence their feelings.

Counseling can then focus on identifying and challenging these distorted thoughts. Patients can be encouraged to:

1. Examine the events leading to their thoughts.

2. Evaluate evidence supporting or contradicting their beliefs.

3. Consider more realistic alternatives.

4. Identify information that might help alter their thoughts.

If needed, practical methods such as seeking others' opinions, testing feared outcomes, or weighing the pros and cons of negative thoughts can help patients adopt more balanced perspectives.

Recommending self-help materials

Self-help materials can complement the guidance given during medical visits by offering additional education and counseling. They provide broader information than what can be covered in an office visit, allowing physicians to concentrate on the patient’s specific needs. Studies show that self-help books, particularly those with cognitive and behavioural approaches, can significantly reduce depressive symptoms in older adults for up to two years when used as a primary treatment for mild to moderate depression.[9]

Essential Components Of Depression Counselling

Psychotherapy

Psychotherapy, often referred to as talk therapy or counseling, helps people with depression by introducing new thought patterns and behaviours and addressing habits that contribute to the condition. This therapy is provided by a licensed mental health professional and can take place in individual or group sessions. Therapy can be successfully delivered both in-person and through telehealth, with additional support from digital tools like apps. Effective treatments for depression include cognitive behavioural therapy (CBT) and interpersonal therapy. Other approaches, such as brief psychodynamic therapy, may also be beneficial for some individuals.

Cognitive behavioural therapy (CBT)

Cognitive Behavioural Therapy (CBT) is a structured psychotherapy designed to address mental health issues by focusing on changing negative thought patterns and behaviours. Key principles include:

1. Identifying Negative Thoughts:Recognizing and challenging unhelpful thoughts that contribute to psychological problems.

2. Behavioural Changes: Addressing harmful behaviours and learning healthier alternatives.

3. Modifying Core Beliefs: Altering fundamental beliefs about oneself and the world to improve mental health.

4. Developing Coping Skills: Teaching effective strategies to manage symptoms and enhance emotional well-being.

CBT typically involves a set number of sessions where individuals explore their thoughts and emotions, and work to adopt more positive patterns. It can be used alone or with other treatments, tailored to individual needs.[10]

Interpersonal therapy (IPT)

 IPT focuses on interpersonal and life events that impact mood and vice versa. IPT aims to help people improve their communication skills within relationships, form social support networks, and develop realistic expectations to better deal with crises or other issues that may be contributing to or worsening their depression.[11]

Problem solving Therapy (PST)

Problem-solving therapy (PST) is a psychotherapy approach that focuses on developing coping skills to handle challenging life situations. Unlike psychodynamic therapy, which examines both current issues and their deeper origins, PST targets immediate problems directly.

Also known as:

- Short-term therapy                                                 

- Problem-solving treatment

- Structured problem solving

If your depression is related to everyday problems, your doctor may recommend PST to help you create strategies to address these issues, potentially reducing your depression symptoms.[12]

Family and Couple therapy

Family and couples therapy involves attending sessions with your partner or family members to address issues that may be contributing to your depression. This approach allows you to work together to improve communication, resolve conflicts, and support one another in managing the challenges that affect your mental health.

Psychodynamic physiotherapy:

Psychodynamic psychotherapy involves exploring past experiences, such as childhood events, to understand how they may be influencing your current behaviour. By gaining insight into these underlying factors, you can work to reduce their impact on your present life.[11]

Complementary medicine: This includes treatments used alongside traditional Western medicine. Therapies like acupuncture, massage, hypnosis, and biofeedback can enhance well-being, especially for those with mild depression or persistent symptoms.

Brain stimulation therapy: This approach is beneficial for individuals with severe depression or depression accompanied by psychosis. It includes treatments such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagus nerve stimulation (VNS).[13]

Psychotherapy compared with anti-depressants:

When considering antidepressant medication as part of your treatment plan, it's essential to be well-informed about the different types of antidepressants, their potential benefits, and possible complications.

Types of Antidepressants:

Here's a concise overview of antidepressant categories:

1. Introduction Patient counselling Ahamed Dawood, MBA
2. SSRIs (Selective Serotonin Reuptake Inhibitors): Increase serotonin levels, commonly first-line due to effectiveness and fewer side effects.
3. SNRIs (Serotonin/Norepinephrine Reuptake Inhibitors): Boost serotonin and norepinephrine levels, used for depression and anxiety.
4. TCAs (Tricyclic Antidepressants): Older antidepressants effective for treatment-resistant depression, with more side effects.
5. Atypical Antidepressants: Includes varied mechanisms and side effect profiles outside typical classes.
6. Serotonin Modulators: Target serotonin receptors for depression and mood disorders.
7. MAOIs (Monoamine Oxidase Inhibitors): Oldest antidepressants for treatment-resistant cases, with dietary restrictions and risks.
8. NMDA Antagonists (N-methyl-D-aspartate): Target glutamate receptors, used in specific depression cases[14]

Counselling Regarding Lifestyle Modification