Authors:
Dr. S. Bidwalkar1, Dr. Yashasvi Shakdvipiya2,, Dr. Ankita Upadhyay3,Dr Shipra Singh3, Rajshree Jangid3
Keywords: Geriatric depressive disorder, Homoeopathy, Geriatric Depression Scale (GDS), Aurum metallicum
Abstract: Depression in geriatric group is most commonest yet undiagnosed condition which conventionally remain untreated in majority of cases. Generally patients >60 years of age do not report depression but clinically present somatic symptoms such as insomnia, anorexia, headache, abdominal distress, change in weight, fatigue, dysphoric mood. A case of depression of 64 year old male being assessed with Geriatric Depression Scale (GDS) is presented here who responded commendatory with Aurum metallicum in 1M potency considering therapeutic approach along with counselling.
Introduction: : Depression in elderly age group is commonest yet undiagnosed and conventionally remain untreated and unnoticed. Despite common myth depression is not a normal part of aging. The median prevalence rate of depression among elderly in India was reported to be 18.2%, which was significantly higher than the rest of the world (5.4%).1
The specific DSM-5 criteria for major depressive disorder are outlined so
at least 5 of the following symptoms have to have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood) -depressed mood, this can also be an irritable mood, diminished interest or loss of pleasure in almost all activities (anhedonia). Significant weight change or appetite disturbance, sleep disturbance (insomnia or hypersomnia), psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness, diminished ability to think or concentrate; indecisiveness, recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide are the symptoms to be elicited for diagnosis2. The treatment aims at reduction and resolution of signs and symptoms of depressive syndrome and restoration of psychosocial functions to optimum. Treatment for geriatric depression includes medication and psychotherapy depending upon factors such as severity of symptoms, presence of psychosocial stress, presence of co-morbid conditions and others.
Case profile
A 64 years old male hindu accountant visited OPD on 11/10/2015, with complaint of heaviness in head since 10-11 months. He progressively became low spirited with feeling of worthlessness.. He, became low spirited with suicidal thoughts. He gradually became sleepless day by day and had palpitations on and off.
HOPC: In Jan 2014 he got to know that his younger brother was convicted by court of law for chain snatching which left him mortified for loss of his position in society. He progressively became hopeless with feeling of unworthiness . He became unwilling to talk to others with irritability especially family members. He constantly talked about commiting suicide with desire of committing suicide, he enetually developed depressive symptoms.. He consulted neuropsychiatrist and was prescribed medicines which made him more lethargic and drowsy as reported by him with no significant relief. When visited patient was known case of hypertension, although he was on hypertensive drugs his blood pressure ranged high.
Mental generals:
- Ailments from mortification
- Fear of loss of position in society
- Extreme worthlessness
- Constantly talk of commiting suicide
- Irritable
- Oversensitiveness for what others will think about him in society
- Does not wish to speak to anyone especially family members
Physical general:
- Desire: Sweets
- Perspiration: Profuse on face
- Sleep: Sleeplessness, wakes up after 2 hrs of sleeping.
Associated complaint:
- Palpitations when over thinking
Family History: Mother- HTN, Alive Father- Haemerrhoids, died(natural death)
Clinical findings: Appearance-expression of hopelessness on face low , Height – 5’7”, Weight – 60kgs. Oedema – slight over face and under eyes. Blood Pressure- 140/100 mmHg.
Investigations: Assessment Criteria: Geriatric Depressive Disorder Using Geriatric Depression Scale (GDS) The Geriatric Depression Scale (GDS) is a 30-item self-report assessment designed specifically to identify depression in the elderly. The items may be answered yes or no, which is thought to be simpler than scales that use a five-category response set. It is generally recommended as a routine part of a comprehensive geriatric assessment. One point is assigned to each answer and corresponds to a scoring grid. A score of 10 or 11 or lower is the usual threshold to separate depressed from non depressed patients. However, a diagnosis of clinical depression should not be made on the GDS results alone. Although the test has well-established reliability and validity, responses should be considered in conjunction with other results from a comprehensive diagnostic work-up. A short version of the GDS containing 15 questions has been developed. 3
Figure 1 : Figure showing Geriatric Depression Scale (GDS) (Long Form)
Image source: Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depressionscreening scale: a preliminary report. J Psychiatr Res 1983; 17:37-49. Available for download at www.neuroscienceCME.com
Provisional Diagnosis: Considering mental symptoms as per specific DSM-5 criteria for depressive disorder, patient was considered depressive . The severity and intensity of depression was assessed on Geriatric Depression Scale(GDS).As per Geriatric Depression Scale the score of the patient on the day of case taking was 24 . A patient with a score between 20-30 is considered severely depressive.
Totality of case:
- Ailments from mortification
- Fear of loss of position in society
- Extreme worthlessness
- Constantly talk of commiting suicide
- Does not wish to speak to anyone becomes irritable especially family members
- Oversensitiveness for what others will think about him in society
- Sleep: Sleeplessness, wakes up after 2 hrs of sleeping
- Perspiration: Profuse on face
- Heaviness in head
- Palpitations
First prescription with justification: Aurum metallicum 1M single dose was prescribed after considering ailments from mortification, extreme worthlessness, hopelessness, desire of committing suicide, heaviness in head, sleeplessness and palpitation as per Hahnemann’s instruction in sec 225 for mental diseases and further referring Materia Medica -Boericke’s New Manual of Homeopathic Materia medica with Repertory4.After that patient was given placebo for 15 days.
Table 1: Follow ups with prescription and justification
| Date | Symptoms | Prescription with justification |
| 25-10-2015 | Irritability reduced, sound sleep, Frequency and intensity of suicidal thoughts reduced, palpitations-SQ Geriatric Depression Score :22 | Rubrum30 twice a day for 30 days along with counselling. As favorable response GDS score improved; wait & watch.*5 |
| 26-11-2015 to 26-01-2016 | Relief in symptom that he does not wish to speak to anyone especially family members, heaviness in head reduced, intensity and frequency of suicidal thoughts reduced, he feels relatively less worthless and hopeless, Sleeplessness reduced, palpitatios -SQ Geriatric Depression Score :20 | Rubrum30 twice a day for 60 days was prescribed along with counselling in every 30 days follow up.As favorable response GDS score improved; wait & watch.* |
| 27-02-2016 to 27-04-2016 | Relatively less suicidal thoughts ,less heaviness head general condition better, Sleeplessness reduced, irritability reduced, he feels more lively and tries to communicate with family and friends, Geriatric Depression Score :17 | Rubrum30 twice a day for 60 days was prescribed along with counselling in every 30 days follow up.As favorable response GDS score improved; wait & watch.* |
| 27-04-2016 to 26-06-2016 | Patient had argument with his son which was followed by heaviness head and irritability, disturbed sleep on and off, he did not had suicidal thoughts though. He said his son doesn’t respect him and he is not worthy of living, felt hopeless again, irritability was reduced, sleeplessness – SQ, palpitations -SQ, Geriatric Depression Score :19 | Aurum metallicum 10 M single dose followed by Rubrum30 twice a day for 60 day**6GDS score increased; higher potency was given along with counselling. |
| 12-07-2016 | Patient felt better sleeplessness reduced Relatively less suicidal thoughts ,less heaviness in head, general condition better, palptation reduced. Geriatric Depression Score :18 | Rubrum30 twice a day for 60 days was prescribed along with counselling in every 30 days follow up.As favorable response GDS score improved; wait & watch.* |
| 27-09-2016 to 27-10-2016 | Relatively less irritable suicidal thoughts ,less heaviness head, general condition better, Sleeplessness reduced, , he feels lively and mentally stable. initiates communication with others. Geriatric Depression Score :17 | Rubrum30 twice a day for 60 days was prescribed along with counselling in every 30 days follow up.As favorable response GDS score improved; wait & watch.* |
| 25-12-2016 to 27-09-2017 | No suicidal thoughts and irritability , general condition is better, no hopeless feeling, irritability , palpitations, sleeplessness reduced,no heaviness in head Sound sleep , no irritability no sleeplessness, mild headache because of wok exertion ocassional palpitations Geriatric Depression Score :16 | Rubrum30 twice a day for next 9 months was prescribed along with counselling in every 30 days follow up. As favorable response GDS score improved and was constant during these months; wait & watch.* |
| 20-11-2017 to 27-05-2018 | Ocassional heaviness in head due to mental exertion at work, relief in other complaits without relapse of symptoms General condition of the patient was better, no new symptoms reported by patient. Geriatric Depression Score :15 | Rubrum30 twice a day for next 5 months was prescribed along with counselling in every 30 days follow up. As favorable response GDS score improved and was constant during these months; wait & watch.* |
| 26-07-2018 To 28-01-2019 | General condition better , no new symptoms reported by patient. SQ Geriatric Depression Score :14 | Rubrum30 twice a day for next 6 months was prescribed along with counselling in every 30 days follow up.As favorable response GDS score improved and was constant during these months; wait & watch.* |
| 26-02-2019 | General condition better , no new symptoms reported by patient. Geriatric Depression Score :13 | Rubrum30 twice a day for next 62months was prescribed along with counselling in every 30 days follow up.As favorable response GDS score improved and was constant during these months; wait & watch.*Patient’s GDS score is improving and is still visiting OPD for egular follow-ups. |
* C.M. Boger in the section “THE REPITITION OF THE DOSE” in Boenninghausen’s Characterstics & Repertory has stated that- No second dose should be given as long as the relief progresses even though slightly . The amelioration is apt to show itself in the mental stat first.
** Accoding to H.A. Roberts” When the potency has exhausted its action and is incapable of further improvement change is potency is called.
DISCUSSION AND CONCLUSION
Depressive illness in later liferequires meticulous management and follow up as the symptoms of the patient in geriatric age group is relatively complex to elicite. In this case totality for prescription was made on symptoms ailment from mortification, extreme worthlessness constantly talk and desire of commiting suicide,does not wish to speak to anyone becomes irritable especially family members, sleeplessness,heaviness in head with palpitations. In initial follow ups, the patient presented in relief in symptoms of sleep, irritability and less intensity and frequency of suicidal thoughts and gradually other symptoms of heaviness in head, hopelessness, worthlessness reduced hence the GDS score was improved. There was relapse of symptoms when patient had argument with his son which lead to irritability, irritation and disturbed sleep , as per H. A. Roberts instruction potency of the same medicine prescribed was changed. The treatment aims at the improvement of GDS score and reduction of intensity and frequency of symptoms. The general condition was better along with optimum day to day activities as reported by patient.
References:
1. F. Amy, W Julie,Gatz M. Depression in Older Adults. Annual review of clinical psychology 2009; Available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852580/#!po=0.549451
2. American Psychiatric Association.Diagnostic and Statistical Manual of Mental Disorders.Fifth Edition. Arlington, VA : American Psychiatric Association, 2013
3. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depressionscreening scale: a preliminary report. J Psychiatr Res1983; 17:37-49. Available at http://www.minddisorders.com/Flu-Inv/Geriatric-Depression-Scale.html
4 Boericke W. Boericke’s New Manual of Homoeopathic Materia Medica with Repertory.New Delhi:B.Jain Publisher;2000
5. Boger C.M. Boenninghausen’s Characteristics & Repertory. New Delhi:B.Jain Publisher(P) LTD.2013
6. Roberts H. A. The Principle and Art of cure in Homoeopathy. B. jain Publishers Pvt. Ltd; 2002.
About the author:
- Dr S Bidwalkar
Professor, Department of Repertory, Dr. M.P.K.H.M.C.H & R.C., constituent college of
Homoeopathy University, Saipura, Sanganer, Jaipur - Dr. Yashasvi Shakdvipiya
Assistant Professor, Department of Repertory, Dr. M.P.K.H.M.C.H & R.C., constituent
college of Homoeopathy University, Saipura, Sanganer, Jaipur - Dr.Ankita Upadhyay
MD PGR (Part II),Department of Repertory, Dr. M.P.K.H.M.C.H & R.C., constituent
college of Homoeopathy University, Saipura, Sanganer, Jaipur - Dr Shipra Singh
MD PGR (Part II),Department of Repertory, Dr. M.P.K.H.M.C.H & R.C., constituent
college of Homoeopathy University, Saipura, Sanganer, Jaipur - Dr Rajshree Jangid
MD PGR (Part II),Department of Organon & Homoeopathic Philosophy , Dr.
M.P.K.H.M.C.H & R.C., constituent college of Homoeopathy University, Saipura,
Sanganer, Jaipur
