SEVERE DEPRESSION
Week 0
INITIAL/SCREENING APPOINTMENT
Miss Fleming presents at the GPs with her partner. The partner reports that Miss Fleming has been very depressed for the past 6 weeks and seems to be getting worse. During consultation the symptoms as described are suggestive of major depression and the PHQ-9 indicates a severe level of depression. The GP is quite concerned about Miss Fleming who has very poor eye contact, appears dishevelled and is monosyllabic allowing her partner to answer the GPs questions. The GP asks about risks and although there does not appear to be any current risk Miss Fleming nods when asked about previous history of self-harm. The medical notes show that Miss Fleming has a long history of depression going back over the last 10 years since she was 13 years old and under the care of Child and Adolescent Mental Health Services. The partner is very supportive and has taken two weeks annual leave from work to look after Miss Fleming. From the medical notes the GP also identifies that the patient has responded to anti-depressants in the past and they agree to recommence the prescription according to the National Institute of Clinical Excellence guidance. The GP explains to the patient that she will be assigned a CPN to manage her case and support and assist her over the next few months, who will contact her by telephone in the next week to discuss the medication. The patient is given a patient information leaflet on depression.
Week 1
INITIAL FOLLOW UP (CPN)
Three days later the CPN contacts Miss Fleming to discuss the medication. They establish that Miss Flemings partner did pick up the prescription and has been ensuring that Miss Fleming takes it as prescribed. The partner is concerned about the lack of improvement and the CPN advises them about how long it may take for improvement to show and encourages them to persevere reassuring them that the medication did work last time. The CPN also informs them that feeling nauseous is a side-effect of the medication which should improve over the next week or so.
Weeks 2-11
FOLLOW UP (CPN)
The CPN continues to contact Miss Fleming to discuss her medication, answer any queries she has, and to give support. Miss Fleming is improving and her partner has returned to work.
Week 12
PROGRESS REVIEW SESSION (CPN)
The CPN sees Miss Fleming to conduct a review of her progress with the PHQ-9. Scoring the questionnaire indicates that Miss Flemings symptoms of depression have improved but not remitted. Further discussion indicates that Miss Fleming has chronic self-esteem issues and finds interacting with others difficult as she has a negative opinion of herself and fears that she will not be accepted or will be ridiculed by others. This leads to her isolating herself and relying on others to do the shopping. She finds stressful life events very difficult to deal with which is when she has in the past resorted to self-harm by cutting her arms and thighs. She would like to feel better, have friends and get a job but does not know how she will be able to achieve this. In line with the care pathway the CPN and Miss Fleming agree that whilst she has benefited from the medication she may improve further with additional interventions available within this step such as some psychotherapy sessions. The CPN makes the referral to the local psychotherapy service and this information is discussed with the GP and added to the medical records.
Week 24
PROGRESS REVIEW SESSION (CPN)
The CPN sees Miss Fleming to conduct a review of her progress with the PHQ-9. Scoring the question-naire indicates that Miss Flemings depression has remitted. This information is fed back to the mental health specialist and the GP.
Months 6 & 9
PROGRESS REVIEW SESSION (CPN)
The CPN sees Miss Fleming and they discuss progress. Miss Fleming continues to feel well and she has started a part-time job which she is enjoying and her relationship with her partner is strong. Scoring of the PHQ-9 indicates that her symptoms are still remitted. They agree to continue telephone contact to ensure that the progress is maintained.
Months 1-12
POST ACUTE PHASE (CPN)
The CPN contacts Miss Fleming on a monthly basis and checks progress is maintained and discusses medication.
Months 6 & 12 (CPN)
The patient is invited for an appointment with the CPN to review progress and the PHQ9 is completed. Miss Fleming has continued to improve and her symptoms remain remitted. This information is written in the medical notes.