INTRODUCTION:

During my clinical postings in female ICU in NIMHANS, I got the opportunity to provide care to the patient, Mrs.Deva i, !ho is diagnosed to have Ma"or depressive disorder .#hen I came across this patient, I developed more interest in no!ing a$out him $ecause of the nature, course and presentation of the illness and I selected this patient for my clinical presentation.

I. a. IDENTIFICATION DATA:
NAM% A'% S%) C+D% No. UNI1 %DUCA1I+N +CCU3A1I+N INC+M% & Mrs.Deva i & (( yrs & *emale & ,-(./0 & Dr S2C & )th & House !ife & 4s. /...5month

MA4I1A6 S1A1US & Married 4%6I'I+N DA1% +* ADMN. DIA'N+SIS & Hindu & ,7 5 8, 58. & Ma"or depressive disorder.

b. INFORMANT:
Name 4elationship !ith the 3atient & Mr.Murugan & *ather

Intimacy and length of ac9uaintance& *rom $irth 4elia$ility & 4elia$le and ade9uate

II. SOURSE OF REFERAL AND REASON FOR REFERAL

*amily

III.CHIEF COMPLAINTS
According to patient: 3atient said that she has feelings of loneliness

According to informant Depressed mood Al!ays thin ing of some thing Not responding to 9uestions as ed Decreased self care Decreased initiative in ta ing care of family:hus$and and children; Hopelessness

IV. HISTORY OF PRESENT ILLNESS:

Illness !as acute in onset, continuous in nature and !as started ( months $ac !hen she sa! her hus$and having e<tramarital relationship !ith one neigh$our lady. She fought !ith her hus$and for the same reason and her hus$and ver$ali=ed that he is !illing to live !ith that lady. *rom the very ne<t day she informed this to her mother and father and they came to ta e her to her home. 1hey found her not tal ing to anyone and depressed mood. 'radually she started developing decreased communication, decreased sleep, decreased food inta e and poor hygiene. 1hey too her to a near$y local hospital and from there she got referred to Christian medical college, >ellore.She !as treated there !ith antidepressants, antipsychotics and mood sta$ili=ers. She got referred from CMC, >ellore to NIMHANS as she started having delusions? she used to complain on others tal ing of her all the time. She got admitted in NIMHANS and got diagnosed as severe depression !ith psychotic symptoms. She has undergone - episodes of %C1 and is on antidepressants and antipsychotics.

V. HISTORY OF PAST ILLNESS:

Medical @ No past history of any medical or surgical illness. At the age of ( she has accidentally poured hot oil over the $ody.

VI. FAMILY HISTORY :

No history of any psychiatric illness in the family.

NonAconsanguineous marriage, no history of suicide, good social support.

VII. PERSONAL HISTORY:

Developmental record MotherBs condition during pregnancy& 1ype of delivery& 1ype of feeding& #eaning& & & & Normal *1ND Creast feeding Normal

%motional attitude of parents& Milestones& Any serious illness& Cehavioural pro$lems&

& & & &

#anted Normal Nil Nil

School record Age of $eginning and finishing 4eason for termination of studies& & & up to 8.th std Not interested 'ood Nil good good good attitude

3erformance of academic activities and sports&

Special a$ilities ,ho$$ies and interests& 4elationship !ith schoolmates& Attitude to!ards teachers& Attitude to!ards play& & & &

Any pro$lems li e fre9uent fight, truancy, stealing, lying, gang activities & & Nothing Nil

Higher studies type

Work record Do$s held #hen ta en Ho! long held 4eason for leaving *inancial return & & & & & House !ife nil nil nil nil

Satisfaction !ith !or 4elation !ith collea9ues and superiors&

&

nil

& & & &

nil Nil Nil Nil

#or related conflicts& 3romotion and a!ards Any !ar e<perience

Social record Social life and nature of relationship & Attitude to!ards relatives and friends& Attitude to!ards religion and politics& Any antisocial trends & 'ood relationship 'ood relationship 4eligious Nil

Sexual and marital history Attitude to!ards men and !omen Se<ual information ho! ac9uired 'uilt and se<ual fantasies & & & 'ood attitude *rom mother Nil Nil

Homose<uality or any other se<ual perversions&

Children 1!o childrenA , male children of 0yrs and Eyrs

VIII. PREMORBID PERSONALITY

social relationship Ho$$ies and interests & & 'ood coo ing

3redominant mood Character and personality Ha$its and addictions

& & &

Cheerful %<trovert and sensitive Nil

MENTAL STATUS EXAMINATION

A. GE E!A" A##EA!A CE A D $E%A&'()! Cody $uild and physical appearance& 'rooming Hygiene Dress *acial e<pression %ye contact 3osture Attitude to!ards e<aminer 4apport Motor $ehavior & & & & & & & & & 1hin $uilt Normal good Appropriate Happy maintained Normally rela<ed CoAperative maintained Nil

$. #S*C%(+(,(! AC,'&',*: It !as normal? she !as rela<ed and ans!ering to all 9uestions as ed. C. S#EEC%: Speech !as delayed and relevant. 1one, tempo and volume !as slightly decreased. 4eaction time !as delayed. No perseveration, echolalia or neologism. D. ,%()G%, 8; *+4M& Ho! do you cele$rate 3ongalF +n that day !e !ill clean our !hole room and decorate the room !ith flo!ers and do poo"a to 'od and ma e pongal and !ill $e placed in poo"a room.

Inference& No formal thought disorder ,; S14%AM& She has no flight of ideas5 circumstantiality5 1angentiality5perseveration5thought $loc (; C+N1%N1& No o$sessions5 compulsions5 thought deviation5 pho$ia

Delusion of persecution was present Depressive ideas present and she is suspecting all tal ing of her and her faults. E. +((D A D A--EC,: Su$"ective& GnA Ho! are youF AnsA Iam fine. Cut her facial e<pression says she is not fine. +$"ective& %uthymic Affect& No la$ility and is not congruent

-. #E!CE#,'( : No illusions, hallucinations, depersonali=ation5dereali=ation. G. SE S(!')+ A D C(G ','( : Consciousness& alert +4I%N1A1I+N 1ime& says that time is normal, 3lace& says that Hthis is NIMHANS, Cangalore 3erson& 4ecogni=es other patients around Inference& +riented to time, place and person. A11%N1I+N AND C+NC%N14A1I+N Digit span test& *or!ardA-, Cac !ardA(. Serial su$traction test& ,. to . in reversed order in 8. seconds, 8..AE una$le to elicit, days of !ee and months in for!ard or reverse order. Inference& Attention aroused and concentration una$le to sustain fully. M%M+4I

Immediate memoryA intact :tested $y digit span test; 4ecent memoryA intact :A$le to recollect address given to him; 4emote memoryA intact :A$le to remem$er past events and cele$rations; IN1%66I'%NC% Name of 3rime MinisterA DonBt no! ( cities in 1amil Nadu A Chennai,Salem,Coim$atore Arithematic: Ho! much is 4s. /JKF Ans. 7 Ho! many chocolates !e can $uy for Rs., if one chocolate costs .., 3aiseF Ans. 0 pencils Inference& Intelligence is normal C+M34%H%NSI+N #hat !ill you do !hen you feel coldF IBll !ear a s!eater #hat !ill you do if find some one falling in the roadFI !ill help them to !al and cross the road. Inference& Comprehension good. ACS14AC1I+N #hat is the difference $et!een pen and pencilF 3en !hen !riting gives colored in , pencil !ill give ash mar ing #hat is their similarityF Coth are used for !riting 3rover$& All that glitters is not goldA not a$le to ans!er Inference @ a$straction is present at concrete level only %. .)DGE+E , 3ersonal& *uture plans @ #ill ta e care of the children Social 1est & Normal, smiles on seeing others and poor interaction & House on fireL 3our !ater.

Inference& Dudgment intact at personal level only. '. ' S'G%, Do you thin that you have a some diseaseF I am having some disease, $ut no! cured almost.

Inference& 3artial insight

PHYSICAL EXAMINATION
/. GE E!A" ' -(!+A,'( a; Constitution $; Stature c; State of nutrition d; 3ersonal appearance e; 3osture f; emotional state g; S in and hair 0. &',A" S'G S a; 1emperatures $; 3ulse c; 4espiratory d; Clood pressure A 70.K * A 005min regular A ,,5min, easy A 88.50.mm Hg A Asthenic A medium $uilt A poor A good A strait A appropriate A $lac

1. %E'G%, A D WE'G%, 8/-cms, // 2g 2. S3' A D +)C()S +E+$!A E: dry, no edema, no s in lesions 4. %EAD: normal, no lesion, hair $lac , face symmetrical 5. E*ES: 3%A46, visual acuity ,.5,. 6. EA!S: normal in shape and si=e, no lesions or hearing loss 7. (SE: normal in shape and si=e, sense of smell is normal

8. +(),% A D ,%!(A,: 1ongue A 3in , coated, all teeth present /9. EC3: normal in si=e, no enlargement of lymph nodes S*S,E+:W'SE E;A+' A,'( : //. C%ES, A D !ES#'!A,(!* S*S,E+: normal in shape and si=e, A%C% /0. CA!D'(&AS)"A! S*S,E+: S8, S, normal, no murmur, 34A 0,5min /1. G',: normal in si=e and shape, liver M spleen not palpa$le /2. GE ',(:)!' A!* S*S,E+: normal, no discharge from vagina.

/5<. E!&()S S*S,E+ a< %igher functions =< Speech c< Cranial nerves d< +otor function : higher functions li e thin ing orientation, Dudgment, insight, impaired A spontaeinity decreased, ans!ers to 9uestion, 4elevant, coherent. : normal : decreased

e< Sensory function : !ithin normal limit f< !eflexes : superficial, deep, visceral refle<es !ithin normal limit

' &ES,'GA,'( S
,ES, Clood glucose Clood Urea S''1 Sr Sodium !ES)", E- mg5dl ,K mg5dl ,,U56 8(0 me956 (!+A" &A")E 0. to 8,. mg5dl 8. to /. mg5dl 0 to K. U56 8(/ to 8K/ me956

Sr 3otassium Sr CI S'31

(.-me956 7E me956 8K U56

(./ to /., me956 7/ to 8.- me956 - to K. U56

,!EA,+E ,
1. +lan=epine ,.mg HS 1.6oraepam 8. mg HS

INTRODUCTION
Mood refers to an internal emotional state of an individual !hile affect is the e<ternal e<pression of internal emotional content. Mood is also referred to the sustained and pervasive emotional response .Affect is the e<ternal e<pression of mood. Mood can $e normal, elevated,or depressed. Depressive disorders are defined as mood disorders !here the mood is depressed .Mood disorders are no!n to maintain anti9uity.

DEPRESSION
An alteration in the mood that is e<pressed $y feelings of elation, inflated self esteem, grandiosity, hyperactivity, agitation, and accelerated thin ing and spea ing. 1o!nsend MC.

E#'DE+'("(G* Ma"or depression is one of the leading causes of disa$ility in the United States. It affects almost 8. percent of the population. 1he #orld Health report ,..8 estimates that there are 8,8 million people !orld !ide suffering from depression. 1he yearly incidence of ma"or depression is 8./7N.1here is a t!o fold greater prevalence of depressive disorder in females than in males. Depressive disorder can $e seen in children as !ell as in old age, $ut recent studies reveal the prevalence of depressive disorder is increasing in younger adults in ,. years of age. Depressive disorders are common in persons !ithout close interpersonal relationships or in those !ho are divorced and in single persons than in married ones.

SE&E!E DE#!ESS'&E D'S(!DE!

Depression is an alteration in the mood characteri=ed $y the depressed mood, depressive ideation, psychomotor activity, physical symptoms, $iological functions and psychotic features. 1he life time ris of depression in males is 0A8,N and in females ,.A,-N.Ho!ever the life time prevalence of ma"or depression is a$out 0N. ETIOLOGY /. $iological theories: Genetic %ypothesis: 1he life time ris for the first degree relatives of recurrent depressive No genetic origin disorder patients are ,.N.1he concordance rate in unipolar depression for mono=ygotic t!ins is K-N and for di=ygotic t!ins is ,.N. 0. $iochemical 'nfluences: Mono amine hypothesis& 1he mono amine hypothesis suggests an a$normality in the monoamine Ocatecholamine :nor epinephrine and dopamine; and serotoninP system in the central nervous system. 1he patients suffering from severe depression !ith suicidal intent5attempt appear to have a mar ed decrease in the serotonergic function, evidenced $y decreased urinary and plasma / HIAA levels and the postAmortem studies. 1. #hysiological 'nfluences: Neuroendocrine studies& %ndocrine function is often distur$ed in depression, !ith cortisol hypersecreation, nonAsupression !ith de<amethasone challenge, $lunted 1SH response to 14H, and $lunted gro!th hormone :'H; production during sleep. Neuro anatomical studies&

In mood disorders, $rain imaging studies have yield suggestive findings. 1hese findings include ventricular dilatation, !hite matter hyperAintensities, and changes in the $lood flo! and meta$olism in several parts of $rain. Sleep Studies& Sleep a$normalities are common in mood disorders. %g& decreased need for sleep in mania, insomnia and fre9uent a!a enings in depression. Decreased 4%M period and delayed sleep onset is seen in depression. In depression, the commonly o$served a$normalities include decreased 4%M latency :i.e. the time $et!een falling asleep and the first 4%M period is decreased;, increased duration of the first 4%M period, and delayed sleep onset. .Neurotransmitters& Although other neurotransmitters have also $een implicated in the pathophysiology of depression, distur$ances in serotonin and nor epinephrine have $een e<tensively scrutini=ed. .Medications& All medications that increase serotonin, norepinephrine, or $oth can improve the emotional and vegetative symptoms of depression. Medications that produce these effects include those that $loc the presynaptic reupta e of the neuro transmitters or $loc receptors at nerve endings :tricyclics? SS4IS; and those that inhi$it monoamine o<idase, an en=yme that is involved in the meta$olism of the monoamines serotonin, norepinephrine, and dopamine. 2. #sychosocial ,heories: .3sychoanalytic theories& In depression, loss of a li$idinal o$"ect, intro"ection of the lost o$"ect, fi<ation in the oral sadistic phase of development, and intense craving for narcissism or self love are some of the postulates of the different psychodynamic theories. Stress & Increased stressors in the early period of development are pro$a$ly more important in depression

.Cognitive and Cehavioral theories& 1he mechanism of causation of depression, according to these theories, include depressive negative cognition, learned helplessness :animal model;, and anger directed in!ards. 1he credi$ility of psychosocial theories has declined in recent years.

DEPRESSION SUBCLASSIFICATION & DIAGNOSTIC GUIDELINES AS PER DSM-IV

D%34%SSI>% DIS+4D%4 #I1H 3SICH+1IC *%A1U4%S According to DSM I> 14 the criteria for depressive disorder !ith psychotic features are the presence of delusions or hallucinations and need to specify !hether they are mood congruent or not. M++D C+N'4U%N1 3SICH+1IC *%A1U4%S Delusions or hallucinations !hose content is entirely consistent !ith the typically depressive themes of personal inade9uacy, guilt, disease, death, nihilism, or deserved punishment. M++D INC+N'4U%N1 3SICH+1IC *%A1U4%S Delusions or hallucinations !hose content does not involve typical depressive themes of personal inade9uacy, guilt, disease, nihilism, or deserved punishment. Included are such symptoms as persecutory delusions :not directly related to depressive themes;, thought insertion, thought $roadcasting, and delusions of control. Depressive disorders are classified as follo!s /.Single episode or !ecurrent: A single episode specifier is used for an individualBs first diagnosis of depression. 4ecurrent is specified !hen the history reveals t!o or more episodes of depression. 0.+ild>+oderate or Severe 1hese categories are identified $y the num$er and severity of symptoms. She is having delusion of persecution. Mrs. Deva i is diagnosed as depressive disorder !ith psychotic features

1.With #sychotic -eatures: 1he impairment of reality testing is evident. 1he individual e<periences delusions or hallucinations. 2.With Catatonic -eatures: 1his category identifies the presence of psychomotor distur$ances, such as severe psychomotor retardation, !ith or !ithout the presence of !a<y fle<i$ility or stupor, or e<cessive motor activity. 1he individual may also manifest symptoms of negativism, mutism, echolalia, or echopra<ia. 4.With +elancholic -eatures: 1his is a typically severe form of ma"or depressive episode. Symptoms are e<aggerated. %ven temporary reactivity to usually pleasura$le stimuli is a$sent. History reveals a good response to antidepressant or other somatic therapy.

5.With Seasonal #attern: 1his diagnosis indicates the presence of depressive symptoms during the fall or !inter months. 1he diagnosis is made !hen the num$er of seasonal depressive episodes is su$stantially higher than the num$er of non seasonal depressive episodes that have occurred over the individualBs life time. 1his disorder has $een identified in the literature as seasonal affective disorder :SAD;. 1I3%S +* D%34%SSI+N Symptomatology of depression can $e vie!ed on a continuum according to severity of the illness. 8.Mild Depressive %pisodes& Mild depressive episode occur !hen the grief process is triggered in response to the loss of a valued o$"ect. 1his can occur !ith the loss of a loved one, pet, friend, home or significant other.As one is a$le to !or through the stages of grief, the loss is accepted, symptoms su$side, and activities of daily living are resumed !ithin a fe! !ee s. If this does not occur the grief is prolonged or

e<aggerated, and symptoms intensify. ,.Moderate Depression& Moderate depression occurs !hen grief is prolonged or e<aggerated. 1he individual $ecomes fi<ed in anger stage of grief response, and the anger is turned in!ards on the self. All of the feelings associated !ith normal grieving are e<aggerated out of proportion, and the individual is a$le to function !ithout assistance.Dysthymic disorder is an e<ample of moderate depression. (.Severe Depression& Severe depression is an intensification of the symptoms associated !ith the moderate level. 1he individual !ho is severely depressed may also demonstrate a loss of contact !ith reality. 1his level is associated !ith a complete lac of pleasure in all activities, and ruminations a$out suicide are common. Ma"or depressive disorder is an e<ample of severe depression. spheres of human functioning& 8.Affective ,.Cehavioral (.Cognitive /.3hysiological ,ransient Depression Symptomas at this level of the continuum are not necessarily dysfunctional. Alterations include& Affect& sadness, de"ection, feeling do!nhearted, having the H$luesQ. Cehavioral &some crying possi$le Cognitive& Some difficulty getting mind of oneBs disappointment. 3hysiological& feeling tired and listless

Mrs. Deva i !as diagnosed as severe depression and she is having lac of pleasure in all activities.

SE&E!E DE#!ESS'( Severe depression is characteri=ed $y an intensification of the

Mrs Deva i is devoid of emotional tone?prevelant

symptoms descri$ed for moderate depression. %<amples of severe depression include ma"or depressive disorder and $ipolar disorder and $ipolar depression. Symptoms at the severe level of depression include& 8.Affective& *eelings of total despair,hopelessness,and !orthlessness? flat:unchanging; affect, appearing devoid of emotional tone?prevelant feelings of nothingness and emptiness?apathy?loneliness?sadness?ina$ility to feel pleasure. ,.Cehavioral& 3sychomotor retardation so severe that physical movements may literally come to a stand still, or psychomotor $ehavior manifested $y rapid, agitated, purposeless movements? slumped posture? sitting in a curledAup position? !al ing slo!ly and rigidly? virtually none<istent communication :!hen ver$ali=ations do occur, they may reflect delusional thin ing;? no personal hygiene and grooming? social isolation is common, !ith virtually no inclination to!ard interaction !ith others. (.Cognitive& 3revalent delusional thin ing, !ith delusions of persecution and somatic delusions $eing most common?confusion?indecisiveness,and an ina$ility to concentrate? hallucinations reflecting misinterpretations of the environment? e<cessive selfAdeprecation, self $lame, and thoughts of suicide. K.3hysiological& A general slo!do!n of the entire $ody, reflected in sluggish digestion, constipation, and urinary retention? amenorrhea? impotence? diminished li$ido? anore<ia? !eight loss? difficulty falling asleep and a!a ening very early in the morning? feeling !orse early in the morning and some!hat $etter as the day progresses. As !ith moderate depression, this may reflect the diurnal variation in the level of neuro transmitters that affect mood and activity.

feeling of nothingness?sadness?ina$ili ty to feel pleasure.

CLINICAL MANIFESTATIONS:
8. Depressed mood& 1he most important feature is the sadness of mood or loss of interest and or pleasure in almost all activities present throughout the day. ,.Depressed Ideation5Cognition& Sadness of mood is usually associated !ith pessimism, !hich can result in three common types of depressive ideas. 1hese are a. Hopelessness:there is no hope in the future; $.Helplessness:no help is possi$le no!; c.#orthlessness :feeling of inade9uacy and inferiority;. (.6oss of Interest & 6oss of interest and an ina$ility to en"oy :anhedonia; are fre9uent. 1he patient sho!s no enthusiasm for daily activities and ho$$ies, that he !ould normally en"oy other!ise. K.An<iety & 3atient feels tensed, una$le to rela<, !ith difficulty in concentration and lac of attention. 1he an<iety is usually accompanied $y somatic symptoms li e dryness of mouth, palpitations, indigestion, s!eating, head ache and giddiness. /.3sychomotor activity & In younger patients, retardation is more common and is characteri=ed $y slo!ed thin ing and activity, decreased energy and monotonous voice. In a severe form patient can $ecome stipourous.Irrita$ility may present as easy annoyance and frustration in dayAday activities, eg.unusual anger at the noise made $y children. -.3hysical symptoms & Multiple physical symptoms :li e heaviness of head, vague $ody aches; are particularly common in the elderly depressives and depressed patients from the developing countries. She has difficulty in concentration and lac of attention Hopelessness and helplessness is present

3resent

+E ,A" S,A,)S E;A+' A,'( 8.Mood,Affect And *eelings Depression is the ey symptom, although /.N of patients deny depressive feelings and do not appear to $e particularly depressed. *amily mem$ers or employers often $ring or send these patients for treatment $ecause of social !ithdra!al and generally decreased activity. ,.Speech Many depressed patients have decreased rate and volume of speech? they respond to 9uestions !ith single !ords and e<hi$it delayed response to 9uestions. 1he e<aminer may literally !ait for , or ( minutes for a response to a 9uestion. (.3erceptual Distur$ances Delusions and hallucinations are said to have a ma"or depressive episode !ith psychotic features. %ven in the a$sence of delusions or hallucinations, some clinicians use the term psychotic depression for grossly regressed depressed patientsAmute, not $athing, soiling. Delusions and hallucinations that are consistent !ith a depressed mood are said to $e mood congruent. Mood congruent delusions in a depressed person include those of guilt, sinfulness, !orthlessness, poverty, failure, persecution, and terminal somatic illness such as cancer. K.1hought Depressed patients customarily have negative vie!s of the !orld and of themselves. 1heir thought content often includes no delusional ruminations a$out loss, guilt, suicide and death. A$out 8.N of all depressed clients have mar ed symptoms of thought disorder, usually thought $loc ing and profound poverty of content. S%NS+4IUM AND C+'NI1I+N 8.+rientation Most depressed patients are oriented to person, place and time, although some may not have sufficient energy or interest to ans!er 9uestions a$out these su$"ects during an intervie!. Decreased rate and volume of speech.

Delusion of persecution present for Mrs. Deva i

,.Memory A$out /.AE/ N of all depressed patients have cognitive impairment, sometimes referred to as depressive pseudodementia.Such patients commonly complain of impaired concentration and forgetfulness. Impulse Control A$out 8. @ 8/N of all depressed patients commit suicide, and a$out t!o thirds have suicidal ideation. Depressed patients !ith psychotic features occasionally consider illing a person as a result of their delusional systems, $ut the most severely depressed patients often lac the motivation or the energy to act in an impulsive or in a violent !ay. Dudgment and Insight Dudgment is $est assessed $y revie!ing patientBs actions in the recent past and their $ehavior during the intervie!. Depressed patients description of their disorder is often hyper$olic? they overemphasi=e their symptoms, their disorder, and their life pro$lems. It is difficult to convince such patients that improvement is possi$le. 4elia$ility In intervie! and conversations, depressed patients overemphasi=e the $ad and minimi=e the good. A common clinical mista e is to un9uestioningly $elieve a depressed $elieve a depressed patient !ho states that a previous trial of antidepressant medications did not !or . Such statements may $e false, and they re9uire confirmation from another source. 3sychiatrists should not vie! patientBs misinformation as an intentional fa$rication? the admission of any hopeful information may $e impossi$le for a person in a depressed state of mind. Mrs. Deva i is having impaired concentration and forgetfulness. She is oriented to time, place and person.

She is having insight.

COURSE AND PROGNOSIS:

Nearly K.N of depressive !ith episodic course improve in ( months,-.N in - months and 0.N improve !ith in a period of one year.8/A,.N of patients develop a chronic course of illness, !hich

last for t!o or more years. Chronic depression is usually characteri=ed $y intense depression, hypochondriacal symptoms, presence of coAmor$id disorders :li e dysthymic disorder, alcohol dependence, personality disorders and medical disorders;, presence of ongoing stressors and unfavora$le early environment. As the age advances, the intervals $et!een t!o episodes shorten and, the duration of the episodes and their fre9uency tends to increase. Although not all patients have relapses, it has $een estimated that up to E/N of patients have a second episode !ithin / years. 3atients !ith depression also have higher mortality rates from cardiovascular diseases and coAmor$id alcohol and drug use disorders. 34+'N+SIS Classically, the prognosis in mood disorders is generally descri$ed as $etter than in schi=ophrenia. Some of the good:and poor; prognostic factors in mood disorders are descri$ed as follo!s 'ood 3rognostic *actors& 8.Acute or a$rupt onset ,.1ypical clinical features (.Severe depression K.#ell ad"usted premor$id personality /.'ood response to treatment 3oor 3rognostic *actors& 8. CoAmor$id medical disorders, personality disorders or alcohol dependence. ,. Dou$le depression :acute depressive episode superimposed on chronic depression or dysthymia;. (.Catastrophic stress or chronic ongoing stress K.Unfavoura$le early environment /. Mar ed hypochondriacal features, or mood incongruent psychotic features.

-.3oor drug compliance.

MANAGEMENT:
1. PSYCHOPHARMACOLOGY A ,' DE#!ESSA ,S Anti depressant treatment should $e maintained for at least - months or the length of a previous episode, !hichever is greater. 3rophylactic treatment !ith antidepressants is effective in reducing the num$er and severity of recurrences. #hen antidepressant treatment is stopped, the drug dose should $e tapered gradually over one to , !ee s. Clinical types of ma"or depressive episodes may have varying responses to particular antidepressants, or to drugs other than antidepressants Antidepressants !ith dual action on $oth seratonergic and noradrenergic receptors demonstrate greater efficacy in melancholic depression. 1he main antidepressants used are

8. N% INHICI1+4S ,./ H1 4%U31A2% INHICI1+4S (. N% AND / H1 4%U31A2% INHICI1+4S K. 34% AND 3+S1 SINA31IC AC1I>% A'%N1S /. D+3AMIN% 4%U31A2% INHICI1+4S -. MI)%D AC1I+N A'%N1S 1he usual starting dose of antidepressants is E/A8/.mg of imipramine e9uivalent. 1he clinical improvement is assessed after a$out , !ee s. In case of no improvement, the dose can usually $e increased up to (.. mg of imipramine e9uivalent. 1ricyclic antidepressantsAImipramine, Amitryptiline Selective Serotonin 4eupta e Inhi$itorsA*luo<etine, Sertraline, Citalopram Serotonin Norepinephrine 4eupta e Inhi$itorsA>enlafa<ine, Dulo<etine 1he antidepressant dosage is monitored on the $asis of clinical improvement. *or the first uncomplicated depressive episode, the patient should receive full therapeutic dose of the chosen antidepressant for a period of -A8, months, after achieving full remission.

ELECTROCONVULSIVE THERAPY: %lectroconvulsive therapy is the induction of generali=ed grandma sei=ures through the application of electric current to the $rain. 1he episode of severe depression is often treated !ith episodes of electro convulsive therapy. 1he indication for %C1 in depression include 8. Severe depression !ith suicidal ris . ,. Severe depression !ith stupor, severe psychomotor retardation, or somatic syndrome. (. Severe treatment refractory depression. K. 3resence of significant antidepressant side effects or intolerance to drugs /. Delusional depression

Severe depression !ith suicidal ris is the first and foremost indication for use of %C1.1he response is usually rapid, resulting in a mar ed improvement. In most clinical situations, usually -A0 %C1 s are needed, given three times a !ee .Ho!ever, improvement is not sustained after stopping the %C1.1herefore, antidepressants are often needed along !ith %C1 s, in order to maintain the improvement achievement. 2. PSYCHOSOCIAL TRETMENT A com$ination of psychotherapy and pharmacotherapy is the most effective treatment for ma"or depressive disorder. 1hree types of short term psychotherapiesAcognitive therapy, interpersonal therapy, and $ehavior therapyAhave $een studied to determine the efficacy of treatment of ma"or depressive disorder. 8. C+'NI1I>% 1H%4A3I Cognitive therapy, originally developed $y Aaron Clac , focuses on the cognitive distortions postulated to $e present in ma"or depressive disorder. Such distortions include selective attention to the negative aspects of circumstances and unrealistically mor$id inferences a$out conse9uences. *or e<ample, apathy and lo! energy result from a patientBs e<pectation of failure in all areas. ,. IN1%43%4S+NA6 1H%4A3I Interpersonal therapy, developed $y 'erald 2lermann, focuses on one or t!o of a patientBs current interpersonal pro$lems. 1his therapy is $ased on t!o assumptions.*irst, current interpersonal pro$lems are li ely to have their roots in early dysfunctional relationships. 1he therapy sessions usually consists of 8, to 8- !ee ly sessions and is characteri=ed $y an active therapeutic approach. (. C%HA>I+4 1H%4A3I Cehavior therapy is $ased on the hypothesis that maladaptive $ehavioral patterns result in a personBs receiving little positive feed$ac and perhaps outright re"ection from society. 1his includes the various shortAterm modalities li e social s ills training? pro$lem solving techni9ues, assertiveness training, self control therapy, activity scheduling and decision ma ing techni9ues. K. 3SICH+ ANA6I1ICA66I +4I%N1%D 1H%4A3I 1he psychoanalytic approach to mood disorders is $ased on psychoanalytic theories a$out depression and mania. 1he goal of psychoanalytic psychotherapy is to effect a change in a patientBs personality structure or character, not simply to alleviate symptoms.

/. *AMI6I 1H%4A3I *amily therapy is not generally vie!ed as a primary therapy for the treatment of ma"or depressive disorder. *amily therapy is indicated if the disorder "eopardi=es a patientBs marriage or family functioning or if the mood disorder is promoted or maintained $y the family situation. -. '4+U3 1H%4A3I 'roup psychotherapy can $e useful in mild cases of depression. It is a very useful method of psycho education in $oth recurrent depressive disorder and $ipolar disorder. 1. &AGA" E!&E S,'+)"A,'( %<perimental stimulation of the vagus nerve in several studies designed for the treatment of epilepsy found that patients sho!ed improved mood. 1his o$servation led to the use of left vagal stimulation using an electronic device implanted in the s in, similar to cardiac pacema er. 1. S"EE# DE#!'&A,'( Mood disorders are characteri=ed $y sleep distur$ance. Mania tends to $e characteri=ed $y a decreased need for sleep, !hereas depression can $e associated !ith either hypersomnia or insomnia. Sleep deprivation may precipitate mania in patients !ho are $ipolar8 and temporarily relieve depression in those !ho are unipolar.Appro<imately -.N of depressive disorder patientBs e<hi$it significant $ut transient $enefit from total sleep deprivation. 1he positive results are typically reversed $y the ne<t night of sleep. Several strategies have $een used in an attempt to achieve a more sustained response to sleep deprivation. +ne method used serial total sleep deprivation !ith a day or t!o of normal sleep inA$et!een. 2. #%(,(,%E!A#* 3hototherapy typically involves e<posing the person to $right light in the range of 8/.. to 8.... lu< or more, typically !ith light $o< that sits on a ta$le or des . 3atient sits in front of the $o< for appro<imately 8 to , hours $efore da!n each day, although some patients may also $enefit from e<posure after dus . 3hototherapy is mostly used in seasonal depression and in reducing the irrita$ility and diminished functioning associated !ith shift !or . (,%E! ,!EA,+E ,S 3sychosurgery is an e<tremely rarely used method of treatment and is resorted to only in e<ceptional circumstances. In depressive episode, !hich is either chronic or

persistently recurrent !ith a limited or a$sent response to other modes of treatment, one of the follo!ing procedures may $e performed. 8. Stereotactic su$ caudate tractotomy. ,. Stereotactic lim$ic leucotomy. )!S' G D'AG (S'S
8. 4is for suicide related to depressed mood, feelings of !orthlessness, anger turned on the self,

misinterpretations of reality Nursing intervention& Create a safe environment for the client. 4emove all potentially harmful o$"ects from the client access. Supervise closely during meals and medication administration. *ormulate a short term ver$al or !ritten contract that the client !ill not harm self. #hen time is up, ma e another and so forth. Secure a promise that the client !ill see out staff !hen feeling suicidal. Maintain close o$servation of client. Depending on level of suicide precautions, provide one to one contact, contact visual o$servation or every 8/ minutes chec s. Maintain special care in administration of medication. Ma e rounds at fre9uent, irregular intervals especially at night, to!ards early morning. %ncourage the client to e<press honest feelings including anger.

,. Dysfunctional grieving related to denial of loss, inappropriate e<pression of anger, ideali=ation or o$session !ith lost o$"ect, ina$ility to carry out activities of daily living.

Nursing intervention& Assess the stage of fi<ation in grief process. Develop trust. Sho!, empathy, concern and unconditional positive regard. %<plore the feeling of anger, and help the client direct to!ards the intended o$"ect or person.

1each normal $ehavior associated !ith grieving. Help client !ith honest revie! of relationship !ith lost o$"ect.

(. 6o! self esteem related to learned helplessness, feelings of a$andonment $y significant other, impaired cognition fostering negative vie! of self.

Nursing intervention& Ce accepting of client and spend time !ith him or her even though pessimism and negativism may seem o$"ectiona$le 3romote attendance in therapy groups that offer client simple method of accomplishment. %ncourage the client to $e as independent as possi$le. %ncourage the client to recogni=e areas of change and provide assistance to!ards this effort. 1each assertiveness and communication techni9ues.

/. 3o!erlessness related to dysfunctional grieving process, life style of helplessness

Nursing intervention& Allo! the client to participate in goal setting and decision ma ing regarding o!n care. %nsure the goals realistic and that client is a$le to identify the areas of life situation that are realistically under his or her control. %ncourage client to ver$ali=e feelings a$out areas that are not !ithin his or her a$ility to control.

-. Spiritual distress related to dysfunctional grieving over loss of valued o$"ect Nursing intervention& Ce accepting and non "udgmental !hen client e<presses anger and $itterness to!ards god. Stay !ith the client. %ncourage the client to ventilate the feelings related to meaning of o!n e<istence in the face of current loss.

%nsure client that he or she is not alone !hen feeling inade9uate in the search foe life Rs ans!ers . Contact spiritual leader of clientBs choice, if he or she re9uest

CIC6I+'4A3HI&
8. 2aplan, Saddoc . Synopsis of 3sychiatry. -th edition. %lsevier pu$lications. ,++-. 3g& ,8/A,,E./((A/-8 ,. 6alitha 2.Mental health and psychiatric nursing an Indian perspective.>M' $oo house.,..0.pge.(.EA(K/. (. 1o!nsend M.C. 3sychiatric Mental Health Nursing. /th edition. Daypee pu$lications. 3g& K0(A/.K K. Ahu"a N. A Short 1e<t$oo of 3sychiatry. /th edition. Daypee pu$lications. 3g& EKA00

CLINICAL PRESENTATION OF MRS DEVAKI WITH DEPRESSIVE DISORDER

SUBMITTED TO:
Mrs. Ven a!a"e s#$% Ass!. Pr&'ess&r Sr% (en a!es*ara C&n Ban-a"&re SUBMITTED BY: Par(a!#) San!#&s# MS+. N,rs%n- . s! )ear sr% (en a!es*ara +&n Ban-a"&re

SUBMITTED ON ./0.012..

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