1. CASE PRESENTATION
Presenter : Kapil S. Kulkarni
Moderator : Dr. C. Pinto, Dr. J.P. Rawat
Dept of Psychiatry
JRH, BCT.

2. History
• A 57 yr old,
Known diabetic & hypertensive,
Right handed,
Marathi speaking,
Married, Hindu male,
Working as Sr. Khalasi,
Residing in Bhayandar
• Complaints-
Self- Loss of interest in work
Ghabrahat

3. • Objective Data- Son & wife (Adequate, Reliable)
• H/o- Sadness of mood.
Minimal communication.
Disturbed sleep (Excess for few weeks &
d
decreased for few weeks)
Irritability
Muttering & gesticulating to self
• Total duration- 2-3 yrs

4. ODP
• Patient was alright 3 yrs back.
• Symptoms started gradually without any stressor and
progressed over period of time.
• He started saying that he has lost interest in work.
He was planning to take VRS and sit at home.
• Sleep was becoming irregular and appetite was
increased.

5. • There was occasional forgetfulness.
• He was feeling that people were talking about him.
• Patient was gesticulating to himself sometimes.
(praying to god, counting finger)
• He was never treated for the illness.

6. Negative History
• No h/o Hearing of voices, loss of self care.
• No h/o Elated mood or big talk.
• No h/o Suicidal attempt.
• No h/o Seizure or any neurological disorder.
• No h/o Cognitive decline.
• No h/o Repeated checking or hand washing.
• Pt has h/o occasional social drinking of alcohol in
past. But no consumption since last 8 yrs.

7. Past & Family History
• No h/o similar complaints in past.
• But there is positive h/o mental illness in family. His
father developed abnormal behavior at the age of 70
yrs i/f/o suspiciousness, bizarre behavior, running
away from home.

8. Personal History
• Birth details not available.
• Studied up to 8th (failed in 9th)
• Married in 1987.
• Joined Railway in 1982 as Khalasi. Promoted to Sr.
Khalasi in 2009. No awards or charge sheet given.
• His social behavior was normal but having minimal
social interactions. He was anxious & avoidant.
He always preferred to be alone. He had minimal
communication.

9. Physical Examination
• General Examination-
Conscious, co operative & well oriented.
Built is average.
Pulse- 84/min
BP-140/90 mmHg
RR- 16/min

10. • Neurological Examination-
Higher function
Motor system
Sensory system
All within normal limits.
• Systemic Examination-
No abnormality was detected in systemic clinical
examination.

11. Mental Status Examination
• General Appearance
Conscious, co operative but had limited
communication.
He was restless.
Fidgedity was present.
His dressing and grooming was proper.
• Eye to eye contact
Initiated but could not be maintained.
• Rapport
Established & maintained.

12. • Attention
Arousable & sustained.
• Mood
Sad & anxious
• Affect
Appropriate to mood.
• Speech
Continuous, coherent & relevant.
Speech decreased in amount.

13. • Thought
Patient had ideas of hopelessness, helplessness &
worthlessness.
He was feeling that life is not worth.
Delusions were absent.
But ideas of reference were present.
Concepts
Both simple and abstract thinking were intact.
• Perception
No perceptual abnormality was present.

14. • Memory
Registration 3/3
Recall 1/3
Recent & remote memory intact.
• Orientation
To time, place and person was present.
• Intelligence
Average

15. • Judgment
Both social & test judgment intact.
• Insight
3/6 (Claims disease as a physical illness)

16. Differential Diagnosis
• D/D can be-
1) Agitated depression.
2) Double depression.
3) Major depressive disorder with psychotic
features.
4) Early features of dementia.
5) Malingering.

17. Investigations
• All routine blood & urine investigations-
Normal
• Dementia work up-
VDRL, HIV ELISA, Sr. Homocystine Sr. Folate, Sr.
Vit B12 – All WNL.
• Fundus examination- Normal.
• MRI Brain- Normal.
• ECG, X-ray chest- Normal.

18. • PSYCHOMETRIC ASSESSMENT-
• ROR- Thought productivity- Below average.
Reality ties good.
Current psychopathology s/o depression.
• BPRS- 38 (Significant psychopathology)
• HDRS- 27 (Moderate to severe depression)
• SAPS- 12 (Positive symptoms of schizophrenia)
• SANS- 14 (Negative symptoms of schizophrenia)
• MMSE- 26/30

19. Diagnosis
• DSM IV TR
• AXIS I- Agitated Depression.
• AXIS II- Cluster C traits present.
• AXIS III- DM, HTN (well controlled)
• AXIS IV- No stressors.
• AXIS V-GAF 61-70 at present & 71-80 before 1yr.

20. Treatment
• Patient was treated on OPD basis.
• PHARMACOTHERAPY-
He was started on
Tab. Escitalopram 10mg (1-0-0)
It was increased to 20 mg after 3 weeks.
Tab. Lorazepam 2mg (0-0-1) was added for sleep.

21. • FAMILY PSYCHOEDUCATION-
Family members were educated regarding illness,
their role in treatment & correct approach to interact
with patient.
• INDIVIDUAL APPROACH-
Patient was made aware of his illness. He was taught
relaxation techniques to cope up the stress.
In next sessions he is planed for cognitive & behavior
therapy.

22. Treatment Response
• Patient was 50% improved in 3 weeks.
• He was >80% better in 6 weeks.
• Currently he has finished 2 months treatment &
follows up in OPD regularly.

23. Depression: A global crisis