Abstract
EDITORIAL: DEPRESSION IN THE MEDICALLY ILL: A COMMON AND SERIOUS DISORDER Medical illness, particularly when associated with chronic disability and depen-dency, causes life changes that present an enormous challenge to the individual. This is especially true for persons with serious illnesses that require frequent outpatient medical visits, repeated acute hospitalizations, or long-term institu-tionalization. Physical illness threatens life and way of life, causing a complex mixture of fear, frustration, and sometimes, demoralization and hopelessness. Medical illness is often interpreted as a sign of inevitable decline, growing dependency, and perhaps even the first step on the ultimate road to death. The sense of purpose and meaning in life may be lost. The person sees him or herself more and more as a burden on others, and even a burden to their self. With such a mindset, depression rapidly ensues and death may not follow far behind. Rates of depression in certain medical settings approximate 50 percent in some reports, depending on how the diagnosis is made and the type of patient population studied [1, 2]. Medical patients with depression have increased mortality and longer hospital stays [3]. Only a small fraction of these depressions, however, are diagnosed and adequately treated by primary care physicians [4, 5]. The latter is not surprising, however, given the difficulty of depression diagnosis in older persons with multiple medical illnesses that present with signs and symptoms that overlap with depression; given the increasingly limited time that primary care physicians have to address psychological issues; given the questionable effectiveness of available treatments; and given the limited training that physi-cians receive on the diagnosis and treatment of psychological disorders in medical patients. In this issue of the Journal, a number of articles address the diagnosis and treatment of emotional disorders in medical patients. Wang and colleagues explore the connection between depression and quality of life in individuals with multiple sclerosis, finding that patients with major depression have significantly lower quality of life in multiple domains. Brown and colleagues investigate psychiatric disorders in inner city outpatients with moderate to severe asthma, finding that mood and anxiety disorders are disproportionately represented in this group. Johnson and colleagues explore the explanations given for symptoms by panic disorder patients and their receptiveness to psychiatric treatment, finding that most primary care patients attribute their symptoms to psychiatric causes and are quite open to psychiatric treatment. Meredith and Mazel examine the kinds of psycho-logical counseling that primary care physicians give to patients with and without emotional disorder. Finally, it is clear from the NIMH abstracts that much current research is now focusing on the identification and treatment of emotional disorders in medical patients. Both pharmacological and psychosocial treatments have a role in these dis-orders. With the emergence of newer antidepressants, the risk of side effects is much lower than when only tricyclic antidepressants and mono-amine oxidase inhibitors were available. Serotonin reuptake inhibitors may even protect patients from experiencing certain types of medical morbidities, such as repeat myocardial infarction due to their anti-platelet properties [6]. If prescribed without accompanying psychological support (or education about how these medications work), however, patients frequently stop treatment when they discover the cost of medications or experience unexpected side effects. In addition to having neurochemical deficiencies addressed, those with chronic medical illness also need to be helped to emotionally adjust to increasing physical limitations. Antidepressants or anti- anxiety agents, while enormously helpful, will not by themselves enable the patient to successfully grieve over physical losses, combat changes in self-esteem, and overcome the social isolation that illness causes. Thus, counseling and other psychosocial treatments play an irreplaceable role in the treatment of depressed medical patients. Persons with chronic illness need to feel that they are still valuable and worthy individuals, despite their physical limitations. They need to see their lives as still having meaning and purpose, still useful in some way to others. Cognitive-behavioral and interpersonal therapies have been used effectively to treat emo-tional disorder in persons with medical illness [7]. Religious beliefs and practices may also convey a sense of meaning and purpose in the setting of medical illness, and support from religious congregations may be particularly important at this time. While religion can certainly have negative effects (see review article in this issue), it may help those with medical illness to adapt more quickly to their health conditions, even impacting survival, as Strawbridge and colleagues study suggests. Thus, the successful treatment of depression and other emotional disorders in medical patients is likely to require a number of different modalities, including pharmacological, psychological, and psychosocial approaches that address the whole person body, mind, and spirit. Any one of these treatment methods alone is likely to address only part of the problem. Much further research is needed to identify the best combination of treatments that leads to the most effective and complete healing in the setting of persistent physical illness and disability. REFERENCES 1. Koenig HG, George LK, Peterson BL. Depression in medically ill hospitalized older adults: Prevalence, correlates, and course of symptoms based on six diagnostic schemes. American Journal of Psychiatry 1997;154:1376-1383. 2. Evans, DL, McCartney CF, Nemeroff CB. Depression in women treated forgot ecological cancer: Clinical and neuroendocrine assessment. American Journal of Psychiatry 1986;143:447-449. 3. Koenig HG, Shelp F, Goli V, Cohen HJ, Blazer DG. Survival and healthcare utilization in elderly medical inpatients with major depression. Journal of the American Geriatrics Society 1989;37:599-606. 4. Rapp SR, Walsh DA, Parisis SA. Detecting depression in elderly medical inpatients. Journal of Consulting and Clinical Psychology 1988;56:509-511. 5. Koenig HG, George LK, Meador KG. Use of antidepressants by non-psychiatrists in the treatment of hospitalized medically ill depressed elderly patients. American Journal of Psychiatry 1997;154:1369-1375. 6. Glassman AH, Shapiro PA. Depression and the course of coronary artery disease. American Journal of Psychiatry 1998;155:4-11. 7. Bombardier C, D Amico C, Jordan J. The relationship of appraisal and coping to chronic illness adjustment. Behavior Research & Therapy 1990;28:297-304. Harold G. Koenig, M.D.