Tackling depression with the Wheel of Life
Dr Ryan Hext
I am currently a GPST2. During my first six months of GPST1, I had a General Practice rotation. Over that time, I was exposed to a variety of complaints. One recurring theme involved general life stressors and low mood.
This consultation played out differently to that of a medical patient, with patients coming to us to open up about their stresses, and the aspect of the job where listening is important and we become councillors.
Initially with my inexperience, I found myself referring to talking therapy or prescribing anti-depressants but was faced with poor compliance and also a feeling that I hadn’t helped enough. I also fell into the trap of transference, at the end of each consultation I felt the weight of the patient’s problems without having felt I had contributed.
During one such consultation, I took notes, and summarized at the end with a wheel divided into sections for the patient, along with a suggested plan for each aspect. She thanked me for this and said that it gave her clarity into these issues, and from my perspective it allowed her to retain ownership of her issues.
Inspired by this, I started using a wheel of life when consulting with depressed or stressed patients as a tool to summarize their problems and agree an action plan. After using it on a small number, it received great feedback, with multiple patients saying it made things clearer, helped simplify their issues and empowered them to act. I showed it to my trainer and other colleagues who thought it was a really good idea and encouraged me to get in touch about it.
What is the wheel of life?
Essentially a pie chart divided into 5 sections:
- Self - how they feel about their own mood
- Hobbies and Interests
- Social Life
I have used different sections depending on the history given by a patient.
How to use it?
During a consultation with a stressed / depressed patient:
- Take a history and assess the patient for depression.
- Make a note of key points or stressors mentioned by the patient.
- Draw a circle and divide into key areas.
- Put the key points outside each specific area.
- Summarise the points with the patient.
- Explore any further information around these key points.
- Agree an action plan for each area of the circle by the next appointment before repeating the process.
A worked example
I saw a tearful 52 year old woman who described herself as going ‘through the mill’. Her mother had died a few months ago, she was undergoing a complex divorce and she felt victimised by a colleague at work. This colleague used to be a close friend but she now felt bullied by her. She lived with her son and daughter-in-law who had been invaluable support but they were planning to move North for her son’s rugby career. I delved further into how she was coping - further history showed no suicidal ideation but just a struggle to cope with the weight of multiple problems.
In my first six months, I have been amazed to see that this sort of presentation isn’t uncommon. Taking a clinical hat off and placing a councilling hat on, I found it incredible how well people deal with multiple issues and also found that, in these scenarios, medication isn’t the answer.
After this lady finished talking through her issues and I had taken note of her key problems, I drew a circle and divided it into 5 sections.
We went around the circle together agreeing bullet points of issues and I encouraged her to suggest an action plan for each problem with my own input. After finishing, she felt relieved to have talked through everything, felt it was all a lot clearer and more positive with clear short term goals. We agreed a follow up appointment for 7-10 days time to review how things were going. No medication was prescribed.
Over the next 3 appointments, things improved for her. Her work confrontation resolved after a simple discussion, her sister was helping to look for housing and work in Cornwall, she had a meal booked with a friend and had a date for talking therapy. The wheel was useful to re-draw and compare to the initial one showing visual improvement for the patient.
She had nothing but positive feedback for how it worked. I then used it with an older gentleman feeling hopeless because of limitations of chronic back pain, a lady with job dissatisfaction and marital problems and all said that the wheel made things clearer, gave them short term goals and made them feel that things were improving and each thanked me for helping.
Having only used this over my first six months, I understand there are positives and limitations from its use and it may not work for everyone. Questions revolve around whether it would work on a larger variety of patients and work for different Doctors, will it hold up over 10 minute appointments - as a trainee I have used it over 20, and finally where to keep it - a paper storage system or should patients hold on to it empowering them to bring it to each appointment to review progress?
Despite the questions, my experience of its use has given me a more active role in consultations and guided patients toward solving their own problems at a time when things can feel overwhelming.