Mary is 61 years old. She initially presented to the GP surgery three months ago with a six-month history of increasingly low mood, poor appetite and loss of energy. A diagnosis of depression was made and she was started on citalopram 20 mg. She says that she is feeling no better.
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a. What are the key questions you would ask her before formulating a management plan?
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Correct answer:
You need to assess how severe her depression is and whether there is a significant risk of suicide. You should ask whether her mood still changes with external circumstances, whether she has feelings of hopelessness and whether she has any suicidal thoughts or plans. You need to know whether she takes the citalopram as prescribed and if not, what her reasons are. These might include fear of addiction and side-effects. It is also important to enquire about any physical or psychological factors that may be preventing her recovery (e.g. recent bereavement or other life stresses or poorly controlled pain). Does she have any physical symptoms suggestive of underlying malignancy?
Mary tells you that she has taken the citalopram every day. She has fleeting thoughts that she would be better off dead, but that she would never act on them because it would hurt her children too much. She worries constantly about them, and also about her elderly father who is in a care home and for the past year has no longer been able to recognize her when she visits. She adds that her husband was initially very supportive, but has now become impatient with her, partly (she thinks) because she has no interest whatever in sex. She has had no particular physical symptoms apart from those described. Despite her poor appetite she has gained 2 kg in the past three months.
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b. Is there any need to do a physical examination or take blood tests?
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Mary’s loss of energy and weight gain raise the possibility of hypothyroidism, which is particularly common in post-menopausal women. Hypothyroidism can make depression more resistant to treatment so it is important to check her pulse, examine her neck and order thyroid function tests.
There are no significant abnormalities on physical examination and Mary’s thyroid function tests are normal.
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c. What options might you consider for managing Mary’s continuing depression?
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You have identified potentially important psychological ‘maintenance factors’ – Mary’s worries about her father and her husband's impatience. Mary might benefit from attending a carers’ group to share her experiences as a carer with others in the same position. It might be helpful (with Mary’s permission) to talk to her husband (or preferably to the two of them together) about her depression and in particular about the problems that have arisen in their relationship. More fundamental relationship problems might also be revealed. A number of pharmacological approaches should also be considered. These include increasing the dose of citalopram, changing to another class of antidepressant (such as an SNRI or mirtazapine) or adding a second drug such as lithium carbonate.
