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Mood Disorder encompasses a spectrum of presentations.
This Case will help you to develop an understanding of what to look for to enable you to identify features present in persons with different types of Mood Disorder.
You will also be asked to think about appropriate plans of management.
Links
(L) Antidepressants – 26 March (L) Hauora Maori: Maori Mental Health and Wellbeing – 27 March (L) Epidemiology of Suicide – 30 March (L) Suicide Self-harm (L) Suicide panel discussion (L) Introduction to Medical Law in New Zealand – 25 March (L) Severe Depression and Bipolar Disorder – 13 April (L) Schizophrenia 1 [Patient Presentation] – 13 April (L) Antipsychotics – 17 April (L) Hypnotics and Anxiolytics – 17 April (L) Global Environment Changes and Health – 1 May
Learning outcomes
By the end of Case 15 students should be able to:
- Describe in discussion and in writing the main clinical features of depressive illness, recognising points of difference between sadness and depression.
- Demonstrate a knowledge of the risk factors for suicide.
- Use the “first-aider” approach to keep a potentially suicidal person safe until professional help is obtained.
- Discuss the importance of support for those affected by suicide.
- Describe difficulties in evaluating the efficacy of antidepressants and non-pharmacological therapies for depression.
- Have an overview of the atiology of depression.
- Understand the basic principles of formulation, using a simple framework, and how this relates to management.
- Know when to refer a depressed person on to a specialist mental health service.
Prep
- Access some personal stories of Kiwis who have experienced depression at https://depression.org.nz/is-it-depression-anxiety/stories/
- Bloch and Singh (2007) Chapter 4: “What Causes Mental Illness’ pages 64-68
Come to your Case tutorial having thought about the difference between someone who is distressed and someone who is ill. Look up the DSM-5-TR diagnostic criteria for major depressive disorder to help you do this. You can access a summary of these using the Medscape link below
Content
Task 1
Anastasia
Anastasia is a 47 year-old female accounts manager who attends her GP at the suggestion of a sympathetic work colleague. For the past 3 months she has been struggling to concentrate at work such that she is making uncharacteristic mistakes. She has also been unusually irritable. Today, when spoken to by her boss, she collapsed in tears.
She gives her GP an account of how she feels tired and lacking in energy and has been reflecting unhappily and pessimistically upon her life and achievements. She frequently wakes during the early hours and tends to ruminate on her problems at this time. In the mornings she feels tired and has none of her usual enthusiasm for the day. She is usually a keen reader and attends a book club but in recent weeks has been neglecting this. Although religious she admits that sometimes she now wonders if it is worth carrying on and whether or not she might be better off dead. Her husband, Rawiri, is kind and sympathetic but she feels he doesn’t really understand her distress. They have two children, a bright 17 year-old girl and an 18 year-old boy who has some cognitive impairment, the result of a head injury in a car accident when he was three. Over the past three months her son has become increasingly angry and difficult to manage at home. He is angry because his sister has been accepted into university while he still remains at high school for another year. It seems he cannot understand why he is older yet unable to attend university with his sister (and is unlikely to do so in the future due to his cognitive impairment). Anastasia reports feeling guilty about her son being upset as she was the person driving the car when he got injured, although it was not her fault the car crashed.
Family history An aunt with bipolar disorder who died by suicide about 5 years previously. Mother had a history of depression. An elder brother is well.
Personal History Mild depression age 18 years old Postnatal depression after first child
Physical Health Intact
Drug and Alcohol use She used to use cannabis as a young adult but has taken no illegal drugs for many years. She enjoys a glass of wine and admits that this has escalated in recent weeks so she is having about 3 glasses each day.
Mental State She looks miserable and is, unusually for her, dishevelled. She hesitantly and slowly but cooperatively responds to questions but when asked about thoughts of suicide she becomes tearful and then irritably snaps “what do you think?” She has lost weight; she is not sure how much and has completely lost interest in things. She appears to have no hallucinations or delusions but blames herself for her son’s head injury and feels hopeless and pessimistic for his future and that of the rest of her family. She is cognitively intact. She appears to accept that she is depressed but cannot see at present that things are likely to improve for her.
Jane
Jane is a 45-year-old female sales assistant who attends her GP because she has been having issues at work. Her husband is worried that she might be depressed and does not know how to help her. Jane reports that she has been feeling down over the past month, especially at work and has had a few sick days because of this. She lives with her husband and 19-year-old son.
She gives her GP an account of how during the week she sleeps well at night, but that sometimes she has difficulty getting out of bed in the morning, as she does not want to go to work. Jane has recently been promoted from sales assistant to sales manager. She reports being initially excited by this new role but has found the increased responsibility difficult to manage and sometimes feels “just useless”. She reports to having turned to “comfort eating”. Jane remains in contact with her friends and has enjoyed going out during the evening to her bridge club and having the odd social netball game. She describes the weekends as feeling better on Saturdays but on Sunday night, she begins dreading the beginning of the working week.
Family History Mother has some history of depression and anxiety and has been on antidepressants. Father died of a heart attack at age 60 years.
Personal History No history of depression or other mental illness.
Physical Health Intact
Drug and Alcohol use No history of any illegal drugs. No other medication. Jane reports enjoying drinking beer with her husband at the end of the day. She admits that this has increased since her promotion and during the week has approximately three beers a night to help her “get over the day”.
Mental State Jane presents with a slightly flat affect. She responds to all questions asked of her and appears tearful when discussing her work situation. When asked about thoughts of suicide she states that she “could never do that to my family”. Despite the reported “comfort eating” Jane has not gained weight since her pervious consultation. She has lost interest in work but appears to still find enjoyment in social activities. Jane appears to have no hallucinations or delusions. She seems pessimistic about her work situation and her ability to do her job. She is cognitively intact. Jane believes that her husband might be right and that she is depressed and needs antidepressants.
- Do Anastasia and Jane both have depression?
- What are the differences between being distressed and being ill [depressed]?
Task 2
- There are concerns that depression is over-diagnosed. Equally, others are of the view depression is under-diagnosed. In your teams, come up with three [3] reasons why depression might be under-diagnosed and three [3] reasons it might be over-diagnosed.
Task 3
- How would you describe this woman’s presentation to a colleague?
- Think about and record the patient’s symptoms.
- What risks does this patient present with [i.e. to self, others, vulnerabilities] and why is her past personal history important in determining this?
- What physical issues may be present with this patient?
- What effects would the patient’s symptoms have on their day-to-day functioning?
Task 4
