Managing depression in physical illness

Siobhan MacHale is a consultant liaison psychiatrist at the Department of Psychological Medicine, Royal Infirmary of Edinburgh (Lauriston Place, Edinburgh EH3 9YW, UK). She trained in general medicine in Ireland before moving to Edinburgh to train in psychiatry. Previous research interests have included psychiatric morbidity following stroke. Her special clinical interest is in perinatal psychiatry. Depressive disorders are 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 (Rodin & Voshart, 1986). Some medical conditions have a stronger association with psychiatric illness than others, for example the prevalence rates of depressive illness in patients with diabetes, cardiac or neurological disease is about 25%, but not much more than the general population in those with hypertension. Medical in-patients are more likely to have depression than are out-patients. There are a number of potential factors that may contribute to this increased risk of depression in people with physical illness, as outlined in Box 1. Despite this increased prevalence, there has been widespread neglect of depression in patients with medical disease (Royal College of Physicians & Royal College of Psychiatrists, 1995), contributing to a number of poor outcomes. Physical problems are underdiagnosed in psychiatric patients. Patients with physical illness and depression have poorer levels of functioning and higher levels of mortality and morbidity compared with patients with similar illnesses but without depression (Wulsin et al, 1999). Physicians may assume that the medical illness caused the depression, or is a contraindication to antidepressant drug treatment. Medical patients with depression use more medical health care resources than those without, both for assessment and treatment – for example, the frequency of a patient’s attendance at a medical out-patient clinic is better predicted by how depressed he or she is than by his or her underlying medical condition. This contrasts with evidence of good outcomes in patients who do receive appropriate treatment, including relief of psychological distress, improved rehabilitation potential (following a stroke or myocardial infarct) and reduced health care costs. This article outlines the assessment of depression in patients with physical illness, explores some of the diagnostic issues involved and reviews the treatment options available.