A 59 year old male, hailing from a lower middle class family of a VDC in Dhading and farmer by profession, was brought to Out-Patient Department at District Hospital, Nilkantha Municipality, Dhading on 2nd October, 2016 with recent history of attempt at self harm, multiple joint pain, headache and abdominal pain for last 3 months. He had already visited a number of health facilities in Dhading and Kathmandu for these symptoms wherein he underwent a series of investigations during consultation and was treated symptomatically with multi-vitamin supplementation and antacids with minimal improvement. His family was worried about his persistent symptoms. He has two sons and 2 daughters.
He was then brought to the district hospital by his wife. He was evaluated by a Medical Officer who had received 9-day mental health and psychosocial care training for prescribers. On detailed history taking, he shared inability to experience pleasure, preference to stay alone most of the time, decreasing interest in social interaction and activities, poor sleep, decreased food intake, forgetfulness, decreased self-confidence, excessive fatigue, tingling sensation and frequent thoughts about self-harm. His wife admitted to the fact that he has shown these changes over last 3 months. He was fed up with his life and started thinking of ending his life. He developed thoughts at self harm frequently. He planned gradually of terminating his life by either hanging himself or by jumping into the nearby river. He did not share his thoughts at self harm with others. However, he met few of his close friends and had been talking in a different manner than usual. He started saying that life is a curse to human and that one has to suffer throughout. He discussed with his family on making the will and distributing his property to his sons. His family was shocked the way he had started behaving and were amazed of what had been happening to him. After 3 months of onset of symptoms, he tried to attempt at self harm by trying to hang himself with a rope in a nearby forest but was rescued by a neighbour. He went to a nearby jungle at 9:00 pm and tied a rope on a branch of a tree. Then he tied a knot and hung himself on it. Suddenly he yelled out in pain and a neighbour rushed to him and rescued him. He was then taken to nearby health post and was treated symptomatically. His family was informed about the incident and was advised to take him for Psychiatric evaluation.He had bought therope from a local market 1 week prior to the incident. He was kept in monitoring after the event and the next day he was taken to the district hospital. He does not take alcohol or any other substance. The prescriber carried out relevant Physical and Mental Status Examination which revealed sad mood and no physical abnormalities.
The prescriber diagnosed him to have Moderate Depression and consulted with Psychiatrist at TPO Nepal whether or not to refer him for admission owing to risk of suicide and persistent suicidal thoughts. However, the patient denied referral for admission due to financial difficulties and was then advised to start Tab Amitryptyline 10 mg built gradually up to 37.5 mg over 3 weeks taken at night time. He received psycho-education on depression and was advised to consult Psychosocial Counsellor in Dhading district Hospital for essential psychosocial support services. Suicidal precautions were well-explained to the family. The PSC provided psycho-education to the patient and family on illness and the need for regular intake of psychotropic medications and follow up. He was also ensured that he did not have any serious physical illness and that he would gradually recover over few weeks. He was also advised to continue regular morning walk and physical exercise and to follow up every week for consecutive 3 weeks.
On subsequent follow up visit, he was found to improve gradually. He started sleeping and functioning well. He started interacting with people and self-confidence was increasing. On third follow up visit, his physical symptoms had also resolved and had no suicidal thought anymore. He was then persuaded to continue treatment and psychosocial support from the counselor. He has been coming to follow up visit every month and is leading a happy life. He thanked the prescriber and counselor for their contribution in successful treatment.