Hugh Momutt, aged 68 years presents with lethargy, depressed mood, loss of interest in his family and friends. His family have asked him to attend you for advice. They are worried that since retiring he seems to have lost interest in everything, but this has been much worse in the past few weeks, and he is now staying in bed, not showering and has lost 5kg in weight. They advise that when he was in his twenties, Hugh had a depressive illness, was hospitalised and was on antidepressant medication for 5 years. However, he then improved and has not had any therapy for at least a decade.
The key to answering this question is for the student to talk about doing a work-up for a patient with depression at an older age. This will require a comprehensive mental health and physical health assessment that focus on the symptoms and signs of depression but also rule in/ out symptoms and signs of potential differential diagnoses.
Differential Diagnosis includes:
Further history and examination:
Complete mental health assessment including:
HPC: More details about this episode, time course, triggers, clarify presence of depressive symptoms, pattern of symptoms (e.g. diurnal mood variation, early morning wakening), look for mood congruent psychotic symptoms, risk to self or others, any physical symptoms (fevers / signs of dehydration/ headache / gait changes / changes to bowel or bladder function).
Past History: Was this like earlier episode? Any episodes of depressed or elevated mood? Substance use? Smoking? Alcohol? Any problems with general health? Consider current and the recent functioning looking for a decline in function.
Mental state examination (MSE)
Specific things to look for on MSE:
Consider using a rating scale such as the Hamilton Depression rating scale (HAM-D), Montgomery-Asberg Depression Rating Scale (MADRS), Geriatric Depression Scale (GDS).
Physical examination
Risk: Passive death wish / thoughts of harm to self / suicidal ideation / plans or intent to end life. Risk of self-neglect
Collateral history
What has family noticed? About personality changes, sleep, strange ideas/preoccupations? Concentration and memory?
Symptoms, signs or investigations suggesting other illness (e.g., chest pain, dyspnoea, headache, jaundice, urinary symptoms), fatigue and weight loss that continues or persists despite treatment. Any neurological symptoms. Severe cognitive changes. A sudden onset of symptoms. Recent change in medications.
Investigations need to be ordered in response to the history and physical exam, the need to rule in / out possible organic causes for presentation and to assess risk of dehydration / malnutrition due to poor oral intake.
Standard investigations from RANZCP guidelines include:
In addition to these, in this case add magnesium / calcium / phosphate, B12 / folate. Also neuroimaging is likely to be beneficial in this case – urgency will be determined by results of history / physical exam.
Depression can be classified in several ways, including by symptoms, by severity or by suspected cause.
DSM-5 classifies in this way:
Classification by symptoms: melancholic depression, psychotic depression, non-melancholic depression, atypical depression.
Classification by course: bipolar or unipolar, recurrent brief depression, seasonal affective disorder.
Depression can also be categorised as primary and secondary (e.g., to medical illness, medications, substance use, tobacco and alcohol dependence, pregnancy, cognitive decline).
From DSM-5
A. One of the following is present during the most severe period of the current episode:
B. Three (or more) of the following:
Note: The specifier "with melancholic features" is applied if these features are present at the most severe stage of the episode. There is a near-complete absence of the capacity for pleasure, not merely a diminution. Psychomotor changes are nearly always present and are observable by others. Melancholic features are more frequent in inpatients, as opposed to outpatients; are less likely to occur in milder than in more severe major depressive episodes; and are more likely to occur in those with psychotic features.
Student should present a biopsychosocial management plan for Hugh looking at immediate care, then short and longer term management plan.
Immediate management: Risk assessment and setting of treatment:
Likely to need inpatient treatment due to severity of depression and poor oral intake. If you are in a GP setting you will need to refer him to the local Emergency department. He will need a psychiatrist to manage his care. Aim for voluntary admission but may need to consider the use of the Mental Health Act due to risk to physical health. Initially stabilise physical health – may need to be admitted under a medical team initially if unstable. Consider IV fluids, monitor for refeeding syndrome. Important to engage with family during this time.
Short term management:
Melancholic depression usually requires a dual acting antidepressant (SNRI, TCA), and may also require an antipsychotic agent, particularly (but not only) if there are psychotic features or if there is a poor response to the antidepressant alone. Lithium can also be used as an augmentation agent in severe unipolar depression, check renal function. During the admission it will be important to monitor sleep, mood, oral intake, functioning / self-care.
If the patient fails to recover or is depressed to the point of being immobilised, not eating and drinking, psychotic or wracked with suicidal preoccupations, then ECT should be considered. The Mental Health Act may also be required in these circumstances.
Psychotherapy is not useful in the acute phase, but behavioural activation may be useful. The family will need considerable support and should be consulted about patient's progress. Psychoeducation is important in the short term.
Longer term management:
On recovery, further psychoeducation is important plus identification of organic (particularly any cerebrovascular risk factors), personality and contextual vulnerability factors, also to look at his early symptoms and signs, as a 'relapse signature', if he were to have any further episodes. Also, to 'debrief with him and his family' about what is generally a traumatic experience.
For Hugh, this would include consideration of retirement as a transition phase in his life, consideration of his general health, lifestyle and whether he has any psychological issues that require attention and consider psychological therapy. It would be important to see him every few months and look for any decrease in cognitive function.