Mohammed T. Abou-Saleh

PHYSICAL ILLNESS AND DEPRESSION 419SOMATIZED DEPRESSIONThis is more common than medical illness presenting asdepression, especially in the current generation of elderly, whotend to somatize their psychological symptoms, having beenbrought up in a society which did not encourage the expression ofemotion. Somatic symptoms in the elderly may represent physicalillness, depression or emotional responses to physical illness. Thesomatic symptoms will need investigation, but depression, ifsuspected, should be treated.Pseudodementia is a specific type of masked depression. One ofthe most important differentiating factors is that the severity ofcognitive impairment fluctuates in depressed patients, remainingconstant or worsening in the evenings in dementia. Depressedpatients tend not to try to succeed in tasks, giving up with ‘‘I don’tknow’’ or ‘‘I can’t’’. Demented patients will try, delighting insuccess but possibly becoming very distressed by failure—the socalledcatastrophic reaction. Biological symptoms of appetite andweight loss, sleep disturbance and headache are typical ofdepression and not dementia. However, depression and dementiacan coexist and the differentiation of the two conditions is notalways easy. If in doubt, a trial of antidepressant treatment willhelp elucidate the diagnosis. The pathognomic symptoms ofmasked or somatized depression include:1. Diurnal variation (symptoms usually worse in the mornings).2. Mild impairment of cognitive processes and concentration.3. Dysthymic mood changes.4. Fatigue, feeling tired, lack of energy.5. Sleep disturbance (waking up early and being unable to getback to sleep).6. An anxious sense of failure or of ‘‘impending disaster’’.LIAISONConsultation-liaison psychiatry is becoming well established as animportant specialty within general hospitals on both sides of theAtlantic. In an ideal situation, psychiatrists would attend wardrounds in the general hospital, particularly on rehabilitationwards, where prevalence of depression is high and the effect ondelayed discharge well documented 42–44 . However, restrictedresources prevent this: psychiatric morbidity is too high for apsychiatrist to see all the patients affected—his main role shouldbe educational 54 , only taking an active part in the management ofmore difficult cases. In many areas there is increasing developmentof specialist liaison nurses who are able to advise on diagnosis andtreatment, reducing delay before assessments. The liaison nurse islikely to be more permanent than junior doctors on rotation andcan often help a patient who refuses to see a psychiatrist or whosephysician refuses psychiatric referral 55 . Liaison nurses can educategeneral nurses in the recognition of psychiatric disorder and can inturn encourage junior medical staff to institute appropriatereferral or treatment. Their development and use has beencompared with that of community psychiatric nurses 56 .The most common reasons for requesting a psychiatricconsultation in a general hospital are 57 :1. Diagnostic uncertainty.2. Recognition of a gross psychiatric disorder.3. Excessive emotional reactions, e.g. fear, anger, depression.4. A patient’s deviant behaviour disturbing ward or medicalprocedures.5. Delayed convalescence, i.e. disability incompatible withobserved pathology, relapse on mention of discharge.6. Crisis in the doctor–patient relationship (e.g. refusingconsent!).7. Patient’s admission of serious psychosocial difficulties.8. Selection and/or preparation of patients, e.g. pre-transplant,cosmetic surgery.It can be seen from the above list that the depressed patient,sitting quiet and withdrawn on the ward or in a home, may not bereferred for a psychiatric opinion. In practice, only about 2% ofgeriatric patients are referred to the liaison services 58–60 . Suggestedreasons for the discrepancy between liaison rate and psychiatricmorbidity are 58,61 :1. High prevalence of transient self-limiting psychiatric disease.2. Physician’s failure to recognize psychiatric disease 62 . Manystudies have highlighted the unrecognized psychiatric problemson medical wards 61 and the underdiagnosis of majordepression in particular has been well documented 63 .3. Medical and nursing staff may actively avoid questioning forpsychological problems, due to fear of precipitating emotionaldistress with which they have not been trained to deal.4. The low priority of psychiatric disease compared to physical,especially in a busy medical ward with acutely ill patients.5. Poor access to, or dissatisfaction with, psychiatric services.6. Physician resistance to psychiatric consultation 47 , due tostigma or underestimating the severity or the potential fortreatment.Use of screening scales is appropriate for assessing depressionin the physically ill: it is common, can be a difficult diagnosis andhas significant morbidity and mortality if untreated. Care must betaken to differentiate between short-lived adjustment disorders,occurring as a reaction to the admission itself, or the crisis whichprecipitated it. Diagnosis in acute admissions should thereforeinclude enquiry into symptoms before admission. If none can beelicited, the patient should be reassessed at a later date, eitherduring rehabilitation or after discharge.Screening scales serve a dual function 64–66 —they identifypatients in need of further assessment and also serve as aneducational tool if given by general staff during routine admissionprocedures. They emphasize the associated symptoms and signs ofdepression in the elderly, who may not show depressed affect andwill deny feeling sad. It is important, however, that educationabout the treatment of depression goes hand in hand witheducation to recognize it, or the liaison services will be swamped.TREATMENTThe fact that one can intuitively ‘‘understand’’ why the physicallyillelderly are depressed does not mean that it should be acceptedas normal and treatment not attempted. Continuing physicalillness is recognized as both a precipitant of depression and a poorprognostic factor, yet despite this, *80% of elderly generalhospital patients are not depressed 42,67,68 . Successful copingmechanisms can prevent the emergence of clinical depression.Even in the terminal patient, depression or dysphoria can berelieved by euphoriants, such as oral or parenteral opiates,reducing the distress of patient and relatives 69 without significantlyreducing the length of life remaining to the patient.It is important that the diagnosis is not missed, as this conditionusually responds well to treatment, at least initially, thusimproving quality of life. Follow-up and early treatment of anyrelapses will further improve the prognosis. Increased self-esteemand ability to cope will reduce demand on families and possibly onservices.Even when the correct diagnosis is made, the depression maynot be treated adequately, if at all: physically ill patients who arealso depressed are more likely to be assigned to the ‘‘not to beresuscitated’’ group, compared with those elderly who are not