Mental health: Case study

Last updated: Thursday, June 16, 2016

Lucy is a 27-year-old woman who suffered a stillbirth 6 months ago after unexpectedly falling pregnant. She sits and weeps for long periods of time and has been unable to talk to anyone about how she feels. Although her mother is alive and well, she lives 200 miles away. She currently lives with her husband. 

Lucy suffers from epilepsy and currently takes sodium valproate. Investigations suggest the valproate was unlikely to have caused the stillbirth. 

Her appetite is poor, she has lost 2 stones in weight and she sleeps poorly, often awakening at 4am thinking how cruel the world is and how she might as well end it all. She cannot cope with her job as a nursing assistant and is not looking after her home or doing any cooking. She constantly argues with her husband who thinks that enough time has passed now and she should be able to get back to work. 

1. What do you think might be Lucy's diagnosis?
  • Depression 
  • Differential diagnosis of postnatal depression. 

2. What aspects of her story made you think this was her diagnosis?
  • Low mood 
  • Suicidal ideation 
  • Reduced and interrupted sleep 
  • Not looking after herself 
  • Weight loss 
  • Symptoms for more than two weeks 

Lucy visits her GP and is prescribed amitriptyline 50mg at night for a month. Four days later she is admitted to an acute psychiatric ward following an attempted overdose. She has no past psychiatric history. 

3. Comment on the appropriateness of the prescription.
  • Not appropriate as Lucy has epilepsy: tricyclics decrease the seizure threshold, amitriptyline being the most convulsive. 
  • Tricyclics are also toxic in large doses, e.g. overdose.
  • Furthermore, there is an interaction to consider. Amitriptyline levels are increased by valproate, and the pharmacokinetics of valproate can be affected by amitriptyline.

4. Which antidepressant would you recommend for Lucy, and why?
  • You could choose an option such as sertraline or citalopram due to lack of interactions with anticonvulsants, and they are less likely to reduce seizure threshold. 
  • For the same reasons, mirtazapine might be an appropriate second choice should Lucy not respond to sertraline/citalopram or be intolerant of side effects. 

5. What events in her life may be causing or exacerbating her condition?
  • Recent pregnancy.
  • Loss of baby. 
  • Husband not supportive. 
  • Mother lives over 200 miles away. 
  • ? Co-morbidity (epilepsy). 
  • ? Social circumstance (needs help at home, feels isolated) 

6. How could you encourage compliance with an appropriate treatment regimen?
  • Involve her husband in the treatment plan. 
  • If you have the opportunity to counsel Lucy you could educate her about antidepressant treatment, including: onset of 4 weeks to action; need to continue for at least 6 months after recovery if first episode; possible withdrawal effects if stop suddenly.