The Nature of Depression as a Psychiatric Condition - Essay Example

? INTRODUCTION The case of the 68-year-old patient Gloria is analyzed and diagnosed. Her physical symptoms are described and investigated to arrive at a conclusion of clinical depression, which is not unusual in elderly widows. The disease of depression is described, and expanded upon with respect to Gloria's specific symptoms. In light of the patient's deteriorating health, depression is viewed as the most likely explanation for her changes in behavior. Following the initial analysis recommendations are given in regards to treatment options. Typically in the psychiatric field a combination of treatment modalities is considered most efficacious. The drugs are not ideal in every case, as they may lead to side effects, chemical dependency, and missed opportunities for intervention and psychotherapy to safely resolve issues regarding mental status. For Gloria, a recommendation for increased social involvement is justified, and descriptions of drug treatment options are given. Pharmacology must entail some strategy for the use of antidepressants. Descriptions are given of families of anti-depressant drugs in order to determine which is most beneficial in Gloria's situation. Based on the available research, both forms of antidepressants exhibit potential. A third drug is also mentioned as a possible emergency stopgap measure in case a rapid intervention is necessary due to a rapidly deteriorating condition. Finally, a reflexive analysis is given where alternative treatments and diagnoses are explored. Additional detail concerning the phenomenon of clinical depression is given, as well as descriptions of alternative psychopathologies. While it is possible to envision alternatives to a diagnosis of depression, it is the initial assessment that is concluded to be most likely with respect to Gloria's condition. PROBLEM ANALYSIS Gloria is suffering from a host of symptoms not uncommon for elderly patients in her situation, having experienced the natural losses that come with age. These losses occur both as a consequence of physical deterioration, and in a social dimension, due to the loss of a lifetime partner. In short, it is likely that Gloria is suffering from depression. Depression in a clinical sense, can affect people of all ages – and is not simply a case of the blues, or temporary feelings of inadequacy. Clinical depression involves identifiable neurological factors which are subject to control with medication. The health burden from depression is considerable. Millions of individuals worldwide suffer from varying of this condition. Experts describe depression as the second leading medical cause of long-term disability. In terms of global burden of disease, depression is presently the fourth cause – but some experts predict it will rise to become the second cause by the year 2020. (Lam & Oetter, 2002) Depression in the elderly may in some cases go unrecognized, due to a subtle conceit that it might be "normal" for the elderly to exhibit many of the signs and symptoms associated with a clinical case. In fact, some seniors will not admit or report symptoms of depression under the assumption that nothing can be done about it, that it is part of life's natural transition and thus do not want to seem demented, or 'weak'. (Cassano & Fava, 2007) while there is some physical overlap between depression and some signs of aging, a major depressive episode is a disease state, and not normal to the aging process. Temporary downturns in mood, and normal feelings of grief are natural, but in Gloria's case, there is evidence of persistent negative moods that impair normal functioning. There may be some professionals as well as laypersons who believe that persistent depression is a legitimate response to deteriorating health, but the condition does not need to be accepted with stoicism. (Depression Guideline Panel, 1993.), (Lebowitz et al. 1997) Yet that is often what does occur. Studies estimate that among the elderly, 60% of all instances of depression go untreated. (Steffens et al. 2000) Instead, it should be treated as vigorously as any purely organic illness wherever it does occur. But depression is a wide spread concern in senior citizens, the very factors that might make it seem supposedly normal on the other hand increase the risk of true depression. Life changes, failing health, as might be expected in cases where the patient suffers multiple physio-organic illnesses. Major Depressive disorders tend to be prevalent in senior citizens; especially among nursing home residents where as many as one-quarter can be found to exhibit the symptoms. (Rothschild, 2006) these rates can rise as high as 40% in cases of severe neurological illnesses. Gloria lost her husband five years ago, and while that alone cannot be said to have precipitated clinical depression, it is one of many contributing factors that no doubt leads to a sense of isolation and purposelessness. Although she is not entirely without social contact, with a daughter and son-in-law with very young children. Inglorious case, there is the perception that depression results from a slow decline in interest and ambition towards her own life and future. If allowed to progress, then simple forms of social intervention from the family she does have left is likely to be insufficient towards an improvement of her situation. Adding to the difficulty is the lurking threat of subsyndromal depression. The psychological factors in conjunction with health related concerns lead to an internal process by which the condition of the patient will worsen steadily, but below any clinical threshold for detection. Experts estimate that 5 million people in the United States alone may be at risk for depression, and carrying a psychological and physiological risk factors that slowly metastasize into a condition requiring substantial psychiatric care. Subsyndromal depression tends to be common among the elderly, and is believed to progress into the full clinical condition, what can be termed major depression. (Horwath et al. 1992) Consistent with a slowly building condition that gradually approaches a clinically detectable phenomenon, is the evidence of the commonality of long-term chronic cases. Where depression does occur, in approximately 50% of cases the affliction may be chronic or intermittent/recurrent. Depression becomes a lingering illness that may require years to fully manifest, but which will remain for many years more in the absence of treatment. The contributing symptoms, such as the decline in physical health and social isolation can be shown to increase the risk both that the disease will be persistent, and in addition the probability increases that depression will return even if therapy appears initially effective. A combination of therapies must be utilized to achieve the goal of complete remission of symptoms, encouraging the patient to resume all prior functionalities; but with the threat of recurrence prevention must also be a factor in any treatment strategy. (Remick, 2002), (Greden, 2001) with respect to a broader analysis, it is essential that cases like Gloria's include a partnership between medical and psychiatric professionals. Evidence listed previously in this analysis delivers a small picture of the prevalence of depression, in the elderly as well as other individuals that may have suffered loss or health failures in the past. Due to this prevalence, there are certain cases where the necessary psychiatric attention that would be ideal in these cases cannot be realized for some patients. A Canadian study revealed that 82% of patients diagnosed with mental disorders received no other treatment besides that which was available from a general medical practitioner. (Michalak et al. 2002) While this example is clearly not ideal, it does underscore the problem that depression may correctly be perceived to cross the boundaries between pure medicine and aberrant psychology. Analyses such as this one are valuable as a way to promote professional development and cooperation between all those likely to encounter patients suffering from complex conditions that often require medication. TREATMENT RECOMMENDATIONS In general, treatment options for depression must include some combination of psychotherapy or antidepressant medications. Of course, the use of medication must be carefully weighed with respect to the patient's health, and whether underlying physiological vulnerabilities are likely to impede the effectiveness of any drug therapy. Any effective drug would also entail a certain level of risk, and synergistic reactions with underlying conditions could create a risk that is not outweighed by the benefits. That said, drugs alone may prove insufficient to penetrate emotional barriers to recovery. There may be cases where guidance; a new approach to a person's familiar problems can be of great relief. Due to the risks of drug dependency and side-effects, if psychotherapy could yield suitable benefits in an acceptable timeframe, it is likely preferable. Some experts advocate what is known as a chronic disease management model in order to reduce the disease burden of depression. Not simply a strategy of pumping the patient full of drugs, a plan must be devised to proactively manage the symptoms of depression through increased social involvement and intervention, but with self-management in mind. While therapy and interventions of various types must be included in any chronic disease management strategy, especially in the case of depression the goal of self sufficiency becomes a vital benchmark. The patient must be motivated to maintain their mental health with a constructive lifestyle or they will simply slipped back into the doldrums once again. (Andrews, 2001), (Badamgarav et al. 2003) It becomes essential, in light of these factors to improve primary care treatment of clinically-presenting psychiatric disorders; if for no other reason than to keep patients stable until they can be transferred to mental health specialists. Still, there is a time and place for drug treatment – and these options must be considered in light of the known psychiatric factors and health risks. Adding to the complication are the physiological realities that elderly patients respond to medication differently than those younger. The chronic medical illnesses common to the elderly will affect pharmacokinetics; reductions in metabolic rates will result in higher than average drug concentrations and a sub optimal ability to excrete byproducts of pharmaceuticals. (Baumann, 1998) with respect to pharmacology, there are two common approaches towards the medication of depression in the elderly: dual action drugs, which exhibit broader areas of effect on the neurotransmitters associated with clinical depression. The other option would be selective inhibitors, or a single action agents. These drugs are more narrowly focused towards the inhibition of specific neurotransmitter activity. (Serotonin) while either option has been shown potentially efficacious in the treatment of depression, research is ongoing to determine the true superiority of either drug strategy. While there are many neurochemical options, recent findings show efficacy in either the single and dual action antidepressants when used in the elderly. (Rosenberg et al. 2007), Wehmeier et al 2005), (Allard et al. 2004), (Oslin et al. 2003), (Schatzberg & Roose, 2006) With respect to Gloria's case, either the single action or the broader, dual action antidepressants could be potentially effective. One pharmacological option for treatment found to be effective is methylphenidate. It has advantages over other antidepressants due to its relatively rapid onset; often benefits occur before 5 days. (Emptage & Semla, 1996) this could be a potentially effective in a last ditch option should Gloria's condition take a dramatic turn for the worst . In that case, rapid intervention could be necessary to protect Gloria's life and health. Otherwise, a proactive strategy involving enhanced social involvement combined with antidepressants would seem a viable course of action. In terms of the antidepressants, with a high probability that either single or dual action drugs will be equally effective a physician must analyze Gloria's particular physiology and determine which option has the least probability of harmful side effects. REFLEXIVE ANALYSIS In the interest of scientific rigor and thoroughness, efforts must be made to justify a diagnosis of depression, while considering other alternatives based upon the information given. Of particular concern is Gloria's arthritis. Amongst elderly patients with depression, it has been mentioned that multiple health problems exacerbate the situation. Experts document that among the elderly, it is common for household chores and personal hygiene to fall by the wayside. It is also common for patients in this condition to become lax with their medication. (Cassano & Fava, 2008) Arthritic symptoms that prevent normal household chores can contribute to this situation both in terms of the physical practicalities, and with respect to the overall health deterioration common to these cases. While depression can be caused by a combination of physical illnesses and deteriorating health, depression can also be an indicator of previously unknown physical ailments. This overlap between the symptoms and cause can complicate a successful diagnosis of depression in the elderly. In some cases, some of the more typical symptoms such as insomnia or fatigue are also concomitant with natural aging, in addition to being symptoms of other physical disease. (Cassano & Fava, 2008) For Gloria, her difficulty in performing her normal cooking and cleaning is a sign of depression, but professional analysis would be helpful in determining the extent to which her arthritis is preventing her from carrying out her normal activities, or if these lapses are the result of an underlying emotional problem. In favor of a diagnosis of depression are the reports of her formerly active life. During psychological analysis, it will be helpful to work closely with medical health professionals to determine the extent to which her arthritis impedes her physical activity, as it was noted she normally goes swimming twice a week. The arthritis was reportedly localized it to her hands, thus it is unlikely that a decrease in all her social and physical activities could be attributable to this singular organic cause, clinical depression is the best fit. Other factors that convey risk of depression are being a widow - in addition to being female, social isolation, as well as handicaps, such as Gloria's arthritis. (Lepine & Bouchez, 1998) symptoms such as these must be watched closely, because in the elderly the likelihood is greater that depression will lead to suicide. In the rates of suicide amongst the elderly are disproportionate relative to their percentage of the population. (CDC, 2005) There may be other organic illnesses that could simply be inflicting physical discomfort upon Gloria to the extent that her prior activities become untenable. Arthritis is certainly a likely explanation for the decline of interest in her normal chores, but it is not a sufficient explanation for a complete behavioral change if localized to her hands. But other organic causes might be considered. Gloria is over 60, and as such is statistically under a greater risk of cancer than the general population. This is simply due to the biological consequence of a high number of cell divisions as the body continues living into old age. The more cell divisions that occur in any organism, the greater the chance for errors in the tumor-suppression gene, and thus cancer. (Knudson, 2001), (Villeneuve, 1994), (Jaffe, 2003) Should Gloria suffer some form of cancer, especially if it were able to metastasize there is a strong probability that it would degrade her overall health in other areas, and might possibly induce fatigue. Gloria has been experiencing weight loss, and a metastatic cancer can lead to the symptoms. Unexplained weight loss should always be investigated as a possible indicator of depression. (Stoppler et al. 2012) In the case of bone cancer specifically, the dramatically organic symptoms including chills, fever, and night sweats should also accompany this weight loss. (Stoppler et al. 2012) Gloria does not demonstrate other symptoms similar to this. Bone cancer has also been associated with frequent breakages of bone without any obvious provocation, and abnormal fibrous growth. (Jeon et al. 2010), (Mayo Clinic Staff, 2011) This has not been reported in Gloria's case. From a strictly psychological standpoint, one might consider the possibility of an alternative disturbance that causes depression like symptoms. A speculative alternative might be some form of a lingering guilt. But there are no known factors in Gloria's presence of background that would justify some form of inner conflict. There are cases where certain forms of bipolar disorder could mimic depression. The oscillation from excitation to depression might be viewed from a cursory analysis as being similar to a major depressive episode. But bipolar disorder is well known, (Altman et al. 1997), (APA, 1994), (Lam et al. 2004), (Yatham, 2010) and should be apparent to Gloria's family and friends due to the blatant animation of a manic state, of which Gloria does not exhibit. Another factor to consider is Gloria's use of cigarettes. While not described as a heavy smoker, cigarettes can influence the smoker's mental status. There are some reports that a withdrawal from nicotine can produce elevated levels of monoamine oxidase, a substance also found in the brains of people diagnosed with clinical depression. (Abma, 2011), (Meyer et al. 2006), (Tipton, et al. 2004) Monoamine oxidase affects levels of other neurotransmitters to control the person's overall mood. (Abma, 2011) The association between Monoamine oxidase and depression has been known to researchers, but recent evidence links changes in smoking behavior towards increasing these levels; and thus producing symptoms similar to depression. While Gloria is indeed a smoker, there is no specific claim that her recent lack of interest in her normal routine extends to her smoking habits. Thus, depression-like symptoms as a consequence of nicotine withdrawal is unlikely. In addition to bipolar disorder, there are other subtypes of depression – none of which precisely fit Gloria's situation. A form of depression exists in some patients only during the winter months, known as seasonal affective disorder. But there is no mention of glorious condition improving during the summer. Other patients might experience psychotic depression, but this is often accompanied with hallucinations of which Gloria does not suffer. (Radua, et al. 2010), (Belanoff, et al. 2001) Nor is postpartum depression likely, as this patient is far past her childbearing years. (Kinnaman et al. 2006), (Cox et al. 1987), (Soares & Zitek, 2008) Specificity with respect to the subtype of disorder is still important: if only for the purpose of eliminating possibilities. Widespread knowledge of depression amongst all styles of clinicians is necessary in order to save lives. It is as other studies indicate that upwards of 66% of all suicides occur in individuals suffering from a major depressive episode. (Remick, 2002) Moreover, due to the nature of depression as a psychiatric condition often accompanied by associated medical issues that precipitate an overall decline in health, it is easy to misinterpret the findings. It is not simply that Gloria suffers from arthritis in her hands, this is but one contributing factor which encourages the patient's retreat from public life even as it joins a host of other symptoms that trigger an overall depressive state was real emotional consequences to the detriment of Gloria and her overall well-being. 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