Tuesday 24 August 2010

Clinical Depression

I recently saw a gentleman, who has dementia of moderate severity, who was low in mood. His GP had reasonably started an antidepressant. Things were no better. I stopped the antidepressant. I reviewed him. Things were no different.

I recently saw a lady who was tearful all the time, felt hopeless and wasn't doing sociable things with friends at the local tea room and Tuesday evening bingo. Her GP had sensibly started an antidepressant, reviewed her, changed it then referred to me. I stopped the antidepressant, reviewed the lady, things were no different.

It's not easy work. In both cases I saw the patient in their home with a CPN colleague, it took over an hour doing an initial assessment then time following up and reviewing them.

The gentleman's scans showed widespread vascular damage. His limbic system was shot to pieces. If the bits of your brain that regulate your mood no longer exist/are damaged, it's unsurprising that peoples' mood is less than perfect.

The lady had low mood because she'd recently been widowed, her sister had also died this year and she had a blood disorder (which slowly is getting worse) meaning she's knackered all the time. Her mood is low because life's grim. She's not mentally ill, there's no psychiatric disease.

If there's no chemical depression, with no chemical solution, answers aren't in a tablet. This makes it harder. Patients and carers need to do something to get better, to change something if they want things to be different. Professionals can't just gift an FP10 and be done. And, invariably, things can be improved, but they can't be "cured" and less than perfect mood needs to be accepted/endured/dealt with rather than "fixed" or changed.

Management of clinical depression is, to my mind, pretty easy. But management of other low mood is grim.


lizzydripping said...

but whatever you do dont refer them to IAPT as it will only make their mood worse.............

lizzydripping said...

for those that dont know IAPT stands for Inadequate Access to Psychological Therapies or Ineffective or Inefficient or anything else that starts with I and means rubbish.
the people i have referred to this service have either got better whilst sat on their waiting list or come bouncing back to our CMHT as believe it or not CBT does not suit everyone. ................. rant over

Liz said...

"Management of clinical depression is, to my mind, pretty easy. But management of other low mood is grim".

Only easy if it can be treated - how often is clinical depression truly successfully treated?
Sorry, just one of the posts that struck a chord....
Treatment resistant clinical depression....

Eileen said...

For several years I suffered from low mood (to the degree of tears for little or no reason) but made a fairish job of getting out to the gym, being with other people, exercising. It helped.

This was all despite almost constant pain and stiffness that was dismissed by the GP with "but all your blood results are normal". Being in pain in everything you do does not help mood. Never mind anything else. I eventually came to accept it was just part of getting old and the rest of life was going to be steadily downhill. Not helpful to mood, I think you'll agree. I was in my mid-50s.

Many hours of reading blogs when I just wasn't up to getting out paid off: one of the GP ones mentioned a patient with stiffness who he thought had polymyalgia rheumatica although the ESR was not really high enough, borderline. But he tried her with steroids and she reappeared as the classical PMR patient: beaming all over her face at the relief.

I ventured to suggest it to my GP. The steroids were tried - despite both ESR being very low and CRP normal. Result: dramatically reduced pain and stiffness, cured low mood. It's up and down, but mostly up now.

I read recently that it is estimated that 1 in 200 over the age of 55 will develop PMR at some point. That seems a fairish number to me and given the difficulty experienced by many in obtaining a diagnosis because it seems "atypical" (too young, normal bloods, simply not recognised) what do you think is the possibility that some of these patients as you describe here may have something more concrete. That PMR patients may be members of this group of "treatment resistant clinical depression"?

No-one really seems to have a handle on it - maybe I'm grasping at straws but I do find it intriguing.

The Shrink said...

My view of IAPT sadly is very much aligned to yours.

Liz, you're right. Management of endogenous, clinical, chemical depression is easy. Treatment that effects a cure doesn't always follow, though, so outcomes aren't always brilliant.

Eileen, I start off assuming that a mental health presentation is through a physical health cause, then a psychosocial cause, before looking for a psychiatric cause. Invariably after spending an hour or two unpicking their wellbeing with someone there's something physical/medication found to improve upon.

Eileen said...

Fair enough - and I wish I'd seen you earlier in my health career!! However - you have to get past the GP first and that is some hurdle, believe me. And when I had been referred to the local psychiatric service earlier (for what was probably "burnout" syndrome) the consultations never seemed to have much relevance to me - 3 of them, same person, all asking the same questions and providing me with no insight or answers to my problems. I did eventually get to see a clinical psychologist after a wait of more than a year - he did at least make me feel I was fairly normal and reasonable, by putting that into the solid words that were apparently beyond others. It was that that kept me going through the PMR marathon - I didn't THINK I was going daft!