Depression in primary care: assessing suicide risk

Major depression is a common condition seen in the primary care setting. This article describes the suicide risk assessment of a depressed patient, including practical aspects of history-taking, consideration of factors in deciding if a patient requires immediate transfer for inpatient care and measures to be taken if the patient is not hospitalised. It follows on our earlier article about the approach to management of depression in primary care.

Managing depression in primary care

Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient.

Major depression in primary care: making the diagnosis

Major depression is a common condition seen in the primary care setting, often presenting with somatic symptoms. It is potentially a chronic illness with considerable morbidity, and a high rate of relapse and recurrence. Major depression has a bidirectional relationship with chronic diseases, and a strong association with increased age and coexisting mental illnesses (e.g. anxiety disorders). Screening can be performed using clinical tools for major depression, such as the Patient Health Questionaire-2, Patient Health Questionaire-9 and Beck Depression Inventory, so that timely treatment can be initiated. An accurate diagnosis of major depression and its severity is essential for prompt treatment to reduce morbidity and mortality. This is the first of a series of articles that illustrates the approach to the management of major depression in primary care. Our next articles will cover suicide risk assessment in a depressed patient and outline the basic principles of management and treatment modalities.

Treatment-emergent hypomania or bipolar disorder? a case report

This case report highlights the clinical dilemmas encountered in deciding the diagnostic status of persons with unipolar depression who develop hypomania during antidepressant/ electroconvulsive therapy. Methods: We report a case of a 52 year-old Chinese lady, diagnosed with unipolar depression, which developed hypomania after she was started on T. Fluvoxamine 100mg daily and completed 8 sessions of Electroconvulsive therapy. Results: Her diagnosis was revised to Bipolar Disorder and she was treated with T. Sodium Valproate 400mg twice daily after which she improved. Conclusion: Treatment-emergent hypomania is likely a subtype of bipolar spectrum disorder and patients with Treatment – emergent Hypomania should be treated as Bipolar Disorder.

Behavioural variant frontotemporal dementia: a case report

This case report highlights the challenges encountered in arriving at the diagnosis of a case with ‘behavioural variant Frontotemporal Dementia’. Methods: We report a case of ‘behavioural variant Frontotemporal Dementia’ diagnosed in a 49 year old Chinese lady. Results: This patient was misdiagnosed as Obsessive Compulsive Disorder (OCD), Parkinson Disease and Psychotic Disorder Not Otherwise Specified (NOS), deemed not responding to medications which was later complicated with Neuroleptic malignant syndrome (NMS). Her diagnosis was revised only after 2 years, after which her behavioural problems stabilised, bringing some relief to her family’s distress. Conclusion: Though not rare, ‘behavioural variant Frontotemporal dementia’ is often misdiagnosed and patients and their families suffer unnecessary suffering before the condition is finally diagnosed.