Evaluating Anhedonia With Patient-Centered Strategies

In part 2 of this Q&A, Brittany Albright, MD, MPH, founder and CEO of Sweetgrass Psychiatry, and Psych Congress Elevate faculty member, discusses 2 of her favorite strategies for treating patients who have anhedonia. Dr Albright shares an insightful, patient-centered approach to assessing and addressing this complex symptom of depression. From distinguishing between anticipatory and consummatory anhedonia to utilizing motivational interviewing and shared decision-making, Dr Albright emphasizes the importance of open-ended conversations, affirming patient experiences, and collaboratively building treatment plans.

Catch up on part 1 of this Q&A: Exploring Anhedonia in Psychiatric Care

Answers have been lightly edited for clarity. 

Psych Congress Network: How can clinicians better evaluate and manage anhedonia in their patients and what patient-centered strategies can be employed?

Brittany Albright, MD: Part of the challenge of anhedonia is, as clinicians, we're not well equipped to ask about it. We have basic surveys like the PHQ-9, but it's very generic and that doesn't really capture the essence of what anhedonia really is. There are 2 different types of anhedonia. There's anticipatory anhedonia, which is not having interest in pursuing anything. There's also consummatory anhedonia, which is what we think of as traditional anhedonia: being able to enjoy activities as they happen. When it comes to screening, we really need to touch on both types because anticipatory anhedonia is more common. In practice, I take the motivational interviewing stance and ask a lot of open-ended questions and put on my psychotherapy hat.

I love psychotherapy. Instead of going through a checklist, I want to know how things are going at home and in their relationships with loved ones. What are they looking forward to? Do they have any vacations planned? How are things at work? Are there any projects that they're excited about? How are they doing with their activities of daily living? Are they struggling to function? Are they able to get all their tasks done? 

I was able to give a talk at Psych Congress Elevate with one of my patients, Emily, who is a nurse. She had such a terrible experience with anhedonia, and it got to the point where she could still show up to work, but she couldn't take a shower. She couldn't make meals, so she was ordering food delivery constantly. The question I should have asked her was “how hard are you having to compensate to overcome your symptoms?” 

Emily pointed out that as a patient, she experienced a lot of shame. It took her months to have the courage to tell me she was struggling with activities of daily living, even though she was showing up to work every day and doing a fantastic job at her career. Because there's so much shame around anhedonia, we need to be more proactive about asking "Are you showering? Are you bathing? Are you able to prepare meals for yourself? Are you experiencing joy when you eat meals?" for example.

Again, I want to emphasize motivational interviewing, open-ended questions, and affirmation. Affirm the patient's experience, use reflective statements. For example, when Emily did finally tell me how much she was struggling with her ADLs, I just reflected to her, "that has to be so hard that you're someone that cares so much about your own wellness, but yet you can't shower every day because it's just too much effort." The last part of motivational interviewing is summary. When you see a patient and they tell you their story, summarize it, and that's a great way of checking in with them to make sure you are understanding them and to also validate the patient so that they know that they're being heard. This can be very easily done in just a few minutes.

There's also shared decision-making. Shared decision-making is what we should all be practicing, because at the end of the day, if our patients have not bought into the treatment plan, nothing else will matter. Patients with anhedonia struggle to follow through with tasks and with treatment plans. So, for example, a patient with anhedonia, I would love to say, "you're going to start exercising every day. You're going to go on the Mediterranean diet, you're going to take this medicine and you're going to get out and do one thing social every day." That sounds beautiful, right? Not going to happen. My job in the shared decision-making model is to present my patient with options, but then ultimately say, "this is not about me. This is about you. And what can you handle? What sounds reasonable to you at this time?"

I often say I have the easiest job in the world as a psychiatrist because my patients come up with their own solution and I just support their self-efficacy and guide them in the right direction using motivational interviewing. Often when I try to apply a therapeutic intervention to get them to overcome their anhedonia, they'll come up with their own plans, and it's so much more brilliant than my plans because they know what they love and enjoy. It's my job not to tell them what to do, but to elicit what brings them joy and hold them accountable to sticking with that. That's part of shared decision-making. We're a team, and I'm coming alongside them. I'm not telling them what to do. 

Brittany Albright, MD, MPH, is a Harvard-trained, double board-certified adult and addiction psychiatrist and the founder of Sweetgrass Psychiatry, the largest physician-owned psychiatry practice in South Carolina. After completing her undergraduate studies at Emory University, she earned medical and public health degrees from the University of New Mexico. Dr Albright completed her psychiatry residency at Massachusetts General and McLean Hospitals, where she served as Chief Resident of Addiction Psychiatry. She now serves as an Affiliate Assistant Professor at the Medical University of South Carolina, where she also trained in addiction psychiatry.

[Back to Part 1]