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Case 1305: I don't want to be like my father
Authors and Affiliations
Ivonne Lichtenberg
School of Medicine, University of Notre Dame Sydney
Bsc. (Chem) Adv. Hons
A/Prof Geraldine Duncan MBBS, Dip. Obs RCOG, FRACGP
A/Prof Michael Wan
Head of BCS Domain
School of Medicine, Sydney
University of Notre Dame
Case Overview
This case highlights some of the difficulties that arise when practising medicine in a rural area. It also
shows the importance of tailoring management to your patient†™s way of life. This case will deal with
a lack of access to specialist health professionals as well as a common health problem that has a high
prevalence in rural areas.
Learning Objectives
- Recognise common signs and symptoms of depression
- Recognise risk factors for depression/suicidality
- Develop management plan for a person with depression, particularly in a rural setting
- Understand first line management for severe depression
- Understand the issues around health care in a rural setting
Question 1 : SC
Question Information:
Jack is 55-year-old cattle farmer who lives two hours out of town. He is brought in to your general
practice today by his daughter Lucy, who is worried he is not coping. His wife passed away five years
ago in a car accident and he has been managing the farm on his own since then. Lucy said she had
come from the city to help him out. She noticed that a lot of the farm jobs were not done and her father
was drinking a lot of alcohol, something he never used to do. She is concerned because Jack†™s
father had a history of depression and attempted suicide on one occasion.
It was initially difficult to get Jack to open up, however he eventually tells you that after his wife passed
away he found things difficult, but absorbing himself in the farm helped him as this was something he
very much enjoyed. For the past month he says he has felt extremely tired and has been finding it hard
to get out of bed. As a result, he recently missed a cattle sale which cost him a large amount of money.
He says he finds it hard to get motivated to do much now and the farm no longer brings him the joy it
once did. He feels guilty that his daughter is taking the time out of her busy life to come and help him so
often.
He tells you that he has taken to drinking more alcohol because he finds that it helps him sleep. On
questioning he tells you that he has lost weight over the last month which he attributes to his lack of
appetite.
In terms of past medical history, Jack is previously well. Besides an appendicectomy at age 20, he has
had no previous operations and is on no medications. He has no known allergies and a family history of
depression and hypertension on his father†™s side.
Question:
What would be your next step in Jack†™s management?
Choice 1: Perform a physical examination looking for causes of tiredness and signs of alcoholism, as well as
some blood tests Score : 1
Choice Feedback:
Although you want to explore any physical causes of Jack†™s presentation, there is also a strong
mood element here. You should be undertaking a mental state examination (e.g. MMSE or K10 or
GDS) as part of your clinical consultation.
Choice 2: Perform a mental state examination Score : 1
Choice Feedback:
There is obviously a mood component to Jack†™s presentation however you also want to rule out any
physical reasons for his presentation. It is important to perform a relevant physical examination and do
some tests to help rule out some of your differential diagnoses.
Choice 3: Reassure Jack and Lucy that this is a normal reaction to grief and advise them to return if anything
changes Score : -1
Choice Feedback:
Incorrect. Jack†™s wife passed away 5 years ago. This does not fulfil the criteria for adjustment
disorder. Jack and his daughter are clearly worried about something and it is important to address their
concerns. You also cannot rule out a physical cause for Jack's symptoms at this time without thorough
physical examination and investigation for metabolic causes.
Choice 4: Perform a physical examination looking for causes of tiredness and if normal, reassure Jack and Lucy
and advise them to return if anything changes Score : -1
Choice Feedback:
Incorrect. Although you want to explore any physical causes of Jack†™s presentation, there is also a
strong mood element here. You should be undertaking a mental state examination (e.g. MMSE or K10
or GDS) as part of your clinical consultation. Jack and his daughter are clearly worried about something
and it is important to address their concerns.
Choice 5: Perform a mental state examination, a physical examination, as well as appropriate blood
investigations. Score : 2
Choice Feedback:
Correct. There is obviously a mood component to Jack†™s presentation however you also want to
rule out any physical reasons for his presentation. Jack and his daughter are clearly worried about
something and it is important to address their concerns.
Question 2 : MS
Question Information:
While you are talking to Jack and Lucy you also perform a mental state examination of Jack.
Question:
What are some of the features you may expect to find in a mental state examination considering the
possibilities of depression or early onset dementia?
Choice 1: Unkempt appearance with mud stains on his clothes Score : 1
Choice Feedback:
Correct. This may be characteristic of a patient with depression. However, for a farmer as part of a busy
work day one might expect mud stains on clothing. However, for a planned town day the majority of
farmers will take care with their appearance and have clean clothes and shiny boots.
Choice 2: Agitated and erratic behaviour Score : 1
Choice Feedback:
The history given does not suggest agitation. It is possible however, that a person with depression may
react this way. Agitation could be a sign of early dementia. It could also be a symptom of psychosis
which would also need to be excluded.
Choice 3: Flat affect Score : 1
Choice Feedback:
Correct. This is a significant characteristic of a patient suffereing depression. Altered affect is also one
of the symptoms of psychosis as well as dementia and Parkinson's Disease. Alcohol abuse can also
lead to flattened affect and aggravate depression.
Choice 4: Depressed or low mood Score : 1
Choice Feedback:
Correct. The history also leads us to believe that Jack has been feeling low recently. Low mood can be
one of the symptoms of dementia and psychosis. Alcohol abuse can aggravate depression.
Choice 5: Flight of ideas Score : 0
Choice Feedback:
Incorrect. You may expect to see this more in a patient with a psychosis or mania. It is important to note
however that alcohol withdrawal can be associated with hallucinations and delusions.
Choice 6: Thoughts of death and suicide Score : 2
Choice Feedback:
Correct. Based on Jack†™s history you would attempt to elicit suicidal ideation. According to Karin
Kolves, Allison Milner, Kathy McKay & Diego De Leo (eds.) 2012, Suicide in males in rural and remote
areas of Australia are significantly higher, 36.32 per 100,000 compared with 18.25 per 100,000 in nonremote areas. It is important to be aware of this risk.
Choice 7: Reports of auditory hallucinations telling him that his daughter is CIA Score : 1
Choice Feedback:
Correct. While Jack's history is suggesting depression as the main diagnosis, at this stage it is possible
he could be suffering from dementia, which may cause paranoid delusions. It is also possible that he
could be suffering a severe form of a psychotic depression hence the importance of taking time to fully
elucidate his symptoms. The family history of attempted suicide in his father is significant.
Choice 8: Disorientation to time and place Score : 1
Choice Feedback:
This symptom would be uncovered by a Mini-Mental State Examination (MMSE), part of your initial
work-up. The history of neglect of farm jobs may suggest a decrease in organisational skills which could
be a marker for early dementia. Disorientation in time and space is also a marker for patients suffering
from delirium or psychosis and should be further defined in your examinations and investigations.
Question 3 : MS
Question Information:
On mental state examination Jack has a slightly unkempt appearance with mud stains on his boots and
clothes. He sits still and quiet and is quite difficult to engage at first. His speech is initially slow but clear.
He has a flat affect, but his thought form comes across as normal.
He reports thinking about death and suicide but states he would not want to put his family through what
happened when his father attempted suicide. He is still worried that one day he may do the same as his
father and worries about his easy access to his guns.
He denies any auditory or visual hallucinations and is oriented to person, time and place. You feel that
he has good judgement and he shows some insight by agreeing that this current state of mind is
interfering with his daily functioning.
His physical examination is unremarkable.
You identify that Jack may be at risk of suicide and decide to perform a formal risk assessment.
Question:
What are the risk factors for suicidality?
Choice 1: Male gender Score : 1
Choice Feedback:
Although females attempt suicide more frequently, males complete suicide more often.
Choice 2: Female gender Score : 1
Choice Feedback:
Females attempt suicide more often however, males complete suicide more often.
Choice 3: Family history of suicide Score : 1
Choice Feedback:
People with a family history of mental illness or suicide attempt are more likely to attempt suicide.
Choice 4: Previous suicide attempt(s) Score : 2
Choice Feedback:
People who have already attempted suicide, are at increased risk or attempting suicide again.
Choice 5: History of mental disorders, particularly clinical depression and psychosis Score : 1
Choice Feedback:
People with depression, psychosis and hopelessness are more likely to attempt suicide.
Choice 6: History of alcohol and substance abuse Score : 1
Choice Feedback:
Current alcohol and other substance abuse are at increased risk of suicidal ideation and attempts.
Choice 7: Isolation, a feeling of being cut off from other people Score : 1
Choice Feedback:
People with lack of support and connectedness often have barriers to accessing mental health support
and treatment posing increased suicide risk. Services may be lacking or insufficient in rural areas.
Choice 8: Loss (relational, social, work or financial) Score : 1
Choice Feedback:
A history of loss and significant situational change in a person†™s life increases vulnerability, anger
and feelings or worthlessness placing them increased suicide risk.
Choice 9: Chronic physical illness Score : 1
Choice Feedback:
People with chronic physical illness are at increased risk of depression and suicidality.
Choice 10: Easy access to lethal methods Score : 1
Choice Feedback:
People with access to lethal means, for example guns, are more likely to complete a suicide attempt
Choice 11: History of thyroid disease Score : 0
Choice Feedback:
Incorrect. A history of thyroid disease does not increase your risk of suicide.
Choice 12: Treatment with statins for high cholesterol Score : 0
Choice Feedback:
Incorrect. There is currently no evidence that treatment with statins increases risk of suicide.
Question 4 : FT
Question Information:
You find that although Jack has many risk factors for suicidality, he currently has no desire to attempt
suicide, nor does he have a plan. Jack does express concern about his access to his own guns and you
work together to arrange for Lucy to temporarily take possession of the keys to his locked gun cabinet.
This eases some of Jack†™s worry.
Before performing any investigations, you want to prioritise your differential diagnosis.
Question:
What is your provisional diagnosis?
Choice 1: null Score : 0
Choice Feedback:
Jack fits the DSM-V criteria for Major Depressive Disorder (MDD).
See synopsis at end of case study for full criteria
Question 5 : FT
Question Information:
You also want to have in mind a few differential diagnoses
Question:
What would you be considering in your differential diagnoses?
Choice 1: null Score : 0
Choice Feedback:
When considering differential diagnosis for psychiatric problems you should consider;
General
medical problems, for example; early dementia, anaemia, cancer, hypothyroidism

Affective problems, for example, bipolar affective disorder, adjustment disorder (although 5 years is a
long lag time for
the
development of an adjustment disorder)
Substances,
for example, drug and alcohol misuse, medication side effects

Personality disorders, for example borderline personality disorder (extremely
unlikely
in this age group)
Psychosis,
for example, schizophrenia, drug induced psychoses
Question 6 : MS
Question Information:
In order to clarify your diagnosis you perform relevant investigations.
Question:
What are the most appropriate investigations to perform in Jack?
Choice 1: FBC Score : 1
Choice Feedback:
Correct. It is important to know if anaemia is present and a high white cell count may point to a chronic
infection.
Choice 2: BGL Score : 1
Choice Feedback:
Although not directly related to the current issue of depression, in this age group and with the current
national concerns regarding undiagnosed diabetes opportunities to assess blood glucose should be
taken. It is theoretically possible that this patient (presumably not a regular attender to medical services)
could have early onset dementia (vascular dementia) related to white matter small vessel disease due
to hypertension and Type II diabetes.
Choice 3: EUC Score : 1
Choice Feedback:
Correct. It is important to know Jack†™s renal function, especially if you are considering commencing
him on medication.
Choice 4: LFT Score : 1
Choice Feedback:
Jack has told you he has been drinking more than he usually would. Liver function tests would indicate
any significant liver damage (eg. fatty liver).
Choice 5: Urinalysis Score : 1
Choice Feedback:
Jack's history is not suggestive of an acute delirium, however, urinalysis may be a marker of
asymptomatic urinary infection.
Choice 6: CMP Score : 1
Choice Feedback:
Calcium estimation is part of the work-up of a confused patient. At this point in time Jack has not
demonstrated evidence of confusion. Note that hypercalcaemia may be due to primary or metastatic
cancers.
Choice 7: TSH Score : 1
Choice Feedback:
Correct. You want to rule out any thyroid hormone deficiencies which may be causing Jack†™s
symptoms
Choice 8: MRI/CT brain Score : 0
Choice Feedback:
Imaging is usually unnecessary in a presentation such as this unless the neurological examination is
abnormal or Jack has focal neurological symptoms such as persistent focal headache or recent
alteration in vision.
Choice 9: ECG Score : 0
Choice Feedback:
ECG is not routinely indicated for this presentation
Question 7 : SC
Question Information:
Assuming the test results are all normal you are keen to start Jack on some management. He tells you
that he is open to trying treatment as he does not want to lose the farm. You have a long discussion
about the best way forward. As Jack lives two hours out of town, and is usually the only person
managing his cattle he cannot manage multiple trips into town for treatment.
There is currently no psychiatrist in town, and although, there is a monthly service from the city, your
referrals in the past have been put on a waiting list of a few months. You and Jack both agree that he
should start treatment earlier than this, so you agree to commence him on an antidepressant.
Question:
What is the most appropriate treatment to commence him on?
Choice 1: Sertraline 50mg Score : 1
Choice Feedback:
Correct. An SSRI is the recommended first line treatment, with 50mg being the recommended starting
dose for Sertraline with review at 2-4 weekly intervals. The review may need to be conducted via the
phone or email due to his location.
Choice 2: Amitriptyline 50mg Score : -1
Choice Feedback:
Incorrect. Amitriptyline is a TCA which is currently not the recommended first line treatment for major
depressive disorder. However it can be very useful in the management of some anxiety disorders.
Choice 3: Citalopram 250mg Score : -1
Choice Feedback:
Incorrect. Although Citalopram is an SSRI, this dose is too high. The correct starting dose is 20mg.
Choice 4: Olanzapine 10mg Score : -1
Choice Feedback:
Incorrect. Olanzapine is an antipsychotic agent and is not indicated for the treatment of major
depressive disorder.
Choice 5: Diazepam 10mg Score : -1
Choice Feedback:
Incorrect. Diazepam is a benzodiazepine. This is not indicated in the management of major depressive
disorder. Benzodiazepines are highly addictive and also contribute to worsening depression.
Question 8 : FT
Question Information:
During initial consultation you explain the side effects of SSRIs to Jack.
Question:
What are the common side effects of SSRIs that you should explain to him?
Choice 1: null Score : 0
Choice Feedback:
Common side effects include:
- Lethargy
- Restlessness, nervousness, agitation
- Headache
- Nausea and vomiting
- Hyponatraemia
- Dry mouth
- Insomnia
- Weight gain or loss
- Blurred vision
- Reduced libido, erectile dysfunction
Less common:
- Increased suicidal ideation / self harm (more common age <25)
- Easy bleeding (interfere with platelet function)
Uncommon but potentially serious:
- Serotonin syndrome (confusion, agitation, diaphoresis, vomiting, fever, diarrhoea and muscle twitching
and loss of consciousness)
N.B The majority of side effects will only last 1-2 weeks while others such as decreased libido and
erectile dysfunction tend to persist. Risk of serotonin syndrome is important to consider when
prescribing other medications affecting the serotonergic pathways.
Continuing to drink whilst on an SSRI will increase drowsiness.
Question 9 : SC
Question Information:
Lucy is currently on 2 weeks holiday and will be staying with Jack to keep an eye on him and help get
the farm back on track. She usually visits once a month to see her father. You also discuss with Lucy
and Jack options for psychological adjunctive therapies in the future.
Question:
What is the most appropriate follow up for Jack and Lucy?
Choice 1: Let Jack know he should be fine now with no follow up appointment necessary Score : -1
Choice Feedback:
Incorrect. SSRIs may show an effect after 2 weeks but can take up to 4 weeks to take full effect. Jack
should be proactively managed for need for titration of dose depending upon efficacy and side effects.
Choice 2: Ask Jack to visit you weekly to check his response and progress Score : 0
Choice Feedback:
This is an unreasonable request for Jack as he lives 2 hours away, however he may be able to keep in
contact via phone or email. The treating doctor should respect that Jack may not be able to get away
from the farm that often. Once a month after initial follow up is more reasonable however, you should
encourage Jack to come if he feels worse or if there is any change. Telemed/tele-health medicine
option could also be considered (see comments in Synopsis).
Choice 3: Ask Lucy to keep a close eye on him for the next two weeks, after that he should be fine with no follow
up necessary Score : 0
Choice Feedback:
Incorrect. SSRIs may show an effect after 2 weeks but can take up to 4 weeks to take full effect. Jack
should be proactively managed for need for titration of dose depending upon efficacy and side effects.
Telemed/tele-health medicine option could also be considered (see comments in Synopsis).
Choice 4: Ask Lucy to keep a close eye on him for the next two weeks. Suggest a follow up with them both before
Lucy goes back home and then once a month unless anything changes Score : 1
Choice Feedback:
Correct. As Jack lives 2 hours away, and will not be able to get away from the farm that often, however
contact can be encouraged via phone or email and a face-to-face appointment at one month after initial
follow up is reasonable. You should however, encourage Jack to come back if he feels worse or if there
is any change. Telemed/tele-health medicine option could also be considered (see comments in
Synopsis).
Choice 5: Arrange follow up in a month to check his response and progress Score : 0
Choice Feedback:
This may be appropriate, however as Lucy will still be here in 2 weeks it would be best to have her keep
an eye on Jack and to see Jack a bit earlier to make sure he is not getting any side effects from the
medication. It is important to ensure Lucy has your phone number and email address should she have
any acute concerns about her father's condition. Telemed/tele-health medicine option could also be
considered (see comments in Synopsis).
Synopsis
The diagnostic criteria for major depressive disorder as per the DSM V is as follows(2);
A.
Five (or more) of the following symptoms have been present during the same 2-week period and
represent a change from previous functioning; at least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels
sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and
adolescents, can be irritable mood.)Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either subjective account or
observation).Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of
body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children,
consider failure to make expected weight gain.)Insomnia or hypersomnia nearly every day.Psychomotor
agitation or retardation nearly every day (observable by others, not merely subjective feelings of
restlessness or being slowed down).Fatigue or loss of energy nearly every day.Feelings of
worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not
merely self-reproach or guilt about being sick).Diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective account or as observed by others).Recurrent
thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide.
B.
The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
C.
The episode is not attributable to the physiological effects of a substance or to another medical
condition.
Depression and mental health problems are highly prevalent in rural areas. Although there was no
significant difference in the number of males reporting mental health disorders amongst rural, remote
and metropolitan areas, there was a significant difference in the number of men seeking professional
help. There were a significantly less number of males from rural and remote areas seeking help
compared to their urban counterparts. There is also a higher rate of suicide in rural areas which has
been shown to be 1.2 to 2.4 times greater compared to the metropolitan cities.(3)
Looking specifically at farmers, suicide rates have increased so much that the rate of crop growth has
been overshadowed with the increase in the growth of suicide cases.
Management of depression(4)
Pharmacological management
Antidepressant therapy is indicated for severe depression with the recommended first line treatments
being an SSRI or an SNRI. Antidepressants should show an effect after 2-4 weeks. Side effects of
SSRIs include;
Nausea,
Sexual
fatigue, agitation, diarrhoea, headaches, insomnia
dysfunction
Beware
of manic switch in patients that actual have bipolar affective disorder
Non-pharmacological management
Cognitive behavioural therapy (CBT) is the first line recommended treatment for mild to moderate
depression.
Studies have shown that antidepressant therapy with CBT gives the best results.
Comment from a rural practitioner in South Australia: 'I work 800km from Adelaide and in SA we would
do a tele mental health assessment with a psychiatrist via Rural and Remote Mental Health service if
we were concerned. This takes a couple of days to organise; there are community nurses who will
either phone, telemed/skype or visit for followup; all GPs would do a Mental Health care plan to access
psychology services which occur as visiting services or by telemedicine.'
References
1. Prevention CfDCa. Suicide: Risk and Protective Factors 2015.
2. Depressive Disorders. Diagnostic and Statistical Manual of Mental Disorders.
3. Tanya M Caldwell AFJ, Keith BG Dear. Suicide and mental health in rural remote and metroplitan
areas in Australia. Medical Journal of Australia. 2004;181(7):10.
4. Murtagh J. John Murtagh's General Practice. 4th ed. Sydney: McGraw-Hill Australia Pty Ltd; 2007.
5. Kairi Kõlves, Allison Milner, Kathy McKay & Diego De Leo (eds) (2012): Suicide in rural and remote
areas of Australia. Australian Institute for Suicide Research and Prevention, Brisbane.
6. NPS Medicinewise (2016). www.nps.org.au. Retrieved on: 8 May 2016
Wagga Wagga
May 2016