Uticopa Blog

Diagnosis of depression in physical illness

There is no doubt that clinical depression is a painful and debilitating condition that often occurs in association with severe physical illness, but how to diagnose it in these circumstances?

The biological symptoms of depression include anorexia, weight loss, sleep disturbance, lethargy and psychomotor retardation; however, all of these may equally be due to the physical illness. A useful guide is the three main symptoms that help to differentiate depression from non-depression in medical patients: depressed mood, morning depression and hopelessness.

Depression is more common in patients with physical illness than in those without, with up to one-third of medical in-patients reporting mild to moderate symptoms of depression. It is known that some medical conditions, in particular, have stronger links with depression than others. For example, depressive illness in patients with diabetes, cardiac or neurological disease is about a quarter more prevalent than in those with hypertension.

Some reasons why there is an increased risk of depression in people with physical illness include physical effects such as hormonal changes and the effects or side-effects of medication, plus the purely psychological, e.g. that subtle sense of loss associated with serious physical illness, the effects on body image, self-esteem and sense of identity or even an impaired capacity to work and maintain relationships.

Conversely, it has been noted for some time that physical problems go largely undiagnosed in some patients with depression. Doctors sometimes assume that the medical illness caused the depression, or that it is a contra-indication to anti-depressant drug treatment. Certainly, medical patients with depression use more medical health care resources than those without, both for assessment and treatment.  This is shown by the fact that depressed patients attend medical out-patient clinics specialising in physical illness more often than those who are not depressed.

Common drugs for physical illness that may cause depression:

Steroids, beta-blockers, non-steroidal anti-inflammatory drugs, Interferon.    

Examples of when a physical illness might trigger depression

These include: a previous episode of depression, a past history of psychiatric disorder, illnesses or treatments affecting the central nervous system (such as stroke), chronic painful disabling or disfiguring illnesses hindering self-care (such as rheumatoid arthritis), life-threatening illnesses such as cancer or myocardial infarction, plus treatments that are major or particularly unpleasant, and even a lack of social support. 

Conversely, physical problems may even develop or increase owing to depressive illness. This may range from acute liver failure following a Paracetamol overdose in a patient with depression, to the physical complications of chronic substance misuse. Also, depressive and physical illness may have a common cause in some patients, for example bereavement or stress triggering stroke and depression.

Depressive illness contributes to other alterations in health-related behaviour, including poor compliance with medications, diet, exercise and usage of health care services. Of course, the depressive illness may be coincidental and unrelated to physical problems, as both physical and psychiatric conditions are common in the general population.

Psychological treatments

The main potential benefit of considering a purely psychotherapeutic approach to treatment is the avoidance of drug interactions or side-effects making the physical problems worse. However, it is often impracticable owing to the expense, lack of availability of skilled therapists, the difficulty in its application in the ward environment or for a patient who has difficulty in travelling, and the fact that it is less acceptable to some patients and their doctors than medication.

As so many patients with depression also have a physical illness, all psychiatrists need to be proficient in the management of depression in physical illness. Recent advances in psychiatric treatments, including brief focused psychological therapies and increasingly selective medications, have now given doctors the opportunity to make a significant impact on the health of this previously neglected patient group.

In conclusion, although clinical depression in association with severe physical illness seems very much like a ‘double-whammy’, all is not lost. Now that modern science is well-attuned to its ‘double’ occurrence, it is but a short step to the alleviation of both.