ࡱ>  bjbjSS *11 HHH\\\8 \?sD4""4"""+ , ,rrrrrrr$u5xrH,++",,r""r///,V"8"r/,r//.$hH0(n "pAfTs..lj@rs0?sj|y.vy4n4nZyHq/,,,rr/,,,?s,,,,y,,,,,,,,, : Scenario Title: OUT OF SORTS Authors: Dr F.N. Contell and Dr James Rucker Updated (2017): Dr Laura Tyler, Dr Sin Fai Lam and Dr James Stone a) Learning objectives. Main HeadingSub-HeadingDetails (please list any further headings under this sub-heading)1. Basic Science & Pathology Normal and abnormal structure and function relevant to this scenarioPhysical IllnessInfection Endocrine HaematologicalPsychologicalPersonality traits Coping styleNeuroendocrineHypothalamic-Pituitary-Adrenal (HPA) axis Hypothalamic-Pituitary-Thyroid (HPT) axisNeurotransmitters5-Hydroxytryptamine (Serotonin) Noradrenaline DopamineGeneticsHeritability of psychiatric disordersEnvironmentalPredisposing adverse events in childhood and adolescence Precipitating psychosocial stressors Perpetuating psychosocial adversity 2. Clinical Science: Physical and Psychological Clinical features of this scenario and related conditions to be covered hereSymptomsBiological Psychological SocialSignsMental state examinationInvestigationsDetailed history Blood tests Collateral history Risk assessmentManagementAntidepressants Psychological therapy Social intervention Admission Electroconvulsive therapyPrognosis and outcomePrognosis in types of mood disorders. Risk of recurrenceOther3. Population Sciences & Health Care Public health issues related to this scenario in the UK or elsewhere. For instance: why does this patient have this problem in this society? What is our response to it?Public health and clinical epidemiology (including statistics)Prevalence of depression Cause of major disability Co-morbid physical ill healthIssues of access to health careStigma Effect of divisions between different levels of care and health care settingsComplementary medicineHypnotherapy Acupuncture Aromatherapy St Johns WortHealth care systemsResource managementHealth educationPromotion of good mental health. Improve recognition and encourage help-seeking behaviorEnvironmental, economic, political influences (both local and global) on the evolution of this conditionIncreased stressors Dispersion with reduced support networksThis condition in other societiesCultural aspects. Availability of range of treatments.Other4. Skills Practical and communication skills related to this scenarioCommunicationRapport Active listening skills EmpathyAspects of history takingImpact on life assessment Risk assessmentAspects of clinical examinationGeneral examination Mental state examinationTeam working Liaison with Psychiatric Team; Social Services.Other 5. Professional Development & Practice Responsibilities, ethical and legal issues, self and professional management issuesResponsibilities and boundaries of a doctorConfidentiality Setting boundaries for personal/emotional involvementValues, impact of personal values on behaviourPersonal attitudes to mental illness Degree of emotional involvementOther ethical issuesCapacityLegal issuesMental Health Act assessment and detention Capacity assessment in psychiatric disorders Child Protection Driving Clinical governanceOther6. The Individual in Society The effect on the individual and on society of this scenario at this timeNormal development and ageingIncreased risk of physical illness.What does this condition mean for this patient and her/his family?Provision of care Altered role in family Effect on employment StigmaCoping with illness and treatmentLabeling Coping with adverse reactions of medication Altered self-conceptLifestyle, behaviour and healthPsychological/social adjustment Fears regards recurrenceOther b) Reading list Please add any recommended reading and textbooks that you feel are relevant to this current scenario and the issues that it addresses. Belmaker, R.H. and G. Agam, Major Depressive Disorder. N Engl J Med, 2008. 358(1): p. 55-68.  HYPERLINK "http://dx.doi.org/10.1056/NEJMra073096" http://dx.doi.org/10.1056/NEJMra073096 Taylor D, Paton C, Kapur S. The Maudsley prescribing guidelines in psychiatry. John Wiley & Sons; 2015 Feb 23. National Institute for Clinical Excellence (NICE). Depression in adults: recognition and management. NICE guidelines [CG90]. 2009 Oct.  HYPERLINK "https://www.nice.org.uk/guidance/cg90" https://www.nice.org.uk/guidance/cg90 Cowen P, Harrison P, Harrison PJ, Burns T. Shorter Oxford textbook of psychiatry. Oxford University Press; 2012 Aug 9. Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. The Lancet. 2016 Apr 15;387(10027):1561-72.  HYPERLINK "https://doi.org/10.1016/S0140-6736(15)00241-X" https://doi.org/10.1016/S0140-6736(15)00241-X  c) Useful links World Health Organization. The ICD-10 classification of mental and behavioural disorders: diagnostic criteria for research. World Health Organization; 1993 Nov 1.  HYPERLINK "http://www.who.int/classifications/apps/icd/icd10online/" http://www.who.int/classifications/apps/icd/icd10online/ Ravindran AV et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical guidelines for the management of adults with major depressive disorder: section 5. complementary and alternative medicine treatments. The Canadian Journal of Psychiatry. 2016 Sep;61(9):576-87.  HYPERLINK "https://doi.org/10.1177/0706743716659417" https://doi.org/10.1177/0706743716659417 Mind: Mental Health Charity  HYPERLINK "https://www.mind.org.uk/" https://www.mind.org.uk/ Royal College of Psychiatrists: Depression  HYPERLINK "http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/depression.aspx" http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/depression.aspx  Section 1. Scenario introduction On the 10th January 2017, Katherine Gill, a 30 year old woman attended her GP practice as she felt out of sorts. She struggled to recall how long this had been the case but was certain that symptoms had persisted for more than 2 months. On further questioning she described difficulty sleeping and poor appetite, resulting in noticeable weight loss. She felt lethargic during the day and struggled to complete tasks around the house. She also described episodes of feeling scared and shaky. At times she worried that she would have a heart attack, as her heart would beat very quickly. Katherine initially thoughts these symptoms were secondary to losing her job eight months ago. This has created tensions in her relationship. Her partner often works away, leaving her to look after their two-year-old and five-year-old daughters. Both children have been unwell recently and she wonders whether she may have contracted an infection that has left her feeling this way. Katherine admits to finding it increasingly difficult to cope.  Question 1. What are the possible diagnoses at this stage?1. Physical illness e.g viral infection. KG presents with an array of non-specific symptoms that may well be due to physical illness. The history also refers to her daughters having been unwell recently, so there is the possibility that she may have contracted a similar illness. Viral illness commonly present in this non-specific fashion with feeling out of sorts. It is important to also consider the possibility of an endocrine (thyroid), haematological (anaemia) or autoimmune disorders. 2. Depressive disorder. KG has social stressors in the form of unexpected unemployment and relationship difficulties which may predispose her to a depressive disorder. She has biological symptoms consistent with a mood disorder poor appetite, loss of weight, poor sleep and lethargy. 3. Anxiety disorder The history describes anxiety symptoms; namely fear with shakiness and palpitation. These may be the result of loss of job and possible financial stress, relationship difficulties, exhaustion due to poor sleep and having to care for her unwell daughters.  Question 2. List 3 broad areas that should be explored further in attempt to clarify the cause of her symptoms.1. Physical status Enquire about physical symptoms that might may clarify diagnosis and help exclude / include possible co-morbid illness. Conditions to be considered include: thyroid disease- hypo/hyperthyroidism. malignancy autoimmune disease anaemia2. Psychological status The following areas should be explored: premorbid personality is the current presentation similar or very different from baseline? coping style how does KG normally cope with crisis? What are the limits to her coping and likely consequences? attitude to self/the world/the future - evidence of negative cognitions; hopefulness, guilt, low self - esteem3.Social status Areas to be considered include: accommodation living conditions, certainty of ongoing tenancy finances income, bills, debts, rent, food shopping, benefits relationships with partner, children, family, friends, confidante social support family, friends, assistance from outside agencies employment security, attitude towards work Question 3. List the potential causes of stress in this case. Describe the coping strategies that may be employed. Which of these would be most useful? (task) Potential Stressors unemployment tense relationship with partner young children, recently unwell fears about own health Coping strategies Defence mechanisms unconscious processes to cope with anxiety work by altering the individuals perception of reality. Coping mechanisms conscious ways of attempting to resolve stress; problem focused direct action to change situation information seeking trying to understand the situation and predict what might happen next inhibition of action doing nothing. May work well where the individual has no control over the situation intrapsychic/palliative coping changing the view of the situation through drugs, alcohol, relaxation & meditation turning to others for help and/or emotional support Locus of control describes the extent to which individuals believe they have control over things that happen to them. The more anxious/depressed the person is, the more external their locus of control tends to be, and this is associated with a greater vulnerability to physical illness. A successful intervention would aim to shift the locus of control from external (outside of individual control) to internal (within individual control). Epidemiology Bipolar disorders The lifetime risk for bipolar disorder is in the range of 0.3-1.5% The 6 month prevalence of bipolar disorder is not much less than the life time prevalence, indicating the chronic nature of the disorder The prevalence in men and women is the same The mean age of onset is about 17 years in community studies Bipolar disorder frequently occurs with other disorders, particularly anxiety disorders and substance misuse. Unipolar depression The 12 month prevalence of major depression in the community is approximately 2-5%. The lifetime rates in different studies vary considerably (range being 4-30%). The true figure probably lies in the range of 10-20% The mean age of onset is 27 years; however recent studies have suggested a bimodal peak system with a second presentation later between the ages of 50-60. Rates of major depression are two times higher in women compared to men.  Section 2: Further history This section will provide the student with a further history of the patient based on an interview. Please indicate below the relevant areas of the patient history that you feel the student would need in order to carry on. You can provide a simple bulleted list of relevant findings from the history or if you prefer present the history in the form of a very short interview (no more that 1 1.5 sides of A4 paper). See Appendix 1 for an example. This transcript might then be converted into a video interview that the students will subsequently have to watch before they are presented with the correct points from the interview that they should have picked up. Further history reveals the following: Symptoms Poor sleep with early morning waking. Diurnal variation in mood. Loss of interest and motivation. Loss of concentration. Reduced energy levels. No history of elated or over excited mood. Past medical history No past medical Past psychiatric history No past psychiatric history. Medication Oral contraceptive pill. Family history Father treated for bipolar affective disorder. Mother died when Katherine was 9 years old. Pre-morbid personality Alcohol misuse in late teens. Recent increase in use to feel calmer and get some sleep. Currently drinking 6 units of alcohol daily. Experimentation with cannabis in teens. Denies any current illicit substance use. Social circumstances Unemployed; struggling to cope on benefits. Loss of social circle as this was tied up with job. Psychosexual history Relationship discord. Children under 11 years old No confidante Question 1: If you considered a presentation to be that of a mood disorder, what factors in the history support the diagnosis of a unipolar disorder as opposed to a bipolar disorder? Answer Depression Mania Family history Loss of parent Social class low social economic status. Physical/sexual abuse. History of bipolar or unipolar disorder History of bipolar disorder Personal history Loss of job. Absence of confidante Marital discord/violence. Children under the age of 11yrs. Interrupted work record due to episodes of illness. Past Medical history Association with low mood Cancer, anaemia, autoimmune disease, stroke, hypothyroidism, chronic disease. Thyrotoxicosis Autoimmune disorders Cushings syndrome Past Psychiatric history Previous depression. Part of bipolar disorder/eating disorder/substance misuse/psychotic disorders such as schizophrenia. Previous hypomania Associated with depression, psychotic disorders such as schizophrenia, substance misuse (cocaine, LSD, amphetamine) Drug History Many and varied- Steroids, contraceptive pill, anti-viral drugs, pegylated interferon, chemotherapy, H2 antagonists, Beta-blockers. Steroids, thyroxine, anti-viral drugs (esp Efavirenz), H2 antagonists, anti-parkinsonian drugs antidepressants and mood stabilisers. Premorbid personality Substance misuse Normal when not hypomanic. Social circumstances Lack of employment Finances poverty; debt. Absence of supportive relationships Precipitant and/or life event Bereavement, loss of job Any life event.  Section 3. Patient examination ExaminationExamination results1. General examinationPale and tired looking. Apyrexial. Skin warm and adequately hydrated. Nasal congestion. Mildly inflamed throat. Evidence of significant weight loss.2. Cardiovascular systemP= 72 bpm, regular. BP = 124/66 No cardiac abnormalities.3. Gastrointestinal systemNAD4. Genitourinary systemNAD5. Mental/psychiatric examAppearance & behaviour: sitting hunched in chair. Evidence of poor grooming/self-care. Poor eye contact- looking down. Easily tearful. Tense. Perhaps fidgety with anxious mannerisms. Sometimes irritable. Difficult to establish rapport. Speech and form of thought. Low in volume. Delayed answers. Paucity of content- monosyllabic answers. Lack of variety in intonation. Tendency to say I dont know to simple questions. No disorder of thought form. Mood: subjectively described as not good. Objectively appears low in mood with tension and anxiety scarcely concealed. Biological symptoms of depression- disturbed sleep pattern, poor appetite, poor concentration, low energy levels, low motivational level. Autonomic symptoms of anxiety (palpitations, shortness of breath, tight throat). No signs of obsessions or compulsions. No signs of abnormal responses to catastrophic trauma (PTSD). Affect: Consistent (congruent) with subjective and objective descriptions of mood. Affect may be reactive (you can cheer them up a bit) or non-reactive depending on severity. Thoughts: Tendency towards Becks negative cognitive triad- self-reinforcing negative cognitions surrounding self, world and future. Guilty and hopeless cognitions. Inappropriate tendency to blame self. Sense of worthlessness. Inappropriate fears, perhaps related to having panic attacks in embarrassing places- social situations, being in crowds, leaving the house or travelling alone. No evidence of delusions. Perception: no evidence of hallucinations. Cognition: Slowed thinking but otherwise broadly cognitively intact. May have difficulty with memory and concentration. Insight: Present to varying degrees- acknowledges low mood and need for treatment. Agreeable to comply with treatment plan. Risk Assessment: denies any deliberate self-harm ideation or intent. Hopeful of recovery and insistent on ability to continue to care for children. Has reasonable social support (friends/family) who can check on her progress between appointments.6. Musculoskeletal systemNAD7. Nervous systemNAD8. Respiratory systemNAD9. Reticuloendothelial systemThyroid moderately enlarged. Smooth, mobile with trachea and non-tender.10. UrinalysisNAD11. OtherNAD The students are usually asked to consider their answers to the questions introduced so far as individuals. They then come together as the group of 8 students to discuss their own views on the interpretation of the examination finding, the diagnosis and the investigations to be done. They are joined by the tutor who reviews their initial ideas on differential diagnosis, helps them with this discussion on examination findings and plans for investigations, and then gives them the results of the investigations as set out below. Explanation of the examination findings. Please indicate the meaning of the relevant findings and how they relate to this case. Indicate where suitable links to learning resources occur. Viral infection. Pale and tired with soft signs of possible throat infection. Anaemia Pale and tired. Thyroid pathology - hypothyroidism, malignancy. Enlarged thyroid gland. Symptoms remain consistent with underactive thyroid. Weight loss and disabling fatigue might raise concerns about possible malignancy although palpation of gland did not reveal any obvious concerning features, e.g. asymmetric enlargement, lymphadenopathy Depressive disorder primary or part of a bipolar affective disorder. Biological symptoms of depression abound in this scenario. Constipation and lowered energy level can also form part of this complex. In atypical depression, low mood may well be absent and hypersomnia and hyperphagia more prominent features. Mental state examination- very suggestive of a depressive disorder, either on its own or comorbid with physical problems. Section 4. Investigations & Results The students are next required to decide what are the most relevant patient investigations that need to be carried out immediately and the most appropriate investigations to be carried out later. Students will not be allowed to progress through the scenario unless they have selected the correct investigations to perform at this stage. When they select the correct investigation the student will be given additional information about the investigation they have selected and its relevance to this scenario. The students are asked: What n investigations would you do now, to have results available within the next two hours (choose from the list)? 2. What would you consider the n most important investigations on the list to be sent off at this stage? The list of investigations has been divided into 11 categories with each of these containing further containing specific investigations. If the investigation does not fit into any of these categories please include it under Other Please select a set number of the most appropriate investigations to do immediately and later from the list below. Please tick the appropriate options from the column labelled Immediate investigation and those from the column Later investigation. Could you please provide brief explanations behind each investigation chosen. You may insert red herrings if you wish but again please also explain why these are not appropriate investigations at this time. Immediate investigation (Y)Later investigation (Y)1) HaematologyFull blood countYESRYCoagulation studiesImmediate investigation (Y)Later investigation (Y)2) Clinical biochemistryElectrolytes, urea, creatinineYLiver function testsYCalcium, phosphate, alkaline phosphataseC reactive proteinYCreatine kinaseTroponinD-dimersThyroid function testsYArterial blood gasesOxygen saturationAlpha1-antitrypsin concentrationImmediate investigation (Y)Later investigation (Y)3) MicrobiologySputum cultureBlood cultureMid stream urineHIV testPneumococcal antigen in urineSputum for acid fast bacilliImmediate investigation (Y)Later investigation (Y)4) HistopathologyCytologyHistologyImmediate investigation (Y)Later investigation (Y)5) ImmunologyMycoplasma, legionella, chlamydia antibody titresAutoantibodiesAnti-nuclear factorAnti-neutrophil cytoplasmic antibodyAnti glomerular basement membrane antibodyImmediate investigation (Y)Later investigation (Y)6) Drug monitoringPhenytoin levelAntibiotic levelsTheophylline levelDigoxin levelImmediate investigation (Y)Later investigation (Y)7) ImagingChest X-rayOther plain X-rays by siteContrast studies (barium meal, enema, IVU)CT chestCT by anatomical siteCT chest (high resolution)CT chest (spiral)MRI by anatomical siteUltrasound by anatomical sitePET scanVentilation/perfusion lung scanThyroid scanBone scanImmediate investigation (Y)Later investigation (Y)8) Cardiological investigationsEchocardiogram24 hour ECGECGTreadmill exercise testImmediate investigation (Y)Later investigation (Y)9) EndoscopyGastroscopyColonoscopySigmoidoscopyBronchoscopyCystoscopyImmediate investigation (Y)Later investigation (Y)10) Psychiatric investigationsInformant history/old case notes YDepression rating scales.YImmediate investigation (Y)Later investigation (Y)11) Other testsRespiratory function testsElectroencephalogramElectromyogramNerve conduction studies Please now provide the clinical reasoning for each of the investigations you selected and indicate where relevant possible links to additional learning resources and areas of study: At this stage in the scenario the students will be able to access the results from the investigations they have selected. For the investigations you selected in the last section could you now provide the results. Please refer to the example scenario for further details if necessary. NB: If you have any images that you think would be useful in this stage of the scenario please include them. These could range from the results of any imaging procedures requested, ECG traces etc. If you include a table of values or an image could you provide a brief explanation of what these data show (if abnormal) Later investigations Investigation 1Investigation categoryHaematologyInvestigation titleFull blood countExplanationTo exclude anaemia and possible infection.ResultsHb normal. WCC normal.Investigation 2Investigation categoryHaematologyInvestigation titleESRExplanationBroad inflammatory marker to help exclude autoimmune diseaseResultsWithin normal rangeInvestigation 3Investigation categoryClinical biochemistryInvestigation titleLiver function testsExplanationPast history of alcohol misuse, with recent increase in use.ResultsResults within normal range.Investigation 4Investigation categoryClinical biochemistryInvestigation titleThyroid function testsExplanation30 year old female with weight loss, fatigue, low mood, enlarged thyroid gland likely hypoactive thyroid.ResultsTSH 2.42 mU/L, T4 18.1 pmol/L (both normal) Investigation 5Investigation categoryClinical biochemistryInvestigation titleCRPExplanationBroad inflammatory marker to help exclude acute inflammatory conditionsResultsWithin normal range Investigation 6Investigation categoryClinical biochemistryInvestigation titleElectrolytes, urea, creatinineExplanationTo exclude electrolyte imbalance causing depression/anxiety symptomsResultsWithin normal range Section 5. Diagnosis Diagnosis option 1HypothyroidismExplanationLethargy and fatigue. Generally slowed down. Enlarged thyroid gland. In a 30 year old female.Correct (Y/N)N Diagnosis option 2Depressive disorderExplanationMultiple stressors and features on history that is predictive of mood disturbance. Somatic symptoms of depression with consistent features on mental state examination. Comorbid substance misuse and anxiety symptoms.Correct (Y/N)Y Diagnosis option 3AnaemiaExplanationFatigue and pallor. General feeling of being unwell; history of considerable stress; poor appetite.Correct (Y/N)N Diagnosis option 4Anxiety disorderExplanationStressful life events, somatic symptoms of anxiety with substance use to achieve relief of symptoms.Correct (Y/N)N- Anxiety often co-exists with depression. In this case, with the prominence of depressive symptoms the diagnosis of major depressive disorder is sufficient explanation for the less severe anxiety symptoms. Section 6. Treatment Working diagnosis; Depressive disorder, moderate severity. Management plan: (Primary Care) (BIO)logical/(PSYCHO)logical/SOCIAL Biological Commence antidepressant treatment Sertraline 50mg/day. Advise regarding possible side-effects, delay in onset of treatment effect and importance of adherence to treatment. Psychological Referred to local Improving Access to Psychological Therapies (IAPT) service Consider relationship counselling and suggest that partner attend at follow-up visit. Substance misuse advice and offer for referral to community substance misuse services if alcohol usage persists. Social Advise caution with driving ( HYPERLINK "https://www.gov.uk/depression-and-driving" https://www.gov.uk/depression-and-driving) Provide information on local toddler groups as this may provide both support and social interaction. Offer Social Services referral, and Health Visitor attendance. She declines referral to her Community Mental Health Team (CMHT). Make a follow-up appointment for 2 weeks time, with advice to attend the surgery sooner should condition deteriorate.  Question 1. Is this an appropriate choice of antidepressant? Answer: Although there are several different classes of antidepressant, the SSRIs are first line agents especially in primary care. They are more tolerable to patients and are relatively safe in overdose. It is also very cheap as it is off-patent. It is the recommended first line antidepressant. The dose of 50mg/day is therapeutic; dosing can start at 25mg daily in the elderly or if risk of GIT disturbance, as can occur with other SSRIs, is present. Dosing can be titrated up to 200mg/day relative to response. The other classes of antidepressants are unlikely to be suitable for prescription in primary care. Tricyclic antidepressants, monoamine oxidase inhibitors and Lithium in particular should warrant specialist referral. Tricyclic antidepressants should never be prescribed as sleeping tablets. Mirtazapine (a NaSSA) may be appropriate for use in primary care but beware of its overt sedative properties. The use of Venlafaxine (a SNRI) in primary care is arguably appropriate, but there are concerns regarding safety and the requirement for ECG monitoring. Question 2. Do you think that night sedation should have been part of the pharmacological management in this case, and why? Answer: It is very common for night sedation to be prescribed alongside antidepressant treatment, mainly as a result of the considerable distress caused by insomnia and subsequent tiredness. All the same, this approach should not be assumed without offering advice as to how to manage the insomnia non-pharmacologically, and then clarifying the indication for sedation, and how long it will be prescribed for. It is important to recognise that sleep disturbance is part of the depression complex and will show response to antidepressant treatment alongside the other symptoms. Use of night sedation by its own nature produces an artificial and abnormal sleep cycle. It is also habit forming and indiscriminate prescription can result in iatrogenic dependence. Be clear about the indication, prescribe sparingly, use the lowest effective dose for a limited time only. Section 7. Scenario review Question 1 Ms Gills partner arrives towards the end of the consultation and is eager to know what the problem is. Having obtained Ms Gills permission, describe how you would explain your findings and treatment plan to him. Section 8. Scenario development Three weeks later, Ms Gills partner brings her to A&E. He reports that she has got a lot worse, crying and shouting that she Cant go on anymore. Ms Gill has been spending long periods in bed, not wanting to see anyone including her children. She has not eaten over the past few days and has had very little to drink. Ms Gills partner had moved out of the home temporarily. On visiting that evening he found her trying to take a handful of tablets with alcohol and thus decided to bring her to the hospital. Further history revealed that Ms Gill had only complied with the antidepressant treatment for a few days and had cancelled the counseling and review sessions with her GP due to feeling unwell. On Examination: She was unhappy to be at the hospital and wanted to return home. She appeared disheveled and mildly dehydrated. On further questioning, she became tearful, saying that she just wanted to Go to sleep forever and for it all to end. She whispered that her neighbours were plotting against her and that they had been watching her and filming her. She was adamant that they were just biding their time before they killed her. She had heard them planning this; their voices coming through the walls at night. She thinks that her neighbours have lured her children away and believes that her children are looking at her in a strange way. She is taking steps to deal with her children due to their betrayal. She refused any examination or investigations and made repeated attempts to leave the A&E department. She refused to engage any further with medical services. Question 1. What are the factors in this history that are particularly worrying? Severe low mood with suicidal ideation and intent. Paranoid delusions; auditory hallucinations. Non-adherence to treatment. Lack of insight. Risk to children. Question 2. Give 3 possible reasons for this deterioration: Natural progression of the illness. Non-adherence with treatment. Worsening social circumstances. Question 3. How would you manage this situation now? Clarify if she had taken an overdose of tablets and alcohol. If in any doubt, carry out physical assessment and urgent toxicology. Request an urgent psychiatric assessment for admission. Due to the risk Ms Gill presents to herself and others, assessment for admission under the Mental Health Act (1983/2007) would be indicated if she refused informal admission. Request Social Services input to advise on assessment and care of children. Ongoing management strategies. Pharmacotherapy All antidepressants show a pattern of response where rate of improvement is highest in the first 1-2 weeks. Therefore a first line antidepressant at a therapeutic dose should be trialed and efficacy reviewed after 2 weeks. If there is no effect between 2 4 weeks ensure that the patient is compliant with medication. If response is absent between 3 4 weeks increase support and consider increasing the dose of the antidepressant medication or switching to an alternative. If presentation is complicated by psychotic symptoms, an antipsychotic may be indicated. This requires a specialist referral. Mood stabilizers may play a role in the management of complex cases. This requires a specialist referral. If condition deteriorates with further mental (severe agitation, psychosis, suicidal ideation and intent) and physical (dehydration and starvation) compromise, electroconvulsive therapy (ECT) may be indicated. Psychological therapy Low-intensity psychosocial interventions (e.g. sleep hygiene, group exercise) High-intensity psychological interventions (e.g. CBT, IPT) Occupational therapy Assessment for level of function. Social services- Assessment on social circumstances and support that can be provided Family meetings- Meetings to ensure there is input from the family as well as an opportunity for psychoeducation. Question 4. What is the likely outcome of treatment? Antidepressants are normally recommended as first line treatment in patients with at least moderate severity depression. Of this patient group, 20% will recover with no treatment, 30% will respond to placebo and 50% will respond to an antidepressant. A response, in clinical trials, is commonly defined as a 50% reduction in depression rating scales. A single episode of depression should be treated 6-9 months after full remission. If antidepressant therapy is stopped immediately on recovery, 50% of patients will have a return of their depressive symptoms within 3-6 months. Of those patients who have one episode of major depression, 50-85% will go onto have a second episode and 80-90% of those who have a second episode will have a third. Continuing treatment with an antidepressant reduces to odds of a depressive relapse by around two thirds. In terms of dose for prophylaxis, the evidence suggests that for SSRIs, adults should receive the same dose as used for acute treatment. Antidepressants are effective, not addictive, not known to lose their efficacy over time and not known to cause new long-term side effects. Overall, the evidence indicates that psychological interventions have a beneficial effect in the treatment of people with depression. According to the Cochrane review on exercise for depression, exercise is moderately more effective than no therapy for reducing symptoms of depression. However exercise is no more effective than antidepressants for reducing symptoms of depression and is no more effective than psychological therapies for reducing symptoms of depression, although these conclusions were based on a small number of studies.      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