Thanks to everyone who contributed to the discussions about Mrs Farlon a 72 year old lady who had presented very low in mood.
You can see the highlights of the discussion on Twitter in the storify.
This week’s question setter was Dr Clare Wadlow, Clinical Teaching Fellow at UCL Medical School and ST5 in Psychiatry.
Information available at the start of the week:
Mrs Margaret Farlon, a 72 year old woman, is very low in mood and not enjoying her usual activities. She presented to the Emergency Department with her daughter, Ellen last night as she has now stopped caring for herself.
Ellen said that her mother had become unwell gradually over the past month following an attempted burglary at her flat. She lives alone and was not eating or washing for the past 3 days. She denies active suicidal ideation but says she wishes she didn’t wake up that morning.
She was dehydrated and given a litre of saline IV in the ED. Her blood tests after this were normal as was her baseline physical examination. Following review by the on call psychiatrist, she reluctantly agreed for informal admission to the Old Age Psychiatry Ward.
You are the junior doctor on the ward looking after Mrs Farlon. She has not slept well overnight and refused breakfast. When you assess her she barely responds to you, she looks at the ground and any movements she makes are extremely slow.
Question 1: What other information might aid in your assessment? ?
Further information released during the week:
- HPC: One month ago, Mrs Farlon awoke in the night to the sound of banging. She was very frightened so she called the police. They disturbed a man trying to enter her house but he ran away. Since this time she has had difficulty sleeping. Her appetite, mood and energy levels have all decreased. She has felt on edge and prefers to be around others. She has noticed her mother’s oral intake is very poor and that she is waking up very early. She says her mother has talked about feeling guilty and thinks that the attempted burglary is somehow her fault, when she talks like this Ellen does not understand what her mother is getting at and cannot reassure her.
- SHx: Mrs Farlon lives alone since her husband died seven years ago from an MI. She normally attends coffee mornings at church twice a week and meets with a neighbour to paint once a week. She is an avid reader and occasionally goes into central London to see a play with her neighbour. She is normally independent around her ground floor flat. There has been no concerns about her memory.
- PPHx: Mrs Farlon has a history of one episode of post natal depression after birth of daughter. Treated successfully by the GP with an SSRI. No other Past Psych history or family history of psychiatric illness.
- PMHx: She is normally fit and well. She takes Amoldipine 5mg for high blood pressure and Atorvastatin 20mg. She has been on these medications for 5 years. She has no known drug allergies.
- Substances: She drinks alcohol rarely, only Christmas and birthdays. She is a non-smoker.
- Personal Hx: She is a retired English teacher, being born and brought up in North London. She was an only child to a single mother. Her father having died when she was just a newborn from unknown causes. Met and married her husband who was an accountant, when she was 20. Busy, happy life, quite sociable.
Further questions discussed on Twitter:
Question 2: The patient’s daughter see’s you on the ward and asks if her mother may be better at home – what risks are there if she is discharged? ?
Question 3: She agrees to stay on the ward but continues to refuse food, what treatments could be considered?
Question 4: She stops drinking and the Consultant decides she needs ECT. What tests do you need to do before the ECT and who else do you need to contact?
Question 5: She and her daughter oppose ECT, should people be given the treatment against their wishes?
1. How dangerous a severe depression can be in the elderly population
2. ECT can be a life saving, effective and essential treatment.
3. The changes to the legal framework around involuntary ECT since the updated Mental Health Act in 2007.
4. What work up people need before ECT.
Guidelines for the management of depression in adults
- NICE guidelines CG90 – Depression in adults: The treatment and management of depression in adults. http://publications.nice.org.uk/depression-in-adults-cg90/guidance#step-4-complex-and-severe-depressionParticularly section 1.10.4
Helpful information leaflets from the Royal College of Psychiatrists
Mental Health Act Information
Dr Clare Wadlow, Clinical Teaching Fellow at UCL Medical School and ST5 in Psychiatry, says:
This was an interesting scenario which brought out some important points surrounding the assessment of depression, management options and problems with declining treatment.
Clinical Assessment and Risk Evaluation
This patient has a severe depression. Probably triggered by the stressful life event of the attempted burglary which has left her with a poor sleep pattern. She has key symptoms of anhedonia, low mood, early morning wakening and guilty cognitions. She may well now be experiencing a psychotic depression given some of the ideas she expressed to her daughter. She is at risk given her age, that she lives alone and has had a previous episode of depression.
Risks of her returning home would include self neglect – poor self care and poor oral intake. She may well become dehydrated again and confused. She denies suicide but she has guilty cognitions and a passive death wish, if she deteriorates further she may be at risk of harm to herself by way of self harm or suicide. There is no evidence that she is a harm to others. She has marked psychomotor retardation and says very little, she may progress to a depressive stupor.
The first approach would be to take a full and detailed history and examination, utilising her daughter and hopefully the neighbour who knows her well to provide collateral information. She would need an MMSE, a full physical examination, close monitoring of her renal function, urine disptick and an ECG. She will need to be on a food and fluid chart and at least initially close observation on the ward. Offering of an activity program would be helpful and ward staff should try to build a therapeutic relationship with her and offer psychoeducation to her and her daughter regarding depression and likely treatments.
As she seems to be deteriorating on the ward and the progression of her now severe depression has been rapid, she is definitely a candidate for ECT. The strongest indication in this woman is her poor oral intake, particularly fluids which has been shown to have had an impact on her renal function. Antidepressant medication should of course be offered and a medication such as Mirtazapine would be appropriate given its helpful side effects of improving sleep and appetite. Unfortunately often compliance is poor. Short term use of sedative medication for sleep may be useful but definitive treatment for this woman seems urgent.
ECT is a relatively fast, safe and effective treatment for severe depression. It still has a bad reputation and is poorly understood by most. In this case it seems appropriate, particularly given the poor oral intake and deleterious effect on her physical health.
Prior to embarking on ECT, patients will need a review by an anaesthetist. Each trust probably has their own protocol/policy for pre ECT but they are likely to need a full set of bloods and ECG. They should have an MMSE prior to treatment and at regular intervals during the course of ECT. It is also good practice to monitor their depressive symptoms on an objective scale such as Becks Depression Inventory intermittently during treatment.
Frequent reviews of mental state and of capacity and consent should be undertaken and noted during the course of treatments.
In this case, after further discussion with Mrs Farlon and her family, her daughter understood why the treatment was necessary. Unfortunately Mrs Farlon continued to believe that there was no point in her having the treatment as she was certain that nothing would help her feel better.
There has been tightening of the legal framework around delivering ECT since the revised Mental Health Act in 2007. The emphasis is now placed on gaining patient’s informed consent to give ECT and every effort should be made to help them understand the risks and benefits of both continuing with untreated severe mental illness versus receiving ECT.
The new amendment to the act states that ECT may not be given to a patient who has capacity to refuse to consent to it. However in this situation, Mrs Farlon does not have capacity to fully understand or weigh up the risks and benefits of ECT (i.e. that she might get better), as the depressive illness is clouding her judgement. The guidance is actually to avoid using the mental capacity act alone for giving ECT but rather if a patient is unable to fully understand why ECT is essential in their treatment plan, they may be subject to a Section 58a. As in this case, their consultant and an Approved Mental Health Professional (AMHP) would need to apply for Section 58a. They also now need an independent second opinion Section12 approved doctor (SOAD) to agree that the ECT is essential before the course can be undertaken.
In rare circumstances, ECT may be given under emergency treatment order Section 62 but only if the treatment is immediately necessary to save the patient’s life or to prevent a serious deterioration of their condition.