CASE SUMMARY #1 DEPRESSION

GENERAL DATA:

This is a case of J.R., 30 years old, Male, Filipino, Roman Catholic, Married with two kids,
Residing at 27 kundiman Street, Tarlac City, her wife is working in a human resources
department of a large manufacturing firm. He was admitted for the first time in NCMH on
October 19, 2020.
CHIEF COMPLAINT:

He has been unable to concentrate.

HISTORY OF PRESENT ILLNESS:

He finds it hard to go back to work because he feels a strong emotional jolt every time he signs
his signature it was like him signing her daughter's death warrant. He feels angry with medical
staff, although he says that they did nothing wrong. He has lost his appetite, his sleep is poor
and he is drinking more alcohol than usual. He feels a general lack of energy and says that he
has difficulty enjoying things any more. Prior to his daughter’s operation he was happy,
although understandably concerned about his daughter’s health. He also regularly went out
with friends followed by drinks and a meal. He could laugh and enjoy himself at this time. He
has no history of depression or psychiatric or psychological problems.

PAST MEDICAL HISTORY:

He has no previous significant psychiatric problems.

MEDICATION HISTORY:

He is taking sleeping pills because of inability to fall asleep

FAMILY HISTORY:

He has paternal mental health problems like depression

SOCIAL HISTORY:

He is living a sedentary lifestyle and prefers to be alone most of the time. He is not able to

Work properly for the past few weeks.

MENTAL STATUS EXAMINATION

GENERAL APPEARANCE:

Male, 30 years old who looks older than age. He is well dressed in chinos and an iron ironed
open neck shirt. Not well groomed with slightly messy hair and beard with not trimmed
recently. His eye contact is good. He is tall and looking weak staying in sitting position. He looks
sad but awake and alert.

BEHAVIOUR:

He is cooperative with no agitation or psychomotor retardation. He is with normal gait and

without any abnormal movements.

SPEECH AND LANGUAGE:

His rate of speech is slow with spontaneous flow in a depressed intensity.

MOOD AND AFFECT:

He feels emotional jolt (every time he signs remembering the consent papers he signed) He
describes being tearful about once per week. Also he feels general lack of energy. He looks
depressed and sad but cooperates. he is with low mood and self-confidence. He expresses
himself in low voice. He shows restricted range of affect. His mood is congruent with affect.

THOUGHT PROCESS:

His thoughts are mostly normal in speed , flow and content but some instances he shows
illogical thoughts such as He was feeling angry towards medical staff unnecessarily and he was
feeling guilty when he laughs. He is not always coherent but most of his thoughts are goal
directed.

THOUGHT CONTENT:

He has no thought passivity or hallucinations or delusions. There are no suicidal ideations even

though he admitted his life seem a bit pointless. he says he would never kill himself because he
loves his son. And also he sees there’s no point of going to work after his baby girl dead, but still
going to bring the money in.

COGNITIVE:

He is well oriented but lack of concentration. He barely managed to concentrate on things. He

also finds hard on work but managed to concentrate on tv shows for now. There’s no significant
problem in his memory and abstraction.
INSIGHT:

Patient can feel the difference in his thoughts and also the reason for it which is his baby girl's
death. Also he can understand the impact of it on his daily functioning such as work life and
other daily routines.

JUDGEMENT:

The patient does cooperate with psychiatrist. He is aware of his behaviour and that’s why he
comes to seek the help of physiatrist.

DIAGNOSIS:

DEPRESSION

Diagnostic Criteria:

Major criteria (essential symptoms) 

A. Persistent low mood 

B. Anhedonia (loss of interest) 

C. Apathy (lack of energy

Associated symptoms

• Reduced concentration and attention 

• Reduced self-confidence and self esteem 
• Ideas of guilt and worthlessness 
• Bleak pessimistic views of future 
• Ideas of acts of self-harm and suicide 
• Disturbed sleep 
• Diminished appetite 

Somatic symptoms

• Loss of interest and pleasure 

• Lack of emotional reactivity 
• Waking in the morning two hours before the usual time 
• Depression worse in the morning 
• Objective evidence of psychomotor retardation or agitation 
 • Marked loss of appetite 
• Loss of weight 
• Marked loss of libido

Mild depression 

• 2 of the essential criteria and two associated symptoms 

• No cease of function completely

Moderate depression 

• 2 of the essential criteria and 3 associated symptoms

• Continuing difficulty in continuing social or domestic activities 

Severe depression 

• All 3 major criteria and 4 associated symptoms

• Unlikely to continue social work
• Mild and moderate depression is associated with somatic symptoms if it is associated
with 4 or more somatic symptoms 

Severe depression can be associated with following psychotic:

• Delusions - mood congruent 

• Persecutory 
• Nihilistic 
• Worthlessness/guilt 
• Hypochondriac 
• Hallucinations
• 2nd person auditory hallucinations (defamatory / accusatory / olfactory rotting 
• Filth) 
• Loss of insight
• Patient shows essential criteria’s of persistent low mood, loss of interest, lack of energy.
• Major criteria’s and reduced concentration, guilt, diminished appetite, poor sleep, which
is 4 associated symptom.

DIFFERENTIAL DIAGNOSIS:

Grief

• Rule in: feeling of emptiness

• Rule out: Persistent sadness
Anxiety

• Rule in: Restlessness

• Rule out: No suicidal thoughts

MANAGEMENT:

• Medication alone and psychotherapy (cognitive-behavioral therapy, interpersonal

therapy) alone can relieve depressive symptoms. A combination of medication and
psychotherapy has been associated with significantly higher rates of improvement in
more severe, chronic, and complex presentations of depression.

Antidepressant medications

• The main medical treatment for depression is antidepressant medication.

Antidepressant medication may be prescribed, along with psychological treatments,
when a person experiences a moderate to severe episode of depression. Sometimes,
antidepressants are prescribed when other treatments have not been successful or
when psychological treatments are not possible due to the severity of the condition or a
lack of access to the treatment.

Psychotherapy

• Cognitive Behaviour Therapy and Interpersonal Therapy are evidence based

psychotherapies that have been found to be effective in the treatment of depression.

• Psychological treatments (also known as talking therapies) have been found to be an

effective way to treat depression. They can help you change your thinking patterns and
improve your coping skills so you're better equipped to deal with life's stresses and
conflicts.

CASE DISCUSSION:

I.DEFINITION

Depression (major depressive disorder) is a common and serious medical illness that negatively
affects how you feel, the way you think and how you act. Fortunately, it is also treatable.
Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed. It
can lead to a variety of emotional and physical problems and can decrease your ability to
function at work and at home.

II.SYMPTOMS

• Trouble concentrating, remembering details, and making decisions

• Fatigue
• Feelings of guilt, worthlessness, and helplessness
• Pessimism and hopelessness
• Insomnia, early-morning wakefulness, or sleeping too much
• Irritability
• Restlessness

III.CAUSES

• Conflict. Depression in someone who has the biological vulnerability to develop depression may
result from personal conflicts or disputes with family members or friends.
• Death or a loss. Sadness or grief from the death or loss of a loved one, though natural, may
increase the risk of depression.
• Genetics. A family history of depression may increase the risk. It's thought that depression is a
complex trait, meaning that there are probably many different genes that each exert small
effects, rather than a single gene that contributes to disease risk. The genetics of depression,
like most psychiatric disorders, are not as simple or straightforward as in purely genetic diseases
such as Huntington's chorea or cystic fibrosis.

IV.RISK FACTORS

Brain Chemistry Imbalances

One potential biological cause of depression is an imbalance in the neurotransmitters which are
involved in mood regulation. Certain neurotransmitters including dopamine, serotonin, and
norepinephrine, play an important role in mood.
Neurotransmitters are chemical substances that help different areas of the brain communicate
with each other. When certain neurotransmitters are in short supply, it may lead to the
symptoms we recognize as clinical depression.
V.COMPLICATIONS

Depression carries a high risk of suicide. Suicidal thoughts or intentions are serious. Warning signs
include:
  A sudden switch from sadness to extreme calmness, or appearing to be happy
 Always talking or thinking about death
 Clinical depression (deep sadness, loss of interest, trouble sleeping and eating) that gets
worse
 Taking risks that could lead to death, such as driving through red lights
 Making comments about being hopeless, helpless, or worthless
 Putting affairs in order, like tying up loose ends or changing a will
 Saying things like "It would be better if I weren't here" or "I want out"
 Talking about suicide
 Visiting or calling close friends and loved ones

VI.PREVENTION

Physical exercise can help treat depression, but it’s best to exercise regularly. To get more exercise, you
can:

• Join a sports team or studio (like yoga or kickboxing), where you’ll be part of a community in
addition to being active.
• Take the stairs instead of the elevator.
• Make it a habit: This is the best way to maintain the fitness level that is most effective in
preventing depression.