‘Is my mother’s depression a sign of dementia?’


Eighteen months ago, my mother, 83, started showing signs of depression. 

Her GP prescribed a low dose of the antidepressant sertraline; she also had a memory test and a brain scan, but was told she didn’t have dementia.

However, a year on she’s virtually lost her ability to cook, do her washing or plan her days and her depression and anxiety is terrible. She improves for three or four weeks then goes downhill.

She’s now on 150mg of sertraline. Could it be making things worse?

Name and address withheld.

A year after showing signs of depression, a reader’s mother a year virtually lost her ability to cook, do her washing or plan her days

Your description of your mother’s symptoms perfectly illustrates the complexity of psychiatry — where there are no objective tests or investigations to definitely diagnose conditions, and effective treatment depends on skilled observation and follow-up.

Despite treatment, your mother is in a cycle of depression and anxiety, with periods when she is very much better. 

This suggests to me her diagnosis must be reviewed and, even if she is still considered to have a form of depression, she should be offered alternative treatment.

One of the principles of psychiatry is that patients with a mood disorder or problems with cognitive function — where they can’t think normally and have problems with memory — should undergo investigations to check for any condition that might be causing their symptoms.

While that includes psychological tests to check for problems such as dementia, it must also involve blood tests to check how well their thyroid gland is working, and to check their levels of vitamin B12 — this is because both can initially cause profound disturbance of brain function before any other symptoms appear.

I’d suggest you organise a meeting with your mother’s GP to check that these steps were followed in her case.

There’s no need to go through the mental health team, as your longer letter suggests: the family doctor is your mother’s advocate and, as the one who holds her medical records and all the relevant correspondence, is best placed to put her in touch with specialists.

This paves the way for your mother to have her diagnosis reviewed by a consultant psychiatrist.

Dr Martin Scurr says that drugs such as sertraline could have adverse effects, and says the woman’s medication is likely to be changed

It is vital that you are present at this next specialist consultation to provide corroboration, i.e. describe what you have seen happening with your mother, rather than relying on the ill patient, who may find it hard to relate the facts in a clear fashion.

At that time, you can ask the consultant whether the sertraline might be having an adverse effect.

It is possible, though I suspect that in any event your mother’s medication will be changed.

I was diagnosed with the skin complaint lichen planus 18 months ago. 

I was told it would probably go of its own accord in about 12 months, but I now have blotches all over my body, with new ones continuing to appear.

I was prescribed steroid tablets but they did nothing, so I’m now using a steroid cream called Elocon, which is helping but, as I was warned, is turning the treated skin black.

I was referred to a dermatologist and told there is no known cure.

Roger Herridge, Folkestone, Kent.

Lichen planus is an itchy rash that affects about 1 per cent of the population, usually from middle age. It causes small, purple-red raised bumps a few millimetres wide

Lichen planus is an itchy rash that affects about 1 per cent of the population, usually from middle age.

It causes small, purple-red raised bumps a few millimetres wide, that typically develop around the wrists and ankles but sometimes also occur on the mouth and genital area.

These bumps are often confused with insect bites, especially when they occur around the ankles — but the colour of insect bites is very different, a definite pink or red.

Any doubt about the diagnosis can be resolved with a ‘punch’ biopsy under local anaesthetic. 

This involves using a special instrument to punch a tiny hole in the skin to obtain a sample, about 3mm in diameter.

A pathologist then examines the sample under a microscope to look for the cell pattern that’s characteristic of the condition.

Despite much research, it is not known exactly what causes lichen planus, though the current thinking is that it’s to do with a disturbance of the immune system in that area of the skin.

It’s thought the immune cells become over-active, which causes the skin to inflame.

In some cases, it may be linked with hepatitis C, a viral infection of the liver, though it’s only an association — i.e., hepatitis C hasn’t been identified as a definite cause for lichen planus, but is a possible risk factor.

These bumps are often confused with insect bites, especially when they occur around the ankles — but the colour of insect bites is very different, a definite pink or red

Some medicines — and there is a long list, including a group of antibiotics called tetracyclines, omeprazole (given for acid reflux), amitriptyline (an antidepressant), simvastatin (a statin), and sildenafil (also known as Viagra) — can also trigger lichen planus.

This is known as drug-induced lichen planus. When we cannot pinpoint the cause, it is known as idiopathic lichen planus.

As you know, the treatments that are available are far from satisfactory — there is very little data from research about how best to treat the condition.

Topical corticosteroids — such as the cream you have been prescribed — are usually tried first. These have an anti-inflammatory effect.

WHAT IS LICHEN PLANUS? 

Lichen planus is a non-infectious, itchy rash that can affect many areas of the body.

Affected areas can include the:

  • Arms, legs and trunk
  • Mouth (oral lichen planus)
  • Nails and scalp
  • Vulva, vagina and penis

The exact cause of lichen planus is unknown. 

Lichen planus is a non-infectious, itchy rash that can affect many areas of the body

However, the condition isn’t infectious and doesn’t usually run in families. 

It can’t be passed on to other people, including sexual partners.  

If this approach fails, then oral steroids, such as prednisolone at a dose of 30mg to 60mg, may be prescribed.

These have an anti-inflammatory effect that reaches deeper layers of the skin than the creams can.

In your case, the treatments were tried the other way round. Phototherapy — where the skin is exposed to ultraviolet B — is also sometimes used.

Though there is minimal research on this, studies have shown favourable results when used three times daily for six weeks.

Other drugs — including antihistamines and even thalidomide — have been used with benefit in some patients, though there is even less supportive data available.

The potential for side-effects (for instance, antihistamines can cause drowsiness) must be always weighed against whether the drug can drive the lichen planus into remission.

You say the skin is darkening, and this can be a sign that the cream you’re using is working.

Lichen planus usually resolves after about two years — and hopefully your symptoms will clear up in the next six months.