Major Depression Disorder - Case Study Example

Major Depression Disorder Case Study Mrs. X was not a voluntary patient; she was brought to the hospital at the insistence of social worker from the department of health after she tried to poison herself by swallowing over 15 tablets in an unmarked bottle thinking they were valium. Fortunately it turned out they were just her husband’s calcium supplement and although her stomach was pumped it turned out her life had not actually been at risk. She was diagnosed with severe major depressive disorder; when she was admitted she refused therapy and insisted that she would not talk to any “shrinks”. She demanded to be allowed to go home since she was not sick and wanted to be let alone. Mrs. X was first diagnosed with MDD after an amputation of her leg below the knee which was result of a fracture ankle and later and MRSA in hospital, following this she developed severe symptoms of MDD and has actually been hospitalized for the same featuring major catatonic characteristics as well as nihilistic themes. When she was first admitted to hospital it was involuntarily, however a month later after undergoing treatment, her condition improved well enough for her to appreciate the gravity of her situation and the fact that she indeed needed help. It was only when she became voluntary that this case study could be commenced since she gave consents on condition of anonymity therefore the use of Mrs. X rather than her real name. Introduction While it is normal for people to feel low or stressed at some point in their life, clinical depression is characterized by a depressed mood for most of the day but more so in the morning hours. For a diagnosis to be made, the patient needs must register these feelings every day for at least two weeks. The DSM-IV manual includes other symptoms that could be associated with major depression, they include; Fatigue and loss of energy, feelings of worthlessness, impaired concentration and indecisiveness (APA, 2013). Insomnia or hypersomnia when wants to sleep all day. A reduction I interest and pleasures of everyday activities, restlessness general fatigue and weight loss or gain, generally a change of the body weight by at least 5%. In extreme cases there patients encounter recurring thoughts of suicide of other self-destructive activities (Sakinofsky, 2007). She lives with her husband who is suffering a pelvic fracture that impairs his mobility, before her admission, her husband had discontinued her medication because of the side effects. Catatonic manifestation of MDD involves body contortions and sometimes abnormal posturing which in her case makes Mrs.X prone to constant falls which sometimes result in injuries. The most manifest catatonic sign in Mr. X the difficulty processing facial expression making it difficult to read her face as it gets contorted with one emotion for long periods (Sterzer et al., 2011; Wu et al, 2012). In addition to the amputation, other secondary co-morbidities are type 2 diabetes mellitus and pulmonary embolism which is further complicated by a case of pulmonary hypertension. She is eligible and receives home care 6 days a week paid for by her insurance. Her father died at 68, from cancer and her mother died a year later from unknown courses, she has 3 siblings and four of her own children, none of them lives with her expect a daughter who occasionally comes to help out with the care. For most of her life, she has been employed as a secretary in her husband’s accounting business. She appears disturbed by the amputated leg and is not always happy to use the prosthetic only that she has to because of mobility reasons. This has been found to lead to her suffering low self-esteem and suicidal tendencies complains of being a burden to her husband and children. Clinical manifestation The negative effects of MDD are often manifested in the patient’s inability to function normally in a personal and social capacity. Given her other pre-existing conditions, many of the symptoms are enhanced and result in a series of clinical manifestations discussed herein. Mrs. X’s subjective manifestation were initially evident when she begun to shun speech and the company of others, she spends a lot of time by herself and the few time she speaks she is cynical and very pessimistic. When the social worker asked her if she wanted to go to talk to a doctor, she said he would only try to poison her again and refused anything to do with hospitals. She also contemplated suicide a lot and she would sometimes be heard muttering that god should not take away her health and her ability to “escape it all”. Her language was generally soft spoken but she displayed some latency in speech, tending to speak slowly and hesitantly and sometimes seeming to lose her stream of though and wondering off the course of the conversation. On admission, her MMSE (mini mental examination) score was 25/30, he though content was low in tempo and the logical coherence was at times challenged. However, after she had undergone medication and two courses of ECT, her speech improved becoming more engaging and she was able to come up with more constructive and logical thought; in the short run, ECT tends to produce more immediate results than antidepressants (Jaworska, and Protzner, 2013 ), however it negatively affected her short term memory albeit temporally . These thoughts were however pessimistic and most of the time she spoke about how sick and old she was, even though she denied suicidal thoughts, she admits that she is worried about being discharged expressing anxiety in her ability to cope with life outside the hospital. Appearance Mrs. X appeared to be sickly overweight and generally disheveled, on her admission to the hospital, despite the relatively cold weather her clothing was not very warm it was dirty and stained. The report filled on her admission reported that she had a strong body odor suggesting she had not taken a shower or bath for quite some time. The diagnostic criterion of the DSMIV-TR for MDD included deficiency in self-care and daily activities such as hygiene and general wellbeing as well as apparent lack of motivation or interest in matters such as nutrition and psychical exercise (APA, 2013) all which the patient appears to have acutely neglected and which served to confirm the diagnosis. Disturbances in mood When she was admitted her mood was very low and for most part she only mumbled something about wanting to be allowed to go home, according to her home care records, he mood was generally flat and she rarely got exited r reacted to anything. However, she appeared to suffer from anxiety especially when asking about home and avoided eye contact during conversation, which was in most cases incompressible until she had been in the inpatient for some days. Major depression has been found to reduce the interest of the patient in what they previously considered pleasurable such as sexual activity or any other form of entertainment (Fitzgerald, 2013). This has been attributed to among other things a general dulling of the senses owing to depression (Andreasen, 2008), when one loses interest in their pleasure seeking activities(), it is explicable that the literally lose the capacity to have fun or enjoy anything which can explain Mrs. X’s apparent disinterest in everything going on around her (Swiecicki et al., 2009) Gender and prior Comorbidities The propensity for women getting major depression disorder is usually twice as high as that for men, which has resulted in considerable research in the underlying gender differences treatment intervention with gender based considerations (Olff et al, 2007; Andrews et al., 2007). However, it is also speculated that this disparity could be based on the fact that women manifest their symptoms at generally lower thresholds than men. The patient is classified as a relapsed since she had been previously diagnosed with the same disorder and treatment was administered, 5 years ago. Between the first treatment and the second admission, she had experienced a minor stroke from which she gradually recovered. One of the factors that aggravated the symptoms of major depressive disorder is a stroke and it is therefore likely that her second episode could be attributed to that in addition to advanced age (Hinrichsen and Emery, 2006). Her medical records show that she had earlier been treated for depression although not diagnosed with MDD in her late teens after attempted suicide. This can be explained by the fact that MDD is prevalent among g teens ager especially girls owing to their hormonal changes, it however often goes undetected (Morris, 2012). Patient Management Under the Mental health Act 1986, involuntarily patients must have a treatment plan, however this is not a legal requirement for voluntary ones, nonetheless this does not however mean that when Mrs. X became voluntary one month after admission she stopped needing one. The patient act and medical logic requires that every patient should have an individualized treatment plan which should be constantly reviewed and revised based on their progress (Hahn et al, 2010). Her plan addresses the following; Mental health physical support and social needs, she should be placed under intensive care and supervision while in hospital (Dale, Sorour and Milner, 2008), in addition, when she is discharged intensive case management should be carried out by daily home visits by a mobile support and treatment team so as to ensure she complies to the meditation given and that her situation does not deteriorate. In addition to this, a risk assessment should be carried out to ensure she does not pose a threat to herself by attempting suicide or destructive behavior (Cooney et al., 2013). The process of managing a patient with clinical depression is a complex one that requires a combination of biomedical Pharmacological and psychological interventions, there is no specific baseline and the caretaker vary treatments based on each individual (Dale, Sorour and Milner, 2008). Initially she had been put on a variety of powerful antidepressants; however these proved inefficient. Owing to her poor eating habits, the antidepressants coupled with several other regiments she had for her physical ills were having a negative effect on her stomach. The therapist settled on ECT which would later be replaced with a new anti-depressant and since her admission, she had received 12 courses of the same. This is because despite of its immediate results, ECT is not always sustainable and patients who are put through it have a higher chance of relapsing (Bourgon, 2000). Mrs. X was also deemed to be at risk of self-neglect, since she had refused to take care of her hygiene and would often go for days without washing or brushing her teeth. She was placed on a 2 hourly pressure care and due to her propensity for falling; she was put on a low bed and kept under constant observation when she was awake to prevent her from another suicide attempt. Cognitive-behavioral therapy (CBT) In addition to ECT and drugs, she was treated through the cognitive behavior therapy, proponents of this theory postulate that human feeling, behavior and depression are all connected. This therapy is based on fostering a collaborative working relationship between the patient and therapist through the application of several mini experiments, this way they change certain aspects of the patient’s thoughts and behavioral patterns. When she recovered enough to be considered voluntary, underwent several sessions with a therapist in which she underwent this therapy gradually unburdening her and this was found to be effective especially when used alongside the other techniques. Mirtazapine Studies have proven that the use of Oral mirtazapine is adults suffering from major depression is more effective than majority of the antidepressant combinations (Lind et al., 2009). In a comparative study in which mirtazapine was compare to 12 other prescription antidepressant drugs, it was proved to have a higher sustained remission rate than them (Neu et al, 2006; Lind et al., 2009). Mrs. X. was already on several treatment regimens for her diabetes and other underlying conditions; therefore the doctors found it best for her if she was to be mirtazapine since had considerably reduced side effects compared to other antidepressants (Neu et al, 2006). In addition, since she had never used it before, she was unlikely to develop resistance as she had for other antidepressants (Rihmer and Akiskal, 2006). She was required to take two pills every day, one in the morning and one at night, one of the major side effects of the drug dry mouth, with the patient often feeling dehydrated. This can be combated by encouraging her to drink a lot of fluids; otherwise the effect will result in discomfort and a reluctance to use her mouth for eating or even speaking which will negatively impact on the physical and psychosocial treatment practices (Raskin et al, 2007). She should also be encouraged to eat healthy and non-fattening foods especially vegetables (Keller, Neale & Kendler, 2007). Studies have also shown that mirtazapine tends to have a comparatively higher success rate in preventing patients from relapsing and during test, patient who used it were reported to have a generally higher improvement of sleep compared to those using citalopram, fluoxetine or paroxetine(Wade et al., 2003; Hong et al., 2003 Leinonen et al, 1999). In the past, it had proved to be especially effective in patients suffering post-stroke depression (Ioannidis, 2008), given that she had recently been through one, it is only logical that the drug should be expected to be the most suitable for her. However there was risk that it could worsen her hypersomnia since it increased sleep patterns is one of its side effects (Maestri et al, 2010). However its other advantages over other drugs such as the fact that it caused considerably less nausea the fact that it did not interrupt REM sleep patterns justified it use in this case. She was put on a dosage of olanzapine, Evidenced based studies have reported that olanzapine had better results with treatment. Like mirtazapine, the drug is highly effective in treating depression and psychotic episodes; however the negative side effects are significantly greater especially in respect to weight. Despite the higher adherence rate, the drug has a metabolic effect of increasing the patients’ weight. In addition to the propensity for obesity, the drug is also puts the patient at risk of getting hypertension, it was noted that Mr. X’s blood pressure went up slightly after she commenced treatment. Although the cause is not apparent, it is quite possible that she has both added weight and blood pressure because of the drug. Patient Education Major depressive disorder is treatable but it cannot always be cured especially when dealing with patients of Mrs. X’s age and medical vulnerability. Therefore the patient and primary caregivers must be advised on the importance of ensuring she adheres to her medication at all times or else risk a relapse that could see her attempting suicide again, and with possible success. In addition, she needs to be advised of how to manage the side effects of Mirtazapine to ensure she understand them so she and her caregivers are better placed to take mitigative action. One of the major to lance issues is dry mouth which could result in serious discomfort and a feeling of dehydration; in addition it has been reported to result in constipation. To mitigate this, a constant fluid intake should be encouraged and a throughout review of her diet needs to be carried out so as to inculcate PRN aperit foods. When the drug is being administered, the medical personal need to be vigilant so as to monitor the drowsiness and blood pressure as well as liver function and blood count which could be affected at the onset of treatment (Sledjeski, Speisman & Dierker, 2008). The drug quite addictive, as a result when the caregivers deem that the patient has benefited from it and needs to stop, the process should not be abrupt. The withdrawal should be carried out gradually over a period or 1 to 2 weeks and before doing this the prescribing doctor or a GP should be consulted. In addition, when the side effects of the drug manifest, they should also be reported to the doctor in charge of the patient, this is because the caregivers may not be qualified to distinguish between a side effect and a symptom (Rihmer and Akiskal, 2006). Her physical health needs should be addressed through interpersonal therapy in patient by the combined effort or her MSTT manager and her general practitioner, primarily the treatment goals should focus on managing her diabetes (Hays et al., 1997) and this can be done be regular visits from a GP and diabetes educator to provide her and her caregivers with a advise on the best medication and nutrition. She also needs support which can be provided by the home care provider; they should ensure they assist her with her hygiene issue by insisting she observes basic hygiene practice and assisting her when she is psychically unable to do so. Conclusion Given that Mrs. X was forcefully brought to the hospital, it may take time before she recovers well enough to understand and accept the reality of her condition and therefore be in a position to contribute to her healing process as opposed to resisting and being in denial. Nevertheless, it is important that she and/or her caregivers understand that while some people do actually end up with a full recovery, one third of those positively diagnosed with MDD suffer relapses in less than 18 months from the time of treatment. Individuals who have suffered from the condition previously are more likely to have recurring episodes of the same and given Mrs. X’s, medical history, she is at a higher than average risk of suffering from MDD even after treatment. This means that the caregivers involved in her treatment and maintained as well as herself needs must put a lot of effort in ensuring that her drug regiment is adhered to and she is also receive treatment for other chronic conditions she suffers from so as to reduce her already higher than average chances of relapsing (Keller, Neale & Kendler, 2007). The fact that she lost both her parents within a year, could have contributed to undiagnosed post traumatic disorder which is one of the major courses of relapse in individuals suffering from MDD (Rytwinski et al, 2013), therefore making her even more prone to a relapse on top of all other considerations. She also stands the risk of hyperintesities which is white matter that is often associated with cerebrovascular disease, in many cases; such vascular depressions have been found to render ones response to standard therapies very poor. References American Psychiatric Association APA. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.,). Arlington, VA: American Psychiatric Publishing. Andreasen, N.C. (2008). The relationship between creativity and mood disorders. Dialogues in clinical neuroscience. 2008;10(2):251–5.  Andrews, G., M.D et al. (2007). 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