Category Archives: Depression

Adult ADHD?

Clinical Case Studies, Depression, Issues & Debates

This young Indonesian man came to us referred by a psychiatrist, in the referral letter it was written that he’s experiencing some psychological difficulties, poor sleep, mood swing, poor concentration, the diagnosis was dysthymic disorder.

When he came to the counter I can see his face in red and him in such an agitated mood, he said, “I’ve been trying to call you guys but something strange happened.” I told him to call us in front of us and so he did. There was indeed some weird sound coming up after he dialed, of course, as he called our fax numbers. So later he was registered and he took a sit, seemed to have calmed himself down listening music with his earphone in the waiting area.

He said his main objective to come to our clinic is to sort out his poor sleep and mood swing problems. He said even with medication from previous doctor, he can’t fall asleep deeply, he just doesn’t feel that he’s sleeping well. At one point he felt like he could no longer control his emotion. His appetite is considerably ok, acceptable as he said. But he said when he gets angry he feels dizzy in his head. The example he gave was the time he was coming to our clinic, but couldn’t find the place, and couldn’t reach us by phone (well, how to get to us with fax number, unless you’re sending a fax I suppose?). He said he was so angry and then he felt light-headed.

We don’t expect people to be flat in their mood (in fact being flat in mood is a negative symptom of Schizophrenia), so people can be sad, happy, angry, calm, depressed, elated… Yet his diagnosis was dysthymia, a disorder characterized by chronic, consistent low mood (just like depression, but less severe, more long-lasting). He didn’t appear so to us. He laughed when I joked. He was angry when he was frustrated. He managed to elaborate his problems with examples. He has interests- he listens to musics as he waits.

One main problem he has is his poor concentration, he’s a student. For a student to not concentrating, not focusing, not remembering, not memorizing, it’s like end of the world (especially if you do care about your studies!). He really wants to finish the study and graduate from it, as he doesn’t want to waste his father’s money.

So we’re suspecting Adult ADHD. I remember I got a copy of Adult ADHD scale just last week and was thinking “I won’t need this. Who’ll come to clinic for this problem?! Nobody.”

Now I realized one thing, it’s right, nobody will come for consultation and treatment for Adult ADHD. Not because nobody is suffering from it, but chances are it’s far under-diagnosed. If you look at the scale (Adult ADHD Self-report), you’ll realize people nowadays are likely to suffer from it (I can’t concentrate, I can’t sit still, I get distracted easily, I keep forgetting the deadlines, I feel restless…).

See here for more Psychological Rating Scales.

Bipolar Disorder

Bipolar Disorder, Depression, Issues & Debates

His family came for consultation on behalf, as he wouldn’t come no matter what. According to what his family (wife, son & daughter-in-law), he is in such a hypomanic stage, with spending spree, agitated mood, and not sleeping much day nor night.

However, we were surprised to know that the man has been taking anti-depressant himself. The son said that he was depressed few months ago, so he willingly went to the general hospital to see a psychiatrist, and got some anti-depressant medication. He has since then been taking it, and got better from depression.

Now that he’s in such a hypomanic stage, imagine he’s still continuing with the anti-depressant?! He gets even hyper and manic. He doesn’t listen to his family’s advice to stop the anti-depressant, as he feels good taking them, energetic, filled with drives, jovial… (but manic in others’ eyes).

So after consulting us, we’ve given advice to the family that they will have to find a way to stop the man from taking the anti-depressant but to start with our medicine. Few days later it was the date for the man to go for appointment in the general hospital, where he usually just collects medicine as the appointment bookings for the psychiatrist is always full. So when the son accompanied him there (he’d never accompanied his father to the hospital), again the nurse asked them to collect the same medicine as the appointment booking is full. This time, with the advice from us, the son refused. He said the man’s condition is no longer the same, he can’t take the same medication. They sent him to Accident & Emergency department where the man was asked to do blood test. Only with blood test result coming out few hours later, they got to see the psychiatrist doctor.

Here it shows the importance to regularly have follow ups and reviews with psychiatrist doctor rather than continuously collecting and taking medicine (which is very common in most government and some private practices, most likely due to the shortage of clinical staff and doctors). As people don’t usually get depressed all the time with medicine (other than dysthymic disorder which is another case), they do recover, so they shouldn’t really be taking anti-depressant for long term without medical review, even if it is just a maintenance dosage, review is still needed and important.

Traumatised Childhood

Clinical Case Studies, Depression, Obsession & Compulsion

She has an over 11 years history of depression with obsessional ruminations, and insomnia, and has maintained relatively well on medication, after a course of 6 ECTs.

She is the 7th of 8 siblings, with no family history of mental illness. Her parents divorced when she was still a child, she lived with her mother who doesn’t really care about her. At young age she was unfortunately raped repeatedly by a relative and his friends. She never really mentions it to others, most of the time she can pretend like it never happened to her before.

She is a hairstylist who works from home. So sometimes when there’s no customer she’s spending a lot of time alone at home. One of her elder brothers sometimes helps her financially, knowing that it costs her a lot to take psychiatric medicine long-term. She has once tried to follow up in the general hospital, but after taken one dosage of the medicine prescribed by the hospital doctor, she spent the whole night trembling and crying, feeling the head spinning. Since then she’s never thought to go to the general hospital (N.B. here I’m not saying that psychiatrists from GH isn’t good, but most of them aren’t Chinese, so there’s a language barrier there, which can cause problems in diagnosis and prescription).

She’s always complaining of head and neck pulling sensation. It’s worst when she can’t sleep well. She spends most of the time being worried about this pulling sensation, although nothing wrong was found physically when she went for check-up.

Sometimes she can be very obsessive, being worried about the same thing continuously, asking similar questions repeatedly, needing a lo of reassurance. She’s currently much better with medication, and with a lot of counselling she can slowly accept occasional poor sleep and insomnia (What to do if I can’t sleep well?).

Adverse childhood experience is always a risk factor for many mental illnesses, but also a perpetuating factor.

Depression Following Stroke

Clinical Case Studies, Depression

His wife came to us after the husband had a stroke. She is very concerned as the patient has had an elder brother who committed suicide after being depressed for years.

She is worried that her husband will do the same as he is currently staying in a hospital doing physiotherapy, being emotionally unstable, agitated, and very bad-tempered. He keeps to himself most of the time, makes no social contact with others, and cannot tolerate the least of any physical discomfort (e.g. sore throat, skin itchiness).

The wife is very keen to bring patient to consult a psychiatrist, yet he is not ready for it at all. If he ever knew that he’s taking any of the psychiatric related medicine he will get so mad. So the wife has been putting medicine in his food and drink. What’s difficult is his poor physical condition, due to the stroke he needs to do a lot of physio, but the medicine is making him drowsy and sleepy. In addition he’s having high blood sugar, high blood pressure and high cholestrol, so whatever kind of medicine that may raise any of these he can’t take it, especially his blood sugar is always sky high.

The wife spends almost 24/7 by his side to look after him. One day their only 15-year-old son made a call to her, saying he missed her and was very anxious about sitting for PMR (exam), he wanted her to pray with him over the phone. The wife decided to discuss with patient, told him to let her to go home and see the son, the patient agreed. However, when the wife wasn’t around, patient went up to the 13th floor of the hospital and attempted to jump down.

When he is okay, he is okay (what kind of sentence is this?). When he’s having a slight of bodily discomfort, he wants to end his life. Nobody really knows what he’s thinking, not even his wife. But he’s very upset and irritated being hospitalized, not being able to earn money and function like normal. What’s worse is his only sister and her family, who lives just next to him but have never come to visit him at all. So the wife seems to be the only connection he has, and when the wife isn’t around, all kind of negative thinkings float in his mind…

“She no longer wants me” “She doesn’t want to care for a sick person” “I’m useless” “Nobody cares about me”

Having a strong supportive family connection is something very essential in the recovery of mental illness. Yet unfortunately he has a brother who left him due to depression, and a sister who lives next to him but built a wall in the middle of two houses.

Who should be the one taking medicine?

Clinical Case Studies, Depression

About half an hour after she and her husband left the clinic, she made a phone call, saying she wanted to speak to the doctor. She asked how serious her “illness” is, what diagnosis she has had, whether she is going crazy etc. At first I thought she was worried about her illness and about not being able to recover. So I explained she just got mood disorder, sometimes a bit harder to control her mood and emotions, but it isn’t serious, and will recover taking the medicine and maybe with some self-help.

However, after my explanation, “but my husband said I’m ok, I don’t have any illness. I told him I need to take medicine, if I’m ok, why do I need medicine?” She, in an almost screaming voice, said this. I volunteered myself to speak to her husband, telling him the importance to have supportive family members in the process of recovery, and although not serious, his wife does have mood disorder, so please try not to upset her, but give her full support and care she needs.

Few days later when I spoke to her again, she has got much calmer having the medicine running in her body. She said her husband still shouts at her, but she has complete no interest in having argument with him now. One thing she still doesn’t understand, her husband is the main reason she needs to take medicine, or else she’ll probably be fine. But why isn’t husband the person who should be taking medicine?

I have encountered quite a number of cases like this, usually the woman who comes for consultation and treatment, quite often due to their partner who is very bad-tempered, easily agitated, or having some not very severe mental health issues, unfaithful, having another family or missus outside etc. The problem of the woman in fact originates from the man, but then the problem continues to develop and the woman becomes easily agitated, paranoid, suspicious, disorientated, … … then she’s coming for treatment!

Though here it’s still very important to emphasise, that there are a lot of women out there who cope with those kind of problems without developing mental health problems themselves, and able to go through it with their resilience.

Epileptic Personality

Clinical Case Studies, Depression, Obsession & Compulsion

She brought a big blue bag into the consultant room. Once she sat down she opened the bag and started to show all kind of handcraft to the doctor, some knitting, some lanterns done with straws, a lot of very neat and tidy letters and writings. At the same time she was talking, or should I say, grumbling about her life, her family, her church friends.

She’s helping her mother who runs a coffee shop, so is her brother. Sometimes she sees people chatting with her brother, laughing happily, she’ll walk away. She wonders, “why never I feel happy? I don’t want to see them being happy. I can never be happy like them.” In the letters that she wrote, she hopes that people will come to talk to her more, make her happy.

But she’s always grumbling. When she rang her younger sister, all she does is grumbling. Her sister is used to it and so she will just listen. She likes people following her way, she knows it, and is still very insisting.

She’s still having fits and seizures, despite taking 10 tablets of Epilim 200mg each day. When it happens she will just stop what she’s doing and lie herself down.

Rigidity, stubborn, obsession, repetitive, enjoy doing works that require a lot of repeating, very tidy, jealousy, depressive, dependent, avoidance, low self-esteem, feeling of not in control of own life … – some very common behavioural and emotional changes in persons with epilepsy, which are usually carried with them for the rest of their lives…