MHM Magazine

Issue 1 | 2023 | MENTAL HEALTH MATTERS | 15 MHM You look gently at Ms du Toit. Despite her smile and softly spoken words, there is evidence of deep pain, grief and profound worry. You explain you will help her, easing her distress, comforting her with professional reassurance. For you the best way to summarise this clinical picture is to draw a diagram: After taking a thorough history from Ms Du Toit, you perform a physical examination which renders no abnormal findings. You decide on a multidisciplinary management plan as an outpatient (as Ms du Toit can consent, is not actively suicidal, requests to be at home, with a support structure from her son and daughter who visit her every day). Consideration is given to each step. You form a wonderful rapport with Ms du Toit, and she agrees to follow your management plan. You also psycho-educate her on a healthy diet, a structured and hygienic sleep routine, and perhaps consider attending physiotherapy for core body strength and regular exercise. You also encourage her to have her vision checked. You return the email to the psychologist, informing her of your management plan and the promise to continue your contact with her so as best to assist the patient. Ms du Toit is grateful for all you have done to help her along this journey. She says goodbye with a far greater smile than what she walked in with. Clasping her handbag, she gets up from her chair slowly and carefully. You wish her well and plan to consult with her in a month, the time taken for the medication to have its therapeutic effect. As you drive home from your rooms you smile to yourself as you know you have made a significant difference to somebody’s quality of life. References available on request. Stop the Benzodiazepine There has been no improvement and increases Ms du Toit’s risk of sedation with a potential fall. Continue clinical psychotherapy This can be used instead of medication. But in the case of Ms du Toit, her symptoms appear moderate-severe, and medication is indicated. Discuss with Ms du Toit all the benefits and risk factors for starting a first-line SSRI medication Evidence-based medicine describes the use of Sertraline/Citalopram (20- 60mg/day) for the treatment of anxiety and depression in the older age. One could also consider an SNRI such as Venlafaxine (150-300mg/day). What if Ms du Toit does not respond? Psychotherapy + Bupropion (150-300mg/ day)/Vortioxetine (10-20mg/day). What if Ms du Toit’s mood progresses to severe depression (for example, she has worsening suicidality)? Electroconvulsive Therapy (ECT) in the case of severe depression could be considered with a combination of psychotherapy and medication. Should Ms du Toit be prescribed a sleeping medication? And what can be done about her Tremor and panic attacks? You decide to initiate Circadin 2-4mg. This is evidence-based for insomnia for the older patient. You want to avoid Benzodiazepines. Instead, you prescribe a β-blocker (Propranolol at 10-20mg/day up to three times per day, depending on her response). You do blood investigations and consider radiological studies This is to rule out an organic cause for her mood pathology.