Case
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Greeting and personal details
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Current complaints
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Past medical history and hospitalizations
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Medications
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Allergies and intolerances
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Gynecological history
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Social history
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Substance use and drugs
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Family history
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Summary and further steps
👨⚕️ Hello, my name is Dr. Schneider. I am responsible for you today. How may I address you?
👩 My name is Anna Berger.
👨⚕️ Ms. Berger, I would like to ask you some questions so I can understand how you are doing. Is that okay?
👩 Yes.
👨⚕️ How old are you?
👩 I am 42 years old.
👨⚕️ How tall are you and how much do you weigh?
👩 I am 1.67 meters tall and weigh approximately 69 kilograms.
👨⚕️ Who do you live with?
👩 With my husband and our two children.
👨⚕️ What brings you to us today?
👩 I have been feeling mentally unwell for several weeks. In the last three weeks it has become noticeably worse.
👨⚕️ What has changed?
👩 I have almost no interest in anything anymore. Even things that used to make me happy now leave me indifferent. I can hardly motivate myself and I constantly ruminate about all sorts of things.
👨⚕️ How are you sleeping at the moment?
👩 I wake up around five in the morning and cannot fall back asleep afterwards.
👨⚕️ How are you during the day?
👩 I am exhausted and have no energy. Even small tasks are too much for me.
👨⚕️ Can you concentrate well in everyday life?
👩 No. Often I can hardly follow a question or do not know how to answer.
👨⚕️ How is your appetite?
👩 I eat about as much as usual.
👨⚕️ Have you lost weight unintentionally recently?
👩 No, not as far as I know.
Thoughts about life and personal safety
👨⚕️ What occupies your mind when you lie awake so long? 👩 I ruminate about what meaning my life still has. Sometimes I think it’s no longer worth it. I hardly see anything beautiful anymore. 👨⚕️ Thank you for speaking so openly about this. When you say life is no longer worth it: Have you thought about taking your own life? 👩 I have such thoughts, but I have not made a concrete plan. 👨⚕️ Have you already prepared anything or tried to harm yourself? 👩 No. 👨⚕️ Can you tell me if these thoughts become stronger during our conversation? 👩 Yes.Mood and family situation
👨⚕️ Has your mood also changed in interactions with your family? 👩 Yes. I get irritated quickly and often have outbursts of anger. I have yelled at my children several times. Afterwards I feel bad. 👨⚕️ How is the relationship with your husband at the moment? 👩 About two months ago we had conflicts. Lately I have also become increasingly suspicious of him. 👨⚕️ What do you mean by “suspicious”? 👩 I question more often what he says and does. I don’t really know why myself.Previous episodes
👨⚕️ Have you felt similarly before? 👩 Yes, about three years ago and before that about seven years ago. 👨⚕️ Were you under medical treatment then? 👩 No. 👨⚕️ Were there periods between these times when you had unusually high energy, needed little sleep and still were not tired? 👩 No, I don’t recall that.
👨⚕️ What medical conditions are known for you?
👩 I have high blood pressure. Three months ago I also had a heart attack.
👨⚕️ Were you hospitalized for the heart attack?
👩 Yes.
👨⚕️ Do you have any other conditions?
👩 I have had migraines for several years, about twice a month.
👨⚕️ Have you ever had surgery?
👩 No.
👨⚕️ Which medications do you take regularly?
👩 Captopril for high blood pressure. Since the heart attack I have been taking acetylsalicylic acid and clopidogrel.
👨⚕️ What do you take for the migraine?
👩 Mostly ibuprofen or naproxen. That usually helps.
👨⚕️ Do you take any other medications, herbal remedies or dietary supplements?
👩 No.
👨⚕️ Do you have allergies or do you not tolerate certain medications?
👩 I am not aware of any allergies.
👨⚕️ When was your last menstrual bleeding?
👩 About two weeks ago.
👨⚕️ Is pregnancy possible?
👩 Not to my knowledge.
👨⚕️ What do you do for a living?
👩 I work in an office.
👨⚕️ How are you coping at work currently?
👩 I find it difficult to concentrate and complete my tasks.
👨⚕️ Is there someone you can talk to about your complaints?
👩 My sister knows that I’m not doing well.
👨⚕️ Do you smoke?
👩 No.
👨⚕️ Do you drink alcohol?
👩 Rarely, occasionally a glass of wine.
👨⚕️ Do you use drugs?
👩 No.
👨⚕️ Are there mental illnesses in your family?
👩 My brother has bipolar disorder and my sister an anxiety disorder.
Summary and further steps
👨⚕️ Ms. Berger, I will summarize briefly: For several weeks you have had almost no interest or pleasure, low drive and many ruminating thoughts. In the last three weeks this has become noticeably worse. You wake early, are exhausted during the day and have difficulty concentrating. At home you have become more irritable. You also have thoughts that life is no longer worth living, and when asked you reported thoughts of taking your own life. You denied having a concrete plan or preparations. Is that correct? 👩 Yes. 👨⚕️ I take your complaints and these thoughts seriously. We will now discuss in more detail how to ensure your safety and what support you need today.-
Personal information
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Allergies
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Substance use and drugs
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Social history
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Family history
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Medications
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History
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Suspected diagnosis and differential diagnoses
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Further management – Therapy
Patient: Anna Berger
Age: 42 years Weight: approx. 69 kg Height: 167 cm
Dear senior consultant,
I would like to present Ms. Anna Berger to you.
No known allergies.
Non-smoker; rarely a glass of wine; no drug use.
Office work; married; lives with her husband and two children. Conflicts with husband for about two months. Her sister is informed about the psychological burden.
Brother: bipolar disorder.
Sister: anxiety disorder.
Captopril for arterial hypertension.
Acetylsalicylic acid and clopidogrel since the myocardial infarction.
Ibuprofen or naproxen for migraine attacks as needed.
Dosages were not specified.
The 42-year-old patient presented due to psychological complaints persisting for several weeks, which had markedly worsened in the last three weeks. She reported a pronounced loss of interest and pleasure, decreased drive and persistent rumination. She wakes around five in the morning and cannot fall asleep again afterwards. During the day she feels exhausted, low on energy and has reduced resilience. Her concentration is also impaired.
The patient expressed thoughts that life “is no longer worth it” and reported thoughts of taking her life when asked directly. She denied a concrete plan, preparations or a previous suicide attempt.
In family interactions she has become increasingly irritable. She reported frequent outbursts of anger and that she has yelled at her children several times. About two months ago there were conflicts with her husband. Lately she has become increasingly suspicious of him.
She had similar psychological episodes about three and seven years ago; no medical treatment was sought at that time. She did not recall periods with unusually increased energy and markedly reduced need for sleep when asked.
Somatic pre-existing conditions include arterial hypertension and an ST-elevation myocardial infarction three months ago. In addition she has suffered from migraine for several years with about two attacks per month, which respond to ibuprofen or naproxen. No prior surgeries are known. Her last menstrual bleeding was about two weeks ago; she does not consider pregnancy likely.
In the interview the patient appeared unkempt, with reduced eye contact and slowed speech. Her concentration appeared limited; she repeatedly answered “I don’t know.”
Depressive episode: Supporting features are the loss of interest and pleasure, reduced drive, early awakening, fatigue, concentration impairment and thoughts that life is no longer worth living. The complaints developed over several weeks and intensified in the last three weeks. There is currently no finding that clearly argues against this diagnosis.
Bipolar affective disorder: The brother’s bipolar disorder as a family risk factor speaks in favor. However, no prior phases with unusually increased energy and reduced need for sleep have been reported. This does not conclusively exclude a bipolar disorder. Hypothyroidism: Fatigue, lack of drive, slowed speech and concentration problems would be compatible with this. The pronounced loss of interest and thoughts about life’s meaning at the same time argue for an independent depressive symptomatology. Information on further typical signs of hypothyroidism is lacking; prior to laboratory testing it can neither be confirmed nor excluded. Concomitant anemia: It could exacerbate the fatigue and reduced resilience. It would not alone adequately explain the loss of interest, rumination and thoughts about the meaning of life. There is also no laboratory finding available yet to fully assess this.First an immediate assessment of suicide risk will be performed. The patient will be asked in more detail about the frequency and urgency of her thoughts, any possible intent, preparations and access to means. Until her current safety is clarified she will remain under personal supervision. In the case of acute suicide risk a psychiatric emergency assessment will be arranged immediately.
For somatic evaluation an examination and laboratory tests including a complete blood count and TSH will be performed.Physical examination
The patient is awake, responsive and oriented to time, place and person. She appears unkempt, maintains little eye contact and replies with marked delay. Speech is quiet and slowed; concentration is limited during the interview. Blood pressure is 132/82 mmHg, heart rate 72/min, respiratory rate 14/min, body temperature 36.7 °C and oxygen saturation 98% on room air. The skin appears slightly pale. Heart and lungs are unremarkable on auscultation. The abdomen is soft and non-tender. There are no peripheral edema. The focused neurological examination shows no focal deficits.Laboratory
| Parameter | Result |
|---|---|
| Hemoglobin | 10,8 g/dl |
| Hematocrit | 33 % |
| MCV | 76 fl |
| MCH | 24 pg |
| Ferritin | 11 µg/l |
| Leukocytes | 6,7/nl |
| Platelets | 286/nl |
| TSH | 2,1 mIU/l |
| Sodium | 139 mmol/l |
| Potassium | 4,2 mmol/l |
| Creatinine | 0,78 mg/dl |
| C-reactive protein | 1,8 mg/l |
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Scenario 1
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Scenario 2
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Scenario 3
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Scenario 4
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Scenario 5
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Scenario 6
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Treatment and monitoring of iron deficiency anemia
Start of treatment
In the patient, Sertralin chosen as therapy. The daily dose is increased according to the regimen marked in the quiz:| Period | Sertralin |
|---|---|
| Day 1–7 | 25 mg daily |
| Day 8–14 | 50 mg daily |
| From week 3 | 100 mg daily |
2nd follow-up after one month
On Sertralin 100 mg daily the patient reports a slight improvement in mood. Instead of eating only in the evening, she again has breakfast and dinner. The previously present wish to die is no longer present. The gastrointestinal complaints from the first week of treatment have completely resolved. Her energy, however, remains reduced. She can usually only do household chores in the late afternoon or evening. Therefore, Sertralin is increased to 200 mg daily and another follow-up in one month is scheduled.3rd follow-up another month later
Despite the dose increase, her mood remains depressed. She notices weight loss; her daily functioning is approximately as impaired as at the previous appointment. Therefore, the medication is switched to Bupropion changed.| Period | Bupropion |
|---|---|
| Day 1–7 | 150 mg daily |
| From week 2 | 300 mg daily |
Improvement, but with undesirable side effects
For treatment the patient initially receives Fluoxetin 20 mg once daily. After four weeks the effect is checked. Because the depressive symptoms have not sufficiently decreased, the dose is increased to 40 mg once daily. After some time the patient is free of depressive symptoms but reports decreased libido. The intake is then changed under medical supervision to 40 mg every other day. At a later follow-up the patient reports being satisfied with this dosing schedule.Depressive symptoms due to hypothyroidism
In another scenario the 42-year-old patient, in addition to her depressive symptoms, reports cold intolerance, constipation, and a swelling at the front of her neck. In this case the psychological complaints largely subside after treatment of the thyroid underactivity.History
The patient presents because she has scarcely felt interest or pleasure for several weeks. She finds it difficult to motivate herself for everyday tasks and ruminates a lot. In the mornings she wakes at around five o’clock and cannot fall back asleep afterwards. During the day she feels exhausted and has little resilience. In the last three weeks the symptoms have significantly worsened. She is more easily irritated than before, has shouted at her children several times and argued with her husband. She has also become more mistrustful of him. In conversation she says that sometimes “life is no longer worth it”. On direct questioning she reports that she occasionally has the thought of harming herself. She denies any concrete plan or preparations. These thoughts are repeatedly asked about at each subsequent presentation. When specifically asked about physical changes the patient reports: 👨⚕️ Are you colder more often than before? 👩 Yes. I even feel cold when my husband and the children find it comfortably warm at home. 👨⚕️ Has your bowel movement changed? 👩 Yes. Previously I could go to the toilet almost every day. Now sometimes it only works every three or four days. 👨⚕️ What have you noticed about your neck? 👩 It’s become thicker in the front. I noticed that a few weeks ago. 👨⚕️ Does the swelling hurt? Do you have problems swallowing or breathing? 👩 No. It does not hurt, and I can swallow and breathe normally. In the psychiatric history the patient reports only a mild episode about three years ago during which she was tired and down for a few weeks. She was able to continue managing her daily life at that time and did not require medical treatment. There have been no further similar episodes. Her brother suffers from bipolar disorder, her sister from an anxiety disorder. The patient herself has known arterial hypertension and an ST-elevation myocardial infarction three months ago. She takes Captopril and, since the heart attack, Acetylsalicylsäure and Clopidogrel. For about two migraine attacks per month she uses Ibuprofen or Naproxen as needed.Physical and mental examination
The patient is awake and oriented. She appears unkempt, makes little eye contact and speaks slowly. Her concentration is impaired; she answers “I don’t know” several times.| Vital signs | Finding |
|---|---|
| Blood pressure | 132/82 mmHg |
| Heart rate | 72/min |
| Body temperature | 36,7 °C |
| Oxygen saturation on room air | 98 % |
Laboratory and thyroid sonography
| Parameter | Finding |
|---|---|
| TSH | 14,2 mIU/l |
| Free thyroxine | 0,58 ng/dl |
| TPO antibodies | positive |
| Hemoglobin | 13,1 g/dl |
| MCV | 87 fl |
| Ferritin | 48 µg/l |
| Sodium | 139 mmol/l |
| Creatinine | 0,78 mg/dl |
Diagnosis
The elevated TSH, the decreased free thyroxine, the positive TPO antibodies and the sonographic finding indicate overt hypothyroidism due to Hashimoto’s thyroiditis. Cold intolerance, constipation, fatigue and psychomotor slowing fit with this. In this case the hypothyroidism is also considered the cause of the current depressive symptoms. The patient’s safety is continuously assessed because of her thoughts of self-harm, independently of this.Treatment and follow-up
Because the heart attack was only three months ago, thyroid treatment is started cautiously. The patient receives L-Thyroxin 25 µg once daily in the morning. During contacts particular attention is paid to palpitations or chest pain. Her mood and possible suicidal thoughts are also repeatedly assessed.-
A: Marked improvement after treatment of hypothyroidism
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B: Partial improvement after treatment of hypothyroidism
Follow-up after eight weeks
The patient tolerates L-Thyroxin well. Palpitations or chest pain have not occurred. She feels less cold and the constipation has somewhat improved. Her mood and concentration have also slightly improved. Free thyroxine is now within the reference range; the TSH is still 6,8 mIU/l. Therefore the dose is increased to L-Thyroxin 50 µg once daily in the morning.Follow-up after another eight weeks
TSH is now 2,9 mIU/l. The patient is no longer unusually cold and has regular bowel movements again. She is interested in her daily life again, can concentrate better and ruminates significantly less. Sleep and resilience have also improved. By her own estimate, her depressive symptoms have decreased by about 80–90%. She denies thoughts that life is no longer worth living or that she might harm herself at this follow-up. The patient continues L-Thyroxin 50 µg daily. Thyroid values, physical complaints and psychological state will continue to be monitored.Follow-up after eight weeks of thyroid treatment
The patient has been taking L-Thyroxin 25 µg once daily for eight weeks. She tolerates the medication well; palpitations or chest pain have not occurred. She feels less cold, and the constipation has somewhat eased. Her mood is also slightly better, however she continues to ruminate and feels limited in everyday life. Free thyroxine is again within the reference range, TSH is still 6,8 mIU/l. Therefore L-Thyroxin is increased to 50 µg once daily. Because of the myocardial infarction only a few months earlier, a telephone check after two weeks will inquire about tolerability, cardiac complaints and psychological condition. The next check of TSH and free thyroxine is scheduled for eight weeks after the dose increase.Follow-up after a total of 16 weeks of thyroid treatment
TSH is 2,9 mIU/l. The patient is no longer unusually cold and has regular bowel movements again. However, by her own assessment her depressive symptoms have only decreased by about 40–50%. She still experiences little pleasure, wakes early, ruminates frequently and can only manage her everyday tasks to a limited extent. Her suicidal thoughts are again directly asked about. At this check she denies current suicidal intent and concrete preparations. The psychiatric history is also taken again. Targeted questioning about previous manic or hypomanic phases does not yield any corresponding indication. Because the depressive symptoms persist markedly despite normalized thyroid values, a depressive episode is additionally diagnosed in this course. The hypothyroidism has contributed to the symptoms but does not fully explain them.Start of depression treatment
The patient begins cognitive behavioral therapy with one session per week. After psychiatric and cardiological agreement she additionally receives:- Sertralin 25 mg once daily on days 1–7
- Sertralin 50 mg once daily from day 8, provided she tolerates the starting dose well
Follow-up after one week of Sertralin
The patient reports mild nausea in the first days but can continue to take the medication. Cardiac complaints or signs of bleeding have not occurred. Mood and suicidal thoughts are again queried. As planned, Sertralin is increased to 50 mg daily from day 8.Follow-up after four weeks of Sertralin 50 mg daily
The initial nausea has subsided. The patient continues to participate in weekly psychotherapy. She reports that she can again complete some tasks earlier in the day and ruminates less often. A full remission has not yet occurred. Since improvement is noticeable and the treatment is well tolerated, Sertralin 50 mg daily and the psychotherapy are initially continued. A further appointment to assess efficacy, daily functioning, side effects and suicidality is scheduled.Hypothyroidism with acute suicidal thoughts
In another scenario the 42-year-old patient reports, in addition to her depressive symptoms, sensitivity to cold and constipation. She has not noticed any swelling in the neck. Unlike in the first scenario, she expresses recurrent suicidal thoughts and cannot say with certainty that she would not harm herself when alone at home.History
The patient has had little interest or pleasure for several weeks. She finds it hard to bring herself to everyday tasks, ruminates frequently and wakes at around five in the morning. After that she cannot fall asleep again. During the day she feels exhausted. Over the past three weeks the symptoms have markedly worsened. At home she has become more irritable, has shouted at her children several times and experienced conflicts with her husband. In response to direct questions she also reports: 👨⚕️ Have you been feeling cold more often lately? 👩 Yes. I’m even cold when it’s warm enough for my family. 👨⚕️ Has your bowel movement changed? 👩 Yes. Sometimes I can only go to the toilet every three or four days. In further conversation the patient says that life is no longer worth living for her. 👨⚕️ Have you thought about taking your life? 👩 Yes. These thoughts come back repeatedly. 👨⚕️ Do you have a concrete plan or have you prepared anything already? 👩 I haven’t prepared anything. But I don’t know whether I’m safe when I’m alone at home again. There is bipolar disorder in her brother and an anxiety disorder in her sister. The patient herself has arterial hypertension and an ST-elevation myocardial infarction three months ago. She takes Captopril and, since the myocardial infarction, acetylsalicylic acid and Clopidogrel. She occasionally uses Ibuprofen or Naproxen for her migraine.Examination and laboratory
The patient is awake and oriented. She appears unkempt, makes little eye contact and speaks slowly. Her concentration is impaired; she answers several questions with ‘I don’t know’. The thyroid is not palpably enlarged.| Parameter | Finding |
|---|---|
| Blood pressure | 130/80 mmHg |
| Heart rate | 70/min |
| TSH | 11,6 mIU/l |
| Free thyroxine | 0,69 ng/dl |
| Hemoglobin | 13,0 g/dl |
| Sodium | 139 mmol/l |
| Creatinine | 0,79 mg/dl |
Diagnosis
The elevated TSH and the decreased free thyroxine confirm a manifest primary hypothyroidism. It can contribute to exhaustion, slowing and depressed mood. At the same time a depressive episode with acute suicidal thoughts is present. The current level of risk must be treated independently of the thyroid disease.Immediate management
Because the patient cannot say for certain that she would not harm herself at home, she remains under personal supervision until the psychiatric emergency assessment. In this case she is voluntarily admitted as an inpatient. During the inpatient stay her suicidal thoughts are reassessed regularly. In interviews a possible intent, changes in the thoughts and protective factors are recorded. Because of her brother’s illness, targeted questions are also asked about previous manic or hypomanic phases. In this scenario no indications are found.Treatment
Because of the myocardial infarction three months ago, treatment of the hypothyroidism is started cautiously with L-Thyroxin 25 µg once daily in the morning. New-onset palpitations or chest pain are monitored for. At the same time, under psychiatric care, treatment of the depressive episode is started. The patient receives Sertralin 25 mg once daily for seven days. Because she tolerates the medication, the dose is then increased to 50 mg once daily. Psychotherapeutic sessions also take place. Because she is taking acetylsalicylic acid and Clopidogrel concurrently, follow-up checks specifically ask about signs of bleeding.Discharge and course
During the further inpatient course the patient reports that the suicidal thoughts have become less frequent. Before discharge she can distance herself from an immediate risk of self-harm. Together with her it is agreed whom she should contact immediately if the thoughts increase again. A prompt psychiatric follow-up appointment and regular psychotherapeutic appointments are arranged. One week after discharge mood, suicidal thoughts, everyday functioning and tolerability of the medications are checked. The patient still has depressive symptoms but denies any current suicidal intent. Eight weeks after starting thyroid treatment the TSH is 6.4 mIU/l. The patient feels less cold and has constipation less often. Since L-Thyroxin has not caused cardiac symptoms, the dose is increased to 50 µg daily. Thyroid values will be checked after another eight weeks. Psychiatric care is continued in the meantime. At each appointment depressive symptoms and possible suicidal thoughts are asked about directly again.Lack of drive after the exam period: A case involving Methylphenidat use
A 21-year-old mechanical engineering student at the University of Basel presents with morning tiredness and lack of drive, increased sleeping on weekends and several binge-eating episodes. The complaints have worsened over about three weeks, beginning one week after the end of the semester exams. He reports having experienced mild mood swings in the past. Currently there are no clear signs of an elevated mood; however he describes himself as someone who is usually always full of energy. He reports feeling during this time “somehow not like himself.” Negative thoughts constantly circled in his head. Over the past month he has repeatedly failed to attend without excuse. About this he says: “I simply could not get up and get dressed.” During the exam period he took Methylphenidat to be more productive and to improve his mood. For the last two exams he increased the dose to 100 mg daily. He denies suicidal thoughts. However, he reports mistrust of his environment and feels anxious and tense during the day. Which measure is most appropriate?- Start treatment with Risperidon at an appropriate dose
- Treatment with an antidepressant
- Wait until the substance is fully eliminated, and if necessary use milder medications
- Inpatient admission
- Methylphenidat
- Methamphetamin
- Kokain
- Ecstasy
- Bipolar disorder type II
- Substance-induced depressive disorder
- Personality disorder
- Adjustment disorder
- Cognitive disorder or dementia
- Psychotic disorder
- Anxiety disorder
- Affective disorder
- Treatment with Sertralin
- Prescription of Bupropion
- Start treatment with Haloperidol
- Preference for psychotherapeutic treatment
Serotonin syndrome: Acute confusion and muscle rigidity in a cyclist
A 38-year-old cyclist is brought to the emergency department. His companions report that since the morning training he has repeatedly experienced weakness and restlessness. Consuming sugary foods also did not lead to improvement. In the club’s rest room he had complained of lightheadedness and dizziness. Over the past hours he had also had multiple bowel movements. In the emergency department the patient speaks incoherently and is disoriented in time and place. He is sweating profusely and is tachycardic. On cardiology assessment the only finding is sinus tachycardia. Treatment with a beta blocker is started. The neurological examination excludes acute cerebral events and a seizure disorder. The patient remains agitated and develops muscle rigidity. After his family arrives, the additional history reveals that he has been taking Citalopram for several months for depression. His wife reports that in recent weeks he had independently also taken her Amitriptylin, which she uses to treat migraine. Toxicology testing is positive for Tramadol. When asked about this, his wife explains: “In addition to his known medications, he occasionally took certain other pills.”Important differential diagnoses:
- Neuroleptic malignant syndrome (NMS)
- Malignant hyperthermia
- Catatonia
Iron deficiency anemia: evaluation, treatment and course
On physical examination slight pallor is noted. Laboratory shows a hemoglobin of 10.8 g/dl, an MCV of 76 fl, an MCH of 24 pg and a ferritin of 11 µg/l. These findings are consistent with iron deficiency anemia. In searching for the cause the patient reports that she rarely eats meat. She denies heavy gynecological bleeding. The fecal occult blood test is negative. Low iron intake therefore may be a contributing factor. However, a negative stool test does not reliably exclude a gastrointestinal bleeding, especially with concurrent intake of acetylsalicylic acid and clopidogrel as well as occasional ibuprofen or naproxen. The patient starts Tardyferon® Depot-Eisen(II)-sulfat 80 mg, a sustained-release tablet once daily. She takes the preparation whole with water and tolerates it well. Four weeks after treatment start blood count and ferritin are checked. Hemoglobin has increased to 12.0 g/dl and ferritin to 19 µg/l. The patient reports feeling somewhat more physically resilient. As the iron stores are not yet sufficiently replenished she continues the treatment. Four months after treatment initiation another check is performed. Hemoglobin is now 13.1 g/dl, ferritin 42 µg/l. The anemia is no longer detectable and the iron stores have recovered. The patient tolerated the iron therapy well during the entire treatment period.Depression during Pregnancy and After Childbirth
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Importance
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Introduction
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Terms and timing
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Symptoms
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Scenarios
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Crisis situations and electroconvulsive therapy
Affective disorders can influence how reliably a mother attends prenatal care, pays attention to her nutrition and health, and later cares for her newborn. An untreated disorder can be associated with additional risks for mother and child. With a confirmed diagnosis, treatment appropriate to the severity is therefore required. This can include psychotherapeutic, psychosocial and pharmacological measures.
Pregnancy brings numerous emotional and physical changes. The news can trigger joy and optimism, but also worries about the child’s health, the birth or future responsibilities. In addition, there are physiological and hormonal changes. Mood swings are therefore initially understandable. However, persistent depressive symptoms with significant impairments in daily life should not simply be classified as a normal accompaniment of pregnancy.
A prenatal or antenatal depression is a depression that occurs during pregnancy. A postpartum depression occurs after birth.
Perinatal depression is the collective umbrella term: it refers to depressions during pregnancy and in the first year after birth. Depending on the diagnostic framework used, shorter timeframes apply for exact classification. Some women experience a depression for the first time during pregnancy. The changes and stresses of this period can contribute to the onset of the disorder. In women who have had depression previously, symptoms can recur or worsen. This can occur both in women who were previously treated and in those without prior treatment.The symptoms can be illustrated by typical statements. Severity, however, is determined by the overall clinical picture and not by a single remark.
- Mild severity: “I am often sad and worry a lot. I still get my tasks done, but everything costs me more energy.”
- Moderate severity: “I can hardly enjoy anything anymore. Just getting up or an appointment overwhelms me. I feel guilty because I don’t feel as happy about my child as I expected.”
- Severe severity: “I can hardly manage to take care of myself anymore. Everything seems hopeless. Sometimes I think my family would be better off without me.”
1. First-time symptoms during pregnancy
A patient develops a depressive episode for the first time in her first pregnancy in the seventh week of gestation. She previously had no comparable psychological complaints and has never received psychiatric treatment. After diagnostic evaluation and a joint benefit–risk assessment, therapy with Sertralin 50 mg once daily is started. Additionally, she receives psychotherapeutic support. Efficacy, tolerability and mental state are regularly monitored.
2. Previous episodes without treatment
A patient develops depressive symptoms again in her first pregnancy in the seventh week of gestation. She reports similar episodes in the past that were not treated. After review of previous disease courses, treatment with Sertralin 50 mg once daily is started. In addition, psychotherapeutic measures and everyday support are organized.
3. Previous treatment, currently without therapy
A patient develops a depressive episode again in her first pregnancy in the seventh week of gestation. A prior episode was successfully treated; she is currently receiving no therapy. When choosing medication, the previous treatment and its effectiveness are taken into account. If Sertralin is suitable for the patient, therapy with Sertralin 50 mg once daily is started. After improvement, treatment is continued for a sufficiently long period to prevent relapse.
4. Pregnancy while on Paroxetin
A patient is being treated with Paroxetin for a depressive disorder and learns that she is in the fourth week of pregnancy. Because of a possible increased risk of cardiac malformations when taken in the first trimester, a timely, physician-supervised switch to Sertralin is decided after psychiatric and obstetric assessment. Possible discontinuation symptoms and the risk of a recurrent depressive episode are taken into account. In addition, an extended ultrasound examination is offered.
5. Pregnancy planning
A patient is being treated for a depressive disorder with Sertralin 50 mg once daily and wants to become pregnant. Her symptoms are well controlled on this dose. Before pregnancy, psychological stability, relapse risk and previous treatment course are discussed. If the indication persists, Sertralin can be continued during pregnancy. If possible, pregnancy is planned after resolution of the acute episode and with a stable condition.
6. Breastfeeding
A patient wants to breastfeed after delivery and still requires antidepressant treatment. On Sertralin 50 mg once daily she is psychologically stable. Effective treatment can be continued during lactation after individual assessment. The infant’s feeding behavior, alertness and weight development are particularly monitored.
For all scenarios: 50 mg is not a permanently sufficient dose for every patient. Further dosing is guided by efficacy and tolerability. In mild depressive episodes, psychotherapeutic measures alone may initially be sufficient.
Pharmacological treatment and pregnancy-related vomiting
When prescribing medications, pregnancy-related nausea and vomiting must be taken into account. Severe vomiting can make regular intake and absorption of a medicine difficult. Dehydration and electrolyte disturbances must also be considered.In cases of acute suicide risk, concrete danger to others, severe psychotic symptoms or significant inability to care for oneself, an immediate psychiatric assessment is required. Inpatient treatment is often necessary. Marked aggressiveness also requires a careful assessment of the risk and possible causes.
After psychiatric and obstetric assessment, electroconvulsive therapy (ECT) may be considered for severe depression, severe mania or a mixed affective episode, or catatonia, especially when the health of the mother or the child is seriously endangered. It may also be relevant if there is no response to or intolerance of pharmacological treatment. During or after ECT, uterine contractions and changes in fetal heart rate may occur. Therefore, careful obstetric planning and monitoring appropriate to gestational age are required.Depressive Disorders in Childhood and Adolescence
Depressive disorders can already occur in preschool age. For the following presentation, a distinction is made between children under twelve years and adolescents or young adults aged twelve to twenty years. For diagnosis and therapy, the individual developmental level is additionally decisive. An early disease onset may be referred to as “Early Onset.” A genetic predisposition plays a role. In assessment, age-appropriate cognitive abilities and understanding must be considered. Children and adolescents do not always show depressive complaints in the same way as adults; symptoms can present differently. In younger children, concrete, pictorial thinking often predominates. Abstract thinking abilities develop gradually. In conversation, this can, for example, look like this:- Understanding transferred meanings: To the question “Do you sometimes feel like you are under a dark cloud?” the child replies: “No, the sun is shining today.” A more concrete question would be: “Was there something today that made you sad?”
- Judging hypothetical situations: The question “How would you feel if your friends excluded you?” may be difficult to understand. More concrete would be: “Were you allowed to play during the last break? How did that make you feel?”
- Assessing long-term consequences: To the question “How do you imagine your future?” the child may be able to say little. More concrete would be: “Are you looking forward to tomorrow? Is there something you are afraid of?”
- Explaining feelings by events: Instead of “I feel rejected,” the child says: “No one wanted to sit next to me.”
- Expressing burdens through observable situations: Instead of “I feel insecure at home,” it says: “When Dad gets loud, I go to my room.”
- Describing changes by activities: Instead of “I no longer enjoy anything,” it says: “I used to like playing soccer. Now I don’t want to go anymore.”
- Drawing: “Draw an ordinary day at home. Afterwards you can tell me what is happening in the picture.” The child’s explanation is crucial; the picture alone does not permit a diagnostic conclusion.
- Playing with figures: “Show me with these figures how things happen during the school break. Who plays with whom? What does your figure do?”
- Discuss feelings using a concrete situation: “Think about this morning before school. Were you more happy, sad, angry or anxious? What happened?”
Flashcards
Practice depression treatment concisely: These 32 flashcards guide you from symptoms and a clinical case through the treatment decision to medications with initial and maintenance doses. Inpatient admission, cognitive behavioral therapy and ECT are also covered. The cards are prepared for double-sided printing.