Depressed Patients

Major Depression

Depression is a term used by most to describe even minor and transient mood fluctuations. It is seen everywhere and is often thought to be normal; therefore, it is likely to be dismissed even when it is serious. This applies all the more to a patient with serious medical illness: If a man has terminal cancer and meets the full criteria for MDD, this mood state is regarded by some as “appropriate.” Depression is used here to denote the disorder of MDD—a seriously disabling condition for the patient, capable of endangering the patient's life; it is not just an emotional reaction of sadness or despondency. If, while recovering from an acute stroke, a patient has a severe exacerbation of psoriasis, no one says that the cutaneous eruption is appropriate, even though the stress associated with the stroke has almost certainly caused it. Moreover, caregivers are swift to treat the exacerbation. When a patient with a history of MDD lapses into severe depression 1 month after beginning radiation therapy for an inoperable lung cancer, some may see a connection to the prior depressive illness and hasten to treat it. Far more common is the conclusion that anyone with that condition would be depressed. The majority of terminally ill cancer patients do not develop MDD no matter how despondent they feel. If a patient is hemorrhaging from a ruptured spleen, has lost a great deal of blood, becomes hypotensive, and goes into shock, no one calls this appropriate. Like shock, depression is a dread complication of medical illness that requires swift diagnosis and treatment.

Two assumptions are made here: (1) A depressive syndrome in a medically ill patient shares the pathophysiology of a (primary) major affective disorder, and (2) proper diagnosis is made by applying the same criteria. Patients who suffer from unipolar depressive disorders typically present with a constellation of psychological and cognitive ( Table 9-1 ), behavioral ( Table 9-2 ), and physical and somatic ( Table 9-3 ) symptoms. Because far less epidemiologic information is available on depression in the medically ill, the requirement that the dysphoria be present for 2 weeks or longer should be regarded as only a rough approximation in the medically ill. According to the DSM-5, at least five of the following nine symptoms should be present most of the day, nearly every day, and should include either depressed mood or loss of interest or pleasure:

• 1.

  Depressed mood, subjective or observed

• 2.

  Markedly diminished interest or pleasure in all, or almost all activities

• 3.

  Significant (more than 5% of body weight per month) weight loss or gain

• 4.

  Insomnia or hypersomnia

• 5.

  Psychomotor agitation or retardation that is observable by others

• 6.

  Fatigue or loss of energy

• 7.

  Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional), not merely about being sick

• 8.

  Diminished ability to think or concentrate, or indecisiveness

• 9.

  Recurrent thoughts of death (not just a fear of dying), recurrent suicidal ideation without a plan, or a suicide attempt or a specific plan for committing suicide.

Two questions (does the patient suffer from depressed mood? is there diminished interest or pleasure?) have a high sensitivity (about 95%), but unfortunately a low specificity (57%), for diagnosing MDD. Consequently, posing these two questions can be useful as a first approach to the patient who presents with risk factors for depression. However, further inquiry is required to establish the diagnosis. Although depressive disorders are frequently associated with medical illnesses, the DSM-5 considers that potential medical illnesses underlying depressive symptoms should be excluded before making the diagnosis of MDD. This hierarchical approach is typically ignored by clinicians, who tend to make the diagnosis of MDD even in the presence of co-morbid medical conditions that may be etiologically related to the condition itself. Nevertheless, the issue of differential diagnosis with medical diseases still exists, as patients may present with transient demoralization as a result of their physical illness or of fatigue or other cognitive and neurovegetative symptoms (but not fulfilling the criteria for MDD or even minor depression). For instance, weight loss and fatigue may also be associated with a variety of disorders (e.g., DM, cancer, thyroid disease). The medical and psychiatric history, together with the physical examination, should guide any further diagnostic work-up.

The aforementioned DSM-5 symptoms may at first seem invalid in the medically ill. If the patient has advanced cancer, how can one attribute anorexia or fatigue to something other than the malignant disease itself? Four of the nine diagnostic symptoms could be viewed as impossible to ascribe exclusively to depression in a medically ill patient: sleep difficulty, anorexia, fatigue or energy loss, and difficulty concentrating. Endicott developed a list of symptoms that the clinician can substitute for, and count in place of, these four: fearful or depressed appearance; social withdrawal or decreased talkativeness; brooding, self-pity, or pessimism; and mood that is not reactive (i.e., the patient cannot be cheered up, does not smile, or does not react positively to good news). Although this method is effective, Chochinov and colleagues compared diagnostic outcomes using both the regular (Research Diagnostic Criteria) and the substituted criteria in a group of medically ill patients. If one held the first two symptoms to the strict levels—that is, depressed mood must be present most of the day, nearly every day, and loss of interest applies to almost everything—the outcome for both diagnostic methods yielded exactly the same number of patients with the diagnosis of MDD.

The first help comes from discovery of symptoms that are more clearly the result of MDD, such as the presence of self-reproach (“I feel worthless”), the wish to be dead, or psychomotor retardation (few medical illnesses in and of themselves produce psychomotor retardation; hypothyroidism and Parkinson's disease are two of them). Insomnia or hypersomnia can also be helpful in the diagnosis, although the patient may have so much pain, dyspnea, or frequent clinical crises that sleep is impaired by these events. The ability to think or concentrate, as with the other symptoms, needs to be specifically asked about in every case.

Unfortunately, to some, a request for psychiatric consultation is tantamount to saying that physical symptoms are only “in your head” or are the result of malingering. Instead, depression is as much a somatic as a psychic disorder. The somatic manifestations of depression (e.g., insomnia, restlessness, anhedonia) may even be construed as proof to a patient that they have no “psychic” illness. “No, doctor, no way am I depressed; if I could just get rid of this pain, everything would be fine.” Persistence and aggressive questioning are required to elicit the presence or absence of the nine symptoms.

If the history establishes six of nine symptoms, the consultant may not be certain that three of them have anything to do with depression but may just as likely stem from a co-morbid medical illness. If the patient was found to be hypothyroid, the treatment of choice would not be antidepressants but judicious thyroid replacement. Usually, however, everything is being done for the patient to alleviate the symptoms of the primary illness. If this appears to be the case, our recommendation is to make the diagnosis of MDD and proceed with treatment.

States Commonly Mislabeled as Depression

Up to one-third of patients referred for depression have, on clinical examination, neither MDD nor minor depression. By far the most common diagnosis found among these mislabeled referrals at the MGH has been an organic mental syndrome. A quietly confused patient may look depressed. The patient with dementia or with a frontal lobe syndrome caused by brain injury can lack spontaneity and appear depressed. Fortunately, the physical and mental status examinations frequently reveal the tell-tale abnormalities. Another unrecognized state, sometimes called “depression” by the consultee and easier for the psychiatrist to recognize, is anger. The patient's physician, realizing that the patient has been through a long and difficult illness, may perceive reduction in speech, smiling, and small talk on the patient's part as depression. The patient may thoroughly resent the illness, be irritated by therapeutic routines, and be fed up with the hospital environment but, despite interior smoldering rage, may remain reluctant to discharge wrath in the direction of the physician or nurses.

Excluding Organic Causes of Depression

When clinical findings confirm that the patient's symptoms are fully consistent with MDD, the consultant must still create a differential diagnosis of this syndrome. Could the same constellation of symptoms be caused by a medical illness or its treatment? Should the patient's symptoms be caused by an as yet undiagnosed illness, the last physician with the chance of detecting it is the consultant. Differential diagnosis in this situation is qualitatively the same as that described for considering causes of delirium (see Chapter 10 ). With depression, although the same process should be completed, certain conditions more commonly produce depressive syndromes and are worthy of comment.

Review of the medications that the patient is taking generally tells the consultant whether the patient is receiving something that might alter mood. Ordinarily, one would like to establish a relationship between the onset of depressive symptoms and either the start of, or a change in, a medication. If such a connection can be established, the simplest course is to stop the agent and monitor the patient for improvement. When the patient requires continued treatment, as for hypertension, the presumed offending agent can be changed, with the hope that the change to another antihypertensive will be followed by resolution of depressive symptoms. When this fails or when clinical judgment warrants no change in medication, it may be necessary to start an antidepressant along with the antihypertensive drug. The literature linking drugs to depression is inconclusive at best. Clinicians have seen depression following use of reserpine and steroids and from withdrawal from cocaine, amphetamine, and alcohol. Despite anecdotal reports, β-blockers do not appear to cause depression. It has been suggested that depression in some cases appears as a reaction to subclinical cardiovascular symptoms, so the differential diagnosis should also take into account medical conditions. The most common central nervous system (CNS) side effect of a drug is confusion or delirium, and this is commonly mislabeled as depression because a mental status examination has not been conducted.

Abnormal laboratory values should not be overlooked, because they may provide the clues to an undiagnosed abnormality responsible for the depressive symptoms. Laboratory values necessary for the routine differential diagnosis in psychiatric consultation should be reviewed. A work-up is not complete if the evaluation of thyroid and parathyroid function is not included. MDD is never “appropriate” (e.g., “This man has inoperable lung cancer metastatic to his brain and is depressed, which is appropriate”). MDD is a common and dread complication of many medical illnesses as they become more severe. To call it anything else is to endanger the patient and neglect one of the worst forms of human suffering. The disability associated with depressive illness is seldom recognized, yet it and mental illness in general show a stronger association with disability than with severe physical diseases. In general, the more serious the illness, the more likely the patient is to succumb to a depressive episode. Careful studies have found a high incidence of MDD in hospitalized medical patients. For more than 50 years, carcinoma of the pancreas has been associated with psychiatric symptoms, especially depression, which in some cases seems to be the first manifestation of the disease. Two carefully controlled studies have shown these patients to have significantly more psychiatric symptoms and major depression than patients with other malignancies of gastrointestinal origin, leading some to suspect that depression in this case is a manifestation of a paraneoplastic syndrome.