Identification data:

Name: Rajeswari Tiwari Bed No: F-8 Education: Madhyamik pass. Father/spouse: Mr. Hriday Tiwari Address: Vill: Nimpurdanga, P.O.- Kundala, P.S. Mayureswar, Dist. Birbjum. Pin- 731246. Age: 36 Yrs. Marital Status: Married Economic Status: Stable Sex: Female Religion: Hindu Language: Bengali

Occupation: House Wife Marital status: Married.

Income: Nil. Religion: Hindu.

Informant:

Mother( Ms.Durga Shil)

Intimacy with the patient- Intimate. Does the informant live with the patient- Sometimes. Duration of relationship. Since Birth. Interest of the informant in the patients property or money: Not present. .

Presenting chief complaints

As experienced by patient: Patients own words Ami sob kichhu vule gecchilam, kauke chinte parchhilam na, ghum peto na, onnomonosko hoye jetam, khide peto na, jokhon tokhon hasi peto- kanna peto, khub matha jontrona hoto jeta osudh khele kome jato. Khub voy lagto , mone hoto keu amar khoti kore debe , keu ghore dhuke guli kore debe, mone hoto dupur bela ghore bagh dhuke jabe, kono kaj korar ichha nei, sobsomay bomi bomi vab lagto. Kono kichhu valo lagto na , mone hoto more gelei valo hobe.

As described by the patients relative: Informants own words. O khub voy pachhilo , bachhader moto kore kotha bolchhilo, khub matha betha korto or, r kauke chinte parchhilo na.

History of present illness:

When symptoms are first noticed by the patient and by the relativesDuration: (days/ weeks /months/years).before 1 wk.

Mode of onset: acute (because 1wk).

Course: Continuous . Intensity: Increasing. Aggravating Factors: Predisposing factors: No significant family history , but her father was very rigid type personality. Precipitating factors: She is tortured mentally by her mother-in-law since her marriage. for 19 yrs. Perpetuating factors: Recent quarrelling with her mother-in-law.

Description of present illness(chronological description of abnormal behavior, associated problem like suicide, homicide, disruptive behavior thought content, speech, mood states, abnormal perceptions etc): She had sleeplessness, decreased appetite, severe headache, absentmindedness, apathy to work, fear of harm by others, nausea, slurred speech and nasal intonation of voice, and then mute. She also had the suicidal ideation.

Has there been any change in personal habit of the patient, physical health : weight gain , sleep pattern- decreased appetite- Poor, Nasal intonation of voice. Are there any change in thinking and behavior of the patient: Yes, she is having changing in talking way, nasal intonation of voice and child like behavior ( demanding of chocolate, biscuits etc, crying like babies) during depression.

Treatment history: Drugs : Tab. Syndopa (110mg) 1- 1- 1. Tab. Pacitone (2 mg.) 1-1-X. Tab. Olimelt (5 mg.) X-X-1. Tab. Zeptal-CR 1-X-1. Tab. Rispond Play 1-X-1.

ECT: Nil. Psychotherapy: Nil. Family therapy: Nil. Rehabilitation: Nil.

Past psychiatric history:

Number of previous episodes/ hospitalization (psychiatric) with onset and course: She is suffering from depression since 5 yrs. She had 2-3 episodes per year and each episode lasts for 1 to 1.5 months. In between the episodes she is having the low mood. No previous hospitalization required. Before starting of this episode the patient became very fearful , but she could not express her fearfulness, and she had collected a knife to kill her mother-in-law, but she never attempted so. Complete or incomplete remission: Incomplete remission.

Duration of each episode: 1 -1.5 months. Treatment details and its side effects if any: She is treated by local psychiatrist. She had severe vomiting for 20 days of unknown medicine. Then treated this side-effect.

Treatment outcome: She is continuing treatment since 5 yrs, the treatment outcome is varying. Details of any precipitating factors if present: Her mother-in-law is mentally torturing her since her marriage.

Medical history:

Surgicalprocedures/accidents/headinjury/convulsions/unconsciousness/DM/HTN/CAD/Venereal disease/HIV positivity/any other: She had Jaundice at her 3 yrs of age and dog bite at her 5 yrs of age and she is having the history of unconsciousness after marriage, but it is now stopped for last 10 yrs. She is also have the history of diphtheria before 5 yrs. Has the patient been using additive drugs or alcohol: No.

Personal history:

i) Perinatal history. Antenatal period: Maternal infections/ exposure to radiation/any complications: Premature dribbling at last trimester. Intranatal period: Type of delivery-normal delivery, Home delivery by local doctor. Birth: Full term . Birth cry: Delayed for 1 to 1.5 hrs. Birth defects: No. Postnatal complications: Nil.

ii) Childhood history:

Primary caregiver: Mother. Breast fed/Artificial mode of feeding: breast fed Age at weaning: 1 year. Developmental milestone: Normal. Behavior and emotional problems: Nail biting. Illness during childhood: Jaundice at 3 yrs of age.

iii) Educational history:

Age at beginning of formal education: 6 yrs.

Academic performance: Average. Specifically for Learning disability and Attention deficit disorders: Nothing significant. Extracurricular achievements, if any: Singing, dancing. Relationships with peers and teachers: Satisfactory. School phobia: No Look for conduct Disorders for example Truancy/Stealing: No.

iv) Play history:

Games played: (at what stage and with whom) : Preferred the indoor games with same age and same sex friends. Relationship with playmates: Good.

v) Emotional problem during adolescence: Running away from home/Delinquency/Smoking/Drug taking/Any other: Running away from home after the scolding from her father.

vi) Puberty:

Age at appearance of secondary sexual characteristics: 12 yrs. Anxiety related to puberty changes: Mild. Age at menarche: 12 yrs. Regularity of cycles, duration of flow: Regular cycle, Flow- normal. Abnormalities, if any (Menorrhagia , Dysmenorrheal ): Nil.

vii) Obstetrical history:

L.M.P: 28.01.2011 Number of children: 2 . Any abnormalities associated with pregnancy, delivery, puerperium: No. Termination of pregnancy, if any: No Menopause: Still not come.

viii) Occupational history: She is a house wife.

Age at starting work:

Jobs held in chronological order: Reasons for changes: -

Current job satisfaction: (Including relationships with authorities, colleagues, subordinates)

Whether job is appropriate to patients background:

ix) Sexual and marital history:

Type of marriage: self choice. Duration of marriage: 19 yrs. Interpersonal and sexual relations: Satisfactory. Extramarital relationships if any specify:No.

x) Premorbid personality:

Interpersonal relationship: Introvert. Family and social relationships: Healthy except with mother-in law. Use of leisure time: Reading religious books. Predominant mood:optimistic; Stable. Usual reaction to stressful events: Become fearful, and anxious. Attitude to self and others : Good. Attitude to work and responsibility: responsible. Religious beliefs and moral attitudes: She is religious. Fantasy life: Day dreams : No. Habits: Eating pattern : Regular. Elimination: Sleep: Regular. Regular

Use of drugs, tobacco, alcohol: No.

Family history:

Description (describe each family member briefly, age education, occupation, health status, relationship with patient, age at death, mode of death.) Are there any history of physical and mental illness in family? Is there any use of alcohol or drugs in the family? A family tree can be used to describe the number of family members, their age group and any death occurring in the family. The following figures give an example of the family tree.

PHYSICAL EXAMINATION- Done on 08.03.2011. General appearance The client appears silent and having apathetic look. Height- 53 Weight- 68 kg. Skin- Fair, skin tone is good. Head- Clean Eyes- Normal Ear- Normal Nose- Normal Mouth- Normal Neck- No abnormality detected Chest- Normal Abdomen- Soft Upper limbs- normal Lower limbs- Normal Back & spine- No abnormality detected LABORATORY INVESTIGATIONSOn 14.02.11- Blood Hb% - 9.9 . TC- 15,000/ cmm. Neutrophil- 62%, Lymphocyte 18%, Monocytes- x Eosinophil- 20% Platelets- 1.5 L/ cmm. On 15.02.11FBS-136mg/dl Blood for Na- 137.6 Mg/dl., Serum K+ - 4.04 Mg./ dl. Sugar- 167 Mg/ dl. Urea- 27 Mg/dl. Creatinine- 1.0 Mg/ dl. Blood for lipid profile- Cholesterol- 127 Mg/dl. Triglycerides- 164 Mg./dl. LFT- Bilirubin (Total)- 0.6 mg/dl , Direct 0.2 mg/dl Indirect- 0.4 mg/dl. SGOT- 49 U/L SGPT- 62 U/L ALP- 233 U/L. Total protein- 7.5 gm/dl Albumin- 3.8 gm/ dl. On 19.02.11- Plasma sugar- 109 mg/ dl. Blood Testing-

MENTAL STATUS EXAMINATION( on 08.03.2011):

Date of doing MSE: 08.03.2011 Time of doing MSE: 10.30 a.m. Level of consciousness: Fully conscious& alert Appearance: Her age, overweight

General Appearance & behaviour-

 Speech

Facial expression: Anxious, fearful Eye-to-eye contact: Maintained but sometimes difficultly maintained Physique: Endomorphic Personal hygiene: Maintained Posture: Closed posture Gesture: Normal Dress: According to season, Clean. Gait: slow walk. Motor activity: Decreased Cooperativeness: Normal. Rapport: Spontaneous. Behaviour: Slight anxious and fearful. Initiation: Speaks when spoken to, minimal Reaction time: Slightly delayed Rate: Slow Productivity - Elaborate replies when asked for otherwise monosyllabic replies. Volume: Soft Amount: Paucity, Tone: Monotonous nasal intonation of voice, Child like tone of voice. Stream: Normal flow & rhythm of speech is normal. Coherence: Fully coherent. Relevance: Sometimes off target but otherwise relevant Others: Nasal intonation of voice, childish voice. Sample of Speech: Q. Who are there in your house? A. Amader barite ami, amar husband, amar dui chele meye, nonod ( Normal expression) ar amar sasuri ache( with little anxious look). Nonod to bidhoba tai amader sathei thake ( with normal expression).

Mood & Affect Quality of mood: Anxious, fearful, and depressed. Stability of mood: Affect labile, mood is flat. Subjectivity (what patient says): Amar monta valo nei, majhe majhe voi lagchhe, kichhu valo lagchhe na. Objectivity (what one observes): She is looking anxious, depressed and fearful. Predominant mood state: Anxious, Fearful Appropriate to thought content.

Thought At formation level: Normal At progression level: No flight of ideas or thought blocking. At content level: No delusions but phobias to crowd, to darkness, to lonliness, & fear of being harmed by others. Sample of speech: Q. What are the thoughts coming in your mind? A. Amar khub voy kore, andhokare thakte pari na, eka thakle khub voy lage, mone hoy keu jano ghore dhuke jabe, amake mere felbe, dupur bela eka thakle mone hoy ghore bagh dhuke jabe. Perception Illusion: Not present. Hallucination: Auditory hallucinations of some voices whispering about her. Immediate: Q. Im telling you three things which you have to remember. After 5 minutes Ill ask you have to tell the three thing. The three things are- tree, rice, and bird. (after 5 min.) Can you remember the three things? A. Ha mone ache, gach, vaat r pakhi. Recent: Q. what food did you have in your last dinner? A. kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother). Past: Q. In which school were you studing? A. ami Rajdanga Uchha Balika Bidyaloye Portam. ( Verified from her mother) Inference: Her immediate, recent and remote memory are intact. Orientation To time, date, day, month, year: Q. Now whats the time can you guess? A. Ha ekhon to sakal bela, 10 ta sare 10 ta baje. Q. Can you tell me todays date and day? A. Ha, aj to mongolbar, ar 8 e Mach, 2011. To place: Q. Which place is this? A. eta to Calcutta Medical College Hospital. To person: Q. Can you tell me who am I? A. (with smile) Ha , aapni to sister didi. Inference: She is fully oriented to time, place and person.

Memory

Insight Q. What do you think about illness- whether it is physical or mental illness. A. Na, eta manasik asukh. Present fully. Insight is rated on a 6 point scale & it is 6. Personal ( future plans): Q. What will you do after going back to your home? R. A. Ami bari gie ghorer e kaj kormo korar chesta korbo....jodi monta valo thake. Social(perception of the society): Q. What will you do if you see that a 2 yrs old child alone in a busy road? A. Ami bachha take gie dhore nie or barite firie debar chesta korbo. Inference: Her personal and social judgement is intact. Attention & Concentration Attention: Aroused with slight difficulty.

Judgement

Digit forward- Q. Can you count forward from 45 to 50? A. 45, 46, 47, 48, 49, 50 Digit backward- Q. Now can you count backward ?
A. 50, 49...47...46, 45

Span of attention: Attention span is slightly impaired. Ability to concentrate: Normally sustained

Names of months(backwards), Names of weekdays( backwards): Q. Can you mention the name of the months and week days from backward? A. Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar. December, November, October,.....September, ....August...July..June...May,.... General Information Knowledge about surroundings, festivals, sports, states, depending on patients socioeconomic status & educational background. Q. which is the national bird of our country? A. Ha, mayur. Intelligence: Arithmetic ability: Q. You have gone to market with 80 rupees, you bought 20 rupees vegetable, 25 rupees fish & 10 rupees dal, how much rupees are left with you? A. hm...25 taka. Abstract reasoning: Q. Can you explain the phrase nachte na janle uthon baka? A. Etar mane holo nije kichhu korte na parle onner opor dosh deoa. Inference: Her knowledge, intelligence and abstract reasoning are intact. Special points-

Appetite: Slightly decreased.. Sleep: Decreased. Bowels: Regular. Bladder: Regular. Libido: Normal. Treatment: Continuing.

MENTAL STATUS EXAMINATION( on 09.03.2011)

Speech Initiation: Speaks when spoken to, minimal Reaction time: Slightly delayed Rate: Slow Productivity - Elaborate replies when asked for otherwise monosyllabic replies. Volume: Soft Amount: Paucity, Tone: Monotonous nasal intonation of voice, Child like tone of voice. Stream: Normal flow & rhythm of speech is normal. Coherence: Fully coherent. Relevance: Sometimes off target but otherwise relevant Others: Nasal intonation of voice, childish voice. Date of doing MSE: 09.03.2011 Time of doing MSE: 11 a.m. Level of consciousness: Fully conscious& alert Appearance: Her age, overweight Facial expression: Anxious, fearful Eye-to-eye contact: Maintained but sometimes difficultly maintained Physique: Endomorphic Personal hygiene: Maintained Posture: Closed posture Gesture: Normal Dress: According to season, Clean. Gait: slow walk. Motor activity: Decreased Cooperativeness: Normal. Rapport: Spontaneous. Behaviour: Slight anxious and fearful.

General Appearance & behaviour-

Sample of Speech: Q. Who are there in your house? A. Amader barite ami, amar husband, amar dui chele meye, nonod ( Normal expression) ar amar sasuri ache( with little anxious look). Nonod to bidhoba tai amader sathei thake ( with normal expression).

Mood & Affect Quality of mood: Anxious, fearful, and depressed. Stability of mood: Affect labile, mood is flat. Subjectivity (what patient says): Amar monta valo nei, majhe majhe voi lagchhe, kichhu valo lagchhe na. Objectivity (what one observes): She is looking anxious, depressed and fearful. Predominant mood state: Anxious, Fearful Appropriate to thought content. At formation level: Normal At progression level: No flight of ideas or thought blocking. At content level: No delusions but phobias to crowd, to darkness, to lonliness, & fear of being harmed by others. Sample of speech: Q. What are the thoughts coming in your mind? A. Amar khub voy kore, andhokare thakte pari na, eka thakle khub voy lage, mone hoy keu jano ghore dhuke jabe, amake mere felbe, dupur bela eka thakle mone hoy ghore bagh dhuke jabe. Perception Illusion: Not present. Hallucination: Auditory hallucinations of some voices whispering about her. Immediate: Q. Im telling you three things which you have to remember. After 5 minutes Ill ask you have to tell the three thing. The three things are- tree, rice, and bird. (after 5 min.) Can you remember the three things? A. Ha mone ache, gach, vaat r pakhi. Recent: R. what food did you have in your last dinner? B. kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother). Past: R. In which school were you studing? B. ami Rajdanga Uchha Balika Bidyaloye Portam. ( Verified from her mother) Inference: Her immediate, recent and remote memory are intact. Orientation

Thought

Memory

To time, date, day, month, year: Q. Now whats the time can you guess? A. Ha ekhon to sakal bela, 10 ta sare 10 ta baje. Q. Can you tell me todays date and day? A. Ha, aj to mongolbar, ar 8 e Mach, 2011.

To place: Q. Which place is this? B. eta to Calcutta Medical College Hospital. To person: Q. Can you tell me who am I? A. (with smile) Ha , aapni to sister didi. Inference: She is fully oriented to time, place and person.

Insight Q. What do you think about illness- whether it is physical or mental illness. A. Na, eta manasik asukh. Present fully. Insight is rated on a 6 point scale & it is 6. Personal ( future plans): S. What will you do after going back to your home? T. A. Ami bari gie ghorer e kaj kormo korar chesta korbo....jodi monta valo thake. Social(perception of the society): Q. What will you do if you see that a 2 yrs old child alone in a busy road? A. Ami bachha take gie dhore nie or barite firie debar chesta korbo. Inference: Her personal and social judgement is intact. Attention & Concentration Attention: Aroused with slight difficulty. Digit forward- Q. Can you count forward from 45 to 50? B. 45, 46, 47, 48, 49, 50 Digit backward- Q. Now can you count backward ?
B. 50, 49...47...46, 45

Judgement

Span of attention: Attention span is slightly impaired. Ability to concentrate: Normally sustained

Names of months(backwards), Names of weekdays( backwards): Q. Can you mention the name of the months and week days from backward? B. Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar. December, November, October,.....September, ....August...July..June...May,.... General Information

Knowledge about surroundings, festivals, sports, states, depending on patients socioeconomic status & educational background. Q. which is the national flower of our country? A. Ha, podma.

Intelligence: Arithmetic ability: Q. You have gone to market with 100 rupees, you bought 20 rupees vegetable, 30rupees fish & 10 rupees dal, how much rupees are left with you? A. hm...40 taka.

Abstract reasoning: Q. Can you explain the phrase angur fol tok? A. Etar mane holo nije kichhu na pele nijeke evabe santona deoa. Inference: Her knowledge, intelligence and abstract reasoning are intact.

Special pointsAppetite: Normal. Sleep: Adequate. Bowels: Regular. Bladder: Regular. Libido: Normal. Treatment: Continuing.

MENTAL STATUS EXAMINATION( on 10.03.2011)

Date of doing MSE: 10.03.2011 Time of doing MSE: 10 a.m. Level of consciousness: Fully conscious& alert Appearance: Her age, overweight Facial expression: Anxious, fearful Eye-to-eye contact: Maintained but sometimes difficultly maintained Physique: Endomorphic Personal hygiene: Maintained Posture: Closed posture Gesture: Normal Dress: According to season, Clean. Gait: slow walk. Motor activity: Decreased Cooperativeness: Normal.

General Appearance & behaviour-

 Speech

Rapport: Spontaneous. Behaviour: Slight anxious and fearful. Initiation: Speaks when spoken to, minimal Reaction time: Slightly delayed Rate: Slow Productivity - Elaborate replies when asked for otherwise monosyllabic replies. Volume: Soft Amount: Paucity, Tone: Monotonous nasal intonation of voice, Child like tone of voice. Stream: Normal flow & rhythm of speech is normal. Coherence: Fully coherent. Relevance: Sometimes off target but otherwise relevant Others: Nasal intonation of voice, childish voice. Sample of Speech: Q. Can you explain your house? A. Amader barite 5 ta room,ache, 1 ta amader, baki 2 to chele meyer, sasurir 1 ta , r nonoder 1 ta.( with normal expression).

Mood & Affect Quality of mood: Anxious, fearful, and depressed. Stability of mood: Affect labile, mood is flat. Subjectivity (what patient says): Amar monta valo nei, majhe majhe voi lagchhe, kichhu valo lagchhe na. Objectivity (what one observes): She is looking anxious, depressed and fearful. Predominant mood state: Anxious, Fearful Appropriate to thought content. At formation level: Normal At progression level: No flight of ideas or thought blocking. At content level: No delusions but phobias to crowd, to darkness, to lonliness, & fear of being harmed by others. Sample of speech: Q. What are the thoughts coming in your mind? A. Amar khub voy kore, andhokare thakte pari na, eka thakle khub voy lage, mone hoy keu jano ghore dhuke jabe, amake mere felbe, dupur bela eka thakle mone hoy ghore bagh dhuke jabe. Perception Illusion: Not present.

Thought

Hallucination: Auditory hallucinations of some voices whispering about her. Immediate: Q. Im telling you three things which you have to remember. After 5 minutes Ill ask you have to tell the three thing. The three things are- tree, rice, and bird. (after 5 min.) Can you remember the three things? A. Ha mone ache, gach, vaat r pakhi.

Memory

Recent: S. what food did you have in your last dinner? C. kal rate ami ruti, chana r kala kheyechhi. ( verified from her mother).

Past: S. In which school were you studing? C. ami Rajdanga Uchha Balika Bidyaloye Portam. ( Verified from her mother) Inference: Her immediate, recent and remote memory are intact.

Orientation To time, date, day, month, year: Q. Now whats the time can you guess? A. Ha ekhon to sakal bela, 10 ta sare 10 ta baje. Q. Can you tell me todays date and day? A. Ha, aj to mongolbar, ar 8 e Mach, 2011. To place: Q. Which place is this? C. eta to Calcutta Medical College Hospital. To person: Q. Can you tell me who am I? A. (with smile) Ha , aapni to sister didi. Inference: She is fully oriented to time, place and person. Insight Q. What do you think about illness- whether it is physical or mental illness. A. Na, eta manasik asukh. Present fully. Insight is rated on a 6 point scale & it is 6. Personal ( future plans): U. What will you do after going back to your home? V. A. Ami bari gie ghorer e kaj kormo korar chesta korbo....jodi monta valo thake. Social(perception of the society): Q. What will you do if you see that a 2 yrs old child alone in a busy road? A. Ami bachha take gie dhore nie or barite firie debar chesta korbo.

Judgement

Inference: Her personal and social judgement is intact. Attention & Concentration Attention: Aroused with slight difficulty. Digit forward- Q. Can you count forward from 45 to 50? C. 45, 46, 47, 48, 49, 50 Digit backward- Q. Now can you count backward ?
C. 50, 49...47...46, 45

Span of attention: Attention span is slightly impaired. Ability to concentrate: Normally sustained

Names of months(backwards), Names of weekdays( backwards): Q. Can you mention the name of the months and week days from backward? C. Robibar, sanibar,..... sukrabar,......hm.... brihaspatibar, budhbar, mongolbar, sombar. December, November, October,.....September, ....August...July..June...May,.... General Information Knowledge about surroundings, festivals, sports, states, depending on patients socioeconomic status & educational background. Q. which is the national bird of our country? A. Ha, mayur. Intelligence: Arithmetic ability: Q. You have gone to market with 60 rupees, you bought 20 rupees vegetable, 25 rupees fish & 10 rupees dal, how much rupees are left with you? A. hm...5 taka. Abstract reasoning: Q. Can you explain the phrase Dustu gorur cheye sunyo goyal valo? A. Etar mane holo asadhu manus thakar cheye na thaka valo. Inference: Her knowledge, intelligence and abstract reasoning are intact. Special pointsAppetite: Normal. Sleep: Adequate. Bowels: Regular. Bladder: Regular. Libido: Normal. Treatment: Continuing.

DEPRESSION INTRODUCTION: Variation of mood are a natural part of life. Like other aspects of the personality, emotions or moods serve an adaptive role. The four adaptive functions of emotions are

social communication, physiological arousal, subjective awareness, and psychodynamic defense. Depression, a mood disorder, is a widespread mental health problem affecting many people.

DEFINITION: Depression: It is an abnormal extension or overelaboration of sadness and grief. The word depression can denote a variety of phenomena ( e.g. a sign, symptom, syndrome, emotional state, reaction, disease or clinical disorder). Dipressive disorder: An illness characterized by depressed mood and loss of interest or pleasure in life. INCIDENCE: The life time risk of depression in males is 8 -12% and in females it is 20-26%. It occurs twice as frequently in women as in men. The median age of depressive disorder is 18 yrs in males and 20 yrs in women. The highest incidence of depressive symptoms has been indicated in individuals without close interpersonal relationships and in persons who are divorced or separated. Prevalence of suicide shows large peak in the spring and a smaller one in October. Psychotic depression is uncommon, less than 10% of all depression.

CLASSIFICATION OF DEPRESSION- ICD-10. F32 F32.0 F32.1 F32.2 F32.3 F32.8 F32.9 F33 Depressive Episode Mild Depressive Episode Moderate Depressive Episode Severe Depressive Episode Without Psychotic Symptoms Severe Depressive Episode with Psychotic Symptoms Other Depressive episodes- Atypical Depression Depressive Episode, unspecified Recurrent Depressive Disorder

CONTINUUM OF EMOTIONAL RESPONSES:

PREDISPOSING FACTORS
GENETICS OBJECT LOSS PERSONALITY COGNITION BEHAVIOURAL LEARNING BIOCHEMISTRY

LOSS

PRECIPITATING STRESSORS LIFE EVENTS ROLES PHYSIOLOGY APPRAISAL OF STRESSOR

COPING RESOURCES SOCIAL SUPPORT ECONOMICS SENSE OF MASTERY

COPING MECHANISMS

CONSTRUCTIVE

DESTRUCTIVE

CONTINUUM OF EMOTIONAL RESPONSES

ADAPTIVE RESPONSES

MALADAPTIVE RESPONSES

Emotional Responsiveness

Uncomplicated grief reaction

Suppression of emotions

Delayed Depression/ Mania grief reaction

Emotions such as fear, joy, anxiety, love, anger, sadness and surprises are all normal parts of the human experience. At the adaptive end there is emotional responsiveness. This involves the person being affected by and being an active participant in the internal and external worlds. It implies an openness to and awareness of feelings. Also adaptive in the face of stress is an uncomplicated grief reaction. Such a reaction implies that the person is facing the reality of the loss and is immersed in the work of grieving. A maladaptive response is the suppression of emotion. This may be a denial of ones feelings or a detachment from them. Prolong suppression of emotion, as in delayed grief reaction, will ultimately interfere with the effective functioning. The most maladaptive emotional responses or severe mood disturbances are recognized by their intensity, pervasiveness, persistence and interference with social and physiological functioning. This characteristics apply to the clinical states of depression and mania, which complete the maladaptive end of the continuum of emotional responses.

ETIOLOGY:
ACCORDING TO BOOK BIOLOGIC THEORIESAlterations in neurochemicals, genetic, endocrine and circadian rhythm functions. Nuerochemical: Levels of norepinephrine and serotonin are decreased Not known and dysregulation of acetylcholine and GABA. Genetic Theories: Major depressive disorders occur more often in first degree No clear etiology is seen. relatives than they do in the general population. Studies of identical twins show that when one twin is diagnosed with major depression, the other twin has a greater than 70 % chance of developing it. Endocrine Theories: The hypothalamic-pituitary-adrenal (HPA) axis is a system that mediates the stress response. In some depressed people this system malfunctions and creates cortisol, thyroid and hormonal abnormalities. IN MY PATIENT

Circadian rhythm theories: Circadian rhythms are responsible for the daily regulation of wake-sleep cycles, arousal and activity patterns, and hormonal secretions. These changes might be caused by medications, nutritional deficiencies, physical or psychological illnesses, hormonal fluctuations. Changes in Brain anatomy: Loss of neurons in the frontal lobes, cerebellum and basal ganglia has been identified.

PSYCHOSOCIAL THEORIESPsychoanalytic theory: According to Freud (1957) depression results due to loss of a loved object, and fixation in the oral sadistic phase of development. In this model, mania is viewed as a denial of depression. Behavioural theory: This theory of depression connects depressive phenomena to the experience of uncontrollable events. According to this model, depression is conditioned by repeated losses in the past. Cognitive theory: According to this theory depression is due to negative cognitions which includes: Negative expectations of the environment Negative expectations of the self Negative expectations of the future These cognitive distortions arise out of a defect in cognitive development and cause the individual to feel inadequate, worthless and rejected by others. Sociological theory: Stressful life events, for example, death, marriage, financial loss before the onset of the disease or a relapse probably have a formative effect.

TRANSACTIONAL MODEL OF STRESS/ ADAPTATIONAccording to this model depression occurs as a combination of predisposing factors ( family history and biochemical alterations), past experiences( object loss in infancy, defect in cognitive development) and existing conditions ( lack of adequate support system, inadequate coping skills, other physiological conditions). Because of weak ego strength, patient is unable to use coping mechanisms effectively. Maladaptive coping mechanisms used are denial, regression, repression, suppression, displacement and isolation. All these factors lead to clinical depression.

PSYCHOPATHOLOGY: The psychopathology of the affective disorders can most easily be described by reference to the similarity of the abnormal affect with normal emotions of the same kind. In depression the patients sadness deepens to a morbid depression, and the difficulty in concentration becomes retardation of all thought and action. Depressive patients may show a complete failure of all insight, deny that they are ill and hold steadfastly to their ideas of guilt and punishment.

CLINICAL MANIFESTATIONS: A typical depressive episode is characterized by the following features, which should last for at least two weeks in order to make a diagnosis:
ACCORDING TO BOOK IN MY PATIENT

Depressed Mood- sadness of mood or loss of interest and loss of Present pleasure in almost all activities(pervasive sadness), present throughout the day(persistent sadness). Depressive cognitions- Hopelessness ( a feeling of no hope in Slightly present future due to pessimism), helplessness( the patient feels that no help is possible), worthlessness( a feeling of inadequacy and inferiority), unreasonable guilt and self blame over trivial matters in the past. Suicidal thoughts- Ideas of hopelessness are often accompanied by the thought that life is no longer worth living and that death had come as a welcome release. These gloomy preoccupations may progress to thoughts of and plans for suicide. Suicidal risk is much more in the presence of following factors: a) Presence of marked hopelessness b) Males; age>40 yrs unmarried, divorced/ widowed. c) Written/ verbal communication of suicidal intent and/or plan. d) Early stages of depression. e) Recovering from depression (at the peak of depression, the patient is usually either too depressed or too retarded to commit suicide) f) Period of 3 months from recovery. Psychomotor activity- In younger patients(<40 yrs), retardation is more common. Slowed thinking & activity, decreased energy and monotonous voice . In severe form, the patient can become stuporous (depressive Stupor). In older patients( e.g. post menopausal women), agitation is common. Marked anxiety, restlessness(inability to sit still, hand wriggling, picking at body parts or other objects) and a subjective feeling of unease. Physical symptoms Heaviness of head, vague body aches, General aches and pains Hypochondrial features Reduced energy and easy fatigability. Somatic symptoms arePsychotic features-15-20% cases. Delusion, hallucinations, grossly inappropriate behaviour or stupor Mood- congruent (e.g. nihilistic delusion, delusion of guilt, delusion of poverty, stupor) Mood-incongruent( e.g. delusion of control) Somatic Syndrome- The somatic syndrome is characterized by: Significant decrease in appetite or weight.

Early morning awaking, at least 2 (or more) hours before the usual time of awakening. Diurnal variation, with depression being worst in the morning. Pervasive loss of interest and loss of reactivity to pleasurable stimuli Psychomotor agitation or retardation.

Other symptoms Fatigue Thought of death Decreased libido Dependency Spontaneous crying. Passiveness.
INVESTIGATIONS AND DIAGNOSIS: ACCORDING TO BOOK Psychological tests- Beck depression inventory. Hamilton rating scale for depression to assess severity and prognosis. 2. Dexamethasone suppression test showing failure to suppress cortisole secretions in depressed patients. 3. Toxicology screening suggesting drug induced depression. 4. Based on ICD- 10 criteria. 1. IN MY PATIENT

Based on ICD 10 criteria- Depression with psychotic feature.

TREATMENT: ACCORDING YO BOOK IN MY PATIENT

I. a.

II. a. b. c. III. a. b.

c. d. e. f.

PSYCHOPHARMACOLOGYAntidepressant- Antidepressants establish a blockade for the reuptake of norepinephrine and serotonin into their specific nerve terminals.This permits them to linger longer in synapses and to be more available to postsynaptic receptors. SSRI- It inhibates the reuptake of serotonin & increasing its levels at the receptor site. Citalopram(Celexa), Fluoxetine(Prozac), Sertraline (Zoloft). TCA- It blocks the reuptake of norepinephrine &/or serotonin at the nerve terminals, thus increasing the NE & 5-HT levels at the receptor site. Amitriptyline (Elavil), Clomipramine (Anafranil), Imipramine(Tofranil). MAOIs- It degenarates the catecholamines after reuptake, a functional increase in the NE & 5-HT levels at the receptor site. Isocarboxazid (Morplan) Other newer Antidepressant drugs- Bupropion. PHYSICAL THERAPIESECT- In severe depression with suicidal risk. Light therapy- During winter months to relieve seasonal depression. Repetitive Transcranial Magnetic Stimulation-(TMS) and Vagus Nerve Stimulation( VNS). PSYCHOSOCIAL TREATMENTPsychotherapy- To gain insight into the cause of their depression. Cognitive Therapy- It corrects the depressive negative cognitions like hopelessness, worthlessness, helplessness and pessimistic ideas. Supportive Psychotherapy- Reassurance, occupational therapy, relaxation. Group Therapy- In mild depression, the negative feelings like anxiety, anger, guilt are improved. Family Therapy- It is used to decrease intrafamilial & interpersonal difficulties. Behavioural therapy- Social skill training, problem solving techniques, assertive training.

14.02.11 Tab. Escitalopram (10) X-X-2. Tab. Sulpitac (50)- X-X-1. Tab. Sodium Valproate (500)-X-X-1. 15.02.11 Tab. Escitalopram (10) X-X-1. Tab. Sulpitac (50)- X-X-1. Tab. Sodium Valproate (500)-X-X-1. Tab. THP (20)- 1-X-X. 19.02.11 Tab. Nexito/ S. Voata (10 mg)- 1-X-1. Tab. Olimelt( 10mg)- 1-X-1. Tab. DVX-Na(500mg)-X-X-1. Tab. THP(2mg)-1-X-X. Tab. Sulpitre(50mg)-X-X-1. 08.03.11 Tab. Olimelt(10)-1-X-1/2 for 1 day. Then= -X-1/2 For 1 day. Then= X-X-1/2 For 1 day Then omit. Continue others. 11.03.11 Tab. Nexito(10mg)-2-X-X. Tab. Na. Valproate(250mg)-X-X-1 For 6 days. Then omit.

DRUG MODALITIES FOR DEPRESSION: DRUG GENERIC NAMEUSES

SIDE EFFECT AS PER BOOK

SIDE EFFECT NURSING ACTION IN MY CLIENT

Tab. Sodium Valpor valproateSR Anticonvulsant

Simple, complex or absence mixed, manic episodes with BPD, organic brain syndrome etc.

Sedation, Weakness drowsiness, depression, weakness, visual disturbances, hallucination, rash, alopecia, nausea, vomiting, constipation

Blood studies should be regularly seen. AST,ALT should be checked. Client is advised to take drug with food to prevent GI irritation. Referred to eye OPD. Client is encouraged to talk with others. Asked to sleep well at

night. Blood and hepatic studies should be checked, vital signs should be checked,

Psychotic disorders Tab. Olimelt Olanzapine (Antipsychotic)

EPS, Constipation, Pseduparkinotachycardia, nism, seizures, dizziness. orthostatic hypotension, tachycardia, weight gain, constipation.

NURSING MANAGEMENT:

Nursing Assessment :
Dysfunctional grieving related to real or perceived loss, bereavement, evidenced by inappropriate expression of anger , inability to carryout ADL. Fear and anxiety of darkness at night related to altered though process as evidenced by verbalization and facial expression. Self esteem disturbance related to learned helplessness, sensitivity to criticism, negative and pessimistic outlook. Altered communication process related to depressive cognitions, evidenced by nasal intonation of voice. Altered sleep and rest, related to depressed mood and depressive cognitions as evidenced by difficulty in failing asleep., early morning awakening and verbal complaints of not feeling well-rested.

NURSING CARE PLAN: (ACCORDING TO BOOK)

NURSING DIAGNOSIS

GOAL/ OBJECTIVE

PLANNING

INTERVENTION

EVALUATION

Nursing Care Plan on 08/03/2011 Nursing Diagnosis

1. Dysfunctional grieving related

Goals STG To help the

to patient to cope up

Planning Enough time should be spent with the client to develop IPR The client should be made to realize that she has been accepted To focus and reinforce reality, irrational thinking should be discouraged. Individual psychotherapy and then group psychotherapy should be given. To provide attention in a sincere, interested manner

Nursing Intervention Enough time has been spend with the patient to develop IPR. The client has been reassured that she had been accepted Irrational feelings are discouraged and client is made to face the reality Individual psychotherapy is done and sample time is given for planned interaction. Attention is given undividedly to the client She is asked and encouraged to do all her daily activities

Evaluation The disturbed thought processes are infrequently been remembered and she is optimistic and practical.

real or perceived loss, effectively bereavement, evidenced inappropriate inability to carryout ADL.

LTG To help her in

by getting over those

thoughts and returning

expression of anger , to normal life.

2. learned

Self

esteem

STG To help the patient feel worthy and competent

To plan activities in which the patient can show her worth

The client has improved and now does many work by herself, takes

disturbance related to helplessness,

Nursing Diagnosis

Goals

Planning Help the client to most of the activities herself. Activities should be planner in such a manner that the client can socialize

Nursing Intervention like doing prayers, taking bath, feeding etc. She is encouraged to take the role of leader so that she regains her past social roles.

Evaluation other patients for prayer.

sensitivity to criticism, LTG To enable the negative and pessimistic patient to develop a outlook.

sense of worthiness, take up social roles, depend less on others

3.Altered communication process related to depressive cognitions, evidenced by nasal intonation of voice.

STG To help the patient in having a interest in talking and sharing. LTG To help the patient to enhance her self concept and increase social interaction.

A convenient environment should be created for socialization Socializations should be planned with other patients also A group should be selected where the client can contribute something A therapeutic environment is provided so that the client can socialize with other patients The client is encouraged to participate in the various ward activities to make her feel that she is wanted. To teach patients The client feels comfortable and socializes with others.

4. Altered sleep and rest, related to depressed

STG Describe factors

The client is taught

Nursing Diagnosis
mood and

Goals

Planning good sleep habits To instruct the client to maintain a fixed sleep time daily at night and rising time at morning. To be gentle but firm while setting limits regarding time spent in bed, when she should be up from bed etc. To provide a quite, peaceful, time for resting To decrease environmental stimuli (bright lights) To provide a night time routine of comfort measure (back rub, tepid bath warm milk) just

Nursing Intervention about the sleeping habits , to sleep by 10:30 pm and rising time at 6am Her mother is asked to provide congenial environment for sleeping. i.e. putting off the lights etc. To provide various activities during the day time so that she is worked up Frequent naps in the afternoon are discouraged

Evaluation The client does not complain of insomnia to an extent as previously done.

depressive that inhibit sleep.

cognitions as evidenced Identify strategies to by difficulty in failing improve sleep. asleep., early morning LTG Report an awakening and verbal optimum balance of rest complaints of not and sleep. feeling well-rested.

Nursing Diagnosis

Goals

Planning before bedtime The client should always be asked to go to sleep by 10:30 pm. To give frequent activities during daytime To discourage the patient for frequent naps in the afternoon

Nursing Intervention

Evaluation

Nursing Care Plan on 09/03/2011 Nursing Diagnosis

1. Dysfunctional

Goals STG To help the

Planning Enough time should be spent with the client to develop IPR The client should be made to realize that she has been accepted To focus and reinforce reality, irrational thinking should be discouraged. Individual psychotherapy and then group psychotherapy should be given. To provide attention in a sincere, interested manner

Nursing Intervention Enough time has been spend with the patient to develop IPR. The client has been reassured that she had been accepted Irrational feelings are discouraged and client is made to face the reality Individual psychotherapy is done and sample time is given for planned interaction. Attention is given undividedly to the client She is asked and encouraged to do all her daily activities

Evaluation The disturbed thought processes are infrequently been remembered and she is optimistic and practical.

grieving related to patient to cope up real or perceived effectively loss, bereavement, LTG To help her in evidenced inappropriate expression carryout ADL. anger , inability to by getting over those

thoughts and returning

of to normal life.

2. learned

Self

esteem

STG To help the patient feel worthy and competent

To plan activities in which the patient can show her worth

The client has improved and now does many work by herself, takes

disturbance related to helplessness,

Nursing Diagnosis

Goals

Planning Help the client to most of the activities herself. Activities should be planner in such a manner that the client can socialize

Nursing Intervention like doing prayers, taking bath, feeding etc. She is encouraged to take the role of leader so that she regains her past social roles.

Evaluation other patients for prayer.

sensitivity to criticism, LTG To enable the negative and pessimistic patient to develop a outlook.

sense of worthiness, take up social roles, depend less on others

3.Altered communication process related to depressive cognitions, evidenced by nasal intonation of voice.

STG To help the patient in having a interest in talking and sharing. LTG To help the patient to enhance her self concept and increase social interaction.

A convenient environment should be created for socialization Socializations should be planned with other patients also A group should be selected where the client can contribute something A therapeutic environment is provided so that the client can socialize with other patients The client is encouraged to participate in the various ward activities to make her feel that she is wanted. To teach patients The client feels comfortable and socializes with others.

4. Altered sleep and rest, related to depressed

STG Describe factors

The client is taught

Nursing Diagnosis
mood and

Goals

Planning good sleep habits To instruct the client to maintain a fixed sleep time daily at night and rising time at morning. To be gentle but firm while setting limits regarding time spent in bed, when she should be up from bed etc. To provide a quite, peaceful, time for resting To decrease environmental stimuli (bright lights) To provide a night time routine of comfort measure (back rub, tepid bath warm milk) just

Nursing Intervention about the sleeping habits , to sleep by 10:30 pm and rising time at 6am Her mother is asked to provide congenial environment for sleeping. i.e. putting off the lights etc. To provide various activities during the day time so that she is worked up Frequent naps in the afternoon are discouraged

Evaluation The client does not complain of insomnia to an extent as previously done.

depressive that inhibit sleep.

cognitions as evidenced Identify strategies to by difficulty in failing improve sleep. asleep., early morning LTG Report an awakening and verbal optimum balance of rest complaints of not and sleep. feeling well-rested.

Nursing Diagnosis

Goals

Planning before bedtime The client should always be asked to go to sleep by 10:30 pm. To give frequent activities during daytime To discourage the patient for frequent naps in the afternoon

Nursing Intervention

Evaluation

Nursing Care Plan on 10/03/2011 Nursing Diagnosis

1. Dysfunctional grieving related

Goals STG To help the

to patient to cope up

Planning Enough time should be spent with the client to develop IPR The client should be made to realize that she has been accepted To focus and reinforce reality, irrational thinking should be discouraged. Individual psychotherapy and then group psychotherapy should be given. To provide attention in a sincere, interested manner

Nursing Intervention Enough time has been spend with the patient to develop IPR. The client has been reassured that she had been accepted Irrational feelings are discouraged and client is made to face the reality Individual psychotherapy is done and sample time is given for planned interaction. Attention is given undividedly to the client She is asked and encouraged to do all her daily activities

Evaluation The disturbed thought processes are infrequently been remembered and she is optimistic and practical.

real or perceived loss, effectively bereavement, evidenced inappropriate inability to carryout ADL.

LTG To help her in

by getting over those

thoughts and returning

expression of anger , to normal life.

2. Self esteem disturbance related to learned helplessness,

STG To help the patient feel worthy and competent

To plan activities in which the patient can show her worth

The client has improved and now does many work by herself, takes

Nursing Diagnosis
negative

Goals

Planning Help the client to most of the activities herself. Activities should be planner in such a manner that the client can socialize

Nursing Intervention like doing prayers, taking bath, feeding etc. She is encouraged to take the role of leader so that she regains her past social roles.

Evaluation other patients for prayer.

sensitivity to criticism, LTG To enable the and patient to develop a pessimistic outlook.

sense of worthiness, take up social roles, depend less on others

3.Altered communication process related to depressive cognitions, evidenced by nasal intonation of voice.

STG To help the patient in having a interest in talking and sharing. LTG To help the patient to enhance her self concept and increase social interaction.

A convenient environment should be created for socialization Socializations should be planned with other patients also A group should be selected where the client can contribute something A therapeutic environment is provided so that the client can socialize with other patients The client is encouraged to participate in the various ward activities to make her feel that she is wanted. To teach patients The client feels comfortable and socializes with others.

4. Altered sleep and rest, related to depressed

STG Describe factors

The client is taught

Nursing Diagnosis
mood and

Goals

Planning good sleep habits To instruct the client to maintain a fixed sleep time daily at night and rising time at morning. To be gentle but firm while setting limits regarding time spent in bed, when she should be up from bed etc. To provide a quite, peaceful, time for resting To decrease environmental stimuli (bright lights) To provide a night time routine of comfort measure (back rub, tepid bath warm milk) just

Nursing Intervention about the sleeping habits , to sleep by 10:30 pm and rising time at 6am Her mother is asked to provide congenial environment for sleeping. i.e. putting off the lights etc. To provide various activities during the day time so that she is worked up Frequent naps in the afternoon are discouraged

Evaluation The client does not complain of insomnia to an extent as previously done.

depressive that inhibit sleep.

cognitions as evidenced Identify strategies to by difficulty in failing improve sleep. asleep., early morning LTG Report an awakening and verbal optimum balance of rest complaints of not and sleep. feeling well-rested.

Nursing Diagnosis

Goals

Planning before bedtime The client should always be asked to go to sleep by 10:30 pm. To give frequent activities during daytime To discourage the patient for frequent naps in the afternoon

Nursing Intervention

Evaluation

PROGNOSIS:
Good Prognostic Factor
1. 2. 3. 4. 5. Acute or abrupt onset Typical clinical features Severe depression Well adjusted premorbid personality Good response to treatment. 1. 2. 3. 4. 5. 6.

Poor Prognostic Factor

Co-morbid medical disorder, personality disorder or alcohol dependence. Double depression Catastrophic stress or chronic ongoing stress Unfavourable environment. Marked hypochondriacal features or mood incongruent psychotic feature. Poor drug compliance.

Conclusion : One of the most important nurses role is to educate the patient and the family member about disease process, treatment and follow up care. Continuation of medicine is necessary to prevent relapse of the disease process.

Bibliography:

5. 6. 7. 8.

Kapoor .B. Textbook of Psychiatric Nursing, vol-1 Second edition 2005, Kumar publishing house, page no 92-103. Kaplan & Saddock , Comprehensive Textbook of Psychiatry, vol-1 8th edition Lippincott Willium P1ublication Sreevani. R.A Guide to mental health and Psychiatric nursing. second edition. Jaypee publication. Townsend C.Mary, Psychiatric Mental Health Nursing , Fifth Edition.Jaypee Brothers Publication.

CASE PRESENTATION OF A PATIENT WITH DEPRESSION

Submitted toMadam Aparna Ray Senior Lecturer College of Nursing Medical College & Hospital Kolkata

Submitted byMousumi Sarkar M.Sc.Nursing, 1st Year Student

CONTINUUM OF EMOTIONAL RESPONSES:

PREDISPOSING FACTORS GENETICS OBJECT LOSS PERSONALITY COGNITION BEHAVIOURAL LEARNING BIOCHEMISTRY PRECIPITATING STRESSORS
LOSS LIFE EVENTS ROLES PHYSIOLOGY

APPRAISAL OF STRESSOR COPING RESOURCES SOCIAL SUPPORT ECONOMICS SENSE OF MASTERY COPING MECHANISMS

CONSTRUCTIVE

DESTRUCTIVE

CONTINUUM OF EMOTIONAL RESPONSES

ADAPTIVE RESPONSES
Emotional Responsiveness Uncomplicated grief reaction Suppression of emotions

MALADAPTIVE RESPONSES
Delayed Depression/ Mania grief reaction