Case Presentation of Depression

Identification data:

Name: Rajeswari Tiwari Age: 36 Yrs. Sex: Female

Bed No: F-8 Marital Status: Married Religion: Hindu

Education: Madhyamik pass. Economic Status: Stable Language: Bengali

Father/spouse: Mr. Hriday Tiwari

Address: Vill: Nimpurdanga, P.O.- Kundala, P.S. Mayureswar, Dist. – Birbjum. Pin- 731246.

Occupation: House Wife Income: Nil.

Marital status: Married. Religion: Hindu.

Informant: Mother( Ms.Durga Shil)

Intimacy with the patient- Intimate.

Does the informant live with the patient- Sometimes.

Duration of relationship. Since Birth.

Interest of the informant in the patient’s property or money: Not present.

.

Presenting chief complaints

As experienced by patient: Patient’s own words-

“ Ami sob kichhu vule gecchilam, kauke chinte parchhilam na, ghum peto na, onnomonosko hoye jetam,

khide peto na, jokhon tokhon hasi peto- kanna peto, khub matha jontrona hoto –jeta osudh khele kome

jato. Khub voy lagto , mone hoto keu amar khoti kore debe , keu ghore dhuke guli kore debe, mone hoto

dupur bela ghore bagh dhuke jabe, kono kaj korar ichha nei, sobsomay bomi bomi vab lagto. Kono

kichhu valo lagto na , mone hoto more gelei valo hobe. ”

As described by the patient’s relative: Informant‘s own words.

“ O khub voy pachhilo , bachhader moto kore kotha bolchhilo, khub matha betha korto or, r kauke chinte

parchhilo na.”

History of present illness:

When symptoms are first noticed by the patient and by the relatives-

Duration: (days/ weeks /months/years).before 1 wk.

Mode of onset: acute (because 1wk).

Course: Continuous .

Intensity: Increasing.

Aggravating Factors:

Predisposing factors: No significant family history , but her father was very rigid type personality.

Precipitating factors: She is tortured mentally by her mother-in-law since her marriage. for 19 yrs.

Perpetuating factors: Recent quarrelling with her mother-in-law.

Description of present illness(chronological description of abnormal behavior, associated problem

like suicide, homicide, disruptive behavior thought content, speech, mood states, abnormal

perceptions etc): She had sleeplessness, decreased appetite, severe headache, absentmindedness, apathy

to work, fear of harm by others, nausea, slurred speech and nasal intonation of voice, and then mute. She

also had the suicidal ideation.

Has there been any change in personal habit of the patient, physical health : weight gain , sleep

pattern- decreased appetite- Poor, Nasal intonation of voice.

Are there any change in thinking and behavior of the patient: Yes, she is having changing in talking

way, nasal intonation of voice and child like behavior ( demanding of chocolate, biscuits etc, crying like

babies) during depression.

Treatment history:

Drugs :

Tab. Syndopa (110mg) 1- 1- 1.

Tab. Pacitone (2 mg.) 1-1-X.

Tab. Olimelt (5 mg.) X-X-1.

Tab. Zeptal-CR 1-X-1.

Tab. Rispond Play 1-X-1.

ECT: Nil.

Psychotherapy: Nil.

Family therapy: Nil.

Rehabilitation: Nil.

Past psychiatric history:

Number of previous episodes/ hospitalization (psychiatric) with onset and course: She is suffering

from depression since 5 yrs. She had 2-3 episodes per year and each episode lasts for 1 to 1.5 months. In

between the episodes she is having the low mood. No previous hospitalization required.

Before starting of this episode the patient became very fearful , but she could not express her fearfulness,

and she had collected a knife to kill her mother-in-law, but she never attempted so.

Complete or incomplete remission: Incomplete remission.

Duration of each episode: 1 -1.5 months.

Treatment details and its side effects if any: She is treated by local psychiatrist. She had severe vomiting

for 20 days of unknown medicine. Then treated this side-effect.

Treatment outcome: She is continuing treatment since 5 yrs, the treatment outcome is varying.

Details of any precipitating factors if present: Her mother-in-law is mentally torturing her since her

marriage.

Medical history:

Surgicalprocedures/accidents/headinjury/convulsions/unconsciousness/DM/HTN/CAD/Venereal

disease/HIV positivity/any other: She had Jaundice at her 3 yrs of age and dog bite at her 5 yrs of age and

she is having the history of unconsciousness after marriage, but it is now stopped for last 10 yrs. She is

also have the history of diphtheria before 5 yrs.

Has the patient been using additive drugs or alcohol: No.

Personal history:

i) Perinatal history.

Antenatal period: Maternal infections/ exposure to radiation/any complications: Premature dribbling at

last trimester.

Intranatal period: Type of delivery-normal delivery, Home delivery by local doctor.

Birth: Full term .

Birth cry: Delayed for 1 to 1.5 hrs.

Birth defects: No.

Postnatal complications: Nil.

ii) Childhood history:

Primary caregiver: Mother.

Breast fed/Artificial mode of feeding: breast fed

Age at weaning: 1 year.

Developmental milestone: Normal.

Behavior and emotional problems: Nail biting.

Illness during childhood: Jaundice at 3 yrs of age.

iii) Educational history:

Age at beginning of formal education: 6 yrs.

Academic performance: Average.

Specifically for Learning disability and Attention deficit disorders: Nothing significant.

Extracurricular achievements, if any: Singing, dancing.

Relationships with peers and teachers: Satisfactory.

School phobia: No

Look for conduct Disorders for example Truancy/Stealing: No.

iv) Play history:

Games played: (at what stage and with whom) : Preferred the indoor games with same age and same sex

friends.

Relationship with playmates: Good.

v) Emotional problem during adolescence:

Running away from home/Delinquency/Smoking/Drug taking/Any other: Running away from home

after the scolding from her father.

vi) Puberty:

Age at appearance of secondary sexual characteristics: 12 yrs.

Anxiety related to puberty changes: Mild.

Age at menarche: 12 yrs.

Regularity of cycles, duration of flow: Regular cycle, Flow- normal.

Abnormalities, if any (Menorrhagia , Dysmenorrheal ): Nil.

vii) Obstetrical history:

L.M.P: 28.01.2011

Number of children: 2 .

Any abnormalities associated with pregnancy, delivery, puerperium: No.

Termination of pregnancy, if any: No

Menopause: Still not come.

viii) Occupational history: She is a house wife.

Age at starting work: -

Jobs held in chronological order: -

Reasons for changes: -

Current job satisfaction: -

(Including relationships with authorities, colleagues, subordinates)

Whether job is appropriate to patient’s background:

ix) Sexual and marital history:

Type of marriage: self choice.

Duration of marriage: 19 yrs.

Interpersonal and sexual relations: Satisfactory.

Extramarital relationships if any specify:No.

x) Premorbid personality:

Interpersonal relationship: Introvert.

Family and social relationships: Healthy except with mother-in –law.

Use of leisure time: Reading religious books.

Predominant mood:optimistic; Stable.

Usual reaction to stressful events: Become fearful, and anxious.

Attitude to self and others : Good.

Attitude to work and responsibility: responsible.

Religious beliefs and moral attitudes: She is religious.

Fantasy life: Day dreams : No.

Habits:

Eating pattern : Regular.

Elimination: Regular.

Sleep: Regular

Use of drugs, tobacco, alcohol: No.

Family history:

Description (describe each family member briefly, age education, occupation, health status,

relationship with patient, age at death, mode of death.)

Are there any history of physical and mental illness in family?

Is there any use of alcohol or drugs in the family?

A family tree can be used to describe the number of family members, their age group and any death

occurring in the family. The following figures give an example of the family tree.

PHYSICAL EXAMINATION- Done on 08.03.2011. General appearance – The client appears silent and having apathetic look. Height- 5’3” Weight- 68 kg. Skin- Fair, skin tone is good. Head- Clean Eyes- Normal Ear- Normal Nose- Normal Mouth- Normal Neck- No abnormality detected Chest- Normal Abdomen- Soft Upper limbs- normal Lower limbs- Normal Back & spine- No abnormality detected

LABORATORY INVESTIGATIONS- On 14.02.11- Blood Hb% - 9.9 . TC- 15,000/ cmm. Neutrophil- 62%, Lymphocyte – 18%, Monocytes- x Eosinophil- 20% Platelets- 1.5 L/ cmm.On 15.02.11-

Blood Testing- FBS-136mg/dl Blood for Na- 137.6 Mg/dl., Serum K+ - 4.04 Mg./ dl. Sugar- 167 Mg/ dl. Urea- 27 Mg/dl. Creatinine- 1.0 Mg/ dl.

Blood for lipid profile- Cholesterol- 127 Mg/dl. Triglycerides- 164 Mg./dl.LFT- Bilirubin (Total)- 0.6 mg/dl , Direct – 0.2 mg/dl Indirect- 0.4 mg/dl. SGOT- 49 U/L SGPT- 62 U/L ALP- 233 U/L. Total protein- 7.5 gm/dl Albumin- 3.8 gm/ dl.

On 19.02.11- Plasma sugar- 109 mg/ dl.

MENTAL STATUS EXAMINATION( on 08.03.2011):

Date of doing MSE: 08.03.2011

Time of doing MSE: 10.30 a.m.

General Appearance & behaviour-

Level of consciousness: Fully conscious& alert

Appearance: Her age, overweight

Facial expression: Anxious, fearful

Eye-to-eye contact: Maintained but sometimes difficultly maintained

Physique: Endomorphic

Personal hygiene: Maintained

Posture: Closed posture

Gesture: Normal

Dress: According to season, Clean.

Gait: slow walk.

Motor activity: Decreased

Cooperativeness: Normal.

Rapport: Spontaneous.

Behaviour: Slight anxious and fearful.

Speech

Initiation: Speaks when spoken to, minimal

Reaction time: Slightly delayed

Rate: Slow

Productivity - Elaborate replies when asked for otherwise monosyllabic replies.

Volume: Soft

Amount: Paucity,

Tone: Monotonous nasal intonation of voice, Child like tone of voice.

Stream: Normal flow & rhythm of speech is normal.

Coherence: Fully coherent.

Relevance: Sometimes off target but otherwise relevant

Others: Nasal intonation of voice, childish voice.

Sample of Speech:

Q. Who are there in your house?

A. Amader barite ami, amar husband, amar dui chele meye, nonod ( Normal expression) ar amar sasuri ache( with little anxious look). Nonod to bidhoba tai amader sathei thake ( with normal expression).

Mood & Affect

Quality of mood: Anxious, fearful, and depressed.

Stability of mood: Affect labile, mood is flat.

Subjectivity (what patient says): ‘Amar monta valo nei, majhe majhe voi lagchhe, kichhu valo lagchhe na.’

Objectivity (what one observes): She is looking anxious, depressed and fearful.

Predominant mood state: Anxious, Fearful

Appropriate to thought content.

Thought

At formation level: Normal

At progression level: No flight of ideas or thought blocking.

At content level: No delusions but phobias to crowd, to darkness, to lonliness, & fear of being harmed by others.

Sample of speech:

Q. What are the thoughts coming in your mind?

A. “ Amar khub voy kore, andhokare thakte pari na, eka thakle khub voy lage, mone hoy keu jano ghore dhuke jabe, amake mere felbe, dupur bela eka thakle mone hoy ghore bagh dhuke jabe.”

Perception

Illusion: Not present.

Hallucination: Auditory hallucinations of some voices whispering about her.

Memory

Immediate:

Q. I’m telling you three things which you have to remember. After 5 minutes I’ll ask you have to tell the three thing. The three things are- tree, rice, and bird. (after 5 min.) Can you remember the three things?

A. “ Ha mone ache, gach, vaat r pakhi.”

Recent:

Q. what food did you have in your last dinner?

A. “ kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

Past:

Q. In which school were you studing?

A. “ ami Rajdanga Uchha Balika Bidyaloye Portam”. ( Verified from her mother)

Inference: Her immediate, recent and remote memory are intact.

Orientation

To time, date, day, month, year:

Q. Now what’s the time can you guess?

A. “ Ha ekhon to sakal bela, 10 ta sare 10 ta baje.”

Q. Can you tell me today’s date and day?

A. “ Ha, aj to mongolbar, ar 8 e Mach, 2011.”

To place: Q. Which place is this?

A. “ eta to Calcutta Medical College Hospital.”

To person:

Q. Can you tell me who am I?

A. (with smile) “Ha , aapni to sister didi.”

Inference: She is fully oriented to time, place and person.

Insight

Q. What do you think about illness- whether it is physical or mental illness.

A. “ Na, eta manasik asukh.”

Present fully.

Insight is rated on a 6 point scale & it is 6.

Judgement

Personal ( future plans):

Q. What will you do after going back to your home?

R. A. “ Ami bari gie ghorer e kaj kormo korar chesta korbo....jodi monta valo thake.”

Social(perception of the society):

Q. What will you do if you see that a 2 yrs old child alone in a busy road?

A. “ Ami bachha take gie dhore nie or barite firie debar chesta korbo.”

Inference: Her personal and social judgement is intact.

Attention & Concentration Attention: Aroused with slight difficulty.

Digit forward- Q. Can you count forward from 45 to 50?

A. “ 45, 46, 47, 48, 49, 50”

Digit backward- Q. Now can you count backward ?

A. “ 50, 49...47...46, 45”

Span of attention: Attention span is slightly impaired.

Ability to concentrate: Normally sustained

Names of months(backwards), Names of weekdays( backwards):

Q. Can you mention the name of the months and week days from backward?

A. “ Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar.”

“ December, November, October,.....September, ....August...July..June...May,....”

General Information

Knowledge about surroundings, festivals, sports, states, depending on patient’s socio-economic status & educational background.

Q. which is the national bird of our country?

A. “ Ha, mayur.”

Intelligence: Arithmetic ability:

Q. You have gone to market with 80 rupees, you bought 20 rupees vegetable, 25 rupees fish & 10 rupees dal, how much rupees are left with you?

A. “ hm...25 taka.”

Abstract reasoning:

Q. Can you explain the phrase “ nachte na janle uthon baka?”

A. “ Etar mane holo nije kichhu korte na parle onner opor dosh deoa.”

Inference: Her knowledge, intelligence and abstract reasoning are intact.

Special points-

Appetite: Slightly decreased..

Sleep: Decreased.

Bowels: Regular.

Bladder: Regular.

Libido: Normal.

Treatment: Continuing.

MENTAL STATUS EXAMINATION( on 09.03.2011)


Time of doing MSE: 11 a.m.









Gesture: Normal


Gait: slow walk.





Speech



Rate: Slow


Volume: Soft

Amount: Paucity,






Sample of Speech:

Q. Who are there in your house?

A. Amader barite ami, amar husband, amar dui chele meye, nonod ( Normal expression) ar amar sasuri ache( with little anxious look). Nonod to bidhoba tai amader sathei thake ( with normal expression).

Mood & Affect







Thought




Sample of speech:



Perception



Memory

Immediate:



Recent:

R. what food did you have in your last dinner?

B. “ kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

Past:

R. In which school were you studing?

B. “ ami Rajdanga Uchha Balika Bidyaloye Portam”. ( Verified from her mother)


Orientation







B. “ eta to Calcutta Medical College Hospital.”

To person:




Insight



Present fully.


Judgement


S. What will you do after going back to your home?

T. A. “ Ami bari gie ghorer e kaj kormo korar chesta korbo....jodi monta valo thake.”





Attention & Concentration

Attention: Aroused with slight difficulty.


B. “ 45, 46, 47, 48, 49, 50”


B. “ 50, 49...47...46, 45”





B. “ Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar.”


General Information


Q. which is the national flower of our country?

A. “ Ha, podma.”


Q. You have gone to market with 100 rupees, you bought 20 rupees vegetable, 30rupees fish & 10 rupees dal, how much rupees are left with you?

A. “ hm...40 taka.”

Abstract reasoning:

Q. Can you explain the phrase “ angur fol tok?”

A. “ Etar mane holo nije kichhu na pele nijeke evabe santona deoa.”


Special points-

Appetite: Normal.

Sleep: Adequate.

Bowels: Regular.

Bladder: Regular.

Libido: Normal.


MENTAL STATUS EXAMINATION( on 10.03.2011)


Time of doing MSE: 10 a.m.









Gesture: Normal


Gait: slow walk.





Speech



Rate: Slow


Volume: Soft

Amount: Paucity,






Sample of Speech:

Q. Can you explain your house?

A. Amader barite 5 ta room,ache, 1 ta amader, baki 2 to chele meyer, sasurir 1 ta , r nonoder 1 ta.( with normal expression).

Mood & Affect







Thought




Sample of speech:



Perception



Memory

Immediate:



Recent:

S. what food did you have in your last dinner?

C. “ kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

Past:

S. In which school were you studing?

C. “ ami Rajdanga Uchha Balika Bidyaloye Portam”. ( Verified from her mother)


Orientation







C. “ eta to Calcutta Medical College Hospital.”

To person:




Insight



Present fully.


Judgement


U. What will you do after going back to your home?

V. A. “ Ami bari gie ghorer e kaj kormo korar chesta korbo....jodi monta valo thake.”





Attention & Concentration

Attention: Aroused with slight difficulty.


C. “ 45, 46, 47, 48, 49, 50”


C. “ 50, 49...47...46, 45”





C. “ Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar.”


General Information


Q. which is the national bird of our country?

A. “ Ha, mayur.”


Q. You have gone to market with 60 rupees, you bought 20 rupees vegetable, 25 rupees fish & 10 rupees dal, how much rupees are left with you?

A. “ hm...5 taka.”

Abstract reasoning:

Q. Can you explain the phrase “ Dustu gorur cheye sunyo goyal valo?”

A. “ Etar mane holo asadhu manus thakar cheye na thaka valo.”


Special points-

Appetite: Normal.

Sleep: Adequate.

Bowels: Regular.

Bladder: Regular.

Libido: Normal.


DEPRESSIONINTRODUCTION: Variation of mood are a natural part of life. Like other aspects of the personality, emotions or moods serve an adaptive role. The four adaptive functions of emotions are social communication, physiological arousal, subjective awareness, and psychodynamic defense. Depression, a mood disorder, is a widespread mental health problem affecting many people.

DEFINITION: Depression: It is an abnormal extension or overelaboration of sadness and grief. The word depression can denote a variety of phenomena ( e.g. a sign, symptom, syndrome, emotional state, reaction, disease or clinical disorder).

Dipressive disorder: An illness characterized by depressed mood and loss of interest or pleasure in life.

INCIDENCE: The life time risk of depression in males is 8 -12% and in females it is 20-26%. It occurs twice as frequently in women as in men. The median age of depressive disorder is 18 yrs in males and 20 yrs in women. The highest incidence of depressive symptoms has been indicated in individuals without close interpersonal relationships and in persons who are divorced or separated. Prevalence of suicide shows large peak in the spring and a smaller one in October. Psychotic depression is uncommon, less than 10% of all depression.

CLASSIFICATION OF DEPRESSION- ICD-10.

F32 Depressive EpisodeF32.0 Mild Depressive EpisodeF32.1 Moderate Depressive EpisodeF32.2 Severe Depressive Episode Without Psychotic SymptomsF32.3 Severe Depressive Episode with Psychotic SymptomsF32.8 Other Depressive episodes- Atypical DepressionF32.9 Depressive Episode, unspecifiedF33 Recurrent Depressive Disorder

CONTINUUM OF EMOTIONAL RESPONSES:

PREDISPOSING FACTORSGENETICS OBJECT LOSS PERSONALITY COGNITION BEHAVIOURAL LEARNING BIOCHEMISTRY

PRECIPITATING STRESSORS LOSS LIFE EVENTS ROLES PHYSIOLOGY

APPRAISAL OF STRESSOR

COPING RESOURCES SOCIAL SUPPORT ECONOMICS SENSE OF MASTERY

COPING MECHANISMS

CONSTRUCTIVE DESTRUCTIVE

CONTINUUM OF EMOTIONAL RESPONSES

ADAPTIVE RESPONSES MALADAPTIVE RESPONSES Emotional Uncomplicated Suppression of Delayed Depression/ Mania

Responsiveness grief reaction emotions grief reaction

Emotions such as fear, joy, anxiety, love, anger, sadness and surprises are all normal parts of the human experience.At the adaptive end there is emotional responsiveness. This involves the person being affected by and being an active participant in the internal and external worlds. It implies an openness to and awareness of feelings. Also adaptive in the face of stress is an uncomplicated grief reaction. Such a reaction implies that the person is facing the reality of the loss and is immersed in the work of grieving. A maladaptive response is the suppression of emotion. This may be a denial of one’s feelings or a detachment from them. Prolong suppression of emotion, as in delayed grief reaction, will ultimately interfere with the effective functioning. The most maladaptive emotional responses or severe mood disturbances are recognized by their intensity, pervasiveness, persistence and interference with social and physiological functioning. This characteristics apply to the clinical states of depression and mania, which complete the maladaptive end of the continuum of emotional responses.

ETIOLOGY:

ACCORDING TO BOOK IN MY PATIENT

BIOLOGIC THEORIES-Alterations in neurochemicals, genetic, endocrine and circadian rhythm functions.

Nuerochemical: Levels of norepinephrine and serotonin are decreased and dysregulation of acetylcholine and GABA.

Genetic Theories: Major depressive disorders occur more often in first degree

relatives than they do in the general population. Studies of identical twins show that when one twin is diagnosed

with major depression, the other twin has a greater than 70 % chance of developing it.

Endocrine Theories: The hypothalamic-pituitary-adrenal (HPA) axis is a system that mediates the stress response. In some depressed people this system malfunctions and creates cortisol, thyroid and hormonal abnormalities.

Circadian rhythm theories: Circadian rhythms are responsible for the daily regulation of wake-sleep cycles, arousal and activity patterns, and hormonal secretions. These changes might be caused by medications, nutritional deficiencies, physical or psychological illnesses, hormonal fluctuations.

Changes in Brain anatomy: Loss of neurons in the frontal lobes, cerebellum and basal ganglia has been identified.

PSYCHOSOCIAL THEORIES-

Psychoanalytic theory: According to Freud (1957) depression results

Not known

No clear etiology is seen.

due to loss of a “loved object”, and fixation in the oral sadistic phase of development. In this model, mania is viewed as a denial of depression.

Behavioural theory: This theory of depression connects depressive phenomena to the experience of uncontrollable events. According to this model, depression is conditioned by repeated losses in the past.

Cognitive theory: According to this theory depression is due to negative cognitions which includes:

Negative expectations of the environment Negative expectations of the self Negative expectations of the future

These cognitive distortions arise out of a defect in cognitive development and cause the individual to feel inadequate, worthless and rejected by others.

Sociological theory: Stressful life events, for example, death, marriage, financial loss before the onset of the disease or a relapse probably have a formative effect.

TRANSACTIONAL MODEL OF STRESS/ ADAPTATION-According to this model depression occurs as a combination of predisposing factors ( family history and biochemical alterations), past experiences( object loss in infancy, defect in cognitive development) and existing conditions ( lack of adequate support system, inadequate coping skills, other physiological conditions). Because of weak ego strength, patient is unable to use coping mechanisms effectively. Maladaptive coping mechanisms used are denial, regression, repression, suppression, displacement and isolation. All these factors lead to clinical depression.

PSYCHOPATHOLOGY: The psychopathology of the affective disorders can most easily be described by reference to the similarity of the abnormal affect with normal emotions of the same kind. In depression the patient’s sadness deepens to a morbid depression, and the difficulty in concentration becomes retardation of all thought and action. Depressive patients may show a complete failure of all insight, deny that they are ill and hold steadfastly to their ideas of guilt and punishment.

CLINICAL MANIFESTATIONS: A typical depressive episode is characterized by the following features, which should last for at least two weeks in order to make a diagnosis:


Depressed Mood- sadness of mood or loss of interest and loss of pleasure in almost all activities(pervasive sadness), present throughout the day(persistent sadness).Depressive cognitions- Hopelessness ( a feeling of ‘no hope in future’ due to pessimism), helplessness( the patient feels that no help is possible), worthlessness( a feeling of inadequacy and

Present

Slightly present

inferiority), unreasonable guilt and self blame over trivial matters in the past.Suicidal thoughts- Ideas of hopelessness are often accompanied by the thought that life is no longer worth living and that death had come as a welcome release. These gloomy preoccupations may progress to thoughts of and plans for suicide.

Suicidal risk is much more in the presence of following factors:a) Presence of marked hopelessness b) Males; age>40 yrs unmarried, divorced/ widowed.c) Written/ verbal communication of suicidal intent and/or

plan.d) Early stages of depression.e) Recovering from depression (at the peak of depression, the

patient is usually either too depressed or too retarded to commit suicide)

f) Period of 3 months from recovery.

Psychomotor activity- In younger patients(<40 yrs), retardation is more common. Slowed thinking & activity, decreased energy and

monotonous voice . In severe form, the patient can become stuporous (depressive

Stupor).

In older patients( e.g. post menopausal women), agitation is common. Marked anxiety, restlessness(inability to sit still, hand

wriggling, picking at body parts or other objects) and a subjective feeling of unease.

Physical symptoms- Heaviness of head, vague body aches, General aches and pains Hypochondrial features Reduced energy and easy fatigability.

Somatic symptoms are-Psychotic features-15-20% cases. Delusion, hallucinations, grossly inappropriate behaviour or

stupor Mood- congruent (e.g. nihilistic delusion, delusion of guilt,

delusion of poverty, stupor) Mood-incongruent( e.g. delusion of control)

Somatic Syndrome- The somatic syndrome is characterized by: Significant decrease in appetite or weight. Early morning awaking, at least 2 (or more) hours before the

usual time of awakening. Diurnal variation, with depression being worst in the

morning. Pervasive loss of interest and loss of reactivity to

pleasurable stimuli Psychomotor agitation or retardation.

Other symptoms- Fatigue Thought of death Decreased libido Dependency

Spontaneous crying. Passiveness.

INVESTIGATIONS AND DIAGNOSIS:


1. Psychological tests- Beck depression inventory. Hamilton rating scale for depression to assess severity and prognosis.

2. Dexamethasone suppression test showing failure to suppress cortisole secretions in depressed patients.

3. Toxicology screening suggesting drug induced depression.

4. Based on ICD- 10 criteria.

Based on ICD – 10 criteria- Depression with psychotic feature.

TREATMENT:

ACCORDING YO BOOK IN MY PATIENT

I. PSYCHOPHARMACOLOGY-a. Antidepressant- Antidepressants establish a blockade

for the reuptake of norepinephrine and serotonin into their specific nerve terminals.This permits them to linger longer in synapses and to be more available to postsynaptic receptors.

SSRI- It inhibates the reuptake of serotonin & increasing its levels at the receptor site. Citalopram(Celexa), Fluoxetine(Prozac), Sertraline (Zoloft).

TCA- It blocks the reuptake of norepinephrine &/or serotonin at the nerve terminals, thus increasing the NE & 5-HT levels at the receptor site. Amitriptyline (Elavil), Clomipramine (Anafranil), Imipramine(Tofranil).

MAOIs- It degenarates the catecholamines after reuptake, a functional increase in the NE & 5-HT levels at the receptor site. Isocarboxazid (Morplan)

Other newer Antidepressant drugs- Bupropion.II. PHYSICAL THERAPIES-a. ECT- In severe depression with suicidal risk.b. Light therapy- During winter months to relieve seasonal

depression.c. Repetitive Transcranial Magnetic Stimulation-(TMS) and

Vagus Nerve Stimulation( VNS).III. PSYCHOSOCIAL TREATMENT-

a. Psychotherapy- To gain insight into the cause of their depression.

b. Cognitive Therapy- It corrects the depressive negative cognitions like hopelessness, worthlessness, helplessness and pessimistic ideas.

c. Supportive Psychotherapy- Reassurance, occupational therapy, relaxation.

d. Group Therapy- In mild depression, the negative feelings

14.02.11- Tab. Escitalopram (10) –X-X-2. Tab. Sulpitac (50)- X-X-1. Tab. Sodium Valproate (500)-X-X-1.

15.02.11- Tab. Escitalopram (10) –X-X-1. Tab. Sulpitac (50)- X-X-1. Tab. Sodium Valproate (500)-X-X-1. Tab. THP (20)- 1-X-X.

19.02.11- Tab. Nexito/ S. Voata (10 mg)- 1-X-1. Tab. Olimelt( 10mg)- 1-X-1. Tab. DVX-Na(500mg)-X-X-1. Tab. THP(2mg)-1-X-X. Tab. Sulpitre(50mg)-X-X-1.

08.03.11- Tab. Olimelt(10)-1-X-1/2 for 1 day.

Then= ½-X-1/2 For 1 day.Then= X-X-1/2 For 1 dayThen omit.Continue others.

11.03.11- Tab. Nexito(10mg)-2-X-X. Tab. Na. Valproate(250mg)-X-X-1 For 6 days.

Then omit.

like anxiety, anger, guilt are improved.e. Family Therapy- It is used to decrease intrafamilial &

interpersonal difficulties.f. Behavioural therapy- Social skill training, problem solving

techniques, assertive training.

DRUG MODALITIES FOR DEPRESSION:DRUG GENERIC NAMEUSES SIDE EFFECT AS

PER BOOKSIDE EFFECT IN MY CLIENT

NURSING ACTION

Tab. Valpor SR

Tab. Olimelt

Sodium valproate-

Anticonvulsant

Olanzapine(Antipsychotic)

Simple, complex or absence mixed, manic episodes with BPD, organic brain syndrome etc.

Psychotic disorders

Sedation, drowsiness, depression, weakness, visual disturbances, hallucination, rash, alopecia, nausea, vomiting, constipation

EPS, Pseduparkino-nism, seizures, dizziness. orthostatic hypotension, tachycardia, weight gain, constipation.

Weakness

Constipation, tachycardia,

Blood studies should be regularly seen.

AST,ALT should be checked.

Client is advised to take drug with food to prevent GI irritation.

Referred to eye OPD.Client is encouraged to

talk with others.Asked to sleep well at

night.

Blood and hepatic studies should be checked, vital signs should be checked,

NURSING MANAGEMENT:

Nursing Assessment :

Dysfunctional grieving related to real or perceived loss, bereavement,

evidenced by inappropriate expression of anger , inability to carryout

ADL.

Fear and anxiety of darkness at night related to altered though

process as evidenced by verbalization and facial expression.

Self esteem disturbance related to learned helplessness, sensitivity to

criticism, negative and pessimistic outlook.

Altered communication process related to depressive cognitions,

evidenced by nasal intonation of voice.

Altered sleep and rest, related to depressed mood and depressive

cognitions as evidenced by difficulty in failing asleep., early morning

awakening and verbal complaints of not feeling well-rested.

NURSING CARE PLAN: (ACCORDING TO BOOK)

NURSING DIAGNOSIS GOAL/ OBJECTIVE PLANNING INTERVENTION EVALUATION

Nursing Care Plan on 08/03/2011

Nursing Diagnosis Goals Planning Nursing

Intervention

Evaluation

1. Dysfunctional

grieving related

to real or

perceived loss,

bereavement,

evidenced by

inappropriate

expression of

anger , inability

to carryout ADL.

2. Self esteem

disturbance related

STG – To help the

patient to cope up

effectively

LTG – To help her in

getting over those

thoughts and

returning to normal

life.

STG – To help the

patient feel worthy

and competent

Enough time

should be spent

with the client to

develop IPR

The client should

be made to realize

that she has been

accepted

To focus and

reinforce reality,

irrational thinking

should be

discouraged.

Individual

psychotherapy and

then group

psychotherapy

should be given.

To provide

attention in a

sincere,

interested

manner

To plan activities in

Enough time has

been spend with

the patient to

develop IPR.

The client has

been reassured

that she had been

accepted

Irrational feelings

are discouraged

and client is made

to face the reality

Individual

psychotherapy is

done and sample

time is given for

planned interaction.

Attention is given

undividedly to the

client

She is asked and

encouraged to do

all her daily

The disturbed

thought processes

are infrequently

been remembered

and she is

optimistic and

practical.

The client has

improved and now

does many work by


Intervention

Evaluation

to learned

helplessness,

sensitivity to

criticism, negative

and pessimistic

outlook.

3.Altered

communication

process related to

depressive

cognitions,

evidenced by nasal

intonation of

voice.

LTG – To enable the

patient to develop a

sense of worthiness,

take up social roles,

depend less on

others

STG – To help the

patient in having a

interest in talking

and sharing.

LTG – To help the

patient to enhance

her self concept and

increase social

interaction.

which the patient can

show her worth

Help the client to

most of the

activities herself.

Activities should

be planner in such

a manner that the

client can socialize

A convenient

environment should

be created for

socialization

Socializations

should be planned

with other patients

also

A group should be

selected where the

client can

contribute

something

activities like

doing prayers,

taking bath,

feeding etc.

She is encouraged

to take the role of

leader so that she

regains her past

social roles.

A therapeutic

environment is

provided so that the


with other patients

The client is

encouraged to

participate in the

various ward

activities to make

her feel that she is

wanted.

herself, takes other

patients for prayer.

The client feels

comfortable and

socializes with

others.


Intervention

Evaluation

4. Altered sleep

and rest, related to

depressed mood

and depressive

cognitions as

evidenced by

difficulty in failing

asleep., early

morning awakening

and verbal

complaints of not

feeling well-rested.

STG – Describe

factors that inhibit

sleep. Identify

strategies to improve

sleep.

LTG – Report an

optimum balance of

rest and sleep.

To teach patients

good sleep habits

To instruct the

client to maintain a

fixed sleep time

daily at night and

rising time at

morning.

To be gentle but

firm while setting

limits regarding

time spent in bed,

when she should

be up from bed

etc.

To provide a quite,

peaceful, time for

resting

To decrease

environmental

stimuli (bright

lights)

The client is

taught about the

sleeping habits , to

sleep by 10:30 pm

and rising time at

6am

Her mother is

asked to provide

congenial

environment for

sleeping. i.e.

putting off the

lights etc.

To provide various

activities during

the day time so

that she is worked

up

Frequent naps in

the afternoon are

discouraged

The client does not

complain of insomnia

to an extent as

previously done.


Intervention

Evaluation

To provide a night

time routine of

comfort measure

(back rub, tepid

bath warm milk)

just before

bedtime

The client should

always be asked to

go to sleep by

10:30 pm.

To give frequent

activities during

daytime

To discourage the

patient for

frequent naps in

the afternoon



Intervention

Evaluation

1. Dysfunctional

grieving

related to real

or perceived

loss,

bereavement,

evidenced by

inappropriate

expression of

anger ,

inability to

carryout ADL.

STG – To help the

patient to cope up

effectively


getting over those

thoughts and

returning to normal

life.

STG – To help the

patient feel worthy

and competent

Enough time

should be spent

with the client to

develop IPR

The client should

be made to realize

that she has been

accepted

To focus and

reinforce reality,

irrational thinking

should be

discouraged.

Individual

psychotherapy and

then group

psychotherapy

should be given.

To provide

attention in a

sincere,

interested

manner


Enough time has

been spend with

the patient to

develop IPR.

The client has

been reassured

that she had been

accepted

Irrational feelings

are discouraged

and client is made

to face the reality

Individual

psychotherapy is

done and sample

time is given for


Attention is given

undividedly to the

client

She is asked and

encouraged to do

all her daily

The disturbed

thought processes

are infrequently

been remembered

and she is

optimistic and

practical.

The client has

improved and now

does many work by


Intervention

Evaluation

2. Self esteem

disturbance related

to learned

helplessness,

sensitivity to

criticism, negative

and pessimistic

outlook.

3.Altered

communication

process related to

depressive

cognitions,

evidenced by nasal

intonation of voice.





depend less on

others

STG – To help the

patient in having a

interest in talking

and sharing.

LTG – To help the

patient to enhance


increase social

interaction.


show her worth

Help the client to

most of the

activities herself.

Activities should

be planner in such

a manner that the


A convenient

environment should

be created for

socialization

Socializations

should be planned

with other patients

also

A group should be

selected where the

client can

contribute

something

activities like

doing prayers,

taking bath,

feeding etc.

She is encouraged

to take the role of

leader so that she

regains her past

social roles.

A therapeutic

environment is



with other patients

The client is

encouraged to

participate in the

various ward

activities to make


wanted.



The client feels

comfortable and

socializes with

others.


Intervention

Evaluation

4. Altered sleep and

rest, related to

depressed mood

and depressive

cognitions as

evidenced by


asleep., early

morning awakening

and verbal

complaints of not


STG – Describe


sleep. Identify


sleep.

LTG – Report an

optimum balance of

rest and sleep.

To teach patients

good sleep habits

To instruct the


fixed sleep time

daily at night and

rising time at

morning.

To be gentle but

firm while setting

limits regarding

time spent in bed,

when she should

be up from bed

etc.

To provide a quite,

peaceful, time for

resting

To decrease

environmental

stimuli (bright

lights)

The client is

taught about the


sleep by 10:30 pm

and rising time at

6am

Her mother is

asked to provide

congenial

environment for

sleeping. i.e.

putting off the

lights etc.

To provide various

activities during

the day time so

that she is worked

up

Frequent naps in

the afternoon are

discouraged

The client does not


to an extent as

previously done.


Intervention

Evaluation

To provide a night

time routine of

comfort measure

(back rub, tepid

bath warm milk)

just before

bedtime

The client should

always be asked to

go to sleep by

10:30 pm.

To give frequent

activities during

daytime

To discourage the

patient for

frequent naps in

the afternoon



Intervention

Evaluation

1. Dysfunctional

grieving related

to real or

perceived loss,

bereavement,

evidenced by

inappropriate

expression of

anger , inability

to carryout ADL.

2. Self esteem

disturbance

STG – To help the

patient to cope up

effectively


getting over those

thoughts and

returning to normal

life.

STG – To help the

patient feel worthy

and competent

Enough time

should be spent

with the client to

develop IPR

The client should

be made to realize

that she has been

accepted

To focus and

reinforce reality,

irrational thinking

should be

discouraged.

Individual

psychotherapy and

then group

psychotherapy

should be given.

To provide

attention in a

sincere,

interested

manner


Enough time has

been spend with

the patient to

develop IPR.

The client has

been reassured

that she had been

accepted

Irrational feelings

are discouraged

and client is made

to face the reality

Individual

psychotherapy is

done and sample

time is given for


Attention is given

undividedly to the

client

She is asked and

encouraged to do

all her daily

The disturbed

thought processes

are infrequently

been remembered

and she is

optimistic and

practical.

The client has

improved and now

does many work by


Intervention

Evaluation

related to learned

helplessness,

sensitivity to

criticism, negative

and pessimistic

outlook.

3.Altered

communication

process related to

depressive

cognitions,

evidenced by nasal

intonation of

voice.





depend less on

others

STG – To help the

patient in having a

interest in talking

and sharing.

LTG – To help the

patient to enhance


increase social

interaction.


show her worth

Help the client to

most of the

activities herself.

Activities should

be planner in such

a manner that the


A convenient

environment should

be created for

socialization

Socializations

should be planned

with other patients

also

A group should be

selected where the

client can

contribute

something

activities like

doing prayers,

taking bath,

feeding etc.

She is encouraged

to take the role of

leader so that she

regains her past

social roles.

A therapeutic

environment is



with other patients

The client is

encouraged to

participate in the

various ward

activities to make


wanted.



The client feels

comfortable and

socializes with

others.


Intervention

Evaluation

4. Altered sleep

and rest, related to

depressed mood

and depressive

cognitions as

evidenced by


asleep., early

morning awakening

and verbal

complaints of not


STG – Describe


sleep. Identify


sleep.

LTG – Report an

optimum balance of

rest and sleep.

To teach patients

good sleep habits

To instruct the


fixed sleep time

daily at night and

rising time at

morning.

To be gentle but

firm while setting

limits regarding

time spent in bed,

when she should

be up from bed

etc.

To provide a quite,

peaceful, time for

resting

To decrease

environmental

stimuli (bright

lights)

The client is

taught about the


sleep by 10:30 pm

and rising time at

6am

Her mother is

asked to provide

congenial

environment for

sleeping. i.e.

putting off the

lights etc.

To provide various

activities during

the day time so

that she is worked

up

Frequent naps in

the afternoon are

discouraged

The client does not


to an extent as

previously done.


Intervention

Evaluation

To provide a night

time routine of

comfort measure

(back rub, tepid

bath warm milk)

just before

bedtime

The client should

always be asked to

go to sleep by

10:30 pm.

To give frequent

activities during

daytime

To discourage the

patient for

frequent naps in

the afternoon

PROGNOSIS:

Good Prognostic Factor Poor Prognostic Factor

1. Acute or abrupt onset2. Typical clinical features3. Severe depression4. Well adjusted premorbid personality5. Good response to treatment.

1. Co-morbid medical disorder, personality disorder or alcohol dependence.

2. Double depression3. Catastrophic stress or chronic ongoing stress4. Unfavourable environment.5. Marked hypochondriacal features or mood –

incongruent psychotic feature.6. Poor drug compliance.

Conclusion :

One of the most important nurse’s role is to educate the patient and the family

member about disease process, treatment and follow up care. Continuation of

medicine is necessary to prevent relapse of the disease process.

Bibliography:

5. Kapoor .B. Textbook of Psychiatric Nursing, vol-1 Second edition 2005, Kumar publishing house, page no 92-103.

6. Kaplan & Saddock , Comprehensive Textbook of Psychiatry, vol-1 8th edition Lippincott Willium P1ublication

7. Sreevani. R.A Guide to mental health and Psychiatric nursing. second edition. Jaypee publication.

8. Townsend C.Mary, Psychiatric Mental Health Nursing , Fifth Edition.Jaypee Brothers Publication.

CASE PRESENTATIONOF A PATIENT WITH DEPRESSION

Submitted to- Submitted by-

Madam Aparna Ray Mousumi Sarkar

Senior Lecturer M.Sc.Nursing, 1st Year

College of Nursing Student

Medical College & Hospital

Kolkata

CONTINUUM OF EMOTIONAL RESPONSES:

PREDISPOSING FACTORSGENETICS OBJECT LOSS PERSONALITY COGNITION BEHAVIOURAL LEARNING BIOCHEMISTRY

PRECIPITATING STRESSORS LOSS LIFE EVENTS ROLES PHYSIOLOGY

APPRAISAL OF STRESSOR

COPING RESOURCES SOCIAL SUPPORT ECONOMICS SENSE OF MASTERY

COPING MECHANISMS

CONSTRUCTIVE DESTRUCTIVE

CONTINUUM OF EMOTIONAL RESPONSES

ADAPTIVE RESPONSES MALADAPTIVE RESPONSES Emotional Uncomplicated Suppression of Delayed Depression/ ManiaResponsiveness grief reaction emotions grief reaction

Documents

Case Presentation of Depression