Depression and health inequalities

Background (age, sex, occupation, baseline function)

• 54-year-old male who currently lives alone
• Recent loss of employment as a joiner for a local window company
• Unmarried and lives alone
• No children but father and a supportive friend who live nearby
• Has a dog

History of presentation/reason for review

• Attends the practice with low mood after starting antidepressant therapy two months ago for depression
• He attends with a supportive friend who is concerned as he has cancelled plans to meet and avoids contact with others, becoming more socially isolated
• On a telephone review four weeks ago, he reported no change to his mood but today has signs of self-neglect
• Has lost half a stone in weight due to reduced appetite, early morning wakening, increased rumination, and a loss of motivation
• He is feeling stressed and anxious about his financial situation, having recently lost his job. He is in rent arrears and has a number of credit card debts. He reports difficulty with managing the rising costs of heating his home and is only eating one meal a day. His internet has recently been cut off

Current medical history and relevant co-morbidities

• Depressive episode, started on antidepressant therapy two months ago
• No previous past medical history of depression/ anxiety
• Asthma (diagnosed in childhood) well-controlled
• Family history of hypothyroidism
• Harmful use of alcohol in the past

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drugs reactions (ADRs): nil

Currently prescribed: 

• Clenil® (beclomethasone dipropionate) 100microgram meter dose inhaler: two puffs twice a day
• Citalopram 20mg tablets: one tablet daily
• Salbutamol inhaler 100mcg meter dose inhaler: two puffs up to four times a day (two inhalers ordered in last 12 months)

Over the counter medicines: nil

Lifestyle and current function

At review:  

• Does little exercise and spends most of his time watching TV at present.
• Has consumed alcohol to harmful levels in the past when has felt anxious or sleep has been poor. Not currently drinking alcohol to harmful levels
• Does not smoke cigarettes but does use cannabis on a nightly basis as he finds that this helps with his sleep
• Diet is high in fat, sugar, salt. Doesn’t tend to cook for himself. Finding food expensive.

“What matters to me” (ideas, concerns and expectations of treatment)

• When asked about his goals he struggles to identify any other than wanting to feel better, but feels helpless as to how to change his situation

Observations, examinations and results 

Note: local laboratory reference ranges may vary

Recent blood tests

• including thyroid function tests within normal range
• low in folate (due to dietary deficiency)
• Weight 95kg, Height 178cm, BMI 30kg/m²
• PHQ-9 score increased from 14/27 (moderate depression) eight weeks ago to 20/27 today (severe depression).

Most recent relevant consultations

• Avoiding eye contact and when asked about mood becomes tearful reporting fleeting, occasional thoughts of ending his life. Whilst no current active plans he discloses has thought about different ways of ending his life (including taking an overdose). He is adamant he would not act on these, citing his father and dog as protective factors.
• He reports taking his citalopram every day for eight weeks but felt little/ no benefit.
• More recently has shared his difficult social circumstances, previously felt unable to do this because he felt ashamed. Building trust with the same healthcare professional (HCP) has helped him feel confident to disclose these wider social issues.

Person specific issues to address

• “Wants to feel better”
• PHQ-9 score increased

 

Person specific issues to address

• Essential medication: Clenil®
• Folic acid replacement recommended

 

Person specific issues to address

• Episode of depression, possibly related to loss of employment. Trial of citalopram 20mg daily – ineffective
• Asthma well controlled however change dosage instructions for salbutamol to two puffs when required for breathlessness

 

Person specific issues to address

• Moderate depressive episode with worsening signs and symptoms, citalopram ineffective

Management with combination of:

• Switch antidepressant as no effect at eight weeks of therapeutic dose
• Psychological intervention (e.g. CBT)
• Non-medicalised interventions e.g. exercise such as walking
• Given history of harmful alcohol use when anxiety/insomnia, supportive general discussion re negative impact of alcohol on sleep and mood (and also increases risk of gastrointestinal side effects/GI bleeding with antidepressants)

 

Person specific issues to address

• Discuss worsening symptoms and possible increasing self-harm/suicide risk. Worsening symptom advice and out of hours telephone numbers (e.g. Breathing Space)
• Follow up review within two to four weeks, or sooner if considered appropriate
• Current medicines have low overdose fatality risk
• Try and ensure continuity of care with the same HCP where possible. Offer in-person appointments rather than telephone-based. Caution re digital exclusion given financial situation
• Discussion about potential harmful effects of cannabis on mental health (paranoid thoughts, anxiety) and lung health. General sleep hygiene advice given

 

Person specific issues to address

• Dry powder inhalers are currently more environmentally sustainable than metered dose inhalers. Once mental health improved consider inhaler device
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Switch antidepressants: last dose of citalopram today, start sertraline 50mg daily tomorrow
• Onset of action: sertraline likely to show effect in two to four weeks, review four to six weeks
• Safety information: suicide prevention advice, contact telephone numbers
• Low intensity exercise such as walking may help
• Friend attending with him is supportive, safety information provided as above
• Try and ensure continuity of care with the same HCP where possible. Offer in-person appointments rather than telephone-based. Caution re digital exclusion given financial situation
• Social interventions – link with practice-based welfare advisor for money advice (fuel poverty, food poverty, rent arrears); link with practice-based community link worker to explore options for community supports (e.g. gym pass, walking group, address social isolation)
• If individual wants to change to AIR/MART they can but asthma is well controlled so not a priority