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

Öz

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.

Anahtar Kelimeler

• Depresyon, Tıbbi Hastalık, Eştanı, Sınıflandırma

Kaynakça

1. Sutor B, Rummons TA, Jowsey SG, Krahn, LE, Martin MM, O’Connor MK et al. Major depression in medically ill patients. Mayo Clin Proc 1998; 73:329-337.
2. Creed F. Assessing depression in the context of physical illness. In Depression and Physical Illness, 1st ed. (Eds MM Robertson, CLE Katona): 3-21. Chichester, England, Wiley, 1997.
3. Cavanaugh SVA, Depression in the medically ill. In Handbook of Studies on General Hospital Psychiatry (Eds FK Judd, GD Burrows, DR Lipsitt): 283-303. Netherlands, Elsevier, 1991.
4. Koening HA, Meador KG, Cohen HJ, Blazer DG. Detection and treatment of major depression in older medically ill hospitalized patients. Int J Psychiatry Med 1988; 18:17-31.
5. Ganzini L, Smith DM, Fenn DS, Lee, MA. Depression and mortality in medically ill older adults. J Am Geriatr Soc 1997; 45:307-312.
6. Stenn PG. Depression medically ill. Can J Psychiatry 1996; 41:65-66.
7. Lane R. The long term management of depression. J Psychopharmacol 1995; 9:191- 198.
8. Perry SW, Cella DF. Overdiagnosis of depression in the medically ill. Am J Psychiatry 1987; 144:125-126.

9. Yates WR, Mitchell J, Rush AJ, Trivedi MH, Wisniewski SR, Warden D et al. Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR*D. Gen Hosp Psychiatry 2004; 26:421-429.
10. Katon W, Lin EH, Kroenke K. The association of depression and anxiety with medical symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry 2007; 29:147-155.
11. Egede LE. Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability. Gen Hosp Psychiatry 2007; 29:409-416.
12. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms and general medical illness. Biol Psychiatry 2003; 54:216-226.
13. Michaud CM, Murray MC, Bloom BR. Burden of disease: Implications for future research. JAMA 2001; 285:535–539.
14. Evans DL, Charney DS. Mood disorders and medical illness: A major public health problem. Biol Psychiatry 2003; 54:177–180.
15. Evans DL, Charney DS, Lewis L, Golden RN, Gorman JM, Krishnan KR et al. Mood disorders in the medically ill: Scientific review and recommendations. Biol Psychiatry 2005; 58:175–189.
16. Sadock BJ, Kaplan HI, Sadock VA. Psychological factors affecting medical condition. In Kaplan &Sadocks Synopsis of Psychiatry, 8th ed (Eds BJ. Sadock, HI Kaplan, VA. Sadock): 797-803. Baltimore, Lippincot Williams&Wilkins, 1998.
17. Möller HJ. Development of DSM-V and ICD- 11: Tendencies and potential of new classifications in psychiatry at the current state of knowledge. Psychiatry Clin Neurosci 2009; 63:595–612.
18. Kandel ER. New entellectual framework for psychiatry. Am J Psychiatry 1998; 155:457-469.
19. Pichot P. The history of the psychiatry as a medical speciality. In New Oxford Textbook of Psychiatry (Eds MG Gelder, JJ Lopez Ibor, NC Andreasen): 17-26. New York, Oxford University Press, 2003.
20. Rissmiller DJ, Rissmiller JH. Evolution of the antipsychiatry movement into mental health consumerism. Psychiatr Serv 2006; 57:863-866.
21. Kupfer DJ, Regier DA, Kuhl EA. On the road to DSM-V and ICD- 11. Eur Arch Psychiatry Clin Neurosci 2008; 258(Suppl 5):2–6.
22. First MB, Westen D. Classification for clinical practice: how to make ICD and DSM better able to serve clinicians. Int Rev Psychiatry 2007; 19:473-481.
23. Eker D. Diagnosis of mental disorders among Turkish and American clinicians. Int J Soc Psychiatry 1985; 31:99-109.
24. Dilling H. Classification. In New Oxford Textbook of Psychiatry (Eds MG Gelder, JJ Lopez Ibor, NC Andreasen): 111-133. New York, Oxford University Press, 2003.
25. Cooper JE, Oates M. The principles of clinical assesment in general psychiatry. In New Oxford Textbook of Psychiatry (Eds MG Gelder, JJ Lopez Ibor, NC Andreasen): 71-86. New York, Oxford University Press, 2003.
26. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association, 2000.
27. Koening HG, George LK, Peterson BC, Pieper CP. Depression in medically ıll hospitalized older adults: Prevalence, characteristics, and course of symptoms according to six diagnostic schemes. Am J Psychiatry 1997; 154:1376–1383.
28. Andreasen NC. The validation of psychiatric diagnosis:new models and approaches. Am J Psychiatry 1995; 152:161-162.
29. Fava GA. The concept of psychosomatic disorder. Psychother Psychosom 1992; 58:1- 12.
30. Karsteen J, Hartman CA, Ornell J, Nolen WA, Pennix BWJH. Subthreshold depression based on functional impairment better defined by symptom severity than by number of DSM –IV symptoms. J Affect Disord doi:10.1016/j.jad.2009.10.013.
31. Solomon A, Haaga DA, Arnow BA. Clinical depression distinct from subthreshold depressive symptoms? a review of the continuity issue in depression research . J Nerv Ment Dis 2001; 189:498 –506.
32. Rundell JR, Wise MG. Textbook of Consultation-Liaison Psychiatry. Washington, DC, American Psychiatric Press, 1996.
33. Bush DE, Ziegelstein RC, Tayback M, Richter D, Stevens S, Zahalsky H at al. Even minimal symptoms of depression incrase mortalitiy risk after acute myocardial infarction. Am J Cardiol 2001; 88:337-341.
34. Druss BG, Marcus SC, Rosenheck RA, Olfson M, Tanelian T, Pincus HA. Understanding disability in medical and general medical conditions. Am J Psychiatry 2000; 157:1485-1491.
35. Hinrichsen GA, Lieberman JA, Pollack S, Steinberg H. Depression in hemodialysis patients. Psychosomatics 1989; 30:284-289.
36. Kimmel PL. Depression with renal disease: What we know and what we need to know. J Psychosom Res 2002; 53:951- 956.
37. Terliun B, van Hout HP, van Marwick HW, Ader HJ, van der Meer K, de Haan M et al. Reliability and validity of the assesment of depression in general practice: The Short depression interview (SDI). Gen Hosp Psychiatry 2002; 24:396-405.
38. Lustman PJ, Griffith LS, Freedland KE, Clouse RE. The course of major depression in diabetes. Gen Hosp Psychiatry 1997; 19:138-143.
39. Endicott J. Measurement of depression in patient with cancer. Cancer 1984; 53:2243-2247.
40. Rodin G, Voshart K. Depression in the medically ill: An overview. Am J Psychiatry 1986; 143:696-705.
41. Chochinov HM, Wilson KG, Enns M, Lander RN. Prevalence of depression in the terminally ill: Effects of diagnostic criteria and symptom threshold judgements. Am J Psychiatry 1994; 151:537-540.