AKT question of the week: psychiatry

by Administrator 20. April 2010 10:00

A 19-year-old beauty therapist has come to see you because she is arguing constantly with her partner. They have been living together for the past six months. She says that the arguments are making her feel miserable and that her only enjoyment in life is her work and evenings out "clubbing" with her friends.

She says that her boyfriend resents her lifestyle and is very "possessive" of her time. She says that she feels depressed when she arrives home when he is there, unless he is working a late shift or it is a night out with her friends.

On examination she is heavily made up and smartly dressed. She talked constantly for the first five minutes about the deficiencies in her partner. Her past medical history includes a tonsillectomy and chicken pox as a child. She is a non smoker and visits the gym four times a week. Following a tearful discussion with a colleague, she was advised to visit you to help her with her problems.

What would be the most appropriate way of managing this patient?

  1. Advise her to take St John's wort
  2. Advise relationship counselling
  3. Prescribe a tricyclic antidepressant
  4. Prescribe an SSRI
  5. Refer to a psychiatrist


Answer and explanation

Advise relationship counselling

There is very little in the history to support a diagnosis of depression. This patient is continuing to lead a normal life and enjoying most of it.

The only aspect of her life which is giving rise to disharmony is her relationship with her partner. There is insufficient evidence to commence treatment with an antidepressant, and certainly no indication to refer to a psychiatrist.

Offering her support and pointing her in the right direction is appropriate and for this reason, the best answer is to suggest relationship counselling.

Guidance and support may be all that is necessary in the absence of core symptoms of depression.

Learning point:
Guidance and support may be all that is necessary in the absence of core symptoms of depression.

Tags: ,

AKT | OnExamination


4/20/2010 6:22:45 PM #

Steve Short

Part of me wants to add in an additional answer of advising her back to the original doctor she saw! She appears to focus a lot on her new partner as a source of problems, and there is nothing which focuses towards moderate to severe depression indicating the need for antidepressants. She appears to still have a degree of motivation if she manages to get to the gym four times a week. I'd be quite unhappy about using tricyclics as first line management for a 19 year old woman even if indicated due to risk in overdose, and would advise against St John's Wort due to drug interactions and differing amounts of active ingredient in preperations. I'm feeling relationship counselling with a review would be the best start. An idea towards any organic features (appetite/sleep etc) and other information with regards to mental state would reassure me, but if she's also well presented I'm assuming the question is suggesting significant depression is not a current feature in this patients problems.

Steve Short United Kingdom |

4/20/2010 7:00:59 PM #


Thanks again for your comments, Steve. Another comprehensive answer. What do others think about this?

Editor United Kingdom |

4/21/2010 3:31:33 PM #


I agree with Steve, advising a relationship counselling will be a good start with this lady. As there is no clear suggestive features of depression,anexity or personality disorder to go with choice 3,4, and even 5 taking into consideration that this problem is not causing deterioration in her functional status.
Of course,we won't advise her to take St John's wort which is an enzyme inducer thus resulting in multiple drug interaction...

Huda U.A.E. |

4/21/2010 7:23:34 PM #


Thanks for your contribution, Huda. What further questions would you ask her during the consultation? What sort of response(s) would lead you to suggest one of the other options?

Editor United Kingdom |

4/22/2010 5:16:00 PM #

Simon Braybrook

The most appropriate answer is 2, as her feelings very specifically relate to one area of her life. This lady does not seem depressed: She is enjoying her hobbies (going out) and her work, and is appropriately kempt (no self neglect). She is active and keeping herself fit. I think it would be worth using the consultation to see if she can figure out the reason she is feeling low herself (i.e. the relationship with her partner). Interestingly, it might be worth exploring her social network. Is there a reason that, despite having an active social and work life, she chooses to share this with a professional?

Although she seems to have quite a healthy active life, might the boyfriend be depressed or lonely? Is he a patient and might she ask him to come in for a chat?

Simon Braybrook United Kingdom |

4/22/2010 5:23:02 PM #


Thanks for your comments, Simon. Some valid points. What sort of questions would you pose to this patient to clarify the possibility of her being depressed (or not)? Are there any symptoms that have not been mentioned in the case scenario that you would wish to clarify further?

Editor United Kingdom |

4/22/2010 10:20:47 PM #

abu elgasim

Most patients with major depressive disorder present to their physician with a normal appearance.
infections include syphilis, Lyme disease, and HIV encephalopathy, which can cause mood and behavior changes should be investigated.
Patients with anxiety disorders are at higher risk for developing co morbid depression should be assessed.
so not to underestimate this pt and option 3 is most appropriate.

abu elgasim Saudi Arabia |

4/22/2010 11:38:27 PM #


Many thanks for your contribution, Abu. If opting to treat medically, what factors make you choose a tricyclic over an SSRI first line? The management and investigation of depressed patients will differ slightly due to local disease prevalence. In the UK, syphilis, Lyme disease and HIV encephalopathy would not be common causes of depression and would not normally be pursued in a first consultation like this in the primary care setting. Whilst I wouldn't necessarily perform any blood tests in this particular case, thyroid function tests and full blood count can be worthwhile in some cases. That said, there is nothing in this history that would make me think that organic disease is high on the list of differential diagnoses.

Editor United Kingdom |

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About the editor

Dr Geraint Preest
Primary Care Editor BMJ Onexamination
GP Principal Pencoed Medical Centre Pencoed