Case Presentation of Depression

Identification data: Name:

Age: 36 Yrs.

Rajeswari Tiwari

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: Income: Nil.

Marital status: Married.

Religion: Hindu.

Informant:

Mother( Ms.Durga Shil)

Intimacy with the patientpatient- Intimate. Does the informant live with the patientpatient- 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 hoto keu amar khoti kore debe , keu ghore ghore dhuke guli kore debe, mone mone hoto dupur bela ghore bagh dhuke jabe, kono kaj korar ichha nei, sobsomay bomi bomi vab l agto. 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 relativesDuration: (days/ weeks /months/years).before /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, 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 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 t he low mood. No previous hospitalization required. Before starting of this episode the patient became very fearful , but she could c ould 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.

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, 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 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 t he low mood. No previous hospitalization required. Before starting of this episode the patient became very fearful , but she could c ould 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: 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 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 INVESTIGATIONSOn 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 15.02.11FBS-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 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. 

Blood Testing-

Indirect- 0.4 mg/dl.

MENTAL STATUS EXAMINATION( on 08.03.2011): 

Date of doing MSE: 08.03.2011

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Time of doing MSE: 10.30 a.m.

General Appearance & behaviour

Level of consciousness: Fully conscious& alert

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Appearance: Her age, overweight

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Facial expression: Anxious, fearful

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

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Physique: Endomorphic

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Personal hygiene: Maintained

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Posture: Closed posture

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Gesture: Normal

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Dress: According to season, Clean.

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Gait: slow walk.

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Motor activity: Decreased

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Cooperativeness: Normal.

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Rapport: Spontaneous.

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Behaviour: Slight anxious and fearful.

Speech 

Initiation: Speaks when spoken to, minimal

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Reaction time: Slightly delayed

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Rate: Slow

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Productivity - Elaborate replies when asked for otherwise monosyllabic replies.

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Volume: Soft

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Amount: Paucity,

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

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Stream: Normal flow & rhythm of speech is normal.

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Coherence: Fully coherent.

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Relevance: Sometimes off target but otherwise relevant

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Others: Nasal intonation of voice, childish voice.

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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.

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Stability of mood: Affect labile, mood is flat.

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

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

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Predominant mood state: Anxious, Fearful

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Appropriate to thought content.

Thought 

At formation level: Normal

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

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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.

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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.”

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Recent: Q. what food did you have in your last dinner? A. “ kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

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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.”

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To place: Q. Which place is this? A. “ eta to Calcutta Medical College Hospital.”

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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 il lness. A. “ Na, eta manasik asukh.” 

Present fully.

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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.”

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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” 

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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 socioeconomic status & educational background. Q. which is the national bird of our country? A. “ Ha, mayur.”

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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.”

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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) 


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Time of doing MSE: 11 a.m.



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Gesture: Normal

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Gait: slow walk.

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Speech 


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Rate: Slow

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Volume: Soft

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Amount: Paucity,

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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 


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Thought 


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Perception 


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Memory 


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Recent: R. what food did you have in your last dinner? B. “ kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

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Past: R. In which school were you studing? B. “ ami Rajdanga Uchha Balika Bidyaloye Portam”. ( Verified from her mother) Inference: Her immediate, recent and remote memory are intact.

Orientation

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To place: Q. Which place is this? B. “ eta to Calcutta Medical College Hospital.”

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Insight

Q. What do you think about illness- whether it is physical or mental i llness. A. “ Na, eta manasik asukh.” 

Present fully.

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Judgement 

Personal ( future plans): 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.”

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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? B. “ 45, 46, 47, 48, 49, 50” Digit backward- Q. Now can you count backward ? B. “ 50, 49...47...46, 45”

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Names of months(backwards), Names of weekdays( backwards): Q. Can you mention the name of the months and week days from backward? B. “ Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar.” “ December, November, October,.....September, ....August...July..June...May,....” General Information

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Knowledge about surroundings, festivals, sports, states, depending on patient‟s socioeconomic status & educational background. Q. which is the national flower of our country? A. “ Ha, podma.”

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Intelligence: Arithmetic ability: 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.”

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Abstract reasoning: Q. Can you explain the phrase “ angur fol tok?” A. “ Etar mane holo nije kichhu na pele nijeke evabe santona deoa.” Inference: Her knowledge, intelligence and abstract reasoning are intact.

Special points-

Appetite: Normal. Sleep: Adequate. Bowels: Regular. Bladder: Regular. Libido: Normal. Treatment: Continuing.

MENTAL STATUS EXAMINATION( on 10.03.2011) 


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Time of doing MSE: 10 a.m.



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Gesture: Normal

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Gait: slow walk.

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Speech 


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Rate: Slow

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Volume: Soft

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Amount: Paucity,

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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 


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Thought 


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Perception 


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Memory 


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Recent: S. what food did you have in your last dinner? C. “ kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

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Past: S.

In which school were you studing?

C. “ ami Rajdanga Uchha Balika Bidyaloye Portam”. ( Verified from her mother) Inference: Her immediate, recent and remote memory are intact. Orientation 


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To place: Q. Which place is this? C. “ eta to Calcutta Medical College Hospital.”

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Insight

Q. What do you think about illness- whether it is physical or mental il lness. A. “ Na, eta manasik asukh.” 

Present fully.

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Judgement 

Personal ( future plans): 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.”

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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? C. “ 45, 46, 47, 48, 49, 50” Digit backward- Q. Now can you count backward ? C. “ 50, 49...47...46, 45”

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Names of months(backwards), Names of weekdays( backwards): Q. Can you mention the name of the months and week days from backward? C. “ 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 socioeconomic status & educational background. Q. which is the national bird of our country? A. “ Ha, mayur.”

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Intelligence: Arithmetic ability: 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.”

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

Special points-

Appetite: Normal. Sleep: Adequate. Bowels: Regular. Bladder: Regular. Libido: Normal. Treatment: Continuing.

DEPRESSION INTRODUCTION: 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 F32.0 F32.1 F32.2 F32.3 F32.8 F32.9 F33

Depressive Episode Mild Depressive Episode Moderate Depressive Episode Severe Depressive Episode Without Psychotic Symptoms Severe Depressive Episode with Psychotic Symptoms Other Depressive episodes- Atypical Depression Depressive Episode, unspecified Recurrent Depressive Disorder

CONTINUUM OF EMOTIONAL RESPONSES:

PREDISPOSING FACTORS GENETICS OBJECT LOSS PERSONALITY COGNITION BEHAVIOURAL LEARNING BIOCHEMISTRY

LOSS

PRECIPITATING STRESSORS 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

Emotional Responsiveness

Uncomplicated grief reaction

MALADAPTIVE RESPONSES

Suppression of emotions

Delayed Depression/ Mania 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 THEORIESAlterations in neurochemicals, genetic, endocrine and circadian rhythm functions. Nuerochemical: Levels of norepinephrine and serotonin are dec reased 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. 

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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.

Not known

No clear etiology is seen.

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 THEORIESPsychoanalytic theory: According to Freud (1957) depression results 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/ ADAPTATIONAccording 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: ACCORDING TO BOOK

IN MY PATIENT

Depressed Mood- sadness of mood or loss of interest and loss of Present pleasure in almost all activities(pervasive sadness), present throughout the day(persistent sadness). Depressive cognitions- Hopelessness ( a feeling of „no hope in Slightly present future‟ due to pessimism), helplessness( the patient feels that no help is possible), worthlessness( a feeling of inadequacy and 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 symptomsHeaviness of head, vague body aches, General aches and pains Hypochondrial features Reduced energy and easy fatigability.    

Somatic symptoms arePsychotic 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 symptomsFatigue Thought of death Decreased libido Dependency Spontaneous crying. Passiveness.      

INVESTIGATIONS AND DIAGNOSIS: ACCORDING TO BOOK 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. . Toxicology screening suggesting drug induced depression. 4. Based on ICD- 10 criteria.

IN MY PATIENT

1.

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

TREATMENT: ACCORDING YO BOOK

IN MY PATIENT

14.02.11PSYCHOPHARMACOLOGYTab. Escitalopram (10) –X-X-2. a. Antidepressant- Antidepressants establish a blockade  for the reuptake of norepinephrine and serotonin into  Tab. Sulpitac (50)- X-X-1. their specific nerve terminals.This permits them to  Tab. Sodium Valproate (500)-X-X-1. linger longer in synapses and to be more available to 15.02.11postsynaptic receptors. Tab. Escitalopram (10) –X-X-1.  SSRI- It inhibates the reuptake of serotonin &  Tab. Sulpitac (50)- X-X-1.  increasing its levels at the receptor site.  Tab. Sodium Valproate (500)-X-X-1. Citalopram(Celexa), Fluoxetine(Prozac), Sertraline Tab. THP (20)- 1-X-X.  (Zoloft). TCA- It blocks the reuptake of norepinephrine &/or 19.02.11 serotonin at the nerve terminals, thus increasing the  Tab. Nexito/ S. Voata (10 mg)- 1-X-1. NE & 5-HT levels at the receptor site. Amitriptyline  Tab. Olimelt( 10mg)- 1-X-1. (Elavil), Clomipramine (Anafranil),  Tab. DVX-Na(500mg)-X-X-1. Imipramine(Tofranil). Tab. THP(2mg)-1-X-X.  MAOIs- It degenarates the catecholamines after   Tab. Sulpitre(50mg)-X-X-1. reuptake, a functional increase in the NE & 5-HT 08.03.11levels at the receptor site. Isocarboxazid (Morplan)  Tab. Olimelt(10)-1-X-1/2 for 1 day. Other newer Antidepressant drugs- Bupropion.  Then= ½-X-1/2 For 1 day. II. PHYSICAL THERAPIESThen= X-X-1/2 For 1 day a. ECT- In severe depression with suicidal risk. Then omit. b. Light therapy- During winter months to relieve seasonal Continue others. depression. c. Repetitive Transcranial Magnetic Stimulation-(TMS) and 11.03.11Vagus Nerve Stimulation( VNS).  Tab. Nexito(10mg)-2-X-X. III. PSYCHOSOCIAL TREATMENT Tab. Na. Valproate(250mg)-X-X-1 For 6 days. a. Psychotherapy- To gain insight into the cause of their Then omit. 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 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. I.

DRUG MODALITIES FOR DEPRESSION: DRUG GENERIC NAM USES

Tab. Valpor SR

Sodium valproateAnticonvulsant

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

SIDE EFFECT AS PER BOOK

SIDE EFFECT NURSING ACTION IN MY CLIENT

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







 



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.

Psychotic disorders Tab. Olimelt

Olanzapine (Antipsychotic)

EPS, Pseduparkinonism, seizures, dizziness. orthostatic hypotension, tachycardia, weight gain, constipation.

Constipation, tachycardia,

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

1. Dysfunctional

STG – To help the

Planning 

Enough time should

Nursing Intervention 

Enough time has

Evaluation 

The disturbed thought

grieving related to patient to cope up

be spent with the

been spend with the

processes are

real or perceived loss, effectively

client to develop IPR

patient to develop

infrequently been

The client should be

IPR.

remembered and she

The client has been

is optimistic and

she has been accepted

reassured that she

practical.

To focus and

had been accepted

LTG – To help her in

bereavement, evidenced



by getting over those

made to realize that

thoughts and returning

inappropriate

expression of anger , to normal life.





inability to carryout

reinforce reality,

ADL.

irrational thinking

discouraged and

should be

client is made to face

discouraged.

the reality





Individual

Irrational feelings are



Individual

psychotherapy and then

psychotherapy is done

group psychotherapy

and sample time is

should be given.

given for planned



To provide

interaction.

attention in a

2.

Self

esteem

disturbance related to learned

helplessness,

sincere,

Attention is given

interested

undividedly to the

manner

client

STG – To help the

To plan activities in

patient feel worthy and competent

She is asked and

The client has improved

which the patient can

encouraged to do all

and now does many

show her worth

her daily activities

work by herself, takes




Goals

1. Dysfunctional

STG – To help the

Planning 

Enough time should


Enough time has

Evaluation 



be spent with the

been spend with the

processes are



patient to develop

infrequently been


IPR.

remembered and she

The client has been

is optimistic and


reassured that she

practical.

To focus and

had been accepted


bereavement,




evidenced



inappropriate







reinforce reality,

ADL.

irrational thinking

discouraged and

should be


discouraged.

the reality





Individual




Individual



group psychotherapy

and sample time is

should be given.

given for planned



To provide

interaction.

attention in a

2.

Self

esteem


helplessness,

sincere,

Attention is given

interested

undividedly to the

manner

client

STG – To help the



Nursing Diagnosis

She is asked and




and now does many

show her worth



Goals

sensitivity to criticism,

LTG – To enable the

negative and pessimistic

patient to develop a

outlook.



Planning

Nursing Intervention

Evaluation

like doing prayers,

other patients for

Help the client to

taking bath, feeding

prayer.

sense of worthiness,

most of the activities

etc.

take up social roles,

herself.





depend less on others

She is encouraged to take the role of



Activities should be

leader so that she

planner in such a

regains her past

manner that the client

social roles.

can socialize

3.Altered communication process related to depressive cognitions, evidenced

STG – To help the



patient in having a

environment should be

A therapeutic

interest in talking and

created for socialization

environment is

sharing.

by nasal intonation of

LTG – To help the

voice.

patient to enhance her



Socializations should be planned with other patients also

self concept and increase social

A convenient

provided so that the

The client feels

client can socialize with

comfortable and

other patients

socializes with others.

 

A group should be

encouraged to

selected where the

interaction.

The client is participate in the

client can contribute

various ward

something

activities to make her feel that she is wanted.

4. Altered sleep and rest, related

to

depressed



STG – Describe factors

To teach patients 

The client is taught

Nursing Diagnosis

Goals





outlook.

Planning


Evaluation

like doing prayers,

other patients for

Help the client to


prayer.



etc.


herself.










leader so that she

planner in such a

regains her past


social roles.

can socialize


STG – To help the



patient in having a


A therapeutic



environment is

sharing.




LTG – To help the

voice.




A convenient


The client feels


comfortable and

other patients


 

A group should be

encouraged to

selected where the

interaction.



various ward

something



to

depressed

Nursing Diagnosis



To teach patients




Goals

Planning

mood and depressive that inhibit sleep.



Evaluation

good sleep habits

about the sleeping

To instruct the client

habits , to sleep by

The client does not

by difficulty in failing improve sleep.

to maintain a fixed

10:30 pm and rising

complain of insomnia to

asleep., early morning LTG – Report an

sleep time daily at

time at 6am

an extent as previously

Her mother is asked

done.

cognitions as evidenced Identify strategies to

awakening and verbal complaints

of

feeling well-rested.



optimum balance of rest

night and rising time

not and sleep.



to provide congenial

at morning. 

environment for

To be gentle but firm

sleeping. i.e. putting

while setting limits

off the lights etc.

regarding time spent in bed, when she



activities during the

should be up from

day time so that she

bed etc. 

To provide a quite, peaceful, time for resting



To decrease environmental stimuli (bright lights)



To provide a night time routine of comfort measure (back rub, tepid bath warm milk) just

To provide various

is worked up 

Frequent naps in the afternoon are discouraged

Nursing Diagnosis

Goals

Planning



Evaluation

good sleep habits

about the sleeping



The client does not


to maintain a fixed

10:30 pm and rising



sleep time daily at

time at 6am


Her mother is asked

done.



of





not and sleep.





at morning. 

environment for




off the lights etc.





should be up from


bed etc. 




To provide various

is worked up 






Nursing Diagnosis

Goals

Planning

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


Evaluation

Nursing Diagnosis

Goals

Planning


Evaluation


Evaluation

before bedtime 









Goals

1. Dysfunctional

STG – To help the

grieving related to

Planning 

patient to cope up

real or perceived effectively loss, bereavement, LTG – To help her in




evidenced

of to normal life.

expression





Enough time has




be spent with the

been spend with the

processes are


patient to develop

infrequently been


IPR.

remembered and she

The client has been

is optimistic and


reassured that she

practical.

To focus and

had been accepted



inappropriate

Enough time should



anger , inability to

reinforce reality,

carryout ADL.

irrational thinking

discouraged and

should be


discouraged.

the reality





Individual




Individual



group psychotherapy

and sample time is

should be given.

given for planned



To provide

interaction.

attention in a

2.

Self

esteem


helplessness,

sincere,

Attention is given

interested

undividedly to the

manner

client

STG – To help the



She is asked and




and now does many

show her worth






Goals

1. Dysfunctional

STG – To help the

grieving related to

Planning 

patient to cope up

real or perceived effectively loss, bereavement, LTG – To help her in




evidenced

of to normal life.

expression





Enough time has

Evaluation 


be spent with the

been spend with the

processes are


patient to develop

infrequently been


IPR.

remembered and she

The client has been

is optimistic and


reassured that she

practical.

To focus and

had been accepted



inappropriate

Enough time should




anger , inability to

reinforce reality,

carryout ADL.

irrational thinking

discouraged and

should be


discouraged.

the reality





Individual




Individual



group psychotherapy

and sample time is

should be given.

given for planned



To provide

interaction.

attention in a

2.

Self

esteem


helplessness,

sincere,

Attention is given

interested

undividedly to the

manner

client

STG – To help the



Nursing Diagnosis

She is asked and




and now does many

show her worth



Goals





outlook.



Planning


Evaluation

like doing prayers,

other patients for

Help the client to


prayer.



etc.


herself.










leader so that she

planner in such a

regains her past


social roles.

can socialize


STG – To help the



patient in having a


A therapeutic



environment is

sharing.


LTG – To help the

voice.






A convenient


The client feels


comfortable and

other patients


 

A group should be

encouraged to

selected where the

interaction.



various ward

something



to

depressed






Nursing Diagnosis

Goals





outlook.

Planning


Evaluation

like doing prayers,

other patients for

Help the client to


prayer.



etc.


herself.










leader so that she

planner in such a

regains her past


social roles.

can socialize


STG – To help the



patient in having a


A therapeutic



environment is

sharing.




LTG – To help the

voice.




A convenient


The client feels


comfortable and

other patients


 

A group should be

encouraged to

selected where the

interaction.



various ward

something



to

depressed

Nursing Diagnosis mood

and



To teach patients




Goals

Planning

depressive that inhibit sleep.



Evaluation

good sleep habits

about the sleeping



The client does not


to maintain a fixed

10:30 pm and rising



sleep time daily at

time at 6am


Her mother is asked

done.



of






not and sleep.




at morning. 

environment for




off the lights etc.





should be up from


bed etc. 








To provide various

is worked up 


Nursing Diagnosis mood

and

Goals

Planning

depressive that inhibit sleep.


Evaluation

good sleep habits

about the sleeping



The client does not


to maintain a fixed

10:30 pm and rising



sleep time daily at

time at 6am


Her mother is asked

done.



of





not and sleep.





at morning. 

environment for




off the lights etc.





should be up from


bed etc. 




To provide various

is worked up 






Nursing Diagnosis

Goals

Planning

before bedtime 









Evaluation

Nursing Diagnosis

Goals

Planning


Evaluation


Evaluation

before bedtime 









Goals

1. Dysfunctional

STG – To help the

Planning 

Enough time should



Enough time has





be spent with the

been spend with the

processes are



patient to develop

infrequently been


IPR.

remembered and she

The client has been

is optimistic and


reassured that she

practical.

To focus and

had been accepted


bereavement, evidenced






inappropriate







reinforce reality,

ADL.

irrational thinking

discouraged and

should be


discouraged.

the reality





Individual




Individual



group psychotherapy

and sample time is

should be given.

given for planned



To provide

interaction.

attention in a

2. Self esteem disturbance related

to

helplessness,

learned

sincere,

Attention is given

interested

undividedly to the

manner

client

STG – To help the



She is asked and




and now does many

show her worth






Goals

1. Dysfunctional

STG – To help the

Planning 

Enough time should


Enough time has

Evaluation 



be spent with the

been spend with the

processes are



patient to develop

infrequently been


IPR.

remembered and she

The client has been

is optimistic and


reassured that she

practical.

To focus and

had been accepted


bereavement,




evidenced



inappropriate







reinforce reality,

ADL.

irrational thinking

discouraged and

should be


discouraged.

the reality





Individual




Individual



group psychotherapy

and sample time is

should be given.

given for planned



To provide

interaction.

attention in a

2. Self esteem disturbance related

to

learned

helplessness,

sincere,

Attention is given

interested

undividedly to the

manner

client

STG – To help the



Nursing Diagnosis

She is asked and




and now does many

show her worth



Goals



Planning


sensitivity to criticism, LTG – To enable the negative

like doing prayers,

other patients for

Help the client to


prayer.



etc.


herself.

and patient to develop a

pessimistic outlook.

Evaluation










leader so that she

planner in such a

regains her past


social roles.

can socialize


STG – To help the



patient in having a


A therapeutic



environment is

sharing.


LTG – To help the

voice.






A convenient


The client feels


comfortable and

other patients


 

A group should be

encouraged to

selected where the

interaction.



various ward

something



to

depressed






Nursing Diagnosis

Goals

Planning


sensitivity to criticism, LTG – To enable the

like doing prayers,

other patients for

Help the client to


prayer.



etc.


herself.

and patient to develop a

negative

pessimistic outlook.

Evaluation










leader so that she

planner in such a

regains her past


social roles.

can socialize


STG – To help the



patient in having a


A therapeutic



environment is

sharing.




LTG – To help the

voice.




A convenient


The client feels


comfortable and

other patients


 

A group should be

encouraged to

selected where the

interaction.



various ward

something



to

depressed

Nursing Diagnosis



To teach patients




Goals

Planning




Evaluation

good sleep habits

about the sleeping



The client does not


to maintain a fixed

10:30 pm and rising



sleep time daily at

time at 6am


Her mother is asked

done.



of






not and sleep.




at morning. 

environment for




off the lights etc.





should be up from


bed etc. 








To provide various

is worked up 


Nursing Diagnosis

Goals

Planning



Evaluation

good sleep habits

about the sleeping



The client does not


to maintain a fixed

10:30 pm and rising



sleep time daily at

time at 6am


Her mother is asked

done.



of





not and sleep.





at morning. 

environment for




off the lights etc.





should be up from


bed etc. 




To provide various

is worked up 






Nursing Diagnosis

Goals

Planning

before bedtime 









Evaluation

Nursing Diagnosis

Goals

Planning


Evaluation

before bedtime 








PROGNOSIS: Poor Prognostic Factor

Good Prognostic Factor 1. 2. 3. 4. 5.

Acute or abrupt onset Typical clinical features Severe depression Well adjusted premorbid personality Good response to treatment.

1. 2. 3. 4. 5. 6.

Co-morbid medical disorder, personality disorder or alcohol dependence. Double depression Catastrophic stress or chronic ongoing stress Unfavourable environment. Marked hypochondriacal features or mood – incongruent psychotic feature. 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.

PROGNOSIS: Poor Prognostic Factor

Good Prognostic Factor 1. 2. 3. 4. 5.

Acute or abrupt onset Typical clinical features Severe depression Well adjusted premorbid personality Good response to treatment.

1. 2. 3. 4. 5. 6.

Co-morbid medical disorder, personality disorder or alcohol dependence. Double depression Catastrophic stress or chronic ongoing stress Unfavourable environment. Marked hypochondriacal features or mood – incongruent psychotic feature. 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 8 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 , Fift h Edition.Jaypee Brothers Publication.

th

CASE PRESENTATION OF A PATIENT WITH DEPRESSION

Submitted to-

Submitted by-

Madam Aparna Ray

Mousumi Sarkar

Senior Lecturer

M.Sc.Nursing, 1 Year

College of Nursing Medical College & Hospital Kolkata

st

Student

Case Presentation of Depression

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