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Case contributed
by: After completion of this case, participants will be able to:
Case Presentation At the next
interview, you review with him the normal findings from lab work,
and review his story in some detail, noting that he has no previous
psychiatric history. He has an uncle who suffers from periodic depression.
He is still struggling to manage his activities, but he is not actively
suicidal or psychotic. You conclude that he is indeed suffering
from depression, and start him on an antidepressant familiar to
you. You also advise him to take one week off work. Two weeks later,
he is tolerating the antidepressant well, and reports that during
his week off, he felt less stress but was unable to do anything,
mostly watching old movies at home rather than tending to any of
the "thousand things" he has to do. He is rather self-critical
about his failure to get organized, and wonders if he will ever
be able to get back on track. At the same time, he reports that
he is feeling a little better overall, and definitely eating more. Questions to Consider:
You advise him
that it is too early to alter the antidepressant; you also recommend
regular exercise and suggest that he take the odd day off work if
he feels too stressed. You will see him every two weeks to monitor
his progress. On his next visit, four weeks after you started medication,
he is substantially better. He reports improved mood, particularly
later in the day, normal sleep, and normal appetite. He can enjoy
things now, but notes that the enjoyment is limited to activities
other than the "thousand things" that he is supposed to
do. He also is quite sad early in the day, and takes a long time
to get going. He is able to go to work regularly, but only manages
the minimum there. On mental status exam, he generally looks much
better, but visibly deflates as he remembers all the tasks he is
not doing. You reassure
him that the depression is coming under control, and that further
improvement is likely over the coming weeks. You decide to increase
the antidepressant dose to ensure adequate pharmacotherapy, to the
mid-range of the recommendations from the recent CANMAT depression
guidelines. However, when
you see him for the next visit – six weeks after starting antidepressant
medication – there has been no further improvement. He belabours
the point that he still feels overwhelmed by all the tasks he should
be doing, and so he avoids as much as he can. Felix says that he
feels much better, particularly on weekends when he visits friends
and doesn't think about responsibilities. He also worries that he
is "permanently bummed out", will not be able to handle
much work in the future, and will simply get depressed again in
the future. He has read that depression is a recurrent disorder,
and believes that he is destined to suffer. From his symptoms
and his mental status exam, you estimate that he has improved about
60-70%. He is not suicidal, but he seems to have persistent difficulties
organizing his life, and has enduring pessimistic thoughts. He is
not enthusiastic about taking more medication, but is open to suggestions. Questions to Consider:
Discussion Purely pharmacological
interventions certainly could be contemplated, but he has already
had one increase of his dose. The problems with poor coping skills
and persistent negative thoughts could be well addressed using cognitive
behavioural therapy (CBT), which offers very specific strategies
to deal with these problems. Referral to a cognitive therapist might
be ideal, but is rarely feasible for financial or other reasons.
CME courses are helpful to the physician seeking to learn CBT, however,
the two chapters on depression and problem-solving from the book
"Cognitive Behavior Therapy for Psychiatric Problems: A Practical
Guide" are also very useful. Many elements of CBT can be applied
by a physician with limited training, as outlined below. The first step
in applying cognitive behavioural techniques is to explain to the
patient that, as part of your role as "healer", you will
be changing to being a "coach" or "teacher".
The patient is coached in applying simple problem-solving skills
and techniques to combat pessimism. Either of two books can also
be "prescribed" – "Mind Over Mood" and
"Feeling Good". These books apply basic CBT principles
and are easy to use; the physician may assign chapters to read and
exercises to complete for the next session, and the chapters and
homework are then reviewed. One study showed the Burns book to be
an effective treatment for patients with mild depression, even in
the absence of a therapist! For this patient,
problem-solving techniques (and your active coaching) would allow
him to priorize the "thousand things" he has to do, and
then to devise small steps towards completing a few of these tasks.
With practise, patients can generally incorporate such problem-solving
approaches independently within a few weeks. Felix’ sense of
competence will be enhanced by successful problem-solving, and this
further mitigates against helplessness and hopelessness. The physician
can also help the patient schedule at least some daily social and
pleasurable activity, and then demonstrate how this activity led
to improvement, however brief. Specific negative cognitions –
for instance, "I don't think I'll ever feel better" –
can be explored in terms of whether the statement is realistic and
what evidence there is to support it. These explorations are collaborative
– not lectures that the thoughts are "not true."
The more confident and capable patient is then able to take these
skills and attitudes further into the future. Research in this area
has demonstrated that patient satisfaction increases enormously
when the patient feels understood and helped through an integration
of pharmacotherapy and psychotherapy; finally, patients who are
successfully treated with formal cognitive therapy have lower rates
of relapse. Suggested Readings: Cognitive
Behavior Therapy for Psychiatric Problems: A Practical Guide Mind Over
Mood Feeling Good Proceed to Section V - "Discussion Forum"
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