Mental health: Case study answers
Lucy has 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?
2. What aspects of her story made you think this was her diagnosis?
Lucy visits her GP and is prescribed amitriptyline 25mg 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.
4. Which antidepressant would you recommend for Lucy, and why?
5. What events in her life may be causing or exacerbating her condition?
Recent pregnancy
6. How could you encourage adherence with an appropriate treatment regimen?
7. Are there any other medicines management considerations?
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Post-natal depression as her illness started within 12 months of giving birth.
2. What aspects of her story made you think this was her diagnosis?
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Low mood – sitting and weeping for long periods
- Suicidal ideation
- Early morning wakening with negative thoughts
- Lack of motivation to do any cooking or look after the home
- Weight loss
- Symptoms for more than two weeks
Lucy visits her GP and is prescribed amitriptyline 25mg 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.
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NICE recommend a generic SSRI for most patients requiring antidepressant treatment. Although the sedative effects of tricyclics may appear to be beneficial in patients with poor sleep, they are associated with a range of other adverse effects such as dry mouth, constipation and blurred vision. Postural hypotension can increase the risk of falls and reduced reaction times may present extra hazards for driving.
- The therapeutic dose of amitriptyline for depression is around 150mg. Lucy has been started on 25mg daily which is below the usual initial dose of 50mg daily.
- Lucy has epilepsy and although all antidepressants decrease the seizure threshold to some extent, amitriptyline is one of the most pro-convulsive.
- Tricyclics are also toxic in large doses (e.g. overdose). No risk assessment appears to have been undertaken to establish whether the patient is likely to attempt self-harm.
- 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?
- As above, NICE recommend a generic SSRI first-line for most patients requiring antidepressant treatment. Of these the most suitable options for Lucy would be sertraline or citalopram due to the lack of interactions with anticonvulsants, and because they are less likely to reduce seizure threshold at therapeutic doses. 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
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Trauma of the stillbirth
- Husband not obviously supportive
- Mother lives over 200 miles away so is geographically distant
- Co-morbidity (epilepsy)
- Social circumstance (feels isolated)
- Pressure at work
6. How could you encourage adherence with an appropriate treatment regimen?
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If you have the opportunity to talk to Lucy you could inform her about antidepressant treatment including: how it may contribute to helping her feel better, the time to onset of action, the need to continue for at least 6 months after recovery if this is her first episode and the possible withdrawal effects if treatment is stopped suddenly. Consider providing some written information to support these points such as Choice and Medication leaflets (see Information sources). You could also ask if involving her husband in the treatment plan would be helpful. .
7. Are there any other medicines management considerations?
Yes – the valproate and pregnancy prevention programme. This needs to be picked up almost certainly at a separate meeting and with the person who manages Lucy’s epilepsy. At this stage simply advising that valproate is no longer routinely recommended as an epilepsy treatment for women who are of childbearing potential is sufficient. This may not be easy as in her current state of mind she may feel the stillbirth was punishment for being on this drug. Remind Lucy that valproate wasn’t to blame for what happened but her epilepsy treatment will need to be reviewed. This is a regulatory requirement.
As further learning you may like to listen to Sarah’s story of experiencing a stillbirth.