10 mins
Mental health screening as part of your consultation process
Julie Scott explains why understanding the psychological landscape of patients is crucial
JULIE SCOTT
Julie Scott is an NMC registered independent nurse prescriber, level 7 qualified aesthetic injector and trainer with over 30 years of experience in the field of plastics and skin rejuvenation. As an aesthetic mentor and international speaker, Scott has won ‘Aesthetic Nurse Practitioner of the Year’ at the Aesthetic Medicine Awards in 2024, and at the Aesthetic Awards in 2024 and 2022.
The integration of mental health screenings into aesthetic consultations has emerged as a best practice that not only enhances patient care but also significantly improves treatment outcomes. This article will explore the importance of mental health assessments, effective screening tools, and practical strategies for building trust with patients, supported by real-life examples demonstrating the benefits of this approach.
THE IMPORTANCE OF UNDERSTANDING PSYCHOLOGICAL FACTORS
Psychological factors play a crucial role in a patient’s decision to seek aesthetic treatments. Many individuals pursue these procedures with the belief that physical improvements will translate into enhanced self-esteem, social acceptance, and overall happiness. 1 However, this assumption can often lead to unrealistic expectations. As practitioners, we must recognise that the pursuit of improved physical appearance is often a means to a psychological end. 2
There are certain periods in life where psychological impacts are greater; research indicates that nearly 40% of women report mood changes during perimenopause, a stage characterised by significant hormonal fluctuations and emotional vulnerability. 3,4 For many women, these changes can amplify feelings of inadequacy, leading to an increased desire for aesthetic enhancements as a form of self-care. Understanding the psychological drivers behind the motivations of your patient demographic is essential for providing appropriate care.
Furthermore, studies have shown that women with a history of mental health disorders, such as anxiety or depression, may be particularly vulnerable during menopause. For instance, the instance of developing depressive symptoms can increase significantly during this transitional period, highlighting the need for practitioners to be vigilant and proactive in their assessments. By understanding these psychological factors, practitioners can make informed decisions regarding treatment suitability and develop tailored approaches that prioritise both physical and mental health. 5
THE CONSULTATION PROCESS
At the heart of our practice lies a commitment to cultivating mutual respect and rapport with our patients, with a thorough consultation process serving as our cornerstone. By prioritising comprehensive assessments, we can identify patients with psychological concerns early on, including those who may struggle with body dysmorphic disorder (BDD) and other mental health conditions.⁶ This diligent patient selection not only helps us avoid difficult situations but also fosters trust and understanding. Managing expectations and delivering educational content throughout the consultation and aftercare process significantly reduces the likelihood of patient dissatisfactions, ensuring that each individual feels valued and supported during their treatments.
The following is the process that I adopt with my patients.
1. Pre-consultation education:
• Patients often follow aesthetic accounts on social media for years, absorbing information passively. To engage these patients proactively, I provide valuable insights through platforms like Instagram and my clinic’s website.
• This foundational education sets the stage for informed discussions during the actual consultation.
2. Detailed consultation appointment:
• I carry out a full medical history assessment, including a thorough mental health and body dysmorphic disorder (BDD) screening. Tools such as the Patient Health Questionnaire-9(PHQ-9) allow for an effective assessment of depressive symptoms. 7,8
• I employ a ‘patient passport’ framework and adopt ‘insights discovery colours personality types’ communication tool to tailor the interaction to each patient’s needs. 9
• My consultation is a 60-minute private and confidential educational experience, prioritising active listening. I conduct a detailed skin assessment and document baseline clinical photos, which serve as critical references for future treatments.
3. Addressing concerns:
• During the appointment, I discuss the patient’s presenting complaints without bias, ensuring there is no ‘planting of seeds’ or judgment. This helps foster an open dialogue about expectations and concerns regarding potential treatments.
4. Formulating treatment plans:
• A clinically indicated treatment plan is developed collaboratively. If a patient is deemed unsuitable for treatment, I refer them to a specialist network or the NHS pathway for appropriate mental health support.
5. Ongoing patient support:
• Following treatment, a post-care regime ensures that patients feel supported.
• I emphasise the importance of a six-month treatment plan review to monitor patient satisfaction.
EFFECTIVE SCREENING TOOLS
Implementing effective mental health screening tools is a vital component of the consultation process. Two widely used diagnostic tools in aesthetic medicine are the PHQ-9 and the Veale body image questionnaire. 7,8
• PHQ-9: Designed to assess the presence of and severity of depression and helps identify patients who may require further evaluation or intervention. 10 The questionnaire consists of nine questions related to mood and behaviour over the past two weeks. Scores help determine the severity of depressive symptoms and help guide treatment decisions.
For example, a patient who scores high on the PHQ-9may reveal underlying issues related to self-image and mental health that warrant further exploration before proceeding with aesthetic procedures.
• Veale body image questionnaire: This tool specifically targets body image concerns, which are critical to assess in aesthetic practices. 5 The questionnaire helps identify patients who may be experiencing BDD or other body image issues. Those exhibiting significant distress regarding their appearance may require a referral for psychological support rather than aesthetic treatments.
Integrating these screening tools into the initial consultation and ongoing patient monitoring allows practitioners to gain valuable insights into the patient’s mental health status and help tailor treatment plans accordingly. By doing so, practitioners can identify potential psychological vulnerabilities, ultimately leading to more informed and compassionate care.
BUILDING TRUST WITH PATIENTS
Creating a trusting and open environment is essential for effective consultations. Patients need to feel comfortable discussing their insecurities and motivations. Here are some techniques for building that trust:
• Active listening: One of the most important skills in establishing rapport is active listening. 11 When patients feel heard, they are more likely to open up about their concerns. Practitioners should practice reflective listening, summarising what the patient has said to ensure understanding and validate their feelings.
• Empathy and understanding: Demonstrating empathy goes a long way in fostering trust and acknowledges the emotional aspects of patients seeking aesthetic treatments. 12 For example, expressing an understanding of how societal pressures can impact a woman’s self-image during menopause can create a deeper connection.
• Transparent communication: Being clear about the consultation process and what patients can expect. 13 Providing accessible information about treatment options, risks, and potential outcomes encourages informed decision-making. Transparency also includes discussing the limitations of aesthetic procedures in addressing deeper psychological issues.
• Encouraging questions: Encourage patients to ask questions and express any concerns they may have. This not only demonstrates openness but also helps clarify any misunderstandings about the treatment process.
CASE STUDY: PRIORITISING MENTAL HEALTH
A patient presented to my clinic for the first time after recently going through a divorce. It was immediately evident from this initial meeting that her self-esteem was extremely low and that she was vulnerable. With this confirmed by her responses to the PHQ-9questionnaire, I explained that it would not be in her best interest to proceed with treatment at this time as she may be seeking to resolve a concern separate to her appearance through aesthetic means. Furthermore, she was not best placed to navigate potential dissatisfaction with the results, or possible complications. I instead referred her for counselling and suggested she return when she felt more secure in herself – which she did eight months later, feeling radiant after her treatment.
CASE STUDY: THE CANDID DISCUSSION
A patient sought treatment from me after having seen another practitioner elsewhere before. She presented as clearly overtreated and as our consultation progressed my assessment and application of the Veale Body Image Questionnaire made evident that she was symptomatic of BDD. An open conversation was necessary in which I explained that it would be inappropriate to proceed with a treatment as she was already overfilled and displaying signs of BDD. Instead, I felt it best to refer her to mental health support. On this occasion the patient left angry, but I still believe this was the correct decision. As practitioners we are in a position where doing the right thing is not optional and practitioners should always prioritise ethics over profit.
CASE STUDY: POSITIVE REINFORCEMENT
Another patient in her early twenties approached me about treatments to reach her aesthetic ideal of a slim jaw and defined chin - an outcome she was striving for as a result of social influence. I discussed with this patient at length how her proportions were in harmony with her own facial features and that treatment was not appropriate. It was important to reassure her that there is no need to conform to a norm and that embracing one’s own beauty is paramount. She left my clinic with only an SPF and instructions to take care of their skin. In return, I received a review in which the patient stated ‘I am beautiful’ – I’ll take that!
“These real-life examples highlight that incorporating mental health screenings into your consultations is not just best practice; it is essential for holistic patient care. Understanding the psychological factors influencing a patient’s decision to pursue aesthetic treatments enables practitioners to provide informed, compassionate care tailored to individual needs.”
CONCLUSION
These real-life examples highlight that incorporating mental health screenings into your consultations is not just best practice; it is essential for holistic patient care. Understanding the psychological factors influencing a patient’s decision to pursue aesthetic treatments enables practitioners to provide informed, compassionate care tailored to individual needs. Our priority is always patient well-being, even if that means making difficult decisions to ‘Say No’ when a particular treatment isn’t in the patient’s best interest. While this can sometimes lead to disappointment of frustration, maintaining your integrity and upholding ethical standards is essential in providing safe and effective care.
Utilising effective screening tools like the PHQ-9and Veale body image questionnaire can uncover underlying mental health concerns, allowing for early intervention and appropriate referrals. 7,8 Building trust through active listening, empathy, and transparent communication fosters a supportive environment where patients feel valued and understood.
Ultimately, the integration of mental health screening into your practice is crucial for fostering a compassionate and effective approach to patient care. By adopting these practices, we ensure that our patients not only look their best but also feel their best throughout their treatment journey.
REFERENCES
1. Cash, T.F. (2000). The Body Image Workbook for Teens: Activities to Help Girls Develop a Healthy Body Image in Today’s World. New Harbinger Publications.
2. Grogan, S. (2016). Body Image: Understanding Body Dissatisfaction in Men, Women, and Children. Routledge.
3. Soares CN, Cohen LS. Perimenopause and Mood Disturbance: An Update. CNS Spectrums. 2001;6(2):167-174.
4. Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of Hormones and Menopausal Status With Depressed Mood in Women With No History of Depression. Arch Gen Psychiatry. 2006;63(4):375–382. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/209523
5. Cash, T.F., & Smolak, L. (2011). “Body Image: A Handbook of Theory, Research, and Clinical Practice.” Guilford Press.
6. Phillips, K.A. & Diaz, S. (1997). “Gender Differences in Body Dysmorphic Disorder.” The Journal of Nervous & Mental Disease 185(9):p 570-577. https://journals.lww.com/jonmd/abstract/1997/09000/gender_differences_in_body_dysmorphic_disorder.6.aspx
7. Kroenke, K., et al. (2001). “The PHQ-9: Validity of a Brief Depression Severity Measure.” Journal of General Internal Medicine, 16(9), pp. 606-613.
8. Veale, D., et al. (2016). “The Development of the Veale Body Image Questionnaire.” Body Image, 18, pp. 83-90. - https://www.veale.co.uk/scales/
9. Insights Discovery Colour https://blog.insights.com/en-gb/blog/the-essential-guide-to-insights-discovery-colour-energies-and-how-to-use-them-at-work Accessed 6/11/24
10. Spitzer, R.L., et al. (1999). “A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7.” Archives of Internal Medicine, 166(10), pp. 1092-1097. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/410326
11. Kennedy DM, Fasolino JP, Gullen DJ. Improving the patient experience through provider communication skills building. Patient Experience Journal. 2014; 1(1):56-60. https://pxjournal.org/journal/vol1/iss1/10/
12. Kahn, S. & Beech, D. (2015). “Building Rapport in Clinical Settings: The Role of Empathy.” International Journal of Health Care Quality Assurance, 28(7), pp. 693-705.
13. Y. Schenker, and A. Meisel, “Informed Consent in Clinical Care: Practical Considerations in the Effort to Achieve Ethical Concerns,” JAMA 35, no. 11 (2011): 1130-1131. https://jamanetwork.com/journals/jama/article-abstract/646101
* Neziroglu, F., et al. (2008). “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Review.” Cognitive and Behavioral Practice, 15(2), pp. 151-158. ** Phillips, K.A., et al. (2010). “Body Dysmorphic Disorder and its Treatment.” Psychiatric Clinics of North America, 33(3), pp. 495-510. ** Hagger, M.S. & Chatzisarantis, N.L.D. (2007). “The Social Cognitive Theory of Health Behaviour: A Meta-Analytic Review.” Psychological Bulletin, 133(1), pp. 128-145.