Educationals

A) Doctor patient relationship

The physicians attitude should be caring , sympathetic and empathetic. There should be a genuine concern for the patient about his life and his sickness. The patient should be allowed and encouraged to talk freely about his complaint without any hindrance or expressing boredom. The patient should not feel that the doctor is not listening or is not interested in his problem. Simple unburdening of problems on a sympathetic listener gives some relief.

B) Aim and modalities of treatment

The aim of treatment is fourfold

• treatment of presenting complaints,
• treatment of psychosocial stressors
• treatment of personality disorder if any and
• prevention.

The therapeutic modalities which are commonly used are

• Psychopharmacotherapy
• Psychotherapy and
• Behavior therapy.

It is important to choose right drug in the dose to be administered at the right time in the right frequency of dose and which is available at the right price. It is good practice to be familiar with a few drugs than to use the latest available drug.

The traditional tricyclic antidepressant drugs include imipramine, amitryptiline, nortryptiline, dothiepin and doxepin. Most of these drugs are gold standard for antidepressant therapy and have proved their worth over a number of decades. One of these drugs (e.g. dothiepin) may be started in the dose 25mg daily and may be increased by 25mg every four days till the dose of 75mg per day is reached. Later on the increment of 25mg should be at the interval of one week till there is improvement or till side effects become unacceptable. These drugs can be safely given in the dose of up to 300mg per day but it would be prudent to seek a psychiatrist's consultation beyond a dose of 150mg per day. The dose may be given as a single night time dose or in 2 or 3 divided doses per day. The night dose should be taken about two hours before bedtime, to avoid hangover next day.

The common side effects include dryness of mouth, postural hypotension and constipation. If the patient is informed of the side effects in advance and advised simple preventive and precautionary measures most of them do not find the side effects unacceptable. Usually the improvement starts within days but sometimes the onset may be delayed. Full improvement is seen within two to three months medication & it should be continued for about 6 to 9 months after full recovery. There after it may be gradually tapered off, some patient may require maintenance therapy to prevent relapse.

Fluoxetine is a prominent molecule from the category of newer antidepressants. It may be started in the dose of 10 mg per day, may be increased to 20 mg after a week. It may be further increased to 40 mg per day after 3 to 4 weeks if there is inadequate response. Fluoxetine should preferably be administered before noon, to avoid insomnia. Side effects are usually mild and minor.

Initially the psychotherapy should aim at developing transference and at facilitating ventilation and catharsis. By transference we mean the positive approach, faith and confidence which the patient develops towards physician. It results from the transfer of patients positive attitude towards the significant formative years of personality development. Ventilation is intellectual expression and discussion of patients problems. Catharsis is expression or discharge of emotions and emotionally charged material often accompanied by crying, anger, resentment etc. At this stage, the physician should listen and make note of important material used in the later sessions. The patient should not be pressurized into doing anything and no false hope should be given. Abreaction is emotional recurring of past traumatic experience. It can give sudden relief at times. Depressed patients have a tendency of taking a negative view of life and magnifying the difficulties than what they actually are, minor obstacles appear insurmountable, patients feel helpless and worthless. They feel being used and exploited by other people. They feel they are not getting any credit or recognition for the good work done by them. Often their anxieties, ambitions, attitudes and priorities are vastly different from their family members. These attitudes need to be discussed with the patient. He should be encouraged to do a stock taking of his life, evaluate assets and liabilities; study strength weakness opportunities and threats and take rational and intellectual decisions to rectify things. He will have to re-examine his attitudes towards spouse, children, work and life in general. Quite often we mortgage our today for a better tomorrow, which unfortunately never arrives. While trying to please everybody else, we disappoint ourselves. We need to be happy here and now today.

Depressed patients have to be encouraged to look at themselves, their undesirable reaction and response to certain patients in situations. Psychotherapeutic process aims at substituting such undesirable behavior by desirable behavior.

Behavior therapy eliminates undesirable behavior and tries to inculcate desirable behavior by using the learning theories. Broadly speaking these are two types of learning processes. In the classical conditional learning also known as Pavlovian conditioning, conditioned behavior is elicited by coupling of unconditioned stimulus and conditioned stimulus e.g. Classical Pavlovian experiment in which dog starts salivating only when buzzer rings; when food and buzzer are coupled in the earlier trials.

On the other hand in apparent learning desirable behavior is rewarded while undesirable behavior is punished.

A psychosomatic disorder like Irritable Bowel Syndrome (IBS) would have given better qualitative and quantitative response if both the medical as well as psychological namely cognitive, behavior and anti-depressant treatment are administered by the primary care physician.