Case discussion of Adjustment disorder with moderate depression done for the Diploma course in Community Mental Health by CIP, Ranchi.

1. CASE PRESNTATION
for
Diploma in Community Mental Health
Dr. IMMANUEL JOSHUA
Junior Resident
Dept. of Community Medicine
Banaras Hindu University
Varanasi-221005
CIP Digital Academy

2. SOCIO-DEMOGRAPHIC PROFILE
 Name: Mr. U
 Age: 25years
 Gender: Male
 Religion: Hindu
 Marital Status: Married
• Education: BA
• Occupation: Salesman
• Socioeconomic status: Middle
• Place: Chiraigao, Varanasi
• Informants: Self and Mother

3. CHIEF COMPLAINTS
 Easy fatigability x 4 months
 Sadness of mood x 3 months
 Decreased sleep x 3 months
 Decreased appetite x 3 months
 Decreased social interaction x 2 months
 Loss of interest in pleasurable activities x 2 months
 Ideas of guilt x 2 months

4. PRESENTING PROBLEMS
• Onset : Acute
• Course : Continuous
• Duration: 3-4 months
• Predisposing factor : Family history of depressive disorder
• Precipitating Factors : Quarrel or argument with his wife
• Perpetuating factors : Wife is not taking care

5. • Patient was apparently asymptomatic 6 months back when he got married.
• His wife is a housewife and she is not well versed with household chores.
• He felt stressed due to his allegation that his wife is not taking care of him
and that his wife comments on his mother.
HISTORY OF PRESENTING ILLNESS

6.  Decreased sleep:
• He developed difficulty in sleep initiation and maintenance.
• He falls asleep after 1-2 hours of lying in bed and his sleep was
disturbed frequently due to thinking of daily happenings at home.
• He wakes up several times during the night.
• He could hardly sleep for 4 hours in a day as compared to his previous
sleep of 6-7 hours.
HISTORY OF PRESENTING ILLNESS
Dr. IMMANUEL JOSHUA (BHU) 6

7.  Decreased appetite:
• He lost his appetite and ate only 2-3 roti compared
to his previous appetite of eating 6 roti per day.
• He ate only on repeated persuasion of his mother.
HISTORY OF PRESENTING ILLNESS
Dr. IMMANUEL JOSHUA (BHU) 7

8.  Sadness of mood:
• He started remaining sad and gloomy all day.
• He did not like talking to family members particularly his wife.
• He did not like to go to work (salesman in a grocery shop)
 Easy fatigability:
• He felt tired the whole day and easily got tired after working for a while.
• He preferred lying in bed whenever he could spare time.
HISTORY OF PRESENTING ILLNESS
Dr. IMMANUEL JOSHUA (BHU) 8

9.  Decreased social interaction:
• He did not like talking to his brother or sister over phone.
 Loss of interest in pleasurable activities:
• He lost interest in watching television and stopped
playing badminton with friends.
• He preferred sitting idle.
• He did not like going out for walk with his dog.
HISTORY OF PRESENTING ILLNESS
Dr. IMMANUEL JOSHUA (BHU) 9

10.  Ideas of guilt:
• He started regretting because his father started asking about his
irregularities in his daily work.
• He felt cornered because his father was repeatedly comparing
him with his friends.
HISTORY OF PRESENTING ILLNESS
Dr. IMMANUEL JOSHUA (BHU) 10

11. • He was brought to Psychiatry OPD in BHU 1month back (after a neighbour asked them
to consult) for the above complaints and he was started on treatment.
• Now he is brought for follow up after 1 month and is admitted in Psychiatry ward for
further management.
• Treatment given:
TREATMENT HISTORY
Drug name Dose
1)T. ESCITALOPRAM
2)T. CLONAZEPAM
20mg/day
0.5mg/day
Overall compliance to treatment is adequate
No h/o of any significant side effects
Dr. IMMANUEL JOSHUA (BHU) 11

12.  No H/O diabetes/ HTN/ T.B./ prolong fever /seizure/mass lesion affecting CNS
 No H/O increase talk/ over-expenditure
 No H/O over-generosity/ over-religiosity / over-planning
 No H/O suspiciousness, hearing of voices
 No H/O thoughts being heard aloud loud/ mutism /incoherence
NEGATIVE HISTORY
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13.  No significant history of any psychiatric illness in the past
PAST HISTORY
PAST MEDICAL & SURGICAL HISTORY
 No significant medical & surgical history
Dr. IMMANUEL JOSHUA (BHU) 13

14. FAMILY HISTORY
Family of Origin Family of In-Laws
32 years
Married
Intermediate
28 years
Married
Intermediate
25 years
Married
BA
23 years
Married
Housewife
19 years
Unmarried
Graduate
Dr. IMMANUEL JOSHUA (BHU) 14

15.  Type of family : Nuclear
 No of family members : 5
 Family concept about illness: His family
members think that he is very shy,
sensitive and his tolerance of stress is low.
 Family stress : Nil (as per respondent)
 Substance abuse :Nil
 Living arrangement : Family lives in a
pucca house in Chiraigao
FAMILY HISTORY
 Head of family : Patient’s father
 Chief caregiver in family : Patient’s
mother
 Chief decision maker : Patient’s father
 Chief earning member in family: Father
 Father has H/O depressive disorder
Dr. IMMANUEL JOSHUA (BHU) 15

16.  Birth history: (from his mother)
• Patient was born at 9 months by normal vaginal delivery.
• Cried immediately after birth.
• All milestones were attained at right time .
 Childhood history:
• No h/s/o hyperactivity, inattention, impulsivity, repeated bullying other
children, stealing, lying, disobedience
 Academic:
• Started schooling at 3.5 years of age and education continued till BA.
• Patient was an average student & didn’t get complaints from his teachers.
PERSONAL HISTORY
Dr. IMMANUEL JOSHUA (BHU) 16

17.  Average built.
 Conscious and co-operative
for the examination.
 BP- 134/84 mmHg
 Pulse- 92 beats/min
GENERAL PHYSICAL EXAMINATION
 Afebrile
 Weight-56kg
 Height-168cm
 BMI-19.84kg/m2
 No PICCLE
Dr. IMMANUEL JOSHUA (BHU) 17

18.  No Abnormality Detected in examination of;
• Cardio-Vascular System
• Respiratory System
• GI System (per abdomen)
• Central Nervous System
SYSTEMIC EXAMINATION
Dr. IMMANUEL JOSHUA (BHU) 18

19. 1. General Appearance and Behavior:
• A young male of average built with normal gait & posture.
• Face looks fatigued, dull and downward.
• He was properly groomed & dressed.
• Hygiene was adequate.
• He was calm & co-operative throughout the interview
• He was well oriented to time, place & person.
• Eye to Eye contact established but not sustained.
• He feels shy to answer questions.
MENTAL STATUS EXAMINATION
Dr. IMMANUEL JOSHUA (BHU) 19

20.  2. Speech:
• Non-spontaneous
• Coherent
• Relevant
• Goal directed
 3.1. Mood: “sad”
 3.2. Affect: “sad”
MENTAL STATUS EXAMINATION
Quantity
Rate
Volume
Tone
Reaction Time
decreased
decreased
decreased
Normal
Increased
Dr. IMMANUEL JOSHUA (BHU) 20

21.  4. Thought:
• Stream : decreased flow
• Form : NAD
• Possession of thought : NAD
• Content : Filled with complaints
• Impression : Ideas of guilt
 5. Perception: Hallucination or illusion could not be elicited
MENTAL STATUS EXAMINATION
Dr. IMMANUEL JOSHUA (BHU) 21

22.  6. Cognitive Function:
• Orientation: patient was oriented to time, place and person.
• Attention & Concentration : Arousable and sustained.
• Memory: Immediate, recent and remote memory are intact.
• Intelligence:
o Arithmetic: good skill (salesman)
o Comprehension: intact
• Adequate abstract thinking
MENTAL STATUS EXAMINATION
Dr. IMMANUEL JOSHUA (BHU) 22

23.  7. Judgement: Patient behaviour in Personals ,Social & Test are intact
 8. Insight: Present
MENTAL STATUS EXAMINATION
Dr. IMMANUEL JOSHUA (BHU) 23

24. A young married male belonging to Hindu middle class nuclear family with no significant
past psychiatric history and with Family H/O father having depressive disorder presented
with following complaints with total duration of illness for 3-4 months. The complaints
were acute in onset with continuous course characterised by decreased sleep, decreased
appetite, sadness of mood, loss of interest, anhedonia, easy fatigability, ideas of guilt.
Speech –Q/V/R decreased with increased RT
Affect is sad restricted, Thought content suggestive of ideas of guilt
Oriented to time/place/person, attention and concentration are arousable and sustained,
memory intact, average intelligence, abstract thinking, judgement intact, Insight is present.
CASE SUMMARY
Dr. IMMANUEL JOSHUA (BHU) 24

25.  Moderate depression
PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
 Adjustment disorder with moderate depression
Dr. IMMANUEL JOSHUA (BHU) 25

26. • Evaluate the patient with some
baseline investigations:
 CBC
 RBS
 LFT
 RFT
 Serum electrolytes
 Thyroid function test
MANAGEMENT
• Detailed general and systemic
examination of the patient
• HAM-D scale
• Treatment:
 T. ESCITALOPRAM (10mg /day)
 T. CLONAZEPAM (0.5mg) HS
Dr. IMMANUEL JOSHUA (BHU) 26

27. • Psychoeducation to the patient and his family members
• Address current psychosocial stressor or the relationship difficulties
• Reactive social networks like family gathering ,outing with friends
• Structure physical activity for 45 min/day for 3 times/week
• Regular follow up in-person or by phone for re-assessing the improvement
NON PHARMACOLOGICAL MANAGEMENT
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