Who Cares Wins - Royal College of Psychiatrists

The general nursing staff request education about CJD from the mental health liaison team and this is
provided over several sessions.
Although a rare condition this case illustrates common problems of differential diagnosis
that can result in an incorrect line of management and also that it is essential for a
mental health liaison nurse to have prompt medical support.
Depression
2.20 In the only randomised controlled trial of antidepressants in this population active treatment was
superior to placebo for the treatment of seriously medically ill older people with depression and
side effects were reported no more often with active treatment than placebo (127).
2.21 There is no strong evidence for the superiority of any particular antidepressant but side effect
profile and safety are particularly important considerations for older people in this situation.
2.22 A single randomised controlled comparison of interpersonal counselling versus usual care for
medical inpatients with minor depression showed benefits for those receiving psychotherapy
(128).
• An appropriate antidepressant and/or psychological treatment should be
considered for all depressed older people in general hospitals.
2.23 While the evidence demonstrates the benefit of actively treating depression there remains a need
for much more research in this important area.
Case Study
Mrs. D is an 85 year old lady admitted with chest pain. The medical team refer her for a mental health
assessment with a diagnosis of acute confusion with psychosis.
She was crying. She believed that she owed the Department of Social Security £50,000 and was waiting
for the police to arrest her for fraud. She was convinced that she would go to Crown Court and receive
a life sentence. She believed she was infested with lice because she felt her skin crawl and could hear
other patients commenting on it. She believed that her story was being broadcast on the television. Her
cognitive function was excellent.
The psychiatrist made a diagnosis of a severe depressive episode with psychotic symptoms. She was
prescribed antidepressant and antipsychotic medication. Due to unstable heart failure it was preferable
to treat her on the medical ward. Subsequently, the family reported that she had been taking an
antidepressant at home and this was stopped on admission 2 weeks before referral.
She made a full recovery and returned home where she was reviewed by the local older people’s
mental health team.
This case illustrates the importance of accurate diagnosis and how those unfamiliar with
psychotic states can be misled. It also demonstrates how treatable severe depressive
states are and how it is unwise to discontinue psychotropic medication without knowing
the indication for its use.
21