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Depression in the medically-ill

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By STEPHANIE ELOISA D. MIACO, M.D.

I had just given a talk on Depression in the Medically-Ill patient to an enthusiastic group of physicians who attended the evening affair. They were brimming with questions, while they shared their experiences about patients who had depression while in the hospital or in their clinics. The ensuing activity of being asked questions and giving answers who were curious about the condition of Depression in the Medically-ill proved that there was a vigorous interest in the “Two-Way Street”. All things considered, this was a very positive response. It got the ball rolling on the conversation on matters that were normally not discussed as often, because of preconceived stigma of psychiatric illness.

The comorbidity of depression and medical illness is fast becoming an important clinical and global public health issue. Several common medical conditions actually increase the risk of depression, and there is a considerably lesser response to antidepressants in this case.

In the same way, a patient having depression is liable to have an increased morbidity and mortality, with a chronic disease burden if with medical disorders.

Bidirectional: One condition affects the other

The two conditions are not independent, in the real sense of the word. The working model to understand the relationship of depression and medical illness is a Comorbidity Model, which describes the two as both coexisting risk factors. In other words, having one or the other would have a negative impact on the course and prognosis and treatment of the other.

Very recent studies have shown evidence that there is indeed an interplay of shared and specific causative factors in both medical and mental illness. The existence of one, with the presence of the other in a single patient accounts for a poorer outcome of treatment.

A person with previous (especially untreated) episodes of depression may be more likely prone to the onset of diseases such as coronary artery disease, stroke, diabetes mellitus, epilepsy and Alzheimer’s dementia.

The way depression affects biological mechanisms such as the Hypothalamic-pituitary-adrenal HPA axis (which control body processes and stress reactions) will ultimately affect the person’s treatment adherence, neglecting self-care, being physically inactive, and not eating properly, and eventually, abusing illicit drugs.

In the same way, a person with a medical condition will also be prone to the development of depression because of direct effects of the illness.

Conditions such as brain injury and thyroid deficiency, and stress-related physiologic mechanisms can be associated with a physical disability, which often leads to frailty and helplessness.

The presence of a medical illness may negatively influence the outcome of depression once it is diagnosed, as the physiologic changes affect the person’s response to antidepressants.

Studies have shown that the shifts in the body’s systems during a medical illness will result to an altered response, either very poorly or very slowly, and a high chance of relapse.

The interrelationship of depression and comorbid medical illness can be best understood as follows; Depression can be caused by an underlying physical illness or be an exacerbated response or a reaction to the illness.

In the same way, it is a consequence of the medications taken by a patient with a chronic medical illness (such as those seen in patients taking anti-hypertensives, corticosteroids and other immunosuppressants, including cancer treatments).

For example, it is also noted that depression occurs approximately 30-40 percent of patients with acute stroke or myocardial infarction, which has been linked poorer recovery rates.

How depression is diagnosed

The essential first step that needs to be undertaken is diagnosing depression correctly. It would also be very helpful to have an awareness of medical illness in patients with depression. Psychiatrists would diagnose depression in patients as follows:

Having five or more of the following symptoms have been present and documented during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure (do not include symptoms that are clearly attributable to another medical condition).

1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful)

2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation)

3) Significant weight loss when not dieting or weight gain (e.g., a change of more than five percent of body weight in a month), or decrease or increase in appetite nearly every day

4) Insomnia or hypersomnia nearly every day

5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6) Fatigue or loss of energy nearly every day

7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide, a period of at least two weeks of noted

This can be a challenge, as the common symptoms of depression, which are anorexia (poor or no appetite), weight loss, sleep disturbances, low libido (sexual desire), fatigue, and anhedonia (or the loss of enjoyment in things that one used to find pleasure in) are also found in patients with medical illness.

It is most useful to use the inclusive approach for ideal patient care.

What this means is that aside from the all symptoms of depression were to be counted, irrespective of whether they were related to medical illness. It is important to treat this, as patients with depressed mood and subsyndromal depressive symptoms may evolve into Major Depressive Disorder in vulnerable patients.

Accurate diagnosis of depression in patients may be facilitated by the use of depression screening instruments in specialized clinics, such as neurology, cancer and cardiology clinics, to promote earlier detection.

Although these are not entirely diagnostic instruments, they are useful in routine screening of depression in the different specialties. Scales are pencil/pen-and-paper tests which take a few minutes for the patients themselves to answer.

Examples of these scales that are commonly utilized (and easily downloadable from the internet) are the Beck Depression Inventory for Primary Care for inpatients, the Patient Health Questionnaire for outpatients and primary care physicians.

Routine screening can also be used, such as incorporating questions during rounds to assess mood, “Are you depressed?”, or “Do you often feel sad or depressed?”, especially when talking to terminally ill and stroke patients.

Impact of depression

Depression in medically-ill patients may respond poorly to antidepressants, however, it is still prudent to treat depressed patients aggressively in accordance with guidelines for treatment-resistant depression. This works in a bidirectional manner as well.

If the medical illness gets treated, the depression often improves. The effect of treating depression in a medically-ill patient reduces disability and suffering in a major way. All things considered, this is THE two-way street to a better patient care and outcomes.

___________________________________

Author’s email: [email protected]

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