Major Depressive Disorder in a 32 Year old Sero-positive Patient

ABSTRACT

A 32 year HIV sero positive and unmarried female presented with 4 weeks history of extreme sadness, lack of sleep, over thinking, loss of appetite and lack of interest in most of the things around her that all started when she lost her job, She reported hearing commanding voices however not discussing him and neither commenting on her actions, associated with failure to recognise people next to her. There was no history of thought insertion, withdraw, broadcasting or echo. No history of increased energy, over talking, and no history of delusions. No history of febrile illness, seizures, alcohol abuse or any substance use, with no suicidal ideation. Had been diagnosed with a psychiatric illness and been on medication 3 years ago from Butabika hospital with improvement, and there is positive history of a mental illness in the family.

 

Keywords: Bipolar affective disorder

Corresponding Author: Lydia Mbatidde ├ö├ç├┤ Department of Medicine, Makerere University College of Health Sciences (MakCHS). Email mlydia@chs.mak.ac.ug Mobile +256(0)775633955 

Article Details: Received January 28, 2014    Reviewed February 4, 2014 Accepted February 22, 2014

Conflicting Interests: The authors have not conflicting interests to declare

 

Citation: Mbatidde Lydia. Major Depressive Disorder in a 32 year sero-positive Old Woman (). MPJ 2014. 12 (1). e7-12

 

 

 

BACKGROUND

Major Depression is a mood disorder characterised by profound and sustained feelings of sadness and lack of interest in previously enjoyable activities for at least 2 weeks.

Major depressive episode is defined by presence of five or more of the following symptoms being present during the same 2 weeks period and represent a change from previous functioning.

A: At least one of the symptoms is either

a) Depressed mood most of the day nearly every day as indicated by either subjective report like feeling sad or empty or observation made by others

b) Loss of interest or pleasure in all or almost all activities most of the day nearly every day as indicated by either subjective or objective observation by others.

Others include:

c) Significant weight loss when not dieting or weight gain (that is change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day

d) Insomnia or hypersomnia nearly every day

e) Psychomotor agitation or retardation nearly every day (observable by others not merely subjective feelings of restlessness or being slowed down

f) Fatigue or loss of energy nearly every day

g) Feeling of worthlessness or excessive or inappropriate guilt (which maybe delusional) nearly every day (not merely self-approach or guilt about being sick)

h) Diminished ability to think or concentrate or indecisiveness nearly every day (either by subjective or observation by others)

i) Recurrent thoughts of death or suicidal ideations without a specific plan or suicide attempt or specific plan for committing suicide.

B: Symptoms do not meet the criteria for a mixed episode

C: Symptoms cause clinically significant distress or impairment in social, occupational or other areas of functioning

D: Symptoms are not due to a direct physiological effect of a substance eg drug abuse or medication, or general medical condition.

E: The symptoms are not better accounted for by bereavement that is after the loss of a loved one the symptoms persist for more than 2 months or are characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms or psychomotor retardation.

Major depressive disorder is defined by the history of one or more of the Major depressive episodes

The patient was diagnosed with a major depressive disorder,  a recurrent episode because she had presented with extreme sadness which described her low mood, lack of interest in her surroundings, lack of sleep  and hallucinations which where congruent in nature. She had a prior episode of depression about 3 years ago which was managed in Butabika hospital and improved and this was a recurrent episode of the same condition. In the mental state examination, she was found to have a low mood, low volume of speech and was tearful especially when we talked about her job and her HIV sero status. Basing on the above signs and symptoms, Ann was diagnosed with a major depressive disorder.

Epidemiology and Risk factors

Prevalence among males is about 2-4% and in females is about 5-9% with a male to female ratio of 1:2. Mean age of onset is about 30 years. Other risk factors include

Ôö¼├Ç         Sex: Females are more predisposed compared to men

Ôö¼├Ç         Age: Onset between 25-50 years

Ôö¼├Ç         Family History: Positive family history puts the patient at a higher risk of mental illness especially with a first degree relative.

Ôö¼├Ç         Recent stressors: For example financial constraints, legal issues and illnesses.

Ôö¼├Ç         Lack of intimacy: confiding relationships and social isolation.

Ôö¼├Ç         Personality: Insecure and, dependency and obsessions can also predispose to depression.

Among all these, Ann was a female and was 30 years around the mean age of onset so putting her at a higher risk of depression. She had a positive family history of depression as her sister had also been diagnosed with depression from Mulago hospital and was on treatment. She had a most recent stressor which was the loss of her job just 2 months prior to the onset of the illness. Lack of intimacy was another stressor and she had just been diagnosed with HIV and had to start treatment just 3months before the loss of her job. Having all this around Ann were reasons to predispose her to another depressive episode.

Aetiology

Neurotransmitter dysfunction at least at the level of synapses that is serotonin, norepinephrine and dopamine. It could be due reduced production, increased reuptake or increased destruction by the enzyme like mono amine oxidase. This leads to reduced transmitter action and predisposes the patient to depression.

Classification

Ôö¼├Ç         Major Depressive Disorder with Psychotic feature: like Hallucinations and delusion. The hallucinations may be mood congruent or mood incongruent.

Ôö¼├Ç         Major Depressive Disorder Chronic: Lasting 2 years or more.

Ôö¼├Ç         Major Depressive Disorder with Melancholic features: like the quality of mood is distinctly depressed, mood is worse in the morning, early morning awakening, severe weight loss, excessive guilt, psychomotor retardation.

Ôö¼├Ç         Major Depressive Disorder with atypical features: like increased sleep, weight gain, laden paralysis, chronic rejection sensitivity.

Ôö¼├Ç         Major Depressive Disorder with Postpartum onset: normally occurs within 6-8 weeks of delivery of a baby.

Ôö¼├Ç         Major Depressive disorder with Seasonal Pattern: Normally occurring with a pattern of onset at the same time every year.

The patient was had one of the differentials s being MDD with psychotic features in view of the hallucinations she had that were congruent as the voices were commanding her to go somewhere where she could find some money.


Investigations

 

BIOLOGICAL

PSYCHOLOGICAL

SOCIAL

a)Complete Blood Count

 

b)Thyroid Function Tests: To find out about any abnormal levels of thyroxine levels indicative of hypothyroidism or hyperthyroidism

 

c)Liver Function Tests: to assess presence of any hepatic impairment as antipsychotic drugs should be used with caution in such patients as they are eliminated by hepatic metabolism and the patient is also taking ARVs so the liver should be in good condition.

 

d)Renal Function Tests: to assess presence of any renal impairment as antipsychotic drugs and ARVs should be used with caution in such patients as they are also eliminated by renal excretion and to also rule out any other general medical condition.

 

Done through the mental exam assessing the:

a)Appearance and behaviour: asses posture, eye contact to rule out the major bipolar depressive disorders

b)Mood and affect: for presence of any signs of major depressive or manic disorders

c)Quality and quantity of speech: looking out for any disorganized speech

d)Thought content: for any delusions, preoccupations, overvalued ideas

 

a)Take a history from the sister  about her behaviour and relationship with others especially since the onset of symptoms

 

b)Attain more collateral history  about the circumstances surrounding the onset of the symptoms

c) More history about how Ann spends her free time and what she loves doing most.

 


For the patient all the rest of the investigations where done to help guide her diagnosis however no biological investigation was done apart from her reporting she was HIV positive and on ARVs and

septrin prophylaxis. Despite all these the patient needed to be requested to come back for review with a few investigations done especially the biological investigations.

Management

 

 

BIOLOGICAL

PSYCHOLOGICAL

SOCIAL

Immediate

Anti-depressants and some Benzodiazepines for some sleep.

a)Tabs Imipramine  20mgs od

b)Tabs Olanzapine

 

Educate the patient about his condition

 

Counsel the patient about the need to initiate medication and maintain it for her better prognosis.

 

 

Talk to the family about the condition of the patient and the prognosis of the condition once the patient starts taking her medication.

Short term

Maintain the dose of the antidepressants and the benzodiazepines given

 

Initiate other psychological therapies like: Cognitive behavioural therapy, Interpersonal therapy and Family group therapy.

Continue to encourage the family members especially her treatment partner to help the patient and encourage her to take her medication.

Long term

Review the patient after one month to check on how the patient is faring on medication and any side effects of these drugs.

 

Group therapy: where she can sit together with people having the same condition to discuss about how they are coping and what they have learnt about themselves. Group therapy is effective in reducing social isolation among the depressed patients

 

Maintenance of the other forms of therapy to continue supporting the patient.

 

Continue counselling the family members to support the patient throughout the course of treatment.

 

All these were done for the patient and once the family and treatment partner all cooperate she will have an excellent prognosis and enjoy her life again.

CASE DESCRIPTION

The patient presented to refill her medication for her mental illness which was diagnosed a week earlier at Nsambya Hospital.

The patient was well until 6 months ago when she started feeling extremely sad, thinking a lot from one idea to another and failure to get sleep in the night due to over thinking, lack of interest in anything around her and loss of appetite. This followed the loss of her small job of selling tomatoes by the roadside in May 2013 when KCCA chased them off the road and carried away her basket of tomatoes. From then she would sit in her house alone, and think a lot on how to get money to pay for her rent and her upkeep and this would cause her to cry.4 months ago she started hearing voices commanding her to go to certain places where she would be able to get money and also instructing her to move to church and pray so as to get some money, however these voices would not give a running commentary on her actions and neither where they discussing or arguing about her. This was associated with moments of seeing many people around her and a lot of things to eat near her while others did not see them. She reported no history suggestive of thought insertion, thought withdraw, thought echo or thought broadcast. She also reported no history of doing things with feelings of influence form any external forces. She reported no history suggestive of any inflated self-worth and neither any other forms of delusions, no excessive talking, no history of excessive energy, and no history of aggressiveness. There was no history of any febrile illnesses, seizures, no history of substance use and no history of alcoholism or any cigarette smoking. She had also never thought of ending her life at any one moment.

Her sisters then got her from her places in August 2013 and after realising she had an altered behaviour they took her to Nsambya where she was counselled about her problem, given some medication for 1 week and now reports no longer hears the voices however had no money to buy more drugs and so decided to come to mulago where she hopes to find free medication.

This was the second episode of a similar condition and about 3 years ago she went through a moment of extreme sadness during which she was over thinking and crying alone and this was because she had spent a lot of her money treating malaria that was not improving even with quinine and she got very worried because she didn├ö├ç├ût have any more money to spend on her treatment. She was admitted in Butabika hospital for 1 month and treated for an extra 2 months as an outpatient and improved.  She reported no history of contact with any traditional or faith healers for her condition.

She is a known HIV positive patient on ARVs and Septrin prophylaxis for now 10months now. She gets her drugs from Kiswa Health Centre. She reported no history of any other chronic illnesses like Epilepsy, Diabetes or Hypertension. She is not taking any medicine for chronic illnesses. She reported no history of any drug allergies or food allergies.

She has no history of any accidents or trauma, operations and blood transfusion.

She is the 1st born of 12 children, and all the other siblings are well and in good condition. The last two are still in school but the rest are married and stay with their husbands apart from the one who follows her who is divorced.  The 7th born in the family was also diagnosed with a mental illness in Mulago hospital and is also on treatment. One of the maternal Aunties who passed away had also been treated in Butabika hospital before.

The mother is still living and in good general condition but the father past away in 2006 due to an unknown condition. No history of any other familial illnesses like epilepsy Diabetes or hypertension. No history of suicidal tendencies in the family, no one in the family was known to be alcoholic and no history of any substance abuse or drug intoxication. No history of mysterious disappearances and no history of any suicidal tendencies. All the members of the family are corporative

The patient was not sure of her birth history, she studied up to primary six and stopped after she had lost her grandfather who was paying her schools and there was no more money to pay for her school fees, however she reports being an average performer at school.

She separated with her husband when she got admitted in Butabika hospital about 3 years ago and he got another wife however he only provides school fees for her 11year old daughter in P.6. She is no longer working and now staying with her younger sister plus her daughter as well.

She has never been involved with police or any other legal authorities. Reported no history of alcoholism or any substance use, the sister described as a sociable person and in her free time she loves to rest and listen to radio.

MENTAL STATE EXAMINATION

Appearance and Behaviour

She was dressed cleanly in her brown dress with black open shoes in her feet, in good nutritional status with normal psychomotor activity. She maintained direct eye contact though whenever I talked about her job and her HIV sero status with the drugs she would look away or look down with teary eyes. She had no mannerisms of any kind. She was also calm and cooperative during the interview and was seated up right on the chair and relaxed.

Speech

Speech was normal with spontaneous and continuous flow. Her responses were elaborate and connected. There was no pressure of speech and the volume of speech was normal however when we talked about her job and HIV sero status she would speak with low volume.

Mood and Affect

Subjective: She reported being sad and unhappy as she had lost her job and had no money to look after herself.

Objective: She appeared sad and unhappy, she was also tearful however not suicidal.

Thought

Form: Was ok with no poverty of thought, no pressure of thought, no loosening of association and flight of ideas.

Content: Had no delusions however was preoccupied by her job as she kept thinking about it and how she was going to survive with no job? She valued it a lot and wished she could just get a job as early as possible and she felt she really needed to work and get some money.

Alienation and Possession: Had no thought insertion, no thought withdraw, no thought broadcast and no thought echo

Perception: She had no illusions however before starting medication a week earlier she had hallucinations as she was hearing commanding voices and had depersonalization and derealisation as she would sometimes donÔÇÖt realise the people around her and could not to tell things in her environment.

Orientation: She was well oriented in person as she knew who she was, place as she knew we were in hospital and was talking to doctors and time as she could estimate the time of the afternoon.

Memory: Immediate ,short term and long term memory was good as she could remember the 3 words I told at the beginning of the mental state examination which were goat ,house and broom, she would also remember what she had eaten for breakfast and new who the president of Uganda was and the Kampala mayor respectively.

Attention and concentration: was good as could tell the days of the week and the months of the year backwards.

Judgement and abstraction: This was also good as when asked what she would do when the room caught fore she replied she would run out to avoid getting burnt and she managed to tell the meaning of one by one makes a bundle.

Numeracy: this was also intact as she managed to tell that 3 people had a total of 30 fingers and that 4 cows had 16 legs.

Insight: The patient had insight in the problem and since she had suffered from this before and been treated with for the same condition it was easy for her to understand that she had a mental illness and was ready to restart her medication again.

INVESTIGATIONS

1.       Biological:  No investigation was done for her that was biological

2.       Psychological

Ôö¼├Ç         Mood and affect: for presence of any signs of major depressive or manic disorders basing on the patient├ö├ç├ûs own feelings and what I would assess as I interview the patient

Ôö¼├Ç         Quality and quantity of speech: looking out for any disorganized speech

Ôö¼├Ç         Thought content: for any delusion, preoccupations or any overvalued ideas

3.       Social

Ôö¼├Ç         Take a history from the sister about her behaviour and relationship with others

Ôö¼├Ç         Attempt to attain collateral history from a relative about the circumstances surrounding the onset of the symptoms

 

MANAGEMENT

BIOLOGICAL

This is by use of antidepressants and benzodiazepines

Immediate:

Imipramine 50mgs b.d x 1/12

Olanzapine 10mgs o.d x 1/12

Short term:

Imipramine to continue the same dose as maintenance for 1 month until she comes back for review.

Long term:

The same antidepressants and Benzodiazepines were continues and patient advised to come back after 1 month for review

PSYCHOLOGICAL

Short term

The patient was educated about her condition and the reason why she was going to take her medication for longer

Long-term

Her sister was asked to encourage Ann to continue taking her medication and she was given a review date to come back and see the paediatrician for continued assessment of her condition and in case of any side effects on how to manage them.

SOCIAL

Short-term

Her sister was educated about her condition as well to act as her treatment partner, she was also given counselling about how to handle her to promote quick recovery.

Long-term

Arrange family therapy directed toward long-range application of stress-reducing and coping strategies and toward AnnÔÇÖs reintegration into everyday life. This was advised by the psychiatrist on duty

Conclusion

The patient was well managed since she had insight she could be managed as an outpatient with hope that she will be able to swallow her medication on time and as instructed. Once all is done she will be better by time she comes back for her next review after one month.

REFERENCES

1.       Robin and Cotran├ö├ç├ûs Textbook of Pathology.

2.       Psychiatry in Africa.

 

 

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