68 year old with tiredness / NSW

Girl Depress … brother committed suicide / Adelaide

Case _Scenario twelve

Role-Play – 15 minutes TIREDNESS/ DEPRESSION

Please answer the following questions

1. How are you going to approach this case?

2. “No examination required “– Seek positive finding from the panel.
3. What are the investigations required for this patient?
4. What is your differential diagnosis?
5. What is your management plan for Sasha?

Sasha, 64-years-old man, is new to you but regular to your clinic and he is coming today to visit you
because he has not been feeling well recently. Mr Sasha has done a general check-up for his body 6
months ago and all investigations turn-out to be normal. He is suffering from Hypertension and
Hyperlipidaemia.

Sasha is taking Perindopril for hypertension and Atorvastatin for Hyperlipidaemia.

He is living with his father who has dementia at the moment.
He has family history of Colon cancer for his mom at the age of 54.
His wife has passed away a year ago.
No previous hospital admissions or surgical operations.
He had influenza vaccine and Pneumococcal vaccine 2 years ago.

You have 2 minutes to read the stem well. When you be ready just inform the panel

- New /registered -review records if any

- I will R/O any emergency (if patient is stable) then I will start with regular consultation
HISTORY
- I understand that you have tiredness and feeling fatigue, can you tell me more about it?
Since how long? All day? Affect daily activity? Anything make it worse or better? any
associated symptoms or event?do u think u r tired mentally or physically?
DD QS

- How is your diet?do u take enough veggies and meat?anemia

- Fever? rash? Night sweats? Recent travel history? Infection
- Polyuria (Do you feel more thirsty)? Polydipsia (excessive passing urine more than before)?
DM
- Weather preference: (Any change in tolerance to hot or cold weather)? heart racing? Chest
pain? SOB? Any cough? Thyroid, CVS, Resp Anemia
- Any tummy pain or change in waterworks
- Do u feel like u r more forgetful than usual?keys?dementia,father hx positive imp
- Have you noticed any recent change in body weight (loss or gain)?
- How is your apetite?any unintentional weight loss?Any lumps and bumps on the body?any
problem with bowel habits? Pain anywhere in your body?any blood in stool? Malignancy
tenesmus,incomptele bowel emptying…..VVVIMP mum had bowel cancer
 - Assure confidentiality:
I know your wife passed away last year,how have u been coping since?
I can imagine it must be very difficult for you.how was your relationship with her?
Do u ever feel you can hear her voice and have flashbacks about her?PTSD
Asking two simple questions may be as effective as longer instruments:
● ‘Over the past two weeks, have you felt down, depressed or hopeless?’
● ‘Over the past two weeks, have you felt little interest or pleasure in doing things?’

Has there ever been a time when your mood was very high?
- Any problems with sleep? day nap? effect on driving, work?
- Appetite? Gained or lost Weight?
- Do you feel guilty about anything??
- Feel tired and lack of energy?
- Psychomotor retardation or agitation?
Is it hard for u to focus or concentrate?
Do you think life is worth living?
- Are there days when everything gets so tough that u feel like harming yourself or other and
putting an end to it? SUICIDALITY

I am now going to ask a few questions that might sound odd but its just routine

Your wife sound like a lovely lady but have u started any relationship since then?
Is there a certain reason behind that?do u feel you have lost your sexual intrests?LIBIDO

Is there anytime u feel like very energetic,talkative,happy? BIPOLAR,MANIA

- Psychotic symptoms: Do you feel/see/hear things that other do not? Do you have any
strange experiences?someone would be putting thoughts in your mind?HELLUCINATION
-
- Insight? Judgment: Fire on street?OR did u feel u need help today?
-
- HEADSS (stress at home, work, financial issues, drugs, sexual history, suicide risk) / support
availability
- SADMA
- I understand you were prescribed antidepressants before, do you know why it was given?

Past medical and surgical; history

- How’s your general health? Immunisation?
-
- Screening tests (FOBT/ CST & Mammogram if female)upto date with colon screening,if not
COLONSCOPY now,referral,moderate risk screening start at 50,mum cancer 54years.

- Family history of chronic illnesses / Cancers,psychiatric disorders

- Do you have any other concern you would like to tell me?

TOOLS
● Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5),
● K 10 (Kessler psychological distress scale (K10):
Omit rest information until DD.
Score under 20- likely to be well
20-24- mild mental disorder
25-29- moderate mental disorder
30 and over- severe mental disorder
● DASS 21
● The Geriatric Depression Scale is used to identify depression in older people in hospital, aged
care home and community settings. The 15 item version is most widely used with self-report
or informant report, and takes 5–10 minutes to complete. Sensitivity ranges from 79–100%.
Specificity ranges from 67–80%. It is suitable for use with residents with a Mini-Mental
Status score of more than 14. It has questionable accuracy when used to detect minor
depression. The Geriatric Depression Scale is available in many languages and can be
downloaded from
www.stanford.edu/~yesavage/GDS.html
Calculate the total score by adding up the ticks in bold (right hand column). Each scores one
point. Scores greater than 5 suggest the presence of depression.

● the Australasian Triage Scale (ATS) with mental health descriptors 8, for suicide
“read ATS questions at end”
● Online suicidal risk calculater / Modified SAD PERSON Scale / Skype group
https://qxmd.com/calculate/calculator_201/modified-sad-persons-scale

DIFFERENTIAL DIAGNOSIS: TIREDNESS

Tumour. Travel. TB. Infections HIV Hep B Hep B Syphilis infective endocarditis RA Endo Diab Thyroid
Addison Electrolytes Depression Drugs Neuromuscular M Gravis Suicide Somatization Chronic
Fatigue Syndrome

DD PSYCHIATRY
Major depressive disoreded
Adjustment disorder
Complicated grief’
Depressive episode of bipolar disorder
PTSD
Generalised anxiety disorder
Schizophrenia with depressive episodes’

EXAMINATION:
- GA: PICCLED (Pallor, icterus Cyanosis, Clubbing, Lymphadenopathy, oedema, Dehydration
(dry mucous membrane/ skin turgor))
- VS: BP, P, RR, Temp, Wt. & Ht for BMI compare to past one ,in depression it can increase or
decrease, waist circumference
- HEENT - for infection
- Neck-LAD, Thyroid
- Chest- quick CVS, RR, Breast especially in female
- Abd- hepatosplenomegaly
- DRE especially in male and has symptoms

INVESTIGATIONS:office test…urine dipstick,BSR

fbe/ iron studies
esr/crP
 Fasting blood sugar
serum electrolyte
KFT/LFT/TFT e GFR
Albumin/creatinine ratiom pt is hypertensive
Lipids pt is on medication statin
fecal occult (FOBT & Colonoscopy if necessary
Vit B12,
Calcium

K 10 questionaire

MANAGEMENT:
Explanation: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/depression
Based on your history and examination finding, most likely you have depression. What do you know
about depression? Most people feel unhappy, sad or depressed every now and again, but there is a
difference between this feeling and the mental illness of depression. Depression is a very real illness
that affects the entire mind and body. It seriously affects our life activity as sleep, level of energy,
appetite and ability to cope with life, and a simple advice like ‘snap out of it’ is unhelpful, because
the person has little or no control over it.
Exact cause of depression is unknown, it does not result from a single event, but from a combination
of biological, psychological, social and lifestyle factors. (death of loved ones, marital separation,
financial issues.
It can occur at any age and affect any person, and its common illness and no one to blame.

Depression is treatable, effective treatments are available, but If left untreated can lead to serious
outcome (suicide).
Or
We have chemicals in our brain that control our mood,in people with depression these chemical are
bit lower.thats why cause such symptoms
We have few ways to deal with it
3 Ss (Support/ GP mental plan, sleep, SNAP)

❖ We need to put a structured plan “GP Mental health treatment Plan”

❖ You will have sessions of Special counselling (psychologist), such as CBT, simply talking about
your feelings is most helpful. Teaches how to deal with thoughts, ventilate and have a chat
about your feelings,behavioural stratigies,
❖ SLEEP Hygiene …. Read in end,if not helpful alone, consider with CBT - more helpful, give it a
try … if not helpful Medication/short term
❖ SNAP advice
Reguler exercise,healthy food,sports gardening
❖ Try to involve in enjoyable activities, go out with friends, go for a walk, take your pet for a
walk
❖ Respite care for dad
To help u take care of him,give u a bit of break

Aged care assessment team review

❖ With patient consent FAMILY MEETING …. SOCIAL SUPPORT (Mental Health Social Worker)
❖ Arrange Review for test results then ….2-3 week review.
❖ But at any time, you develop any Warning signs … if you thought of harming yourself…. seek
help
➢ PHONE COUNSELLING (NSW Mental Health Line 1800 011 511)
 ➢ GP ??
❖ Document in records
❖ Reading Materials
➢ Print fact sheet (depression, sleep hygiene)
➢ PHONE APP: Smiling MIND
➢ Websites:
■ Beyond Blue: https://www.beyondblue.org.au/
■ Black dog: https://www.blackdoginstitute.org.au/
❖ FOR GP; GP Psych Support
❖ If patient happy with treatment plan, I will double check with my supervisor
❖ Additional - if patient had suicidal risk then do formal risk assessment Mental Health
Team… if safe to send home… prepare SAFETY PLAN
➢ Warning signs
➢ considering the Lethality of method
➢ Coping strategies
➢ Whom to call for help

From iman s notes

In case if pt require medication
Consider hx anf previous response to anatidepressnat and side effects
SSRI ,esetalopram ,fluxitine Is first line therapy for elderly
Safe SE PROFILE
Quick onset of action 7 to 10 days
Good anxilytic effects
Max benefit may take upto 6 weeks
Should be continued for at least 6 months
May feel a bit strange in benging but start working after 2 weeks
Side effects falls,sexual dysfunction,sedation,suicidality’
Follow up in one week

TREATMENT:
MILD:
GP Mental health treatment Plan
A mental health care plan is a plan your doctor writes with patient about treating a mental health
condition. It helps patient to access eligible allied health professionals like psychologists, social
workers or occupational therapists who can help patient to get better and live well.
The MHTP provides an opportunity to complete a comprehensive assessment, including mental state
examination and risk assessment. The MHTP framework includes diagnosis/formulation and use of
an outcome tool. It is a collaborative process that involves discussion about the assessment with the
patient, and identification of treatment goals and strategies to achieve these. Psycho-education,
addressing lifestyle factors, crisis planning and relapse prevention are part of the process. Crisis and
relapse prevention planning would be in place. Follow-up arrangements (including potentially recall)
would be part of the plan. Arranging a second appointment to complete an MHTP is recommended,
as it is unlikely that this level of planning can be undertaken at the initial visit in Jim’s case.

SLEEP Hygiene

Obtain an appropriate amount of sleep

Most adults (including shift workers) require 7.5–8 hours of sleep.
• The bedroom is a place for sleep and intimacy only
 Avoid eating, watching television or working in the bedroom.
• Develop a routine prior to retiring to bed
A routine prior to bed could involve reading or relaxing.
• Remove or reduce any environmental distractions in the
bedroom
Remove environmental distractions such as light (wear an eye mask),noise (wear ear plugs),
temperature extremes and pets in the bedroom.
• Use a comfortable mattress and pillow
• The most common cause of sleep onset insomnia is ‘racing thoughts’ or dwelling on the day’s
events
Learn techniques to take your mind away from this.
• If you are unable to fall asleep within 30 minutes, leave the bedroom and perform a non-
stimulating task in dim light. Only return to bedroom if ready to fall asleep
• Wake up at the same time every day and be exposed to natural light and exercise (ie. a brief walk
is adequate)
• Avoid daytime naps
If a nap is necessary, nap in a room separate to your bedroom that is lit.
• Avoid vigorous exercise within 4 hours of bedtime
• Avoid coffee, tea, chocolate, cola and cigarettes
• Avoid large meals close to bedtime
• Reduce alcohol intake and avoid sedative medications
Use of alcohol or sedatives do not solve the problem.
• Address all medical issues that may interfere with sleep
Medical conditions causing symptoms such as pain, breathlessness, cough, reflux, chest pain,
frequent urination may need to be addressed.

MODERATE
Antidepressants: antidepressant medication is useful in moderate to severe depression or when
depression has an anxiety disorder co-diagnosis. Antidepressant therapy should be avoided if
bipolar disorder is suspected, and screening should be actively conducted for symptoms of past or
previous mania.
— In terms of which drug to use, there is no single drug that is preferred. However, selective
serotonin reuptake inhibitors(SSRIs) are considered to have the most favourable balance of benefit
to harm in moderate to severe depression. Sexualdysfunction and gastrointestinal side effects are
common. Other suitable first-line agentsare reboxetine (common side effects include hypersomnia,
fatigue and nausea) and mirtazepine (which can cause weight gain and drowsiness). SSRIs have a
relatively flat dose response curve, but dose increase within the recommended range is reasonable if
there is a partial response at a lower dose and no troublesome side effects.
— Combining different antidepressants or augmentation with lithium or antipsychotics should be
done with psychiatrist Supervision
— Serotonin and noradrenaline reuptake inhibitors (SNRIs) appear to be more effective in treating
severe depression symptoms (and may be a suitable first-line option here) but otherwise adverse
effects may limit them to second-line treatment. Tricyclic antidepressants (TCAs) and monoamine
oxidase inhibitors (MAOIs) are considered second-line because of their side effect
citalopram   less than 65 years of age: 20 mg orally, in the morning less than 65 years of age: 40 mg [NB3]

more than 65 years of age: 10 mg orally, in the morning more than 65 years of age: 20 mg [NB3]

• Start at a low dose and increase the dosage as tolerated

 • Length of use to be advised (whether 6–12 months for a first episode, or longer for relapses). It is
important to educate the patient about antidepressants:
• The nature of current antidepressants (eg different types, mechanisms of actions, effectiveness)
• Commencement dosage and when to increase dosage under the supervision of the GP
• Time for response to occur (two to six weeks)
• Potential short-term adverse effects, particularly nausea, headache or anxiety, and their usual
time to resolution (one to two weeks)
• Potential long-term adverse effects (eg sexual dysfunction)
• Talking with their GP if they have any concerns or questions about the antidepressant
• Potential drug interactions
• Length of use
• Not stopping antidepressants abruptly or without consulting the GP
• Perpetuating effect of alcohol on depressive symptoms and the benefit of avoiding alcohol
consumption during treatment
• Addressing any myths about antidepressants (eg that they are associated with addiction)
• Always contacting the GP if anxiety worsens considerably or suicidal thoughts increase (can occur
in a small percentage and can be dangerous)
• Refer to a psychiatrist if the patient is not responding to medication after an appropriate period of
time at optimal dose. The literature consistently confirms that such education about antidepressant
medication improves adherence

EXTRA POINTS TO REMEMBER

DSM-IV criteria for major depression are five or more of the following symptoms persisting over a
2 week period causing clinically important distress or impairing work, social or personal
functioning (with depressed mood or decreased interest or pleasure as one of the five):

• Depressed mood most of the day, occurring most days (subjective or observed)
• Markedly diminished interest or pleasure most of the day, nearly every day
• Significant weight or appetite change
• Insomnia or hypersomnia
• Psychomotor agitation or retardation (observable by others)
• Fatigue or loss of energy
• Feelings of worthlessness or inappropriate guilt
• Diminished ability to concentrate or make decisions
• Recurring thoughts of death or suicide plans

DSM-5 diagnostic criteria for major depressive disorder JM 7th Edition

At least five of the following symptoms nearly every day for 2 weeks (criterion 1 or 2 essential):
1. depressed mood or irritability (subjective or objective) most of the day
2. loss of interest or pleasure
3. change in weight (5% change over 1 month) or appetite
4. change in sleep: insomnia or hypersomnia
5. psychomotor agitation or retardation
6. loss of energy or fatigue
7. worthlessness or guilt
8. impaired concentration or indecisiveness
 9. suicidality: recurrent thoughts of death or suicide ideation or any suicide attempt

The importance of putting these safety issues at the beginning of the management process is
reflected in the SET A PACE7 model of treatment, proposed by Mahli et al.
To clarify the risk of suicide and appropriate response, ask about: 14
● suicidal thoughts
● plan
● lethality
● means
● past history
● suicide of family member or peer

Low risk (fleeting thoughts of self-harm or suicide but no current plan or means):
● Discuss availability of support and treatment options.
● Arrange follow-up consultation (timing of this will be based on clinical judgment).
● Identify relevant community resources and provide contact details.

Medium risk (suicidal thoughts and intent but no current plan or immediate means):
● Discuss availability of support and treatment options.
● Organise reassessment within 1 week.
● Have contingency plan in place for rapid reassessment if distress or symptoms
escalate.
● Develop a safety plan (a prioritised written list of coping strategies and sources of
support to use when experiencing suicidal thinking).

High risk (continual/specific suicidal thoughts, intent, plan and means):

● Ensure that the person is in an appropriately safe and secure environment.
● Organise reassessment within 24 hours and monitoring for this period.
● Follow-up outcome of assessment.

After safety is established (and this will need to be continually reassessed at each consultation),
the two other aspects that need to be developed early in the process (and also continue on
through the long-term management of the patient) are educating the patient about his or her
condition and individual situation, and establishing a therapeutic relationship.
Assessment includes:
● characterising the symptom profile
● calibrating the severity and chronicity—rating scales can be employed here
● corroborating (if possible and appropriate) medical and psychiatric comorbidities
and context. Significant psychiatric, physical and social comorbidities of
depression are common. These include 49% suffering an anxiety disorder, 40%
reporting child sexual abuse, 57% child physical abuse, 42% having been at some
stage afraid of their partner and 72% reporting a chronic physical condition. 16
Putting the patient’s condition into his or her individual psychosocial and medical
context will improve the assessment
● considering coping styles, and the social, financial and occupational
consequences of the patient’s condition and situation

This assessment is often spread over multiple consultations.

Depressive symptoms can be summarised as follows:
• affective (emotions) – depression, anxiety, guilt, anger, hostility, irritability, inability to experience
pleasure
• behavioural – agitation, facial expression, slowing down of movements, speech and thought, and
crying
• attitudes towards self and world – self-criticism, low self-belief, feelings of helplessness,
hopelessness, pessimism, thoughts of death or suicide
• cognitive – impaired thinking and concentration bodily complaints – loss of appetite, sleep
disturbance, low energy or libido.

Given the competing

Risk factors for suicide in the elderly

Depression
• Co-occurring depression and anxiety
• Limited social interaction
• Previous suicide attempt(s)
• Recent discharge from psychiatric hospitalisation (within 3 months)
• Male gender
• Bereavement (especially for men)
• Chronic relationship problems
• Concerns about being a burden to others
• Tension with caregivers
• Recent visit to primary care physician (in the last month)
• Physical illness (pain, chronic disability)
• Vulnerable personality traits (hopeless/helpless, rigid, unable to sustain close relationships)
• Recent change in accommodation

Protective factors
• Family warmth, support and acceptance
• Community support and a strong cultural identity
• Pregnancy (self/partner) or having young children
• A strong sense of belonging and connection
• Support from ongoing medical and mental health care relationships
• Skills in coping and problem solving, conflict resolution, and non-violent ways of handling disputes
• Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
• Experiences with success and feelings of effectiveness
• Interpersonal competence

Risk factors for adolescent suicide

• Past or present mental illness (for example, mood and anxiety disorders, substance use disorders
or both concurrently)
• Previous suicide attempt(s)
• Male gender
• Previous self-harm
• Social skills deficits
• Hostility, aggression and impulsivity
• Homosexuality/bisexuality
• Current suicidal thoughts
• Interpersonal conflict or loss
• Ongoing physical or sexual abuse, or emotional stress (for example, bullying)
• Parent-child discord
• Recent commencement of antidepressant therapy
• Feeling of isolation
• Availability of firearms or lethal means
• Close friends who have died by suicide

Future risk factors, which can be anticipated to a certain degree, including:

• access to preferred method of suicide
• compliance with treatment
• future service contact
• future response to drug treatment
• future response to psychosocial intervention
• future stress.

Persons presenting to EDs in Victoria after a suicide attempt are commonly assessed by:
the Australasian Triage Scale (ATS) with mental health descriptors 8,

● Do you ever feel like giving up?

● How does the future seem to you?
● Does your life ever seem so bad that you wish to die?
● How severe are the thoughts? How frequent?
● Have you made any plans?
● How close have you come to doing something? (Access to methods
of suicide, eg. firearms, stockpile of medications)
● What stops you doing something? (Protective factors such as religious
beliefs or love for children/family members)

www.capefearpsych.org/documents/SADPERSONS-suiciderisk.pdf
My Link:
http://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh