Case study 7: Highs and lows

Depression

This lady presents with symptoms of depression, apparently related to bereavement. Supposing she works full-time as a secretary - how might her symptoms affect her attendance and performance at work?

She may have difficulty with:

• Pace of work - not keeping up with demand because of lethargy and poor concentration,
• Problems with decision-making - if her mood and confidence are low,
• Interpersonal relationships in the office - if she is 'upset' and 'not herself',
• Time-keeping and tiredness at work - if her sleep is affected.

How might work itself affect her illness?

Work can be very therapeutic. Her colleagues - and maybe her boss - would probably know about her bereavement and may have been helpful and supportive in the general work/social context.

However, they may not continue to be supportive and sympathetic if her performance continues to deteriorate over several months and she may become increasingly anxious ('stressed') about her own performance and the relationships in the office.

By the time she presents to her doctor with suicidal thoughts, low self-esteem and low mood, she may well have gone off work. When she starts antidepressants she won't feel an immediate benefit and this may adversely affect her confidence - particularly if she wants to return to work quickly.

In summary, the situation by this stage is this:

• People around your patient know she has had a tough time and has reacted badly to it but now, she has "disappeared" from work and things seem to be going from bad to worse,
• If she goes back to work too early, she is likely to fail,
• BUT the longer she stays away, the harder it is to get back.

This is a very common and often very difficult paradox.

How would you explain these problems to your patient? How would you attempt to deal with the distorted perception and chronic anxiety which often accompanies this common clinical situation?

Some patients believe that they should stop their medication as soon as they feel better. How would you counsel this lady in relation to continuing treatment and particularly in relation to returning to work whilst taking antidepressants?

Premature stopping of antidepressant medication (whether sanctioned by a doctor or done by the patient's own choice) is a common cause of relapse of symptoms. One in three patients who stop their medication as soon as they feel better will become depressed again within six months. Normal advice is to continue with the medication for 4-6 months after the patient feels better.

Withdrawal from the medication needs to be done carefully, with specific advice on withdrawal period or reduced doses dependant on the class of drug.

Possible side-effects from antidepressants may affect her fitness for work. Sedation is the side-effect most likely to affect both her ability to perform her work tasks and even her ability to get to work if she has to drive any distance.

Would your advice on continuing treatment and returning to work differ if she was a shift worker, on three shifts (6am-2pm, 2pm-10pm, 10pm-6am), rotating at weekly intervals?

Her sleep patterns would be more difficult to re-establish if she works shifts. It will depend to a certain extent on how she coped with shift work prior to her illness, but you may need to advise her and her employer that she should work 'regular day shifts' for a period of time until her symptoms have fully resolved.

Her illness may be defined as a 'disability' within the terms of the Equality Act, and the 'reasonable adjustment' of allowing her to work regular days shifts for a while may be appropriate.

When she presents with symptoms of 'mania', she will probably need a further spell of time off work, while her treatment is established. How might her symptoms affect her work?

• Her performance is likely to decline markedly as she is unable to concentrate,
• Her behaviour may appear 'bizarre' to her colleagues,
• Her dress and personal appearance may become 'odd' or fall in standard,
• Her attendance may suffer if she can't focus on work.

Would her actual job affect your decision on the timing of a return to work when her clinical condition improves? Supposing she was a Nursing Sister on an ICU Unit, rather than a secretary?

In general terms, you need to assess the risks to herself and others of her return to work. Although your aim should be to try to resettle her at work as soon as possible, you may wish to see a significant period of stability on - and compliance with - medication before you would allow her to return to an emotionally demanding and responsible job. Six months may be a 'reasonable' period of assessment before sanctioning return to work as a nurse. You may even want to talk about a temporary change of job while she recovers and re-establishes her working life.

The idea of "risk assessment" may be a novel one to you but in clinical, therapeutic terms it is inherent to the management of patients. Every time one prescribes a regimen of treatment, one is taking a "risk" where benefit is balanced against the potential for harm. By extrapolating this idea away from your patient and into the broader society of which your patient is a part, you stay within a familiar framework (in terms of supporting and protecting your patient) but you are increasingly pushed to consider your broader social duties too.

Supposing whilst "manic" your patient, as the nurse in charge of the ICU, killed a patient in her care!

Jot down some ideas about the letter of explanation you would write:

• To the General Medical Council,
• To the dead patient's family,
• To your lawyer when the family sued you!