Mental health articles

Case study: Jean – a 34-year-old with dysthymia and depressive episodes. Jean is a 34-year-old woman who has experienced dysthymia, that is, persistent low mood, for most of her adult life. However, over the last five years this has become particularly distressing and her mood has often deepened to include long spells of disabling depression. These depressed spells began after the birth of her first daughter and were diagnosed initially as postnatal depression. Jean reports that she has always been a melancholy person but denies feeling depressed in the past. However, after the birth of her first child Jean became extremely depressed and after the midwife and health visitor became concerned about her low mood and lack of self-care, although she continued to care for her child, they arranged for her to see her general practitioner who prescribed an SSRI. After several weeks Jean’s mood had not improved and her husband became concerned about her because on three occasions, she had talked about committing suicide. Jean was seen by the community psychiatric nurse (CPN) who arranged for her to see a consultant psychiatrist; the psychiatrist increased the dosage of her SSRI medication and referred her for cognitive behavioural therapy.

During this time Jean received regular visits from a CPN who monitored Jean’s mood and spent time discussing how she felt. The CPN also ensured that Jean was taking her medication and, with Jean’s permission, discussed Jean’s problems with her husband with the aim of reducing his feelings of isolation and blame, and to help him support Jean. Jean did not notice any improvement in her mood at first. However, the waiting list for CBT was six months and while waiting for a place Jean noted that her mood had begun to lift. Over the following six months Jean’s mood returned to what she described as normal and she told the CPN that she had not felt so well since before her first child was born. Jean did not want to continue to take the SSRIs but to take cognitive behavioural therapy alone to see if it could help her. In discussion with her psychiatrist it was agreed that Jean will attend for cognitive behavioural therapy and that she will be withdrawn slowly from her SSRIs while her mood is closely monitored. Jean agreed, in collaboration with the psychiatrist and the CPN, to recommence taking the SSRIs in addition to the CBT course if her mood deteriorates either from her perspective or, as importantly, from the perspective of her family. Jean’s case illustrates that early diagnosis of depression is important, as is evidence-based treatment, to a successful outcome. Although Jean has seen a psychiatrist, her care has been carried out in the community and her main point of contact and support has been her husband and the CPN.

In working with Jean the CPN performs three key roles. She is: an advocate for Jean, a source of information for Jean and her family, and, as the key worker, she monitors the effect of Jean’s treatment and changes in her mood. The case shows also that the resolution of depression takes place in the medium, rather than the short term and that individuals should not stop taking anti-depressant medication without support, continued monitoring and without having sought advice.

Tags: Bipolar Disorder, case study