Major depressive disorder is a leading cause of disability worldwide. Over the past years, the prevalence of depression indicators has increased. Major depressive disorder is associated with poor health, impairment, substance use disorders, mortality, disease and economic burden(1).
A 55-year-old Caucasian male with a long history of alcohol abuse was taken in June 2020 by the ambulance to the emergency department of the Craiova Clinical Hospital of Neuropsychiatry, Psychiatry Clinic I, for restlessness, autolytic impulses, low impulse control, and tremor in the extremities.
Medical family history
Insignificant in the context of the mental illness.
Psychiatric and medical history
Many presentations at the emergency department of the Clinical Hospital of Neuropsychiatry of Craiova for mental and behavioral disorder due to use of alcohol.
Chronic obstructive pulmonary disease (he takes salbutamol 5 inhalations/daily).
Pulmonary tuberculosis 10 years ago.
Living and working conditions
The patient is living alone in a rural environment, in the canton of a forest. He satisfied the military service. He worked at the chemical plant. Now he benefits from social aid. He divorced 28 years ago. The couple had two children together, aged 32 years old and 34 years old, with whom he has no contact at this time.
Alcohol and tobacco use
He smokes 20 cigarettes daily and drinks alcohol almost daily.
General appearance: conscious, overweight (BMI = 29).
Vital signs: HR = 89 bpm, BP = 140/95 mmHg,T = 36.7°C.
Respiratory symptoms: shortness of breath, cough, hyperresonance on percussion, prolonged expiration, wheezing, expanded chest.
Appearance: careless attire; neglected self-hygiene; facial expressions and gestures that betray anxiety; achievable psychic and verbal contact.
He denies perceptual productive phenomena at the time of examination.
Spontaneous hypoprosexia, difficulties in concentration.
Fixation and evocative hypomnesia.
Slightly slowed down ideo-verbal flow, low-pitched voice, thought content focused on the idea of uselessness, incurability, incapacity; diminished capacity for logical operation, abstraction and generalization.
Social withdrawal and social isolation; diminished self-preservation instinct; low self-esteem; psychoemotional lability; autolytic ideas with the elaboration of a suicide attempt by self-burning; anxiety; loss of interest in all normal activities; feelings of worthlessness and guilt fixating on past failures.
Fatigability, diminished vitality.
Poor social integration and adaptability.
Insight: partially present.
Blood tests: lymphocytes = 1.31x109/L; red blood cells = 4.59 x1012/L; red cell distribution width = 14.5%; hematocrit = 40.2%.
Severe depressive psychic structure, he manifests poor coping methods and poor strategies, lacking strength and focus (high self-blame, persistent and intense ruminating, poor positive refocusing, poor action planning, catastrophizing and blaming others). Mood fluctuations in anxiety, sleep disorders, marked fatigue, social withdrawal.
Interpersonal: he considers himself defenseless, he fears abandonment, he feels discouraged.
Cognitive: pessimistic, he shows the feeling that things will not improve. Internal representations of the past seem to be forgotten, removed from memory, leaving the patient feeling deprived.
Major motivational and relational deficit, marked tendencies towards introversion and social isolation, psychoemotional lability, anhedonia, diminished vitality.
Major depressive disorder as concluded from the anamnestic data and psychiatric examination which comply to the ICD-10 citeria.
The collaboration between psychiatrist and psychologist was essential. The treatment for this patient included both medicines and psychotherapy. During hospitalization, the patient was given haloperidol 25 drops/daily, sodium valproate 1000 mg/daily, and escitalopram 10 mg/daily.
Future proposed plan
Avoidance of drugs with increased hepatotoxicity.
Avoidance of alcohol use.
Complex and multidisciplinary therapeutic approach with a good psychiatrist-psychotherapist collaboration.
Pneumological evaluation for the chronic obstructive pulmonary disease.
Prolonged counseling of the patient on depressive symptoms and an awareness regarding the obligation to follow the therapeutic scheme.
Appropriate and prompt antidepressant treatment that takes into account the patient’s comorbidities.
At discharge, we recommended that the patient continues the treatment with sodium valproate sachets 1000 mg/daily, escitalopram 10 mg/daily and visit the psychiatric department once a month.
Expected outcome of the treatment plan
Short-term: favorable, with a decrease until complete remission of depressive symptoms.
Long-term: due to multiple previous hospitalizations and all the risk factors, low treatment compliance is expected.
The environment, the fact that he is a Hungarian citizen, living alone, with an abusive alcohol use, have an important impact on the patient’s compliance, due to the lower level of education, limited access to investigations and low economic potential, which leads to decreased compliance and therapeutic adherence, many complications, unfavorable evolution and poor prognosis.
His case impressed us very much, so we started a collaboration with the “Sfântul Grigorie Teologul” Theological Seminary and the Jewish Community so the patient got a job in the Jewish cemetery, where he has a secure home in the cemetery yard, food, all utilities and salary.
In the past year, the patient has stopped drinking alcohol, he comes to a psychiatric check-up every month and his mood has improved. The treatment has been modified and now he is taking duloxetine 60 mg/daily, quetiapine 200 mg/daily, alprazolam 0.5 mg/daily and comes to a psychiatric check-up every month. He no longer has recurring thoughts of death, he makes plans for the future, occupies his time with many activities and is more sociable.
The patient is always supervised, the Orthodox clergyman meets frequently with him and if he notices any mood change, he informs us. This collaboration is extremely important because we can have an early intervention, so that there is no need for the patient to be admitted to the psychiatric department.
For an adequate therapeutic success, there must be a rational understanding of suffering. In order to understand the patient, you should neither excuse him or judge him, nor even to put yourself in his place, but only to feel his behavioral reactions. Even though we are talking about individual therapeutic activity or institutional care, we must understand these reactions because the development of diagnosis and prognosis cannot be done without starting with discovering the meaning of the symptoms(2).
Listening and empathizing with the patient’s suffering, we discovered an insecure, anxious attachment, a sensitivity to small fluctuations in mood and the actions of others, the patient considering himself responsible for things without a real reason. He has a tendency to do or say things that he later regrets, further increasing his anxiety and suicidal tendency. Over the years, the patient formed several defense mechanisms and this could be seen from the first hospitalizantions. The most notable were:
Denial – his refusal of reality even though he was put in front of clear evidence.
The return to one’s own person – the possible suicidal tendencies can be explained by the fact that the patient ends up feeling miserable because he feels a violent rage against someone else. The fact that he was forced to give up everything he had, to change his lifestyle and live in a canton built in him a frustration that contributed to a form of hostile aggression.
Evasive behavior – from the first hospitalizations, the patient developed this behavior trying to lie, conscious and calculated, most likely in order to defend against anxiety.
Repression – the patient avoids discussing certain sufferings because they caused him pain and embarrassment, as well as a reluctance to protect himself from interpersonal relationships, social anxiety, fear of exclusion or humiliation.
The depression-somatic disorder association has the potential to complicate the patient’s perception of the disease, the sensitivity threshold of generalized symptoms being increased compared to those associated with somatic disease(3).
It should be the task of professionals to look for the best form of reintegration. For some patients, it will be a sheltered living and working, a protective climate of a home or the society in which they can take up their role again. Being mentally ill could become a label and a stigma when it comes to going back to a normal life. Many studies support the importance of enhancing social network and social support to strenghten the rehabilitation process of the patients(4).
In the present situation, it has been proven that, regardless of specialty, ethnicity or religion, humanity and the common interest in helping the hopeless prevail.
Major depressive disorder is highly comorbid, prevalent and disabling. The need to reduce the prevalence of major depressive disorder remains. There is a need for an effective multidisciplinary approach and appropriate and prompt antidepressant treatment that takes into account the patient’s other comorbidities. Social and professional reintegration is imperative for the well-being of the patient.
This kind of approach is always the key to success, fighting on many fronts but for a common goal: relieving the patient’s suffering.