Depression

Question 1

40 yo aboriginal lady. Brought into ED by daughter with a few days of food refusal and suicidality. Stem had a paragraph essentially outlining a progressive melancholic depression / catatonia picture that acutely worsened recently when her teenage son was sexually assualted. She has a hx of DV and sexual assualt and her mother was part of the stolen generation. 1. what are your ddx 2. what are your immediate concerns 3. how do you create a culturally safe management plan

Answer 1

Impression
Melancholic depression (given catatonia) with acute deterioration in patient with significant psychosociocultural stressors and past trauma. Would be concerned about immediate risk of harm to self, would want to assess emerhently and manage appropriately.

DDX to consider:
Mood disorders
- Other form of depression (psychotic, MDD)
- Anxiety disorder (PTSD, GAD)
Non-affectives
- schizoaffective disorder
- BPD, other personality disorder

Immediate concerns/priorities:
- risk of suicide/harm to self given refusal to eat
-

Question 2

Depression, Melancholic - History

Answer 2

History
PC -
- depression: mood, anhedonia, psychomotor, eating, sleeping, suicide (intent, plans, attempts). Other melancholic features (early morning wakening, psychomotor slowing, diurnal variation in mood)
- anxiety: nightmares, flashbacks, past trauma, panic attacks, understand cognitions (driving fears)
- screen for mania + psychotic features
- screen risk: suicidality, concrete plans, previous attempts, family history of suicide
- Rest of psych history (past, fam, substance, social, developmental, forensic)

Question 3

Melancholic depression - Examination

Answer 3

Examination

• MSE: looking for further evidence of mental state aberrations supportive of provisional diagnosis/DDx.
• appearance
• behaviour
• speech
• mood/affect
• content
• form
• perception
• cognition, insight, judgement
• anthropomorphic measurements

Question 4

Melancholic depression - Investigations

Answer 4

Investigations

• Bedside: BP, vitals, BSL, urine toxicity, urinary b-HCG, ECG
• Bloods: TFT, LFT, FBC, UEC, lipid panel
• Imaging: ?MRI-B, ?CXR

Question 5

Melancholic depression - Management

Answer 5

Management
Short-term
1 - Safety/location:
- schedule patient to be treated in hospital given significant risk of suicide

2 - Non-pharmacological

• counselling/psychotherapy
• Indigenous case workers/contact with Indigenous support officers if available

3 - Pharmacological

• medication review
• antidepressant medication (SSRI), consider use of additional agents/ anti-psychotic if psychotic features, mood-stabiliser if ?bipolar
• treat any co-morbid substance use disorder/withdrawal

Long-term
1 - continue medication regime in outpatient setting with regular review period with AMS
2 - aboriginal liaison services if possible
3 - counselling
4 - psychotherapy (CBT)