A Clinicl Case Report on Black Dog (Depression)

Aim: The intent of this case report is to define the top practice for a person detected with depressive disorder who has been denoted to a public mental health facility for treatment. To identify the black dog symptoms early to provide treatment and prevent potential complication. Presentation of case: A 45-year-old male patient got admitted in psychiatric ward AVBR Hospital Sawangi Meghe Wardha, Maharashtra, with the complaints of insomnia, low mood, social withdrawal, irritable, lack of interaction, lack of interest, sadness, hopelessness, helplessness, decrease appetite and suicide ideation such as hanging. patient was apparently asymptomatic 10 month ago when his younger brother passes away and his started show above clinical features of depression. patient received antidepressant drug citalopram, Imipramine and two-time Somatic therapy (Electroconvulsive Therapy). symptoms were minimized. Result: The patient was received psychopharmacological treatment antidepressant drug sertraline, citalopram, fluvoxamine along with somatic therapy (ECT) two times and psychosocial therapy, coping strategies, family therapy, yoga, recreation, meditation and symptoms was minimized. Discussion: Millions of people worldwide suffer from depression. it is most common disorder in outpatient clinic. which can result impairment and disability of individual ability to cope up with daily life. Conclusion: A positive outcome gets by the patient not only with the help of therapeutic management but also the family coping and support even. later on, due to proper psychopharmacological treatment, patient shown positive feedback and slowly all the aims are achieved which were planned in period. Finally, the patient got discharged from the hospital and now he is continuing his on follow up. Case Study Meshram et al.; JPRI, 33(39A): 181-185, 2021; Article no.JPRI.70731 182


INTRODUCTION
Depression is affective condition. affective disorder shows pathological changes in mood [1]. Depression is a most common mental condition characterized by a sad mood, lack of interest or pleasure, feelings of guilt or low self-worth, sleep or hunger disturbances, low energy, and impaired focus [2]. It affected worldwide 121 million people. More women have depression than men are affected [3]. There are various types of clinical depression, depression Major Depression, Dysthymic disorder, Minor depression, psychotic depression, seasonal affective disorder, situational depression, bipolar disorder, atypical depression, and postpartum depression [4]. Most generally, the term "black dog" is used to define a state of depression, marked by either bad conduct or deficiency of desire to do something, even belongings that you once enjoyed. For depression patients and those with loved ones experiencing depression, this example may be helpful, since the picture of a large, intrusive black dog can more easily define the sometimes problematic-to-understand parts of depression [5]. The "black dog" primary used to define a feeling of reflective sadness (melancholy) [6].
There are many factors responsible for depression such as genetic factors disturbance in neurotransmitter, environmental factor, psychological and social factors additional condition such as bipolar illness [7].
Clinical symptoms such as depressed mood, lack of interest and enjoyment, feelings of shame and low self-worth, insomnia or anorexia nervosa, low energy, and lack concentration are typical characteristics. A sad or irritable mood, lack of interest in any or most things that used to be pleasurable are typically the maximum common symptoms of depression. In spite of having done nothing wrong, patients can often experience remorse, as well as Useless feeling, helpless, or have persistent feelings of wanting to die, kill, or otherwise injure themselves, such as cutting or burning themselves [8]. Patients may also experience guilt despite having done nothing wrong, as well as feeling worthless, hopeless, or have recurring thoughts of wanting to die, kill, or otherwise harm themselves, as in cutting or burning themselves. It is also possible to correlate physical depression with physical symptoms. Fatigue or low energy, disturbed sleeping, particularly waking early in the morning, especially headaches, treatment Feeling or appearing to be slowed or irritated [9].
Treatment of this antidepressant, antipsychotic drug, antihypertensive, anticonvulsant antipsychotics, benzodiazepine and antianxiety along with this psychotherapy is most important such as speaking therapy, Light therapy, alternative therapies, exercise, medication, yoga [10]. If it not treated complication can include physical pan, substance use problems, panic attacks, wight gain or loss, social isolation, self-harms, and suicide thought [11].

PRESENTATION OF CASE
A case selected from AVBR Hospital Sawangi (Meghe), Wardha where lack of mental health services for the remote population, or Acharya Vinobha Bhave Rural Hospital provided psychiatric health facilities for all the needy people.

Patient Information
A 45-year-old male patient got admitted in psychiatric ward, Acharya Vinobha Bhave Rural Hospital with the complaints by the verbalization of patient and body ache and insomnia and relative low mood, social withdrawal, irritable, lack of interaction, lack of interest, sadness, hopelessness, helplessness, decrease sleep and appetite. As per relative of patient his son verbalization, the patient was apparently asymptomatic 10 month ago when his younger brother passes away and his started show clinical features of depression like low mood and decreased interaction with people, his was always irritable and gets angry all the time, sadness, hopelessness, helplessness, decrease sleep and appetite, suicide ideation such as hanging. All necessary investigation like history collection, physical examination mental status examination blood investigation was done and Doctor Diagnose Black Dog. he was admitted in ward for further evaluation and treatment.

Precipitating Factors
His younger brother passes away (loos of love object) before 10 months.

Perpetuating Factors/ Ongoing Challenges
The patient is poor compliance to medication for the past week, developed severity of symptoms he tries to suicide attamed such as hanging self.

Past Psychiatric History
Prior to approach to these hospitals patient admitted in government hospital Yavatmal he takes treatment antidepressant, antipsychotic drug. as there was no positive outcome from the patients, residents referred this patient to present hospital. The patient scored 38 points on the 30item Inventory of Depressive Symptomatology (IDS), which is indicative of a severe depression.

Physical examination
Unstable gait, lack of social interaction, facial expression sad, anxious.

Mental status examination
Mental status examination was done and finding of patient facial expression was anxious. mannerism present. Speech reaction time was delay reaction. mood and affect, thought, and disorder of perception was not present. his well oriented of time, place and person. Memory, abstract, intelligence, judgement and insight were intact.

Data Extraction
Data extracted from PUB MED, Medline, and Cochrane database library.

Psycho Pharmacologic Interventions
The patient is on following treatment regimen which is: Benzodiazepine hypnotics were administered from the date of admission to the patient on the antidepressant, but without any change in symptoms. A first-line antidepressant, as well as on Vitamin and multimineral as well as on symptomatic SOS treatment, he was started on citalopram 20mg once a day 6 weeks before his referral.
Citalopram, indication for depression as well as disorder of anxiety, his depressed mood marginally improved or symptoms of reduced anxiety within three weeks [12].

Benzodiazepine hypnotics
The benzodiazepine is clonazepam. Clonazepam is thought to function by stimulating the production of some brain neurotransmitters. They inhibit the central nervous system with these medications. Benzodiazepines and barbiturates are addictive or should not be used in the long term. Sedative hypnotics function on the brain's GABA A receptors [13].

Imipramine
Dose Maintenance: oral administration of 100 to 200 mg once a day. Imipramine works by inhibiting the reuptake of certain neurotransmitters in the brain, including acetylcholine, dopamine, norepinephrine, and serotonin. It also operates on many other receptors, for example histamine receptor H 1. Imipramine usually is given to IM and IV [14].
Sertraline /Zoloft: 50m HS /day. Sertraline is a selective regulator of serotonin uptake that is used for treating depression. Sertraline is a selective serotonin uptake inhibitor that is used in the treatment of depression. (12) As a Serotonin Uptake Inhibitor, the mechanism of action of sertraline. SSRI is used in depression treatment and anxiety disorders [15].

Somatic therapy (electroconvulsive therapy)
patient received two-time somatic therapy. ECT is the induction by the application of electric current to the brain of a grandma seizure. somatic therapy is successful in the management of extreme depression or highly suicidal patients, mainly in those patients who also experience psychotic symptoms and those with psychomotor retardation or neurovegetative changes, like sleep, appetite, or energy disorder. Along with Provided Yoga and meditation therapy, and group therapy its help to reduce stress [16].
Most common treatment of depression is talk therapy since it helps people to explain what they are going through or well realize their own needs or thoughts. CBT (Cognitive Behaviour Therapy) involves talk therapy, which aims to rearrange dysfunctional and unproductive thought habits to boost general psychological health or stability [17].

Scientific discussion and strength and associated limitations regarding the case report
This is a pure case of a black dog. The 45-yearold male admitted in an AVBRH hospital with the typical symptoms of lack interests, low mood sad, hopelessness, helplessness, social withdrawal, suicidal ideation. The plan of care completely based on interventions were includes a various management that were pharmacological management, medical management, nursing management as well as the therapeutic management. Since from the first day of hospitalization, plan of action was planned with rationale; and according to the planning the implementation also done with positive outcomes. A positive outcome gets by the patient not only with the help of therapeutic management but also the family coping and support even. Due to proper Psycho pharmacological treatment, patient shown positive feedback and slowly all the aims are achieved. Finally, the patient got discharged from the hospital after one month now he is continuing his follow up.

Prognosis
The prognosis is the first and foremost dependant on early and successful treatment of black dog. As well as the prognosis also depend upon the severity of the disease condition but also the socioeconomic background of the family and meanwhile family coping. treatment regimen, later on the patient given a positive outcome and finally he discharged from the hospital while staying in hospital near about 20 days. During the hospitalization of a patient, as family were not able to afford the cost of treatment regimen, family approached for the fund and some Yojana; from these sources the family got little bit of help.

DISCUSSION
Millions of people worldwide suffer from depression. it is most common disorder in outpatient clinic. which can result impairment and disability of individual ability to cope up with daily life. one of the research studies in Australia said Assuming similar signs of sadness, we independently put on a depression finding method on three separate datasets (Black Dog, Pitt, AVEC) to explore generalizability or scalability in combination [18].
Investigator recognized importance of to identify risk factor like interpersonal conflict, sexual coercion or marital disharmony. They also define cost-effective treatment models that can be conveniently use in primary care, helping to treat depression clients effectively [19].
One of the research researchers found folds relationship between Black dog and living single.
They also presented a 4-fold rise in the probability of widows or widowers becoming depressed. Spousal harm a living alone has also been found to be strongly connected with the risk of depression. The WHO has well-defined adverse life measures as risk factors for depression among older people, including divorce, separation, lack of sufficient social support or social isolation, lack of sufficient social support [20]. In comparison, depression was most frequently related to biological or medical causes by health practitioners, associations or academic organisations. In other words, in mass media posts, clinical help was most associated with low efficacy, which could deter people in need from pursuing professional help [21].

CONCLUSION
Only the psychotherapy is not appropriate therapy for treating the sever depression bipolar disorder, psychosis. In sever depression combination of dug and psychotherapy somatic therapy is most effective for this. along with CBT (cognitive behaviour therapy), problem-solving therapy and interpersonal therapy. must be integrated psychiatric management. Finally, the patient got discharged from the hospital and now he is continuing his on follow up.

CONSENT AND ETHICAL APPROVAL
As per international standard or university standard guideline patients consent and ethical approval has been collected and preserved by the authors.

ACKNOWLEDGEMENT
The authors thanks to Mrs. Jaya Gawai HOD and Associate Professor of mental health department, SRMMCON, Sawangi (Meghe) Wardha, Maharashtra, India for continuous support and valuable suggestion. Authors also thanks to Mrs. Pooja Kasturkar, assistance professor of mental health department SRMMCON, Sawangi (Meghe) Wardha Maharashtra, India for provided time to time support and guidance for success. Authors also thankful to participant of this study for giving their time.

COMPETING INTERESTS
Authors have declared that no competing interests exist.