28 Mar 2018
Depression does not sound bizarre for the society in this 21st century because it is now one of the most common psychological disorders that everyone in the world could have. According to World Health Association (WHO) 2012, depression actually affecting 350 million of people in the world with different ages where it can contribute to as much as one million people’s death per year. That’s make up the reason for this case study to be conduct.
J is a male who now aged 56 years old that work as a technician supervisor in a factory. J’s life is very simple by having a family that consists of three children and a lovely wife. J’s routine started with the time to work and after work he sometimes like to go jogging, wash his car or just go out play badminton with children. All the things look fine until J was 44 years old, J started to feel tired and does not feel like going out for anything including work. J feel that lost interest in doing thing that consider as routine for J and always feel down but no reason can be told to others where that feeling of down coming from for him it feels like something is stuck between the chest and throat that cause him unable to breath sometimes.
To make the situation worse, J was unable to perform in the works that end up having a little financial crisis for the family. J decided to temporary stop working and decided to seek for help. He went to Hospital University Kebangsaan Malaysia (HUKM) and seek the help from psychiatric. The psychiatric had given him Prozac which is quite popular in that period of time for the treatment for depression. The medication taken makes him feel better and J was able to go back to work but that’s not the end of story. Even with the help of medication, J can feel more “normal” with the decrease of the feeling of down or bored but he cannot stop the medication as the symptom of depress will come back when he stop the medication.
The situation remains for more than 10 years that J decided to seek for other help such as counseling. In the period of 10 years, J stated that he would had few months of depress and back to normal or “hyper” that comment by his family members for two months and back to depress. J also decided to change the psychiatric that he attend to due to the reason of too much patient and the cost. J later went to a well-known private psychiatric that cause him a nightmare. “The psychiatric ‘s seems in a rush and always push me to speak about my problem but I can’t really tell and I stop to think but The psychiatric keep on saying that I am not telling the problem that he/she can’t help me.” J told the experience with a bad feedback that he would not go back there for help. Other than that, J also went for counseling but he said that it depends on counselor, some counselor he went make him feel more reluctant to speak but some make him want to speak more.
Later in the time about five years ago, J went to Kajang Hospital for help and new medication was given to him. Fifty milligrams of Setraline was given to him but J still prefers Prozac that he feels more comfortable or better.
Throughout the interview where take place in a corner of a restaurant that was requested by J. He seems very quiet and does not give much eye contact throughout the interview. J looks very tired as the facial expression and he constantly put his right hand on both side of his forehead when answering the question. He also does not look very comfortable when there’s people walk by because he will stop the conversation. He also admit that he is current in depress mood as he had been out of work for one weeks and plan to take unpaid leave as he feel terribly uncomfortable especially the headache he face now. Other than that, J also tends to slow in answering the question when it is related the condition he has and the tempo is slower than normal people.
Despite of the information retrieved from J himself, I also further understanding his condition with his sons and wife. According to his wife, J had an observable changes when he is in the depress mood where he tend to spend a lot of time in the bedroom. Whenever they ask him, J will tend to answer that he was tired and needed sleep but does not seem enough sleep even tough spending the whole day in bedroom. Furthermore, the son said when J was not in depress he tend to be more involved in family activities where they will go play badminton together, go out to park or zoo but when J is depress he will lost all the interest even with his lovely fishes about 100 of it that he kept but usually few will left alive when he is depress. They also told that J never told the children about his condition and the wife only knew it until J say he need to go to hospital for help. The children only know his condition when they are all about teenager and all that they remember were J seems to be active in their activities for a while but then become very quiet.
As a confirmation, I ask the wife about J’s personality and she said that J not actually that quiet but when he met someone he can talk to then he will be very talkative. Moreover, I also understand that J does not binge around with any friends or colleagues after work and describe by the wife that J will come home after work and not going out with others after work. They also told that they already get used to J’s condition and they still will accompany him to psychiatric or any therapy sessions that J is going to.
According to Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5), for a person to be diagnosed as having Major Depressive Disorder (MDD) few criteria need to be fulfill (American Psychiatric Association, 2013). J in this case has shown some symptom in MDD and Cyclothymic Disorder.
Major Depressive Disorder
In the interview , J had shown the symptom for MDD such as feel down or depress with no justifiable reason and loss of interest on his hobby when he was depress. Other than that, there are sign of hypersomnia, feeling of restlessness and fatigue that J portrait through the interview which seems to fulfill the criteria of diagnose as Major Depressive Disorder according to DSM 5. J had stated in the interview and triangulation with the family members that J actually experiencing few month of depress whereby he can’t go to work at all. Moreover, J also told that he feel down in a period of time without reason or purposely thinking about something. The first stressor that trigger MDD for J was work stress but the depress feeling does not stop.
Cyclothymic Disorder require the patient to had for at least 2 years of depress and hypomanic episode that occurs in the period. In J’s case, the depress mood is easily identify by the family members and J himself but then in the triangulation where the sons stated that J will be more hyper in a period of time and in both scenario it is very consistent.
Rationale for diagnosis, rule outs and differential diagnosis
For this case study, it would purpose that J would had MDD more preferable than Cyclothymic Disorder. According to Tennant (2001) and Melchior et al. (2007), stress at work such as always had overtime or rushing for the work to complete can contribute to depression for people in the work. J had fulfill the criteria that he said that the depression is cause by the work stress.
Moreover, J also experience hypersomnia that indicate in DSM 5 count as one of the criteria for MDD (American Psychiatric Association, 2013). J’s wife had stated that J often feel tired and always stay in bedroom to sleep that show the symptom of hypersomnia or insomnia in the catorgory. Follow by the feeling of mood that even J cannot explain in the interview fulfill the criteria of depress mood for more than two weeks (American Psychiatric Association, 2013). J had experience the depress mood for more than two weeks are determine by the day he started to take leave until he decide to take unpaid leave.
The symptom of loss of interest also can be trace in J’s case as mention by the sons and J himself that he will not feel to take care the fish that he kept for more than 100 when he was in the depress mood. In DSM 5 it take five or more symptom that one person need to fulfill to be diagnose as having MDD and J had five of it and the two which haven’t been mention is the feeling of fatigue every day and having hard time to focus or concentrate on anything as shown in the interview where J tend to indicate that he is having headache when some question asked (American Psychiatric Association, 2013). Meanwhile, the reason of Cyclothymic disorder was rules out is due to the issue that hypomanic episode that occur are very few and not consistent compare to the depress mood as sometimes the hypomanic episodes does not occur in one year and through the family members also know that the period of become active is very rare throughout the whole 12 years of J having MDD.
Therefore, J had moderate severity and recurrent episode of MDD which is 296.32 as indicated in DSM 5 (American Psychiatric Association, 2013). There is no comorbidity in J’s case where four other disorders are excluded such as manic episode with irritable mood or mixed episode, mood disorder due to another medical condition, substance/medication-induced depressive or bipolar disorder and attention-deficit/hyperactivity disorder (ADHD) (American Psychiatric Association, 2013). Manic episode with irritable mood or mixed episode was ruled out as the manic episode did not met the criteria and J had no substance abuse or any medication before the depress symptom come out so mood disorder due to another medical condition, substance/medication-induced depressive or bipolar disorder were ruled out and attention-deficit/hyperactivity disorder (ADHD) are not solid enough to support that J had ADHD than MDD.
Review Intervention or Recommend Treatment Plan
As mention in above J had taken Prozac before and now taking 50 mg of Setraline which also known as Zoloft for his treatment for MDD (Medline Plus, 2014). But it had side effects that harmful to the body that fit J’s situation now which he alays encounter headache (U.S. Food and Drug Administration, 2012).
In my opinion for J’s future treatment, he can consider different types of psychotherapies despite on rely fully on medication. Therapies such as cognitive-behavioral therapy, psychodynamic therapy, grou therapy, and also problem-solving therapy (Fochtmann, L. J., & Gelenberg, A. J., 2005). Unfortunately, so far J ahd encounter some bad experiences in counseling but J can consider to try on another angle of help which are therapies that suit him the best. It would be better than J combine both the medication adn therapy that could probably make the most effective works in helping J overcome this disorder.
Risk assessment or Prognosis
From the interview and analyze conducted above, it can be said that J actually had a good insight about his own condition whereby he was able to take action when he know that there’s somethign wrong about him and the way he went to seek help from psychiatric and counselor. Eventhough, J had good insght, but currently still is a crtitcal period for J as the new medication had bring the side effect that so severe that he can’t go to work.
The prognosis of J would be in progress of adapting himself on new medication and his own condition. He was quite well in handling himself where the family support was there and his positive attitude to seek for help. Soon enough that, J would be able to handle the new medicationa and back to his work life. The risk that cannot be forget would be the side effect of the Zoloft taken and it would be advisable that J cut off the dosage to reduce the headache and had time adapt to new medication instead of Prozac that J feels the most comfortable with and there might be chance of tolerence.
Reflection & Conclusion
Reflecting on the case of MDD done in this case study, the key essence of MDD would be the feeling of down. It was fasinating that we human are being fool by our own brain that make us feel so inferior. In J’s case, I found the positive side of J in how family support and his way of thinking on seeking help instead of defensing the ego by denial that he need help. Coming from a family that MDD had affect most of the member including my own father, sometimes I was wondering what actually they are thinking until the MDD are trigger. Maybe there are some biological deficit that my family have but in J I saw some positive where my family members who affected by MDD don’t. The attitude of facing the problem impress me and I think J was courage enough to tell me; a stranger about his problem and story.
I did learn from this case study and it helps me to understand the world of MDD instead of just guessing whether all MDD patient are very passive or vice versa. In conclude, MDD is too common in the society yet hard to detect if you are not detail enough. MDD can lead to fatal sucide where I think the public should be educate more and do not forget about the family support with proper medication and therapy helps in the journey of fighting Major Depressive Disorder.
World Health Association. (2012). Media Centre.Depression .Retrieved from http://w ww.who.int/mediacentre/factsheets/fs369/en/
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Melchior, M., Caspi, A., Milne, B. J., Danese, A., Poulton, R., & Moffitt, T. E. (2007). Work stress precipitates depression and anxiety in young, working women and men.Psychological medicine. 37(08). doi:10.1017/S0033291707000414.
Tennant, C. (2001). Work-related stress and depressive disorders.Journal of psychosomatic research,51(5), 697-704. Retrieved from http://www.uic.edu /sph/glakes/occupational/reading_lists/73102/pdfs/tennant.pdf.
Medline Plus. (2014). Sertraline . Retrieved from http://www.nlm.nih.gov/med lineplus/druginfo/meds/a697048.html.
U.S. Food and Drug Administration. (2012). Medication Guide ZOLOFT (ZOH-loft) (sertraline hydrochloride) (Tablets and Oral Concentrate (solution). Retrieved from http://www.fda.gov/downloads/Drugs/DrugSafety/ucm089832.pdf.
Fochtmann, L. J., & Gelenberg, A. J. (2005). Guideline watch: practice guideline for the treatment of patients with major depressive disorder.Focus: The Journal of Lifelong Learning in Psychiatry. 3(1). Retrieved from http://psychiatryonline. org /data /Book s/prac/PG_Depression3rdEd.pdf
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