Extra Case 1

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Extra Case 1

• How do you solve a problem like Maria?

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• 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.

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

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

• Marias 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
• Marias 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

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

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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?

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

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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

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

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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
• Pts 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

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• 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.

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

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

• Biological treatments
• Antidepressant medication TCAs better for
  depression with melancholic features and SSRIs
  and MAOIs 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 SEs from
  antidepressants. There are no absolute
  contraindications to ECT
• Alternative therapies The best studied is St.
  Johns 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 patients life

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

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

• Maria has a mental illness
• Marias illness requires immediate treatment
• Marias proposed treatment is available at an
  authorised mental health service
• because of Marias 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.

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

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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.

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• 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.

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

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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.

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

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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 depression
• Maria 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.

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• 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.

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

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Q 10. What information can you provide to the
father about ECT?
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• Q 11. How has the treatment changed from 40 years
  ago?

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

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

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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
  shouldnt 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 dont 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
  doesnt 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 dont feel right in yourself for any reason,
  contact a doctor immeadiately.

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

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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.

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• 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 lt 1.5 x 109/L
• BP ? monitor during dose titration
• UEs ? 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 BMIgt30 or waist/hip
  ratio is gt1.0 in males or gt0.8 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

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

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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.

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• 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?

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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-releas
  ing 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