Extra Case 1

How do you solve a problem like Maria?

Maria is a 20 year old single woman living at home with her parents who has attended your practice for several years. She has a history of anxiety and difficulties coping with work (she works as a sales representative) and with her relationships. There has been some alcohol abuse in the past and some episodes of disordered eating (binging and purging). She has often presented with multiple physical complaints but has always been fit and healthy. She has received some supportive counselling in the past for distress associated with sexual abuse that occurred during her childhood. This had occurred in the context of a friend's father abusing her whilst on sleep-overs at her friend's house when Maria was 12 years old.

On this occasion, Maria reports that her mood has been very low for the past three weeks. She has no energy, profound and pervasive anhedonia. She describes that her thinking is very slow, she has missed appointments with customers and she has received a warning at work. She also describes an overwhelming sense that something bad is about to happen but she can't identify what that might be.

She has lost about four kilograms in weight unintentionally. She describes lying awake at night and ruminating on how pointless her life is. She has felt that she would be better dead on occasions but states she would not act on this thought because it would hurt her family too much. She states she very much wants to get better. She says she feels like she is dead inside but says she does not actually believe this.

Q 1. What is your provisional diagnosis and differential diagnosis? Justify the reasons for your answer.

Q 1. What is your provisional diagnosis and differential diagnosis? Justify the reasons for your answer.

Maria’s clinical picture supporting provisional of Major Depressive Episode:-Depressed mood for 3 weeks-Profound and pervasive Anhedonia-Significant impairment in occupational functioning-Unintentional weight loss-No energy – Fatigue-Suicidal ideation-Diminished ability to concentrate - slowed thinking

Maria’s Risk factors for depression:-Childhood sexual abuse-Alcohol abuse-Age -Gender

Ddx for this case:Dysthymia, Initial Bipolar II Disorder, Post-traumatic Stress Disorder, substance – induced mood disorder

Common Ddx in general:Dysthymia, Adjustment disorder with depressed mood, Schizoaffective disorder, Bipolar disorder, ADD/ ADHD, Bereavement, Substance – induced mood disorder, Mood disorder due to general medical condition/ Tx

Q 2. What further information would you seek to clarify your diagnosis and management - justify each of your answers?

Q 2. What further information would you seek to clarify your diagnosis and management - justify each of your answers?

• Duration of per cent body weight loss?• Any sleep disturbance?• Any particular event or stressor which brought

symptoms on?• How structured are suicidal thoughts ie.

Plans/ means?• Recent drug use?• Previous episode of feeling down?

Q 3. What physical investigations would you request - justify each of your answers?

Q 3. What physical investigations would you request - justify each of your answers?

• Neuro exam – investigate for brain neoplasms, stroke etc

• CVS exam – investigate for anaemia, HF etc

Q 4. Would you raise the issue of Maria's childhood trauma at this point in the consultation? Why or why not?

Q 4. Would you raise the issue of Maria's childhood trauma at this point in the consultation? Why or why not?

• Childhood sexual abuse carries with it a high risk of developing adult depression

• Pt’s may be hesitant to divulge childhood abuse unless asked about it directly ‘Were you every physically, emotionally, or sexually abused?’

• If pt is extremely distressed due to current psychiatric symptoms, it may be prudent to temporarily delay asking about abuse Hx to avoid worsening the distress

Your patient, Maria, is accepting of a provisional diagnosis of Major Depression and reports that there was no actual event to cause her depression. She denies a recent increase in alcohol intake. She then agrees to treatment with Fluvoxamine 100mg and to return in three days having guaranteed her safety. You provide her with a medical certificate to allow her sick leave. The physical investigations are all normal.

Maria returns for review accompanied by her mother. Maria reports that nothing has changed. She continues to feel depressed. You observe that she appears exhausted and her speech is slow. She reports that she goes to sleep feeling very tired but awakes around midnight and cannot return to sleep. She continues to report that she would be better dead but guarantees that she won't kill herself. She can't articulate what is keeping her going. Her mother says she appears "spaced out all the time" and has wondered if she is using drugs (Maria denies this). Her mother also reports that she is not eating anything. Maria says she is not hungry. You are left feeling very worried about her but she is refusing to go to the hospital for further assessment. She agrees to see a private psychiatrist however it will be ten days before she can get her initial appointment.

Q 5. What treatment options are available at this time?

Q 5. What treatment options are available at this time?

Biological treatments:•Antidepressant medication – TCA’s better for depression with melancholic features and SSRI’s and MAOI’s better for depression with atypical features•Electroconvulsive Therapy (ECT) – One of the most rapidly effective treatments for depression, esp for those cases complicated by psychotic or catatonic features, suicidal ideation, and recurrent episodes or intolerable SE’s from antidepressants. There are no absolute contraindications to ECT•Alternative therapies – The best studied is St. John’s wort, which has been shown effective in the treatment of mild-to-moderate depression

Psychosocial interventions:•Cognitive behavioural therapy (CBT) – specific styles of habits of thinking and behaving are identified and systemically challenged using a variety of techniques•Interpersonal psychotherapy (IPT) – Like CBT but focussed on interpersonal problems and challenges in the patient’s life

Q 6. Give the reasons for and against the use of involuntary treatment for hospitalisation?

Q 6. Give the reasons for and against the use of involuntary treatment for hospitalisation?

• Maria has a mental illness• Maria’s illness requires immediate treatment• Maria’s proposed treatment is available at an authorised mental health service• because of Maria’s illness:- there is an imminent risk that the person may cause harm to herself or someone else, or- Maria is likely to suffer serious mental or physical Deterioration there is no less restrictive way of

ensuring she receives appropriate treatment for the illness, and• Maria:- lacks the capacity to consent to be treated for the illness, and- has unreasonably refused proposed treatment for the illness.

Maria meets all the requirements of the Mental Health Act 2000 stipulated to deem a patient appropriate to be subject to an involuntary treatment order, although she has consented to visit a private psychiatrist in 10 days. I would feel that 10 days is a long time to wait without extra specialist support and treatment. It is too risky to take the chance with taking the promise of someone who is not competent to make good decisions by themselves to present for help in 10 days. If her Mum promises to support her and regularly check on her you might consent to let her be managed at home with daily presentations to GP clinic while waiting for psychiatrist review.

Q 7. What things might you do to reduce the risk of harm befalling Maria?

Q 7. What things might you do to reduce the risk of harm befalling Maria?

• Involve a family member or person close to the patient, if allowed.– Work with these people also to make sure they are aware of the risk of self harm and suicide

and are willing to stay with Maria at all times• Ask about the availability of lethal means (eg, firearms, medications) and make

them inaccessible to the patient.• Increase the frequency of contact with the patient; communicate a commitment

to help.• Begin aggressive treatment of psychiatric disorders or substance abuse.• Treatment options may include hospitalization, medication, more frequent

psychological intervention, mobilizing supports, access to crisis intervention services, and no-suicide contracts.

• The level of intervention depends upon the level of suicide risk, available support, and the ability of the child or adolescent to join with those who seek to keep him or her safe.

• Immediate psychiatric evaluation (through the emergency department or psychiatry crisis clinic) and/or hospitalization is indicated when there is an imminent risk of suicide (eg, an active plan or intent without solid support or psychiatric or psychological intervention already in place to maintain safety)

• Referral to a mental health professional is warranted if the risk is not imminent. However, consideration of the availability of the mental health professional is important, so as to avoid delays in needed treatment.

You get Maria to come back the next day and she attends with her mother. You are struck by how depressed Maria appears. She makes no eye contact. She states that the world would be better without her because she is so evil. She states that nothing will help her to get better. She complains of the repugnant smell coming from her body and believes her organs are rotting. She also reports that her father was very upset because his mother had acted like this periodically and received ECT for these episodes many years ago. Maria's mother reports that they had hidden tablets at home because Maria had started telling them that she was already dead. Maria has also stopped eating and drinking and clinically she is mildly dehydrated.

Q 8. What is the likely diagnosis and what symptoms have made this diagnosis more probable?

Q 8. What is the likely diagnosis and what symptoms have made this diagnosis more probable?

Major depression with psychotic features•Maria exhibits features of Major Depression, as this was her provisional diagnosis earlier.•She now also has developed acute psychotic symptoms as exhibited by her negative and self-critical thoughts regarding her evil soul and her body undergoing decomposition and also experiencing olfactory hallucinations of this rotting odour. •These thoughts and hallucinations make a diagnosis of Major Depression with psychotic features (Psychotic Depression) more likely.

Q 9. How are you going to manage this situation in your general practice?

Q 9. How are you going to manage this situation in your general practice?

Maria exhibits features that indicate referral to a mental health team or psychiatric specialist:•severe depression that is endangering her life •psychotic depressionMaria may be treated using psychological and pharmacological therapies (both antidepressants and antipsychotics), although in her case ECT should be seriously considered as a form of treatment as it is shown to be a highly effective, well tolerated and safe treatment for depressive disorders where melancholic or somatic features are present, and/or psychosis is present. ECT is effective in more than 90% of patients suffering from severe melancholic depression or psychotic depression.

After some discussion that goes around in circles, you decide to call an ambulance and ask Maria's mother and your receptionist to supervise Maria. She is taken to hospital where the staff advise you of her progress. She continues to express the belief that she is dead, rotting inside. She refuses to eat, drink, wash or bathe. She is seen by two psychiatrists and she is treated as an involuntary patient under the mental health act. The plan is for her to receive ECT. You then are met by Maria's father who is very angry that you sent her to hospital. He is very worried Maria will receive ECT and wants to know more about it. He states her mother was never the same after receiving ECT and he remembers her often having bruising from being held during the treatment.

Q 10. What information can you provide to the father about ECT?

Q 10. What information can you provide to the father about ECT?

Q 11. How has the treatment changed from 40 years ago?

Q 11. How has the treatment changed from 40 years ago?

Maria returns to see you one month later having been diagnosed with Major Depressive Disorder with Psychotic Features. Her current medication is venlafaxine XR 225mg Mane and risperidone 2mg Nocte. She is euthymic and has little recollection of the events that lead to her hospitalisation. She wants to know how long she needs to remain on the medication and the possible side effects it might cause her.

Q 12.What advice will you give Maria regarding side effects of the antidepressant and the atypical antipsychotics such as risperidone?

Q 12.What advice will you give Maria regarding side effects of the antidepressant and the atypical antipsychotics such as risperidone?

All medication have side effects, some of the side effects are useful but some can be unpleasant – but most of the time they are worth putting up with for the benefit they give. Risperidone can be associated with weight gain, which might be useful in your case, but can be managed with an exercise and diet program which should be part of your treatment anyway. Risperidone can also make you drowsy, so taking your dose at night may negate this side effect and allow a better nights sleep anyway. So you shouldn’t drive while you feel you are under the drowsy effects of the medication. Side effects like involuntary movements, movement difficulty and increased saliva that some people experience can be managed by other medications, but most people don’t get them. If you ever experience muscle spasms and increasing muscle tremors or fever then tell your doctor immediately.

Venlafaxine also has side effects, including Nausea, insomnia/ drowsiness, dry mouth and constipation. Regular checkups on your blood pressure will need to be done to make sure it doesn’t change to much. While the medication is starting to work in your system you may have increased negative thoughts about your future life – if you do please promise to tell a doctor or psychologist/ mental health worker. If you start having palpitations, profuse sweating with increased nausea, vomiting or diarrhea… or if you just don’t feel right in yourself for any reason, contact a doctor immeadiately.

Q 13. What physical examination and investigations will you do at base line and follow up for a patient on atypical antipsychotics?

Q 13. What physical examination and investigations will you do at base line and follow up for a patient on atypical antipsychotics?

Before starting any antipsychotic drug ECG and cardiovascular physical examination should be undertaken to identify any specific cardiovascular risk, if the patient has a history of cardiovascular disease or a family history of long QT syndrome, especially if antipsychotic is known to prolong QT. Aggranulocytosis and heart failure due to cardiomyopathy is also potential but rare risk with some antipsychotic use. Concurrent anaemia and immune status should be identified too.

• ECG recommended at baseline; also monitor ECG if there are risk factors– Major risk factors: IHD, LVH, congenital long QTc syndromes, family Hx of early cardiac death, prior QTc

prolongation or Torsades de Pointes– Always monitor for signs of arrhythmia (SOB, presyncope, LOC, palpitations)

• Fasting blood glucose increased DM in schizophrenia (causality/risk uncertain)– When changing/starting medication and also every 3-6 months– If diagnosed with DM: monitor glycosylated Hb every 3-6 mths (glycaemic control)

• FBC monitor for neutropenia– Every 3-6 mths; stop medication and consult haematologist if < 1.5 x 10^9/L

• BP monitor during dose titration• U&Es if RF for arrhythmia, monitor 6 monthly• LFTs if signs/symptoms of hepatic damage and/or Pt has pre-existing conditions• BMI and waist/hip ratio check at least every 3 months (r/v treatment if BMI>30 or waist/hip ratio is >1.0 in

males or >0.8 in females)• Neuroleptic malignant syndrome monitor for muscle rigidity, fever, autonomic instability (esp diaphoresis,

unstable BP), cognitive changes, elevated creatine phosphokinase– Muscular symptoms due to D2-blockage

• • Amisulpride, olanzapine, risperidone: monitor plasma prolactin level• Quetiapine: thyroid function test (baseline and at one month)• Clozapine: clozapine monitoring system

– Obligatory: FBC– Additional: ECG and troponin I small inc risk of myocarditis and cardiomyopathy

Q 14. How long will Maria need to stay on these medications?

Q 14. How long will Maria need to stay on these medications?

• The NHMRC website has the antipsychotic therapy guidelines put out by the Western Australia Therapeutics Advisory Group– “Treatment should be continued for at least 12 months,

then if the disease has remitted fully, may be ceased gradually over at least 1-2 months.”

• RACGP guidelines on antidepressants: “Antidepressants should be continued for at least four months beyond initial recovery or improvement after a single episode of major depression to prevent a relapse within this period.” “Patients receiving higher doses, those with a previous history of discontinuation symptoms and those who develop withdrawal symptoms and those who develop withdrawal symptoms when the antidepressant is ceased, may require tapering over 4-7 days, or longer, if discontinuation symptoms are severe.”

Q 15. During one of her appointments, Maria asks if the abuse she experienced in childhood is the cause of her psychotic depression? What is the association between the childhood trauma that Maria experienced and her psychotic depression?

Q 15. During one of her appointments, Maria asks if the abuse she experienced in childhood is the cause of her psychotic depression? What is the association between the childhood trauma that Maria experienced and

her psychotic depression?

• Childhood trauma = risk factor for adulthood depression, esp with additional stress– Childhood trauma sensitization of the neuroendocrine

stress response, glucocorticoid resistance, increased central corticotropin-releasing factor (CRF) activity, immune activation, and reduced hippocampal volume close parallel of the neuroendocrine features of depression

– But not all depression is related to childhood trauma and there are biologically distinguishable subtypes of depression due to childhood trauma