Approximately one fourth of people who suffer depression have the so called psychotic depression which includes such symptoms as delusions, irrational thoughts, fears, anxiety, morose, physical immobility and general psychosis. Psychotic depression is not a mental illness because those with psychotic depression are usually aware that their thoughts are not true, they can be ashamed and try to hide them. For this reason this type of depression is difficult to diagnose. Treatment of psychotic depression is the long process combining hospital say and follow up by the mental health professionals. People are able to recover within the year and return to the normal life. The 52 year old man in the given case has a very severe depression and the symptoms he presents are very common for the psychotic depression, nevertheless, the properly developed treatment and close follow-up can bring him back to regular life.
Depression is considered to be the logical part of life of the aging people. Currently, old age depression affects approximately 5 million Americans aged over 50 and only 10 percent of them receive the proper treatment (Preston 2004, p.10). Psychotic depression of often accompanied by the loss of social support systems because of retirement, change of residence and medical illnesses. Studies of nursing home patients who have serious physical illnesses indicate that the depressive people have greater likelihood of death from those diseases.
The man from the case study presents some troublesome aspects such as somatization and lack of motivation (apathy to surrounding world). He is focused on the physical symptoms – he is confident that he has some serious illnesses. Some of the elderly patients are focused on the bowel problems and even if they agree that they have a depression they attribute their mental state to the chronic pain or diseases (Shuchter 1996, pp. 47-50). Attribution if the depression symptoms to the medical illnesses is the area of potential confusion and many result in the selection of improper therapy. For example, the lack of appetite can be the result of depression or lung cancer, or both. However, the 52 year old man does not have any serious medical diseases and his apathy is the result of depressive state.
It has been noted that psychotic depressions are more prevalent among elderly than among young people. It is very important to identify psychosis because patients with psychotic depression are at high risk for self-destructive behaviors and suicide. In the year 2000, population aged over 50 constituted 20 percent of American citizens and 18 percent of all suicides (O’Connor 2001, p. 119). In addition, they respond better to the combination treatment: antidepressant and antipsychotic therapies. In addition this man is at high risk of developing impairment in function and excessive usage of medicaments.
Therefore, the first step to be taken is to ask the patient with psychotic depression about passive or active suicidal intentions directly. The questions might be asked in the following form “Do you think that your life has never been worse?”, “Have you thought about harming yourself?”. If the answer is “yes”, the patient should be hospitalized immediately ((Badal 1997, pp 32-39). The wife, who has reported the feature of husband’s behavior and thoughts, should be queried as well because the husband will share his intentions more openly with the family members rather than with the physician. Despite of insignificant correlation between diseases and depression, the person in the state of psychotic depression has higher risk of health problems – therefore, depression is one of the predictors of increased risk for mortality among elderly.
Further, the close examination of patient’s history and physical examination are required. History examination includes the drug and alcohol usage. At this stage the cooperation of health professionals with family members is very helpful taking into account the uncommunicative state of the patients with psychotic depression. Families are able to provide useful information. There are two scales available to diagnose depression: Geriatric Depression Scale and Hamilton Depression Rating Scale. However, these scales have proved to be less effective instruments in developing the therapy compared to the evaluation and interaction with the patient and his family members (Burns 1999, pp. 510-514).
The man from our case study will not benefit from traditional modes of therapy. In this situation the rule of thirds seems to take place: one third of elderly patients get better, one third get better but relapse, and one third do not get better at all (Badal 2002, pp. 94-95). With time patients with psychotic depression recover later in life but it takes long months of treatment, psychological support and medical intervention.
The key in treating psychotic disorder in elderly is early intervention. It is already identified that the 52 year old man has a psychotic depression caused by the false thoughts about health problems and probably loss of social interactions, such as job. The personality changes are obvious, he lacks enthusiasm, does not experience joy and is closed for communication. It is unclear for how long this man has the depressive symptoms. If the depression is recently established, the psychotherapy can be the only treatment option and there is no need for pharmacotherapy. Behavioral and cognitive therapies are helpful in reintegrating the patient into the social environment after the psychotic depression and help to prevent relapse (Beck 1979, p. 52). Psychotherapy is conducted by mental health social worker, psychiatric or the team of professionals.
Psychotherapy can help this man to identify the factors the make him feel depressed and health professional is able to find the approach to deal effectively with these psychological and interpersonal causes of depression. Psychologist can do the following steps (Weissman 2000, pp. 265-273):
- Identify the problems that contribute to depression, understand the roots of these problems and find the way to solve them
- Identify the negative thinking patterns that cause this man to been hopeless and seriously ill (the man is over-generalizing his physical condition)
- Explore the behaviors that contribute to the depression (psychologist is able to help depressed man to interact with other people better)
- Help to regain the pleasure in life (help the man to recall the activities that used to be joyful in the past and motivate the patient to include these activities into life again)
Types of therapy
There are several types of psychotherapy: individual, group, marital, and family (Compact Clinicals 2001, p. 20). In our case, the 52 year old man might need to be treated with all types of therapy for the better result. For example, the individual therapy involves only the patient and the therapist – if the patient trusts his physician, he will be more open to share his fears. Group therapy involves two or patients. It is very helpful to develop teams with patients at different stages of treatment – in this case the new patient will see how others are coping with their state and will believe in his abilities as well. Marital therapy will help the wife to understand why her husband has the depression. The wife will learn about the behaviors and changes in communication that can help her husband to cope with the depression (Yapko 1998, pp. 246-248). Family therapy involves all family members in order to explain them what the person they love is experiencing and why.
In addition to the different therapy formats, the mental health professional has the choice in therapy approaches such as psychodynamic, interpersonal, and cognitive behavioral. Because the causes of the psychotic depression in our case are unknown, the psychologist might assume that the depression is the result of the unsolved inner or social conflicts. The goal of this therapy is to teach the patient to cope with the feelings through talking about experiences (Greenberger 1995, p. 102). Interpersonal therapy has the goal to improve communication skills and increase self-esteem. If the depression of 52 year man caused by the social isolation or relationship conflicts, this therapy can work well for him.
Cognitive behavioral therapy is recommended for patients who behave in the way that worsens the depression and for those who have interpersonal problems. In our case, the man is morose and not willing to communicate, therefore, this type of theory can be applied to him as well. Cognitive behavioral theory helps patients to identify and change wrong perception they have about themselves and the world around (Beck 1972, pp. 162-163).
Tips for the patient
In order for the psychotherapy to be effective, the patient should attend all appointments and actively participate. This man should help the psychologist to identify the sources of stress. For example, he might keep the journal and note both stressful and positive moments of everyday life. Communication is vital for rehabilitation – patient should explain the way he feels to someone he trusts. Therapy is about evaluation of thoughts and behaviors, and if the patient is cooperative, it is easier for the psychologist to identify the stresses that contribute to the depression (Klein 1994, p. 94).
Psychotherapy is beneficial for those patients who prefer not to take the medicine, or are afraid of side effects. In our case, the man believes that he has some serious diseases, and might not refuse to use antidepressants. However, pharmacotherapy is applied only in those cases when the depression is very severe and the patient is not willing to cooperate at all.
The wife of 52 year old man having psychotic depression has a very important role – to encourage him to stay with the treatment until the symptoms of depression disappear. Depressed person will not make the appointment or express the desire to be treated. The wife has to assume these functions and accompany the depressed husband to the doctor (Papolos 1997, pp. 211-213). Emotional support is of high importance as well. The wife should try to understand her husband, to be patient and provide an encouragement. For example, in our example, the wife should engage the husband in conversation and listen very carefully. Remarks about suicide should be reported immediately.
The depressed person should be invited for walks and other activities. Of course, the patient will refuse, but the wife, the health professional or the nurse need to be gently insistent. The family members should recall several activities that used to bring pleasure to the depressed person and encourage the patient to renew his hobbies. In addition, the depressed person should not be accused of laziness or complaints about false diseases. Patient is not able to get better in few day, psychotherapy usually takes as long as several months before the elderly person gets better.
In conclusion, mental health professionals and nurses assume a very responsible role – bringing back the depressed individual to normal life and reintegrating him into societal structure. Patients with psychotic depression are not cooperative, they are not willing to communicate and share their thoughts. For this reason, the nurse should try to become the person he trusts. Patience, understanding and emotional support are the key to successful psychotherapy. Family members should help the health professional to learn as much about the patient and his mental condition as they know. Psychotic depression has become very common among older people recently, unfortunately, only one third of them is getting better. Depression is not a mental diseases, but rather the emotional state when the individual sees no sense in his life and does not experience pleasure in anything. Psychologist and family members are able to renew patient’s interest in life and leave depression in the past.
- Egoism. Stanford Encyclopaedia of Philosophy. 7 August 2006 <http://plato.stanford.edu/entries/egoism/>.
- Lander University. Psychological Egoism. 7 August 2006 <http://philosophy.lander.edu/ethics/egoism.html>.
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