Case Studies

Mr Ashok also had difficulty in falling asleep at night, he would lie in bed for hours together, finally fall asleep only after taking a self administered sedative. Inspite of this, he would have an interrupted sleep.

He also lost his appetite and began to loose weight as a result of skipping meals. Slowly, he began to withdraw from society, stopped going out with friends and began to refuse invitations from even family members. He told his wife that he was "not in the mood" to socialise and was feeling very blue. He said that he was feeling very sad but did not know the reason. He also told his wife that he was worthless, good for nothing and a burden on the family. During this period, Mr. Ashok, claimed to be feeling very tired, restless and fatigued.

For the last 15-20 days prior to seeking a psychiatric consultation his wife and family members noticed that he would hardly say a word at home and showed no interest in his family.

Mr. Ashok had no previous history of any psychiatry illness neither was there any family history of psychiatric illness. There were no significant stresses prior to his illness nor was there any general medical condition which could be held accountable for this episode.

Management

After carrying out all the necessary laboratory investigations, Mr. Ashok was started on T Dotheipin on an out patient basis.

He was initially started on T Dothiepin 75mg at bedtime, gradually within a period of three weeks this was increased to 225 mg i.e. T Dothiepin (75mg) thrice a day. Mr. Ashok was explained of the side effects that could occur because of the drug. In event of dryness of mouth, he was explained that he could reduce it by talking small sips of water throughout the day or by chewing sugarless chewing gum. In the event of constipation a purgative was prescribed.

Mr. Ashok’s relatives began to notice a definite improvement within two months. They noticed that he began to interact with them once again and re-started going to work and his biological symptoms of depression began to decrease.

Mr. Ashok would follow up in the OPD initially once a week for the first month and then once in 15 days. The patient followed up regularly for six months when it was noted that there was 100% improvement. After six months, the drug was slowly tapered and finally discontinued. It was explained to the patient that any time the patient or relatives felt the symptoms reappearing, he has to be brought to the OPD immediately.

Along with pharmacotherapy, the patient was also being given regular supportive psychotherapy and counselling.

Discussion

After a detailed interview with the patient and psychological testing, Mr. Ashok was diagnosed as suffering from major depressive disorder. According to the DSM IV criteria for major depressive episode, the patient must have five or more of the following symptoms for a minimum period of two weeks and represent a change from previous functioning.

• depressed mood (can also be irritable mood in children and adults)
• diminished interest or pleasure in all activities
• significant weight loss (Occ. weight gain)
• insomnia or hypersomnia
• psychomotor agitation or retardation (observed by others)
• fatigue or loss of energy nearly every day
• feelings of worthlessness / excessive or inappropriate guilt
• decreased concentration, indecisiveness
• recurrent thoughts of death, suicidal ideations

Of the above symptoms, Mr. Ashok had almost all except suicidal ideations and recurrent thoughts about dying.
In the event of these symptoms causing significant impairment in socio occupational functioning, not being better accounted for by any other psychiatric or general medical condition substance abuse, we classified it as a major depressive episode.