Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years.

1. Case
Study
B Y / K H O L O U D M O H A M E D
FA M I LY M E D I C I N E R E S I D E N T

2. • Personal Data: 51 years old, male patient, muslim, Egyptian, married with 3 off
springs and the youngest is 14 years old , lives in Al Qalyubia, illiterate and he is
a worker, he smokes 1 pack of cig/day for 30 years, and shisha occasionally.
• Source of referral: the patient was referred from the neurology clinic.
• Cause of referral: To seek help for his condition.
• Complaint of the patient: Severe headache of one year duration, not responding
to medical treatment despite of multiple consultations from several medical
specialties.

3. • Family History:
Medical: his Father was diabetic and hypertensive.
Psychiatric: No abnormality reported
Substance: No history of substance use
• Past History:
Medical: No abnormality reported
Surgical: partial thyroidectomy 5 years ago.
psychiatric: No abnormality reported
Substance: No history of substance use
• Personal History:
Prenatal, natal, postnatal and developmental: no abnormality reported
Educational History: Patient is illiterate.

4. Work Record: The patient was employed as a worker at electronics factory 16
years ago. His performance was good till his condition started. Over the last 4
months, his performance has markedly declined with multiple sick leaves. He
has good relations with his colleagues and managers.
Psychosexual history: The patient reached puberty at the age of 13 years with
male gender role and identity. He has heterosexual orientation with no history of
extramarital affairs.
Military history:
The patient did not join military service.

5. • Marital history: The patient is married for 26 years with 3 off springs, the
youngest is 14 years old. He has a good relationship with his wife.
• Premorbid Personality:
No special traits .
Introvert with a few number of friends
Reacted to stress by isolation
Muslim, believer, not regularly practicing

6. • History of present illness:
The condition started 1.5 years ago when the patient had headache. It was not
preceded by any stressor. The headache was bilateral and dull aching with
progressive course. It occurred almost daily and lasts allover the day with
moderate severity. It was not aggravated by any factor and was partially relieved
by analgesics. It was not associated with motor or sensory abnormalities,
autonomic abnormalities, photophobia, phonophobia, or blurred vision. The
patient sought medical advice at neurology clinic and was diagnosed as tension
headache with partial improvement on analgesics. Also, the patient sought
medical advice at ophthalmology and ENT clinics and no abnormality was
detected.1 year ago, the patient developed sad mood and decreased interest in
previously pleasurable activities such as watching TV. The patient also reported
increased fatigability with difficulty in doing his usual everyday tasks. The patient
also complained of decreased concentration and found it difficult to focus
during working. 2 months later, the patient started having decreased appetite
than usual and increased sleeping hours than usual.

7. The patient sought medical advice and the following investigations were requested:
CBC, metabolic panel, thyroid profile, MRI brain, EEG and they were normal. 4
months ago, the patient reported feeling worthless and helpless and the headache
severity markedly increased. Also, the patient had death wishes about 6-7 times per
day, each lasting about 10 minutes to which the patient reacted by sadness. The
patient sought medical advice at neurology clinic in El-Demerdash Hospital and was
referred to the psychiatry clinic.
There were no other mood symptoms, no psychotic symptoms, and no symptoms
suggestive of other medical conditions.
General Examination:
Vital data: within normal range
Complexion: no pallor, no jaundice, no cyanosis
No abnormal facies, eye abnormalities or special decubitus
Neck: surgical wound for partial thyroidectomy.

8. • MSE:
General appearance and behavior: adult male patient, with average body built,
appropriate grooming and self- hygiene, decreased eye to eye contact, cooperative,
with no hallucinatory behavior, no abnormal movements or catatonic features.
Sensorium: Conscious, alert, oriented to time, place, person, attentive,
concentrating with intact recent and remote memory.
Mood: sad
Affect: sad, stable, appropriate.
Speech: Slow stream, low amount and volume.
Thinking:
Stream: Slow
Form: no formal thought disorder
Control: no thought control disorder

9. Content:
The patient has negative thoughts about himself in the form of worthlessness
and helplessness.
The patient has a negative view about life and the future.
Death wishes about 6-7 times per day, each lasting about 10 minutes to
which the patient reacted by sadness.
Abstraction: Fair
Perception: No perceptual abnormalities
Judgement: Fair
Insight: Patient is insightful
Other systems (Neurological, cardiac, respiratory and GIT) : No abnormality
detected.

10. Provisional diagnosis: Major Depressive Disorder with chronic headache.
Differential Diagnosis:
1- Mood disorder due to medical condition.
2- Persistent depressive disorder (Dysthymia).
3- Adjustment disorder.
4- Bipolar disorder.
5- Schizoaffective disorder.
Management:
Nonpharmacological:
• Psychoeducation about disease, symptoms, early warning signs of relapse,
compliance.
• Cognitive behavioral therapy.
Psychopharmacology:
Cymbalta 30 mg cap once daily

11. Formulation: 51 years old male patient, married with 3 off springs and the
youngest is 14 years old, presented with a 1,5 year history of symptoms suggestive
of depression with chronic headace. Depression presents in form of: sad mood,
decreased energy, anhedonia, decreased appetite, increased sleep, decreased
concentration and death wishes. The patient was prescribed Cymbalta 30 mg once
daily.

12. Epidemiology:
• Depression is a common illness worldwide, with an estimated 3.8% of the population
affected, including 5.0% among adults and 5.7% among adults older than 60 years.
Approximately 280 million people in the word have depression. It can cause the affected
person to suffer greatly and function poorly at work, at school and in the family. At its
worst, depression can lead to suicide. Over 700 000 people die due to suicide every year.
Suicide is the third leading cause of death in 15-29-year-olds.
• Although there are known, effective treatments for mental disorders, more than 75% of
people in low- and middle-income countries receive no treatment. Barriers to effective
care include a lack of resources, lack of trained health-care providers and social stigma
associated with mental disorders.

13. WHO response:
• WHO’s Mental Health Action Plan 2013-2030
highlights the steps required to provide appropriate interventions for people with
mental disorders including depression.
• Depression is one of the priority conditions covered by WHO’s Mental Health
Gap Action Programme (mhGAP). The Programme aims to help countries
increase services for people with mental, neurological and substance use
disorders through care provided by health workers who are not specialists
in mental health.

14. WHO has developed brief psychological intervention manuals for depression that
may be delivered by lay workers to individuals and groups eg:
• Problem Management Plus manual.
• Group Interpersonal Therapy for Depression manual.
• Thinking Healthy manual.
Available at: https://www.who.int/news-room/fact-sheets/detail/depression

15. The specific DSM-5 criteria for major depressive disorder :
At least 5 of the following symptoms have to have been present during the same 2-week period (and at
least 1 of the symptoms must be diminished interest/pleasure or depressed mood) :
 Depressed mood
 Decreased interest or loss of pleasure in almost all activities (anhedonia)
 Significant weight change or appetite disturbance
 Sleep disturbance (insomnia or hypersomnia)
 Psychomotor agitation or retardation
 Fatigue or loss of energy
 Feelings of worthlessness
 Diminished ability to think or concentrate; indecisiveness
 Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt
or specific plan for committing suicide
• The symptoms cause significant distress or impairment in social, occupational or other important areas
of functioning.
• The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
• The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia,
delusional disorder, or other schizophrenia spectrum and other psychotic disorders
• There has never been a manic episode or a hypomanic episode.

16. Management :

17. Considerations for treatment choice in Major Depressive Disorder:
FIRST AID FAMILY MEDICINE BOARDS
CONSIDERATION CHOICE OF SSRI
Depression with low energy level An activating SSRI (like fluoxetine ) or bupropion
Depression with anxiety symptoms A calming SSRI like paroxetine or a TCA like imipramine, avoid
bupropion
Obsessive compulsive features Any SSRI or clomipramine
Trouble sleeping Trazodone or mirtazapine
Comorbid chronic pain Consider duloxetine
Sexual side effects are problematic Bupropion
Need to quit smoking or lose weight Bupropion( do not use with anorexia or bulimia)
Seizure disorder Do not use bupropion, mirtazapine or SNRIs
Did it work for a close relative ? Give that medication a trial

20. THANK YOU