Major Depressive Disorder - Essay Example

 Major Depressive Disorder Introduction Depression (Major Depressive Disorder-MDD) is a high-impact disease, with a multi-factorial etiology, that causes severe debilitation of the individual, depriving him of a normal every day living. The disorder is defined as depressed mood or diminished interest or pleasure and also at least three of the following symptoms: significant weight loss or gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, diminished ability to think or concentrate, indecisiveness, recurrent thoughts of death, suicidal ideation/suicide attempt, or specific plan for suicide (American Psychiatric Association ed. 2000). These symptoms have to be present concurrently for at least two weeks and interfere with the patient’s everyday activities (American Psychiatric Association ed. 2000). According to the World Health Organization the number of people suffering from depression is 121 millions, resulting in 850.000 suicide deaths every year (WHO 2010). Various factors, have been implicated in the etiology of the disorder, such as genetic factors (Plotsky et al. 1998, Anacker et al. 2010, Janssen et al. 2010), biological factors(Seitz et al. 2010, Weinberger et al. 2010, Kirsh 2010) and social factors (Brendgen et al. 2005, Costello et al. 2008, Wright et al 2010). The need for an individualized approach to the assessment and more importantly, to the treatment plan and follow-up of each patient, becomes evident. The main goal of this essay is to review the case study of a client with major depressive disorder, addressing all the pertinent issues, such as patient’s history, assessment procedures, diagnostic formulation and therapeutic options. Case presentation Mary is a 53-year-old housewife and a mother of three sons, their ages being 35, 34 and 28 years, which are all living independently and two of them moved abroad a few years before. Nine months ago she lost her husband, who died of cancer rather unexpectedly. Her husband was diagnosed with widespread metastatic disease after their summer vacation, and he had visited his doctor to complain for an “innocent low back pain”. Mary was present at the doctor’s office the day they were given the bad news. Her husband deteriorated rapidly afterwards and lived only for five months, suffering a tragic end. Through the course of her husband’s disease, Mary was his main assistance. She would drive him for his chemotherapies, make all the necessary arrangements with his physician, cook in a “sterile” manner, give him his painkiller injections, and even bathe him in the end, when he was bedridden. After his death she immediately moved out of the house where she lived for the past 32 years. Mary was referred to the psychiatrist by her general practitioner. The referring physician decided that she needed a psychiatric evaluation because for the past nine months she was feeling constantly tired, had lost her appetite, lost weight and had trouble sleeping, without an identifiable somatic cause. Personal History As a child, Mary grew-up in an average sized city, in a family of four people. Her mother was a housewife, her father owned a neighborhood pastry shop, and none of her parents had official education. Her mother is described as a nice, low-profile woman, that was mainly occupied with housework and raising the children (Mary has a younger sister). Her fathers was described as being very strict, strong-headed, and cruel at times, that he would yell at his wife and punish somatically his daughters, when he felt that they did not obey his will. Mary recalls that she and her sister were really afraid of him. Mary was a good pupil and she liked school. She dreamed of becoming a dentist. When she was fourteen years-old, she met John, a young man who lived in her neighborhood. He was 13 years older than her, and her father hired him as a math tutor for Mary. John was just a high school graduate, but he was very bright and everyone in the neighborhood respected him. Mary fell in love with John, they got engaged and she quit school at the age of 16. She got married to John when she was 17 years old, and she had her first son a year after her marriage. She recalls that she was really happy because she married her sweetheart, but also she was very satisfied because she escaped her father’s supervision and could finally live independently. Mary had another son a year after her first boy, but she desperately wanted a baby girl. She finally got pregnant again and unfortunately she miscarried the baby at the sixth month of pregnancy. She recalls that she was extremely unhappy, since the baby was female. After that, she had her third son. She never quite overcame her desire to have a daughter and she mentions that she felt hostility towards her third son during the first six months after his birth. Mary was never employed outside her house. She was a very good housewife and she had a very good relationship with her husband. She mentions that the only thing she detested was the fact that he did not like traveling, so they never actually left their neighborhood, except for the summer vacation, at a small cottage that her husband bought by the sea. But even there, she had to put up half of the time with her husband’s friends, that he insisted on inviting to spend time together. Mary mentioned that at times she felt like a maid and detested her husband for that. The income of Mary’s family was low to average. She had to do a lot of things in the house by herself in order to save money, but she refers to her life as satisfactory on the whole. Mary became a grandmother at the age of 47 years, by her eldest son. She has four grand children and declares that she loves them more than her own life. At the age of 52 her husband was diagnosed with metastatic colon cancer. She recalls the day that the physician gave them the bad news as the most disastrous in her life thus far. She remembers that she could not accept the fact that her husband was going to die. She stood by him during his illness and watched him die in terrible pain and disfigured from metastases to the facial area. She never had many friends, so the only people that partially supported her during this difficult time were her parents, her sister and her eldest son. She mentions that she can’t stand the idea of her aged parents being alive but her husband had to die and she complains about her sister who only pays attention to her own family and ignores her own pain. Mary also complained about her son, mentioning that he doesn’t visit her as often as she would like. After her husband’s death, her periods that were regular until then, stopped suddenly. She lost her appetite and start losing weight. She felt exhausted most of the day and could not sleep well at night. She would get aroused around midnight and she could not sleep again until dawn. She spent most of her time outside the house at the graveyard, visiting her husband’s grave. She decided to visit her general practitioner, because she was preoccupied with the idea that she had cancer too. Her physician decided to refer her for a psychological evaluation. Medical history Mary is a 165 cm tall Caucasian female, weighs 52 kilograms and has fair, rather pale complexion. She did not suffer from any significant illness in the past and she was never hospitalized. She gave natural birth to her three sons, had one miscarriage and had regular periods until nine months ago. She does not smoke or drink and she does not take any medication. She was diagnosed with osteopenia three years ago, but she wasn’t given any therapy. She was also diagnosed with iron deficiency anemia seven years ago, and she received oral iron supplementation for two months. Family medical history Mary’s father is 75 years old and he is treated for knee osteoarthritis with no other medical problems. Her mother is 72 years old and had an osteoporotic hip fracture twenty years ago and also suffers for the past one year from cardiac insufficiency. Her sister is two years younger and she had surgery for kidney cysts and is on thyroxine to treat her multinodular goiter. Finally, Mary’s younger son was diagnosed with insulin-dependent diabetes at age 20. There is no history of psychiatric illnesses in the family. Medical Examination Results 1) Full Blood Count revealed iron deficiency anemia. 2) Mid stream Urine Sample (MSU) : normal results for urinary free cortisol. 3) Thyroid function Test (TFTs) : normal results 4) Electro Encephalogram (EEG) during sleep : revealed reduced duration of REM periods 5) Kidney Function Tests – nil abnormalities detected 6) Urine testing for substance Abuse showed negative results 7) CT Brain Scan showed normal results foa patient’s age 8) Blood biochemical profile was normal. 9) Urine analysis was normal. 10) Pap smear and mammography showed normal results in respect to her age. 11) Gastroscopy and colonoscopy showed normal findings. 12) Upper and lower abdomen ultrasound showed normal findings. 13) Physical examination did not reveal any pathological findings. Psychiatric assessment Mary’s primary care physician suspected that she suffered from depression and referred her for appropriate evaluation. The Quick Inventory of Depressive Symptomatology (Clinician-Rated) (QIDS-C16) was used, in compliance with the idea of a “measurement-based care approach” (Gelenberg 2010). Mary was asked to answer sixteen questions that best described her situation in the last seven days. Her answers were the following: 1. Sleep-onset insomnia 2 Takes at least 30 minutes to fall asleep, more than half the time. 2. Mid-nocturnal insomnia 3 Awakens more than once a night and stays awake for 20 minutes or more, more than half the time. 3. Early-morning insomnia 3 Awakens at least 2 hours before need be, more than half the time. 4. Hypersomnia 0 Sleeps no longer than 7–8 hours/night, without naps. Highest score (1–4): 3 5. Mood (sad) 2 Feels sad more than half the time. 6. Appetite (decreased) 1 Eats somewhat less often and/or lesser amounts than usual. 7. Appetite (increased) 0 No change from usual appetite. 8. Weight (decrease) within the last 2 weeks 2 Has lost 2 pounds or more. . 9. Weight (increase) within the last 2 weeks 0 Has experienced no weight increase. Highest score (6–9 above): 2 10. Concentration/decision making 1 Occasionally feels indecisive or notes that attention often wanders. 11. Outlook (self) 1 Is more self-blaming than usual. 12. Suicidal ideation 0 Does not think of suicide or death. 13. Involvement 2 Finds only 1 or 2 former interests remain. 14. Energy/fatigability 1 Tires more easily than usual. 15. Psychomotor slowing 0 Normal speed of thinking, gesturing, and speaking. 16. Psychomotor agitation 0 No increased speed or disorganization in thinking or gesturing. Highest score on either of the 2 psychomotor items: 0 Total Score: 12 According to Rush et al. (2003) this result is interpreted as “moderate depression”. The patient was also evaluated according to the DSM-IV-TR (American Psychiatric Association 2000) and the results were the following: Axis I : 296.22 Major Depressive Disorder, Single Episode, Moderate Axis II: No long standing chronic conditions that may affect the clinical syndromes listed in Axis I Axis III: No medical conditions Axis IV: Psychosocial and environmental stressors that may affect the clinical syndromes listed in Axis I: Difficult childhood years, premature death of husband, lack of strong emotional support from friends and family. Axis V : Global Assesment of Functioning (GAF) : 65 V code: V62.82 (Bereavement) Based on all the aforementioned information Mary was diagnosed with Major Depressive Disorder of moderate severity. Treatment The first-line treatment options for Mary were psychotherapy and antidepressant therapy (National Guideline Clearinghouse 2010). She was initiated on drug therapy, and agreed to initiate psychotherapy. She was prescribed anti-depressants, of the class selective serotonin reuptake inhibitors (Fluoxetine) (National Guideline Clearinghouse 2010). The psychiatrist also recommended certain book-reading (bibliotherapy) and she was advised to engage in moderate aerobic exercise (such as walking) (National Guideline Clearinghouse 2010). Mary will meet regularly with the psychologist to talk about the symptoms, and discuss ways to cope with her feelings. The goal of cognitive treatment is the exploration of all the factors that contributed to the patient’s depression and the improvement of symptoms through acquisition of inner self knowledge and personal empowering. Mary agreed to participate actively in her treatment plan. Discussion of current problems that may influence the course of illness Mary is a patient experiencing a single episode of depression. She is a healthy person, with no comorbid conditions and her medical check-up results were very satisfactory for her age .Despite her difficult childhood, due to the relation with her father, and the fact that she was a minor when she got married, she managed to create a normal family. Although factors such as family structure and the quality of relationship with the parents appear important in the development of depression (Brendgen et al. 2005, Costello et al. 2008), Mary was not driven to depression in her adolescent years. It is known that psychosocial factors, like loss of a loved one, often incapacitate people in a significant degree, even at the point of being unable to use their usual coping mechanisms. The life-changing event for Mary was the premature, tragic death of her husband. It is obvious from the case analysis that this was the initiating event for her illness. Mary is not working, so she doesn’t have to face the stressful environment of a job that could predispose her to the depression she developed (Voltmer et al 2008), but also she never had the chance to create a social network through a job. At this difficult time of her life, she doesn’t really have close friends or relatives that could support her emotionally. She feels bitter towards her parents, her sister and son, because she believes that they are continuing with their lives, without paying much attention to the fact that her own life was shattered. These feelings and the actual lack of emotional support constitute drawbacks in her attempt to recover (Hirschfeld 2000). Mary does not appear to have a genetic predisposition for the disease (Plotsky et al. 1998, Anacker et al. 2010), since no other relative suffers from depression. Also, she never suffered a psychological illness in the past, although she had experienced stressful events (i.e. difficult relationship with her father, miscarriage at a young age, younger son diagnosed with chronic illness) (ed. Porter 2010). A threatening life event can be the initiating cause leading depression. Depression can occur when an event disrupts the primary role that constitutes the basis for a person’s sense of self, especially when there are no alternative situations that allow for the maintenance of that sense (Astbury et al 1994, Oatley & Bolton, 1985). In Mary’s case, her husband was the person that provided her with economic and emotional support and his existence allowed her the role of the wife. If Mary complies with her therapy and is willing to participate actively in her treatment effort, it seems highly probable that she will be able to achieve remission of her symptoms. Summary Mary is a 53 year-old housewife that was referred for psychological evaluation by her general practitioner. Her main complaints were sleep pattern disruption, loss of appetite and weight and constant tiredness. Her symptoms begun after the loss of her husband who died recently from cancer. Her personal history revealed difficult childhood due to family relationships, resulting in the decision of marriage in late adolescence. Her medical examinations revealed no significant pathology that could explain the current symptoms. She had no personal or family history of mental illness. She was assessed for depression with the use of QIDS-C16 questionnaire and the DSM-IV criteria and was found to suffer from moderate depression. Appropriate treatment with anti-depressants and psychotherapy meetings was initiated. A discussion of her current living situation and conditions that can affect her course and recovery is provided. Conclusion Major Depressive Disorder is a multi-factorial entity, with great impact on personal, family and social life. It can be a debilitating disease that deprives the individual from the energy and even the desire to continue living. Many socioeconomic parameters influence occurrence and also the prognosis of the patients: age at first presentation, gender, marital status, quality of marriage and family relationships, social support, socioeconomic status, personality traits and disorders, life events and bereavement. Attention to the individuality of each patient is essential in the course of assessment, diagnosis and treatment. There are several up-to-date assessment methods that can assist with making the correct diagnosis. The appropriate treatment can be selected afterwards, by respecting the patient’s personal preference, whenever possible. Therapeutic intervention has a major impact in the course of the disorder and can improve quality of life substantially. Hopefully, in the future, the input of various clinical trials on various intervention modalities will allow for more effective ways of preventing and treating depression, the result being the reduction of incidence and morbidity of the disorder. REFERENCES: American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision) 4th edition, Washington DC, American Psychiatric Publishing, Inc. Anacker, C, Zunszain, PA, Carvalho, LA & Pariante, CM (2010) The glucocorticoid receptor: Pivot of depression and of antidepressant treatment? Psychoneuroendocrinology. doi:10.1016/j.psyneuen.2010.03.007 Astbury, J, Brown, S, Lumley, J and Small, R (1994). Birth events, birth experiences and social factors in depression after birth. Australian Journal Public Health, 18: 176-184. Bhalla RN & Bhalla PM, (2010) Depression, eMedicine, [online] . 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What is depression? [Online]. Available from http://www.who.int/mental_health/management/ depression/definition [Accessed April 17, 2010] Wright, LJ, Schur, E, Noonan, C, Ahumada, S, Buchwald, D & Afari, NJ (2010) Chronic Pain, Overweight, and Obesity: Findings from a Community-Based Twin Registry.The Journal of Pain , doi:10.1016/j.jpain.2009.10.004 LOGBOOK Patient name : “Mary” Monday, 8th of March 2010 (Appointment 1) Appropriate introduction to the patient and initial discussion. Patient was asked to provide consent to engage in the study of her case. Consent was granted. 53-year-old housewife, has three sons, ( 35, 34, 28 years), Nine months ago husband died of cancer . Was shocked when husband was diagnosed. Cared for him exclusively till death. Moved to a new neighborhood recently. Present condition: can’t sleep as used to, lost appetite, lost weight, feels tired, periods were regular but stopped after husband’s death. Referred by her general practitioner. Depression? Scheduled for physical+ psychological assessment. Friday 12th of March 2010 (Appointment 2) Physical came back normal ( except for iron deficiency anemia).. Childhood: father rather abusive. Drop-out of school to get married. Had one miscarriage. Younger son chronically ill (diabetes, insulin dependent at age 20). Recalls family life as happy. Liked traveling, husband did not. Never worked (total dependence on husband’s income). Few friends. Parents are alive (mother suffers from chronic lung insufficiency, father is ok) . She had one sister (thyroid goiter, surgery for kidney cysts). No history of mental illness in the family. Monday 15th of March 2010 (Appontment 3) Complains about son not coming to see her. Bitter about old parents being alive while her husband is dead. Reports no suicidal ideation. Social network for support?? (few friends..). Will fill out QIDS-C16. Friday 19th of March 2010 (Appointment 4) QIDS-C16 score: 12 (moderate depression). DSM-IV Major Depressive Disorder, Single Episode, Moderate, GAF 65 Monday 22nd of March 2010 (Appointment 5) Denies medication. Agrees on psychotherapy. Advised to exercise+ study certain topics. Next Scheduled meeting: in ten days. Read More