CASE STUDY: An exploration of a practical case in depression
The current health of the nation report has once again shown that two out of three consultations in general practice involve a mental health component; either as the primary or as an associated factor.
This is a discussion around a case prepared by Dr Catherine Andronis. Jess’ case below represents a common presentation in general practice. Our expert panel will provide feedback and opinions about how GPs might manage this case.
Jess is a 26-year-old primary school teacher, living in a share house. She is in a “good” relationship with her partner, Ben, of 10 months duration, but has felt “depressed” and can’t understand why she is “getting upset and crying over minor issues” and her sleep has become quite broken.
Her job is “stressful, and busy as usual, but OK” with no recent changes. Her partner is concerned about her “frequent melt-downs” and has encouraged her to see her GP for a check up.
Jess tells you that she has been on escitalopram 10mg since university days when another GP suggested this would help her manage her stress around exam time, and because this was helpful, she continued to take it, as it “ keeps me happy”. She initiated her own increase in dose to 20mg about 4 weeks ago but doesn’t feel any better.
Dr Catherine Andronis: So how would you approach this David? We’ve got two David’s, so maybe I’ll start with David Horgan.
A/Prof David Horgan: Yes, it’s interesting that she’s been taking this medication with good effect from university days, so she’s been taking about six years and the question is, why did it suddenly stop being effective? We do talk about antidepressant poop out or antidepressants suddenly stop being effective for reasons we don’t understand and as they say, sometimes it actually means they are actually getting over medicated. So, I would be wondering if, in fact, she actually- as things were improving in her life- actually needed to reduce her antidepressants, not increase them. So that’s one possibility.
Um, I say she’s got what I call the YES syndrome; yawning, expression problems, word-finding problems, some silly mistakes. And it would be worth reducing the dose.
The other possibility, of course, is that, yes, she has indeed experienced the poop out of the antidepressant, and it may just have to be changed.
But it’s also of interest that her relapse coincides with being in a relationship and would want to wonder, is there something going on in the relationship that’s stirring up skeletons in the cupboard or whatever, so there would be a number of pathways that could be considered.
Dr Catherine Andronis: Okay, thanks, David. And can I ask you, Malcolm, you talked about sexual function being something that’s often not talked about. Do you think that women are less likely to complain about it than men?
Prof Malcolm Hopwood: Of course, it depends a little who they’re talking to, as well, I’m sure that’s an interactional thing isn’t it? On average, my suspicion is yes. But I suspect some people would say, “Well, that might be because of who you are, Mal, too.” But I think, yes, I think either way, developing some appropriate ways of enquiring is really an important skill. And, the usual clinical skill of monitoring has that interaction going? How does it feel? Knowing when to “Okay, they’re not quite really to talk about this with me. And maybe the conclusion is this would be important to talk about at some point somehow”, and it’s likely be relevant here.
I agree with David. I probably would on the latter side of thinking “Well, whatever the reason, this anti-depressant, four weeks on that dose now and not working? Probably time to look at a change whilst exploring the other factors. I would be mindful of sexual dysfunction in my next choice. I would be mindful she’s a young woman of childbearing age, and we need to think about those issues. Possibly more if we need to warn men but, got to be mindful of those issues. Um, I also suspect, you know, meltdowns can mean many things can’t they as a term, but I wonder about the prominence of anxiety in this case and what factors might be fuelling that and what else we can do. Even in simple lifestyle terms to help with that anxiety and a lot of explanation wouldn’t do any harm.
Dr Catherine Andronis: Well, it’s often very difficult to make that differentiation between anxiety and depression, and in general practice we see this quite often. And do you think that if you were to change medications, quite often, patients will come in and say it’s not working anymore, I need to change to something else.
Prof Malcolm Hopwood: I think one of the key messages there, if I get one of the key messages, is that’s not uncommon. Um, and although it may have worked in the past, we know that in the given episode, only 40% of people will fully respond to antidepressant one. So you’re acting the majority, and that doesn’t mean we’re not going to be able to find something that works. That maintenance of hope is very important, isn’t it? Because many people do give up, that sort of expectation “well it should work!” It didn’t work, well, that’s it. It’s all over. So I think the maintenance of hope is very important.
I would generally be looking to change class and in that shared decision-making way, exploring what would be the important issues for Jess, you know, next choice. I dare say, as a primary school teacher, she probably doesn’t want to be asleep during class. That’s probably not the right look, and I could be wrong, but I suspect weight might be something she’s got in mind as well.
Dr Catherine Andronis: Right. So why do you think that some patients prefer medical treatment, a drug treatment over therapy treatment? I found was that quite interesting that…
Prof David Castle: I’m not sure if it’s so much, that one should look at them separately because my view is that we should always offer psychological treatments and also lifestyle issues. Mal alluded to this and in our college guidelines, which are commend to people, partly because they’re quite sensible, mal was one of the authors I should say, it’s also because they’re eccentric lifestyle issues. So exercise, diet is really important. And also looking at other lifestyle issues, avoiding substances which are not so helpful. So, in any scenario, you need to take the history of alcohol, other drugs.
But I think engaging people in a psychological discussion of some sort is absolutely critical to care of anyone and indeed, for this young woman, it seems there’s a whole lot of very important life issues going on, transitioning into a relationship that might raise all sorts of issues in terms of herself and a sense of herself, she’s transitioning into a career which is a tough, tough job – teaching. And that would be raising a whole lot of potential issues for her. So not to engage those things would be a dereliction of duty.
Medication could be additionally beneficial on top of that, but I would never do medication without psychological therapy. Of course, some people are difficult to engage and that needs to be explored in and of itself.
Prof Malcolm Hopwood: I think one of the hidden factors that we don’t talk about. We talk a lot about – and patients often volunteered to us – past experience with medication. Many patients, perhaps an increasing number with programmes like better access have also had past experience of therapy, and they too can be more or less useful, and more or less satisfactory.
Um, and that could be a bad match between therapist and patient. And there, too, it could be just as important to stress “Okay, that didn’t work. That’s not everyone’s experience. Don’t be put off. Let’s try someone different.”
Picking the right match of therapist and patient. There was a point in my life, I thought I could do that a bit. I’m not so sure I can anymore. You get older and you get wiser but try someone different and it might be valuable.
Dr Catherine Andronis: Yeah, that’s very sage advice.
We always talk about the range of anti-depressants. We have a vast range of psychological approaches and, you know, just thinking, Oh, well, it’s CBT fits everybody. Well, that’s definitely out the window, and there’s lots of other therapeutic approaches.
Schema therapy, for example, is really coming into its own, I think. A lot of people really like that
And some people are getting very expert in delivery of that. Interpersonal psychotherapy, there’s lots off them and Mal’s quite correct. It’s about the match of the individual to the therapist, but also to the therapy style, which is important.
A/Prof David Horgan: However, I think one of the realities for many general practice patients is the great difficulty there is in finding a therapist at all. Whether be a psychiatrist, a psychologist and then if it doesn’t work out, going starting from scratch and going onto somebody else’s waiting list can be very difficult. So I to encourage general practitioners to do what Mal and David are suggesting which just sit and talk to people about the stresses in their lives, because ventilation, what’s going on, and their thoughts that they have about the relationship, et cetera, and perhaps raising if they wish to talk about the sexual issues can be very helpful to people, especially if you start off therapy, so to speak, by saying ‘now if there’s anything you don’t want to discuss’, just tell me you don’t want to discuss it, and that gives people a safety area in which you can then start exploring as you say, ‘Why is it that when her life is going well, her symptoms intensifying?’
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