Depression in Medical Disorders: Diagnostic Problems

Abstract

Depressive symptoms are very common among referrals to general hospital and comprise the most frequent cause for psychiatric consultation. Comorbidity of medical and psychiatric disorders are common among uneducated, unemployed people with low income. These conditions make it difficult to recognize and treat such patient group. The prevalence of medical disorders increase when there is a difficulty in reaching health services. The depressive mood may decrease the person's willingness to access health service. Additionally, the problems in most of the people seeking for medical help are not recognized by the health providers. It is quiet difficult to diagnose depression in patients with medical disorders. Being sick, being in an hospital, inability to work, loss of functionality lead to a change in social roles which may cause mourning-like symptoms, symptoms quite similar to depression's. Besides, vegetative and somatic symptoms used for the diagnosis of depression can be direct consequences of the medical disorder itself. Thus such phenomenological signs and symptoms are suggested not to be considered as sufficient criteria for a diagnosis of depression among patients with medical disorder. This diagnostic complexity is also reflected in the studies searching for depression prevalence in medical disorders. For instance, the prevalence of depression ranges from 0% to 100% among renal patients. The physical signs and symptoms of medical conditions can overlap with the symptoms of depression and this overlap stands as one of the major diagnostic challenge for researchers. There are several other reasons that might explain the discrepancies in depression prevalence among patients with medical disorders such as changes in diagnostic criteria over time, use of different diagnostic scales for depression, and studying the prevalence of depression in non-standardized populations. Depression prevalence is affected from demographic variables, type, severity and chronicity of comorbid medical disorder. The differences in the prevalence rates brings questions about reliability and validity of diagnostic tools used. Though using DSM and ICD as diagnostic tools have standardized the psychiatric diagnosis in many ways, there still remains some difficulties for reaching valid psychiatric diagnosis among patients with medical disorders. Controversies and discussions about reliability and validity problem in this issue still continues. Subclinical depressive symptoms in medical disorders, effect of comorbidity on the diagnostic process and lower interobserver agreement rates for the diagnosis of depression due to a general medical condition are among several factors that should be carefully investigated to overcome these problems.

Keywords

• Depression, Medical disorder, Comorbidity, Classification

Tıbbi Hastalıklarda Depresyon: Tanısal Sorunlar

Abstract

Depresyonla ilgili bulgular genel hastane başvurularında yaygındır ve hastane içi konsültasyonların en sık nedenidir. Tıbbi hastalıklar ve depresyon birlikteliği düşük gelirli, eğitime ulaşımı sınırlı, sosyal güvence sorunu olan, işsiz, boşanmış zor sosyoekonomik koşullarda yaşayan insanlarda sıktır. Bu özellikler hastalıkla ilişkili grubu tanıma ve tedavide zorluklar içerir. Sağlık hizmetine ulaşımda zorluk olduğunda tıbbi hastalıkların oranları artabilir. Kişinin içerisinde bulunduğu depresif duygudurum sağlık hizmetine ulaşım istemini azaltabilir. Öte yandan bir biçimde tıbbi yardım arayan hastaların önemli bir kısmı sağlık çalışanları tarafından fark edilememektedir. Major depresyonu tıbbi hastalığı olan grupta değerlendirmek oldukça güçtür. Çünkü birincisi hasta olmak, hastanede yatmak, çalışamamak, işlev kaybı, sosyal rollerde bir değişim yapar ve bu yas sürecine benzer sorunlar ortaya koyar. Bu durumlardaki bulgular depresyondaki bulgulara çok benzer. İkincisi major depresyon tanısı koymak için kullanılan vejetatif ya da somatik bulgular fiziksel hastalığın sonucu olabilir. Bu tanısal karmaşa tıbbi hastalıklarda görülen depresyon çalışmalarına da yansımıştır. Örneğin böbrek hastalarında yapılan çalışmalarda depresyon oranları %0-100 arasında değişmektedir. Gerçektende birçok kronik tıbbi durumlardaki bulgularla depresyon bulgularının örtüşmesi araştırıcılar için en önemli sorunlardan biri olarak görülmektedir. Literatürdeki tıbbi hastalıklarda depresyon oranlarındaki farklılıkların yukarıda sayılanlardan başka nedenleri de vardır. Tanı sistemlerinin yıllar boyunca değişimi, depresyon değerlendirmesi için farklı araçlar kullanılması, daha da önemlisi standardize edilmemiş topluluklarla çalışılması farklılık yaratabilir. Depresyonun sıklık oranları demografik özelliklerden, tıbbi hastalığın tipinden, ciddiyetinden, süreğenliğinden etkilenmiş olabilir. Tanı sıklıkları arasındaki büyük farklılık tanıların ve tanı koyma araçlarının güvenirliği konusunda soru işaretleri ortaya çıkarmaktadır. Psikiyatride sınıflandırma sistemlerinin tanı aracı olarak kullanılması psikiyatrik tanıların standardize hale gelmesini sağlamıştır. Ancak tanı koyma yöntemlerinin getirdiği sorunlar tıbbi hastalıklar gibi özel gruplarda henüz çözümlenememiştir. Tartışmalar çalışmalarda tanıların hem geçerliliği hem de güvenilirliği sorununun sürdüğünü göstermektedir. Tıbbi hastalıklarda depresyon tanısı koymak için eşik altı belirtilerin klinik önemi, eştanı tartışmalarının tanısal sürece etkisi, genel tıbbi duruma bağlı depresyon kararı ve klinik olarak anlamlı derecede bozulma kararının klinisyenler arasında farklılık göstermesi gibi önemli noktaların araştırılması bu tanı grubu ile ilgili şüphelerin ortadan kalkmasına yardımcı olacaktır.

Keywords

• Depresyon, Tıbbi Hastalık, Eştanı, Sınıflandırma

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