Depression Case History
A 52 year old female hospital doctor, with no previous history of depression, presented with symptoms of increasing fatigue, poor concentration and feelings that her mood had been drifting down over 6-9 months. There was no particular life event or other external cause leading to the change in mood. Family members had commented on increased irritability, although she blamed simple fatigue for this. She saw her GP who checked her physical health. All tests (thyroid function etc) were normal.
The impact on work during this time included a noticeable withdrawal from involvement in departmental meetings. Her secretary noticed letters waiting longer to get checked, and on one occasion she snapped at a colleague and had to apologise. Her manager wished to refer her to Occupational Health but she declined and went off sick.
At a further GP appointment depression was recognised as the cause of her symptoms. She acknowledged that the difficulties had been building up, unnoticed by her, for some time. She was started on antidepressants and signed off work. She was referred for counselling but didn’t feel able to develop a therapeutic relationship with the counsellor. She switched to a therapist in the private sector where she felt better able to engage in therapy.
Side effects from the antidepressant were not well tolerated and an alternative was prescribed.
Occupational Health Advice and Adjustments
After 2 months off work, she started to feel better and agreed to a referral to Occupational Health. The improvement was noted but it was agreed it was too early to plan a return to work (RTW). A review 3 weeks later demonstrated continued improvement such that a phased return to work could be planned. Along with supporting an effective return to work for the doctor, the concerns of the manager had to be addressed. These included capability of the doctor to fulfil the duties of the role, ensuring safe practice whilst working with vulnerable patient groups, relationships with others and risk of future absence.
The doctor discussed her anxieties about the return to work. She felt ashamed of her diagnosis and was concerned how she may have come across to colleagues when she was ill, and what she would say to people when she returned. Meetings were arranged with her clinical director and secretary, to map out the first few weeks of her return, to ensure that everyone would work together, with realistic expectations. It was agreed that she would not undertake ‘on calls’ during the first month of RTW, to ensure robust colleague support was always available, while her confidence was restored. After 6 weeks of work followed by a week of annual leave, on call work was resumed. By this time she had been on medication 3 months, had 8 sessions of CBT and both she and OH agreed she was ready.
The prognosis for this doctor is very good. The risk of relapse is small and, with greater insight and early access to strategies to manage mood and energy, there are no features which raise concern in the long term. A further 6 months of medication helped to ensure that she remained optimally well beyond the initial RTW. The short duration of this episode meant that this is not considered a qualifying condition under the Equality Act 2010.
This case highlights not only the difficulty that some doctors have in recognising the symptoms of depression, but also how important it is to recognise the challenges the therapist may have working with an experienced clinician over such issues. Having confidence that the counsellor/therapist will understand the clinician’s particular issues and concerns is paramount to a successful outcome. If this is not the case, it may be easy for doctors to evade or minimise the issues and thus traverse therapy without receiving any long term effective help.