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Refective case studyBY DR. AMIR M. HANAFI

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Objectives

1.  To preset a case o! a "eta# $ea#t$ disorder.

%.  To ideti!y c$a##e&es i t$e case.

'.  To (ei&$ optios o! itervetio.

).  To refect o t$e itervetio decisio.

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*ase presetatio +Descriptio,

Ms Nes"a is a si&#e %- year o#d #ady ($o ca"e tot$e outpatiet psyc$iatry c#iic !or a depressed "oodduri& t$e past severa# "ot$s t$ere (as o evett$at s$e cou#d #i/ t$e "ood depressio to but s$e

a#so reports #oss o! iterest to $er $obbies #i/ereadi& ad &oi& out (it$ !rieds. 0$e reports t$ats$es s#eepi& too "uc$ ad $as a decreasedappetite.

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2uestio

Furt$er 2uestios3

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*ase presetatio

0$e stopped &oi& to (or/ recet#y as s$e (as$avi& a very $ard ti"e cocetrati& ad s$e !e#ts$e (ast tryi& $ard eou&$ to succeed i $er (or/ad s$e !ee#s s$es a source o! stress ad sadess to

$er !a"i#y. 0$e says s$e !ee#s do( "ost o! t$e ti"e but "uc$

#ess o!te s$e !ee#s "uc$ better ($e s$e "eets acertai !ried o! $ers.

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*ase presetatio

0$e deies ay t$ou&$ts o! suicide +says 4ODprevets $er !ro" edi& $er o( #i!e, or $ar"i&ot$ers o "aic or $ypo"aic episodes a#so ode#usios or $a##uciatios.

Her !at$er $ad depressio ad died i va&uecircu"staces ($ere t$ere (as a suspicio t$at $eco""itted suicide.

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2uestio

Furt$er 5uestios i t$e $63

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*ase presetatio

0$es a /o( case o! 7*O0 receivi& treat"et siceear#y %81) +oret$isteroe,. No re#evat sur&ica# $6.

Her "eses currety are re&u#ar every %9 days !or -days i t$e :rst ' days s$e uses -;< pads per day t$e

s$e uses 1;% pads per day t$e re"aii& days s$ese#do" &ets "estrua# cra"ps or iter"estrua#spotti&.

0$e a#so deies s"o/i& dri/i& a#co$o# or usi& ayrecreatioa# or i##icit "edicatios.

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2uestio

Ho( do you scree dia&ose ad assess

depressio3

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7H2;= too#

For iitia# dia&osis>

1. 7atiet co"p#etes7H2;= 2uic/DepressioAssess"et.

%. I! t$ere are at #east )'s i t$e s$aded

sectio +ic#udi&2uestios ?1 ad?%, cosider adepressive disorder.

'. Add score todeter"ie severity

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Dri##

No( as/ "e oe by oe@

Ad score t$e patiet.

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2uestio

$at e#se (ou#d you #i/e to assess3

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A6iety ad Depressio

Its ot uco""o !or so"eoe (it$ aa6iety disorder to a#so suCer !ro"depressio or vice versa. Near#y oe;$a#! o!

t$ose dia&osed (it$ depressio are a#sodia&osed (it$ a a6iety disorder. $ttp>(((.adaa.or&about;adaapress;roo"!acts;statistics

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A6iety>4ADE Re!ereces>

0piter RG roe/e i##ia"s BGo(e B. A brie! "easure !or assessi&&eera#ied a6iety disorder> t$e4AD;E. Arc$ives o! itera# "edicie.May %% %88-J1--+18,>18=%;18=E.7MID> 1-E1E1E1

roe/e 0piter RG i##ia"s BMoa$a 7O Go(e B. A6ietydisorders i pri"ary care> preva#ecei"pair"et co"orbidity ad

detectio. Aa#s o! itera# "edicie.Mar - %88EJ1)-+9,>'1E;'%9. 7MID>1E''=-1E

Go(e B Dec/er O Mu##er 0 et a#.Ka#idatio ad stadardiatio o! t$e4eera#ied A6iety Disorder0creeer +4AD;E, i t$e &eera#popu#atio. Medica# care. Mar%88<J)-+',>%--;%E). 7MID> 1<'<<<)1

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Dri##

As/ "e oe by oe@

Ad score t$e patiet.

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A6iety>4ADE Re!ereces>

0piter RG roe/e i##ia"s BGo(e B. A brie! "easure !or assessi&&eera#ied a6iety disorder> t$e4AD;E. Arc$ives o! itera# "edicie.May %% %88-J1--+18,>18=%;18=E.7MID> 1-E1E1E1

roe/e 0piter RG i##ia"s BMoa$a 7O Go(e B. A6ietydisorders i pri"ary care> preva#ecei"pair"et co"orbidity ad

detectio. Aa#s o! itera# "edicie.Mar - %88EJ1)-+9,>'1E;'%9. 7MID>1E''=-1E

Go(e B Dec/er O Mu##er 0 et a#.Ka#idatio ad stadardiatio o! t$e4eera#ied A6iety Disorder0creeer +4AD;E, i t$e &eera#popu#atio. Medica# care. Mar%88<J)-+',>%--;%E). 7MID> 1<'<<<)1

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Itervetio

B#ood (or/ (as ordered !or t$e patiet ic#udi& a *B* *M7 T$yroidpro:#e Kita"i D ad B1% assays.

 T$e patiet (as treated usi& a co"bied approac$ usi& Lscita#opra"18"& oce dai#y !or t$e e6t - (ee/s ad psyc$ot$erapy sessios.

 T$e c$oice o! Lscita#opra" (as based upo t$e !act t$at oe o! $er

sisters $ad used it !or depressio ad s$o(ed "ar/ed i"prove"et.

0$e (as &ive a appoit"et i - (ee/s to revie( respose totreat"et ad #ab resu#ts.

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Fo##o( up a!ter - (ee/s

 T$e patiet reported "i#d i"prove"et i $er "ood but o c$a&e i$er s#eep or cocetratio $er 7H2;= (as 1< deoti& a poor resposeto treat"et.

Her b#ood (or/ $ad s$o( a or"a# *B* a or"a# *M7 ad a or"a#edocrio#o&y pro:#e e6cept !or a vit. D o! 1% &"#.

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2uestio

Ho( (ou#d you dea# (it$ !ai#ure o! treat"e

its acute p$ase3

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Itervetio %

e decided to &ive t$e Lscita#opra" ) "ore (ee/s o t$e sa"e dose (it$cotiuatio o! psyc$ot$erapy sessios p#us e"p$asis o t$e o;p$ar"aco#o&ica# treat"et "oda#ities suc$ as>

L6ercise

Diet

0ocia# support +"eeti& !rieds ad !a"i#y,

Idu#&i& i a $obby +patiet #i/ed to read,

0#eep $y&iee

Breat$i& e6ercises

e a#so decided to address $er vita"i D de:ciecy issue by prescribi& 98888I o! er&oca#ci!ero# oce (ee/#y !or t$e e6t < (ee/s.

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Fo##o( up % i ) (ee/s

 T$e patiet reported "ar/ed i"prove"et i $er "ood"ore days t$a ot ad $er 7H2= score at t$is visit $addecreased to =.

 T$e patiet as/ed i! s$e ca stop t$e psyc$ot$erapy

sessios as s$e !e#t s$e (as &etti& better ad cou#dtappreciate t$eir va#ue at t$e ti"e bei&.

0$e (as advised to cotiue t$e atidepressattreat"et !or - "ot$s to 1 year be!ore starti& to taperoC.

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 T$e 2uestio@

Is depressio i t$is case> Primary or secondary

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Refecti& o t$e case

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Met$odo#o&y o! t$e refectio

I t$is refective study I used o$s "ode# o! structure refectio+1==), ad 4ibbs refective cyc#e +1=<<,

 o$s "ode# cosists o! t$e !o##o(i& !ra"e(or/>

1. Descriptio o! t$e e6periece

%. Refectio

'. Ifueci& !actors

). Geari&

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Fee#i&s

I (as tryi& to ac$ieve opti"u" resu#t !ro" "edicatio be!orec$a&i& t$e dru& or t$e dose by adjusti& a## !actors re#ated #i/e#i!esty#e ad vit D de:ciecy ad eve i #i&$t o! $er pre;e6isti&coditio o! 7*O0.

I !e#t t$at depressio (as a i""ese burde o t$e patiet ad $e

o( $ouse$o#d ($ic$ &eerated t$e !ee#i& o! &ui#t s$e $ad ad I !a#so t$at t$e treat"et itse#! (i## be "ore o! a burde.

0o beside se#ecti& t$e treat"et o! t$e best sa!ety pro:#e I decidestic/ (it$ t$e iitia# dose uti# I" ab#e to adjust a## t$e a!ore "eti!actors.

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Kit. D addepressio

$ttp>

bjp.rcpsyc$.or&cotetbjprcpsyc$%8%%188.!u##.pd! 

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7*O0

Depressio is ) ti"es"ore preve#at i(o"e (it$out.

$ttp>(((.cbi.#".i$.&ovpub"ed%'E%<-EE

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*otraceptives3

 T$e patiet (as ooret$isteroe astreat"et !or 7*O0.

$ttp>o#ie#ibrary.(i#ey.co"doi18.1111j.1-88;8)1%.%811.81'''.6pd! 

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Lva#uatio

$at I $ad #eared>

A #ot o! diCeret !actors ca precipitate depressio

 T$ere is a t$i #ie bet(ee pri"ary ad secodary depressio

A#(ays ta/e care o! o;p$ar"aco#o&ica# treat"et o! depressio

A#(ays address co;"orbid "edica# coditios

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*oc#usio

I (ou#d $ave #i/e to address $er socia# status "ore t$orou&$#yespecia##y (it$ t$e stro& !a"i#y $istory s$e $ad.

0uicide ris/ assess"et s$ou#d $ave bee doe i !u## as s$e a#so $as aprobab#y !a"i#y $istory o! suicide +Fat$er,.

*otacti& t$e OB4YN tea" !o##o(i& $er coditio (ou#d $ave added

va#uab#e i!or"atio ad $e#ped "e e$ace syste" based practiceco"petecy.

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Itroductio

Depressio is t$e "ost up#easat t$i& I $ave ee6perieced. . . . It is t$at absece o! bei& ab#eevisa&e t$at you (i## ever be c$eer!u# a&ai. absece o! $ope. T$at very deadeed !ee#i& ($ic

so very diCeret !ro" !ee#i& sad. 0ad $urts but it$ea#t$y !ee#i&. It is a ecessary t$i& to !Depressio is very diCereQ .. Ro(#i&

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Thank you.