Reflective case study

BY DR. AMIR M. HANAFI

Objectives
1.

To present a case of a mental health disorder.

2.

To identify challenges in the case.

3.

To weigh options of intervention.

4.

To reflect on the intervention decision.

Case presentation (Description)

Ms Nesma is a single 26 year old lady who came to

the outpatient psychiatry clinic for a depressed mood
during the past several months, there was no event
that she could link the mood depression to, but she
also reports loss of interest to her hobbies like
reading and going out with friends. She reports that
shes sleeping too much and has a decreased
appetite.

Question

Further Questions?

Case presentation

She stopped going to work recently as she was

having a very hard time concentrating and she felt
she wasnt trying hard enough to succeed in her work
and she feels shes a source of stress and sadness to
her family.

She says she feels down most of the time, but much
less often she feels much better when she meets a
certain friend of hers.

Case presentation

She denies any thoughts of suicide (says GOD

prevents her from ending her own life) or harming
others, no manic or hypomanic episodes, also no
delusions or hallucinations.

Her father had depression and died in vague

circumstances where there was a suspicion that he
committed suicide.

Question

Further questions in the hx?

Case presentation

Shes a known case of PCOS, receiving treatment since

early 2014 (norethisterone). No relevant surgical hx.

Her menses currenty are regular every 25 days, for 6

days, in the first 3 days she uses 6-8 pads per day then
she uses 1-2 pads per day the remaining days, she
seldom gets menstrual cramps or intermenstrual
spotting.

She also denies smoking, drinking alcohol or using any

recreational or illicit medications.

Question

How do you screen, diagnose and assess

depression?

PHQ-9 tool

For initial diagnosis:

1.

Patient completes
PHQ-9 Quick
Depression
Assessment.

2.

If there are at least 4

3s in the shaded
section (including
Questions #1 and
#2), consider a
depressive disorder.

3.

Add score to
determine severity

Drill

Now ask me one by one!

And score the patient.

Question

What else would you like to assess?

Anxiety and Depression

It's

not uncommon for someone with an

anxiety disorder to also suffer from
depression or vice versa. Nearly one-half of
those diagnosed with depression are also
diagnosed with an anxiety disorder.

http://www.adaa.org/about-adaa/press-room/facts-statistics

Anxiety:
GAD7

References:

Spitzer RL, Kroenke K, Williams JB,

Lowe B. A brief measure for assessing
generalized anxiety disorder: the
GAD-7. Archives of internal medicine.
May 22 2006;166(10):1092-1097.
PMID: 16717171

Kroenke K, Spitzer RL, Williams JB,

Monahan PO, Lowe B. Anxiety
disorders in primary care: prevalence,
impairment, comorbidity, and
detection. Annals of internal medicine.
Mar 6 2007;146(5):317-325. PMID:
17339617

Lowe B, Decker O, Muller S, et al.

Validation and standardization of the
Generalized Anxiety Disorder
Screener (GAD-7) in the general
population. Medical care. Mar
2008;46(3):266-274. PMID: 18388841

Drill

Ask me one by one!

And score the patient.

Anxiety:
GAD7

References:

Spitzer RL, Kroenke K, Williams JB,

Lowe B. A brief measure for assessing
generalized anxiety disorder: the
GAD-7. Archives of internal medicine.
May 22 2006;166(10):1092-1097.
PMID: 16717171

Kroenke K, Spitzer RL, Williams JB,

Monahan PO, Lowe B. Anxiety
disorders in primary care: prevalence,
impairment, comorbidity, and
detection. Annals of internal medicine.
Mar 6 2007;146(5):317-325. PMID:
17339617

Lowe B, Decker O, Muller S, et al.

Validation and standardization of the
Generalized Anxiety Disorder
Screener (GAD-7) in the general
population. Medical care. Mar
2008;46(3):266-274. PMID: 18388841

Intervention

Blood work was ordered for the patient including a CBC, CMP, Thyroid
profile, Vitamin D and B12 assays.

The patient was treated using a combined approach using Escitalopram

10mg once daily for the next 6 weeks and psychotherapy sessions.

The choice of Escitalopram was based upon the fact that one of her
sisters had used it for depression and showed marked improvement.

She was given an appointment in 6 weeks to review response to

treatment and lab results.

Follow up after 6 weeks

The patient reported mild improvement in her mood but no change in

her sleep or concentration, her PHQ-9 was 18 denoting a poor response
to treatment.

Her blood work had shown a normal CBC ,a normal CMP, and a normal
endocrinology profile except for a vit. D of 12 ng/ml.

Question

How would you deal with failure of treatment in

its acute phase?

Intervention 2

We decided to give the Escitalopram 4 more weeks on the same dose, with
continuation of psychotherapy sessions plus emphasis on the nonpharmacological treatment modalities such as:

Exercise

Diet

Social support (meeting friends and family)

Indulging in a hobby (patient liked to read)

Sleep hygiene

Breathing exercises

We also decided to address her vitamin D deficiency issue by prescribing 50,000

IU of ergocalciferol once weekly for the next 8 weeks.

Follow up 2 in 4 weeks

The patient reported marked improvement in her mood

more days than not, and her PHQ9 score at this visit had
decreased to 9.

The patient asked if she can stop the psychotherapy

sessions as she felt she was getting better and couldnt
appreciate their value at the time being.

She was advised to continue the antidepressant

treatment for 6 months to 1 year before starting to taper
off.

The Question!

Is depression in this case: Primary or secondary?!

Reflecting on the case

Methodology of the reflection

In this reflective study, I used Johns model of structure reflection

(1994) and Gibbs reflective cycle (1988)

Johns model consists of the following framework:

1.

Description of the experience

2.

Reflection

3.

Influencing factors

4.

Learning

Feelings

I was trying to achieve optimum result from medication before

changing the drug or the dose, by adjusting all factors related, like
lifestyle and vit D deficiency, and even in light of her pre-existing
condition of PCOS.

I felt that depression was an immense burden on the patient and her
own household which generated the feeling of guilt she had, and I felt
also that the treatment itself will be more of a burden.

So beside selecting the treatment of the best safety profile, I decided to

stick with the initial dose until Im able to adjust all the afore mentioned
factors.

Vit. D and
depression

http://
bjp.rcpsych.org/conten
t/bjprcpsych/202/2/100
.full.pdf

PCOS

Depression is 4 times
more prevelant in
women without.

http://
www.ncbi.nlm.nih.go
v/pubmed/23728677

Contraceptives?

The patient was on

norethisterone as
treatment for PCOS.

http://
onlinelibrary.wiley.co
m/doi/10.1111/j.1600-0
412.2011.01333.x/pdf

Evaluation

What I had learned:

A lot of different factors can precipitate depression

There is a thin line between primary and secondary depression

Always take care of non-pharmacological treatment of depression

Always address co-morbid medical conditions

Conclusion

I would have like to address her social status more thoroughly,

especially with the strong family history she had.

Suicide risk assessment should have been done in full as she also has a
probably family history of suicide (Father).

Contacting the OBGYN team following her condition would have added
valuable information and helped me enhance system based practice
competency.

Introduction
Depression is the most unpleasant thing I have ever
experienced. . . . It is that absence of being able to
envisage that you will ever be cheerful again. The
absence of hope. That very deadened feeling, which is
so very different from feeling sad. Sad hurts but it's a
healthy feeling. It is a necessary thing to feel.
Depression
is
very
different.
J.K. Rowling

Thank you.