Volume 01
July 2007
Issue 07
Editorial Depression: A Submerged Health Problem So much has already been written on depression. However, knowledge about depression has not reached the desired level among health professionals, the general public or consumers (or patients). This is especially true in the South Asian countries. Depression is one of the leading causes for disability in the world. It is an important mental illness with (exogenous) or without (endogenous) a known precipitator and is often associated with many medical conditions either as a cause, effect or comorbidity. Depression is a common condition in hospitalized patients and in general practice, demanding active diagnosis and management. We do not see much of the classical, endogenous type of depression in our region, where the local language does not have an equivalent word for depression. Nevertheless we do come across several patients who present with culturally specific symptoms of depression (like Perumuchchu syndrome, burning sensation throughout the body, somatization etc.) and atypical manifestations of depression (like unresolved pain, substance abuse, deliberate self harming behaviour etc.). Many of these patients improve with biological, psychological and social approaches of management. In this issue, we would like to focus on the diagnosis of depression and its management. We believe that this will be of useful to all the practicing clinicians!
CONTENTS 1. Diagnosing depression in its local context 2. Pharmacological Management of Depression 3. Understanding Grief 4. Psychiatry- MCQ
Diagnosing depression in its local context
D
Thinking
iagnosing depression is always an active process in our culture. A detailed symptom focused history and mental state examination is crucial in the formulation and diagnosis of depression. Having knowledge on culturally specific symptoms of depression is an added advantage for the clinicians. In this article we discuss the common presenting symptoms of depression in the local context.
A whole range of abnormalities can be seen in thinking. The abnormalities mainly focus on the change in their thinking process and perspective. Low self esteem is common, which is associated with loss of hope in the self, future and world. Pessimism dominates over optimism and they tend to be preoccupied with negative thoughts, ignoring the positive aspects of their life. The relationship of emotion on memories (emotional memories) brings out the more negative events that have happened in their life, thus reinforcing their negative thinking.
Low mood We do not have a specific local word to describe low mood. However, our patients usually present with sad feelings, crying spells or feeling like crying, dullness and a sense of uneasiness in their mind. Lack of interest in their day to day activities and inability to enjoy pleasurable things (anhedonia) are characteristic but need active probing though they are commonly present in many depressive patients. The mood ranges from dysphoria to severe depression.
In our culture, relations may complain the person is thinking too much, more preoccupied than usual, silent and withdrawn. An important part of the thinking is loosing hope in their future and they may develop suicidal ideations and/or intentions. A hierarchy of suicidal thoughts are listed in box one. Suicidal
Lack of energy
Box one: Hierarchy of suicidal thoughts
Many of our patients do not use the word energy, but they present with complains like tiredness, lassitude, weakness, inability to do things effectively as they did in the past and not having sufficient motivation or initiative. Lack of energy level is an important symptom of depression. July 2007
§ § § § § § § §
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Transient thoughts - once in a way Frequent suicidal thoughts - daily Preoccupying with the thoughts Thinking of vague plans Selecting a plan Rehearsing internally Preparing the setting Irresistible thoughts of trying out The News Letter of the Jaffna Medical Association
apprehension, anticipation of bad events and other physical symptoms of anxiety. Therefore, if someone presents with marked anxiety symptoms, we should actively look for the depressive symptoms and if it is there then to find out which is primary. Irritability, abusiveness and aggression in mild to moderate degree, frustration, guilt (which is rare in the local context), shyness, and shame are some of the other emotions present along with depression.
risk assessment is crucial in patients with depression particularly with moderate to severe suicidal thoughts.
Biological features Depression causes sleep problems which characteristically present as early morning awakening. Although this is diagnostically significant, many patients present with non specific sleep problems. They feel worse in the morning hours, but feel some what better in the evenings. This diurnal variation in the mood is one of the important symptoms and may need active probing. People with depression may present with low appetite, poor food intake, decreased bowel opening and loss of weight. However, this may change in atypical depression, where people present with having more sleep, voracious eating and weight gain. Females can get irregularities in their menstruation. But important to all, depression may take away the libido, the thriving force of humans according to Freud. Needless to say, this information needs direct questioning in a supportive manner.
Somatic complaints This is the main presenting mode of depression to most of our patients. They usually present with one or more somatic complaints without having any underlying pathology. In our culture, somatization is a known method, which is partly learned through generations, to express our emotional distress. Somatization generally presents with aches and pains in one or many parts of the body. In contrast they may present with various unheard expression of symptoms, local idioms or with some special complaints. Interestingly the symptom of burning sensation all over the body is an important expression of depression in all parts of Sri Lanka and is well documented. In Jaffna, Perumuchu and difficulties with breathing are well known manifestations. A clinician should be sensitive towards these presentations and be able to diagnose the underlying depression.
Associated emotions Anxiety is an important association and we do see many patients presenting with both depressive and anxiety symptoms Mixed Anxiety Depressive Disorder (MADD). When people do not understand the depressive mood and its manifestation, they develop fear, July 2007
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symptoms, then a mini mental state examination is mandatory in addition to obtaining other information related to dementia, amnesic syndrome, or organic confusional state.
Psychotic features Depressive patients too can have psychotic symptoms like delusions and hallucinations, but usually they are mood congruous. i.e. they could be understood or explained through their depressive mood. Auditory hallucinations can occur; usually second person in nature; but sometimes accusing the patient as s/he has done something wrong or commanding the patient to commit suicide. They sometimes see dead figures, smell dirty odour or 'funeral smell' and have bad taste. Nihilistic delusions, the belief that nothing exist i n t e r n a l l y, a r e v e r y c o m m o n . Hypochondriacal delusions are not uncommon. But delusion of guilt is a rare presentation in our culture. People may have overvalued ideas, which do not mount to the extent of delusions but are emotionally taxing in nature, about some explanatory beliefs like sorcery, planets related explanations and bad time. They are not diagnostically significant but could be considered as important factors for placing the patients in their context.
Behaviour All the above mentioned symptoms and experiences shape the behaviour of the depressed patients. Psychomotor retardation is a well known phenomena in depression. There is a marked slowness in their movements, speech and other psychic functions. Thoughts loose their richness; words become monosyllabic; execution suffers. Social withdrawal is common in most patients. They seem to isolate themselves; stay in a room or dark corner. They do not show interest in maintaining social contacts. In fact, they actively avoid social situations like functions and festivals. They tend to neglect their cleanliness and dressing. There is paucity in their facial expression if not overt sadness and they may present with downward lips and furrows in the forehead (omega sign).
Cognitive problems
H o w e v e r, s o m e p a t i e n t s w i t h depression may present with agitated, hyperactive behaviour which is not uncommon in our settings.
Many young persons primarily present with one or more problems in their cognitive functions namely, poor attention span, lack of concentration, difficulty in recalling their lessons, memory loss, and impairment in their judgmental capacity. Many of them score well in the cognitive functions test. If an elderly person presents with these July 2007
We have seen some of the important features of depression and seen how they fit into the local context. These symptoms fit well within the ICD 10 4
The News Letter of the Jaffna Medical Association
its self remitting nature can give us a past history of similar episodes.
classification, which is a useful guide to diagnose depression.
¬D e p r e s s i o n u s u a l l y h a s a n
Some useful facts
association with a life stressor even though it is primarily endogenous. Attention should be paid to identify the physical / psychological stressors and to address those issues.
¬Depression runs in the family. We may get a positive family history in many patients.
¬The episodic course of depression and
By: Dr.S.Sivayokan
Melancholy is the melody of life... Happiness comes in between.
Mental health services in Jaffna Clinics In accordance with the national mental health policy, at present, psychiatric clinics are available in four different hospitals. ª ª ª ª
T.H. Jaffna Mon -Sat B.H point pedro Tue & Thu D.H Tellipalai Mon, Wed & Thu D.H Chavakachcheri Wednesdays
8 am 8 am 8 am 8am
3 pm 12 noon 12 noon 12 noon
Inpatient services Inward treatment facilities are available in the following institutions ª T.H Jaffna ª D.H Tellipalai ª B.H Point pedro
Medical wards Psych. wards Psych. wards
Acute management only Acute & intermediate management Acute & intermediate management
Counseling and other multi disciplinary services These services are available in the above mentioned institutions
.Long term management facilities and rehabilitation services are not available at present July 2007
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The News Letter of the Jaffna Medical Association
Phar macological Management Of Depression SOME USEFUL TIPS
¬In many parts of the world, pharmacological treatment still remains as the main path of depressive management. Electroconvulsive therapy, psychological therapies, social case work and family work are also effective in the management.
¬Pharmaceutical companies invest a lot on antidepressants, resulted in producing a number of new antidepressants. Hence, it is important to familiar with few antidepressants of different generations.
¬Generally, antidepressants
differ in their side effects but not in their therapeutic
effects. We have to remember that they take about 10-14 days to produce the antidepressant effect, though the side effects appear early and lead to poor drug compliance. It is advisable to continue the treatment for a period of at least six months in order to prevent early relapse.
Brief review of different anti depressants
Drugs
Tricyclic anti depressants.
SSRI
SNARI
Examples Amitriptyline Imipramine
Anticholinergic effects weight gain
Well tried Inexpensive Promote sleep
Citalopram Escitalopram Fluoxetine Fluvoxamine Sertraline
Less anticholinergic & cardiac side effects No weight gain
Reboxetine
No sedation No weight gain
Mirtazapine
Promote sleep Less sexual problems
Venlafaxine
Slightly early onset of action, No weight gain.
Others
July 2007
Common adverse effects
Advantages
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Nausea & vomiting, Dyspepsia. Initial anxiety Insomnia, Postural hypotension Weight gain, Headache, Convulsion. Constipation GIT symptoms
Caution
Dosage
Toxicity in over dose, suicidal risk.
75- 150mg
Serotonin syndrome Drug interactions
20- 40mg mane for Fluoxetine
Rarely causes SIADH
4mg bd
Agranulocytosis
15 – 30 mg noct.
May cause hypertension
37.5- 150mg per day
The News Letter of the Jaffna Medical Association
¬
Trycyclics are believed to be safe in pregnancy and lactation.
¬
Most of the depressions can be managed by physicians and General Practitioners. However, the following situations may need referral to a mental health professional. Site of action of some anti depressants with examples
©
Severe depression with psychotic features
©
Depression with severe biological symptoms including failure to eat or drink
©
High suicidal risk / difficulty in assessing suicidal risk
©
Failure to respond to the initial treatment
©
Relapsing or recurrent depressive disorders
Compiled by: Dr.T.Thavaruban & Dr.(Ms).L.Raveendran
Well Done ! Dr.S.Sancheav who is currently working as an SHO, Surgery, has passed the MS(Surgery-Part I) Examination held in July 2007. The JMA News Letter Congratulates Dr.Sancheav and wish him success in his future endeavours. We also wish good luck for those who are going to sit for the post graduate examination this year. July 2007
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The News Letter of the Jaffna Medical Association
Understanding Grief
G
spending time with the person who has been bereaved. It is not so much words of comfort that are needed, but more the willingness to be with them during the time of their pain and distress.
rief, mourning and bereavement are terms that apply to the psychological reactions of those who survive a significant loss. Grief is the subjective feeling precipitated by the death of a loved one; mourning is the process by which the grief is resolved and bereavement literally refers to being in the state of mourning.
However, when the symptoms go beyond the limits or the time period lasts more than one year or if it presents after long time of a death or in an atypical way, that grief should be considered as abnormal grief and needs intervention. Literature and clinical experience suggest that some people experience atypical, complicated or pathological bereavement reactions in response to a major loss. Recently researchers show interest on working with traumatic grief, bereavement associated with the traumatic loss of a beloved one.
Grieving takes place after any sort of loss, but most powerfully after the death of someone we love. It is not just one feeling, but a whole succession of feelings, which take a while to get through and which cannot be hurried. Typically it goes through different stages. According to Bowlby's criteria, the first stage is characterized with shock, benumbing and denial. The second stage consists of intense yearning and search for the person who has died. In the third phase, the grieving person has started to feel the reality of loss and to show the reactions to it. The fourth stage is the resolution phase where the person gradually come back to the normal life and internalized the dead person.
Sudden unexpected deaths, having dependent or ambivalent relationship with the deceased, poor psychosocial support, lack of ceremonial mourning and disappearances can complicate the grieving process. Personal factors, personality and pre existing psychiatric problems are also important.
Grief is a normal healthy reaction. Usually it lasts for about six moths to one year. Anniversary reactions are common. People have their own coping mechanism to cope with the grief. People from different cultures deal with death in their own distinctive ways. Supportive system plays an important role in coping with grief. Family and friends can help by July 2007
Studies show that grieving people are subject to increased physical and psychiatric morbidity and mortality. Depression, suicidal behaviour, alcohol and other substance abuse, somatisation and exaggeration of pre existing conditions are not uncommon. They are more vulnerable to infections, 8
The News Letter of the Jaffna Medical Association
cardio vascular disease and other psychosomatic illnesses. They may not show interest to continue their medications and to have regular follow up.
Meditation Programme for cancer patients A meditation programme was commenced for cancer patients at the cancer ward, Teaching Hospital, Jaffna, last month.
Clinicians can play a role in identifying the normal grief reactions and reassuring their patients. The associated physical and psychological complications, if any, need to be addressed. Complicated and traumatic grief reactions may need referral to the mental health clinic.
This programme will be conducted on Poya day of each month. This will help to improve the psychological and spiritual aspects of health.
Compiled by: Dr.S.Sivayokan
Disappearance: The silent suffering Disappearance is one of the major life stressors for a family. It is a special type of loss, occurs when some one leaves the home without telling any body, some one leaves the country and then lost contact or in a mass scale fatal accidents and disasters where no one knows about the fate of the lost persons. In war situation, disappearances can occur in the battle field or in a massive attack where the bodies couldn't be recovered or collected properly. However, in a civil war situation, disappearances are being made in a systematic manner to suppress the opponents and to terrorize the communities. Disappearance is a special type of loss which was categorized as one of the ambiguous losses by Boss et al. This ambiguous nature of the loss, usually the bread winner or a productive member of the family, invariably affects the family members' well being. Often, the authorities and the relevant parties inform the families that they have no idea about the disappeared person, making the event as a mystery. Stories about the recovery of bodies of disappeared members or release of disappeared members after long years lead the family to live in a state of dilemma with hope and despair. The sudden ambiguous loss disturbs the family dynamics and affects all the members of the family. The parents and women suffer silently. The children are often being informed with a fabricated story. The grief remains as unresolved for many years. Re-traumatisation occurs when recurrent inquiries are made and/or new reports are released by different authorities and organizations. The psychological and physical morbidities of the affected members are on the increase. July 2007
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The News Letter of the Jaffna Medical Association
Feature District Level Psychosocial Forum in Jaffna
T
he District Level Psychosocial Forum was established in 2005 to enhance the coordination between various government, non-government, and international organizations involved in psychosocial activities in Jaffna District. It is chaired by Regional Director of Health Services, Jaffna and technically supported by the District Psychiatrist. Coordinating, monitoring and evaluating the psychosocial activities conducted by various organizations; Exchanging information of the activities carried out by various organizations and the areas of implementation; exchanging information on the lessons learnt and best practices; understanding the psychosocial needs in the communities and what actually is being implemented by the organizations; ensuring and improving the quality of services; getting technical guidance from consultants; avoiding duplications and identifying the laps and gaps of services are the objectives of this forum. This forum organizes monthly meetings at R.D.H.S Office, Jaffna. The forum also established divisional level psychosocial forums at Karaveddy, Jaffna, Kopay, Chavakachcheri, Point Pedro, Sandilipay, Chankanai and Tellipalai under the chairmanship of the Divisional Secretaries to improve the coordination mechanism. The divisional forum coordinators attend to the district forum meetings. The district forum provides technical supports and makes policy decisions. The district psychosocial forum has been linked with the national level psychosocial forum coordinated by Consortium for Humanitarian Agencies (CHA). At present, the district forum is involved in the process of establishing a Technical Evaluation Committee and the development of a Psychosocial Framework. July 2007
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Psychiatr y - MCQ 1. The following are examples of illusions a. Image
c. Mirage
b. Vertigo
d. Lightening
e. Sun moving in the sky
2. Hallucinations a. occur in clear consciousness
d. denotes organic illness
b. includes thought echo
e. can be caused by drugs
c. is a thought disorder 3. Psychological stress is a. a stress which has no neurohormonal explanation b. known to cause emotional angina and precipitate myocardial infarction c. proved to worsen surgical outcome d. not responsive to drugs e. more in psychosis than neurosis 4. A man suspects his wife of having extramarital affair. Which of the following will make you think that he has morbid jealousy a. When you confirm that his wife does not have such an affair b. When you know that he himself have another affair c. When his reasoning is illogical and not challengeable d. He is a heavy alcoholic E. He has sexual problems and shows features of depression 5. A known psychotic female of 25 years who was on long term Haloperidol presents with icterus ,loss of appetite, nausea and vomiting for a week preceding which she has had fever for five days, which is settled now. She shows abnormal behaviour and is having third person auditory hallucinations on admission. a. Haloperidol should be continued as she was on it for long term b. Hepatic encephalopathy should be ruled out by careful examination and if necessary investigations c. Haloperidol is the obvious cause for the icterus d. Third person auditory hallucination rules out wilson's disease in this setting e. A notifiable infectious disease is one of the main differential diagnoses July 2007
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6. Best Psychiatric interview techniques a. Sit at an angle to patient than facing the patient b. Use more closed than open questions c. Patient's eye level should be above yours than being equal d. Have firm moral judgments than being vague e. Show empathy than sympathy 7. Unexplained physical symptoms a. can be explained with more precise lab investigations b. needs to be referred to relevant specialists for explanation c. can be managed with good outpatient psychological care d. could have social explanations e. each symptom needs individualized care 8. Which of the following drugs are correctly combined in view of similar therapeutic indications a. Venlafaxine, Sertraline, Imipramine b. Quetiapine, Risperidone, Chlorpromazine c. Lithium carbonate, Sodium valproate, Olanzapine d. Alprazolam, Lorazepam, Chlordiazepoxide e. Haloperidol, Bambuterol,Stilboestrol 9. The following drug prescriptions are appropriate a. Chew and swallow the Trifluoperazine b. Take Fluoxetine an hour before sleep c. Take Folic acid with Valproate d. Increase furosemide dose with Lithium to ensure good urine output e. Increase the Benzexol dose if tardive diskinesia appears 10. In Obsessive Compulsive Disorder a. Hallucinations have an obsessive quality b. SSRI medications have significant role c. Cognitive behavior therapy is found to be effective d. Impulses are often acted upon e. Is a feature of obsessive personalities By: Dr. T. Thivakaran Answers for Haemato Oncology MCQ (Volume 1, Issue 6) 1. TTTTT 2. TFTTT 3. TTTT 4. TTTTF 5. TTFTT 6.TTTFT 7. FTTTT 8. TTFTF 9.TTTTT 10. TTTFT
Answers for the Psychiatry MCQ will be given in the next month issue.