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Depression in the Medically Ill
Perspective Depression in the Medically 111 Critical Issues in Diagnostic Assessment STEPHANIE VON AMMON CAVANAUGH,
M.D.
Diagnosing depression in the medically ill is a difficult diagnostic task that will not be clarified appreciably by DSM-IV. The author reviews diagnostic validity as it relates to depressive disorders in the medically ill. Suggested guidelines for using the DSM-IV to diagnose depressive disorders in the medically ill also are reviewed. (Psychosomatics 1995; 36:48-59)
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Received January 27. 1994; revised March 9. 1994; accepted April 7. 1994. From the Depanment of Psychiatry, Rush-Presbyterian 51. Luke's Medical Center. Chicago. IL. Address reprint requests to Dr. Cavanaugh. Depanment of Psychiatry. Rush-Presbyterian 51. Luke's Medical Center. 1753 W. Congress Pkwy., Chicago, IL 60612. Copyright © 1995 The Academy of Psychosomatic Medicine.
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he first step in establishing diagnostic validity is called "face validity."1 Face validity is the extent to which, on the face of it, clinicians agree that a particular syndrome or pattern of clinical features describes a mental disorder. "Descriptive validity"! is the degree to which the characteristics of a particular mental disorder are unique to that disorder. Several assumptions are made about descriptive validity. First, the mental disorder is a distinct group of symptoms rarely seen in other groups of mental disorders. Second, the disorder is a discrete entity with discontinuity between it and other disorders. Third, the characteristic features are always present. Fourth,joint occurrence of these symptoms is rare if the disorder is not present. Finally, when the symptoms occur together, they are considered abnormal and indicative of a mental disorder. Most of the research thus far has attempted to establish descriptive validity for depressive disorders in the medically ill. In this endeavor, several problems have been encountered. The first is determining whether the characteristics of depressive disorders seen in the medically ill are the same or different from those seen in psychiatric populations. Moffic and Paykel,2 Stewart et al,,3 and Clark et al. 4 have shown that the symptom profile for persons who are medically depressed may be different than that seen in those who are psychiatrically depressed. This is probably because of the covariance of other emotional, mental, and physical disorders in the medically ill, which may obscure or alter diagnostic criteria. First, the stress and loss associated with medical illness PSYCHOSOMATICS
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may result in depressive symptomatology. Also, each disease category leaves its own imprint on the signs and symptoms of depressive disorders. 5 Further, physical illness can produce the somatic or vegetative symptoms of depression.6--K In addition, delirium and dementia may produce symptoms that can be confused with those seen in depressive disorders. Boland9 reported that an organic disorder was diagnosed in 54% of consultation requests for evaluation of depression. Finally, as with psychiatric patients, character pathology and cognitive style can make the evaluation of depressive symptoms difficult. The second problem is defining what depressive symptomatology is indicative of a depressive disorder in the medically ill and what represents a normal reaction to medical illness. If an epidemiological population is compared to a medically ill population, a much higher prevalence of depressive symptomatology is reported in the medically ill population. K.IO . 11 Although it is estimated that 10-20% of patients will have a depressive disorder that requires intervention,5.JO 30% or more of medically ill patients have depressive symptomatology, depending on what diagnostic instrument is used. 5.JO.11 Approximately 6-17%5.10 of medically ill patients have a major depressive disorder, depending on the diagnostic criteria used. This represents an only slightly higher prevalence than is seen in epidemiological populations. I I Likewise, dysthymic disorders are found at only slightly higher levels than those found in community samples. 5.1O•11 Although it is estimated that one-third or more of medically ill patients have a medical condition or are receiving a medication or treatment might contribute to the depressive disorder, the prevalence of a disorder solely caused by a physical illness or treatments is much 10wer. 13- lb The remainder of depressive disorders and depressive symptomatology in medically ill patients consists of patients with an adjustment disorder with depressed mood or a life-circumstance problem. It is this group that accounts for the difference between the 10-20% that have a depressive disorder requiring intervention and the remaining 10-20% with "normal" depressive symptomatology. For example, irritability, crying, mild depressive symptoms, discouragement with future, mild difficulty with decisions, and mild anhedonia are found in one-third of all medically ill patients and might be considered a "normal" reaction to medical iIIness.s Most of these reactions are mild and remit without treatment as the patient adjusts to the illness, leaves the hospital, finishes unpleasant treatments, or improves physically. But those with more severe depressive symptomatology require intervention and carry much the same risk as those with dysthymia and major depressive disorder, that is, decreased quality of life, less participation in life and medical care, increased disability,l7 increased utilization of health care services,IK.19 and increased medVOLUME 36· NUMBER 1• JANUARY - FEBRUARY 1995
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ical morbidity and mortality.2o.21 DSM-III-R and DSM-IV do little to help us with these significant but subsyndromal minor depressions that do not meet criteria for major depressive disorder, dysthymic disorder, and organic mood disorder, which are usually called adjustment disorder with depressed mood. Several problems ensue from using this diagnostic category with medically ill patients. First, adjustment disorder with depressed mood in the medically ill is rarely considered by the patient, family, or medical staff to be in excess of the stressor of medical illness and its concomitants. Second, because of the confounding variable of medical illness, it is difficult to evaluate social or occupational functioning unless a detailed and lengthy instrument such as the Psychological Adjustment to Illness Scale 22 quantifies these parameters. Unfortunately, adjustment disorder in the medically ill has become a wastebasket term for a significant depression that does not meet criteria for other depressive disorders. In many cases a diagnosis of a life-circumstance problem might be more appropriate, but in practice the diagnosis is rarely made because it is not reimbursable or does not reflect the severity of the depressive disorder being considered. Perhaps a diagnosis of minor 3 or subsyndromal depression, rather than adjustment disorder with depressed mood, would be more appropriate and would reflect the syndrome's severity and treatment need. Another problem is determining whether depressive disorders in the medically ill are distinct categories or represent a continuum of severity. DSM-IV is categorical. For example, are adjustment disorder with depressed mood and major depressive disorder a continuum of increasing severity and numbers of symptoms, or are they distinct diagnoses? The distinction between the two diagnoses becomes particularly confusing if the medical diagnosis prevents accurate assessment of somatic or vegetative symptoms. As a result, if the somatic symptoms are counted, a diagnosis of major depressive disorder is established. If, however, the somatic or vegetative symptoms are not counted, a diagnosis of adjustment disorder with depressed mood would be made. 50
After face and descriptive validity are determined, the next step is to establish predictive and construct validity. "Predictive validity'" is the degree to which a particular diagnosis predicts the course of the illness, treatment, and complications. "Construct validity'" is the extent to which evidence supports a theory that is helpful in explaining the etiology of a disorder and the specific pathophysiological process. The DSMIII-R and DSM-IV have attempted to move away from etiology and toward description of phenomenology only. This is a departure from the medical tradition in which understanding etiology is helpful in treatment. As with medical disorders, one would hope that a DSM-III-R or DSM-IV diagnosis of a mental disorder would suggest a particular treatment strategy. In examining depressive disorders in the medically ill, two issues continue to plague us regarding predictive and construct validity. Specifically, is the etiology and treatment of depressive disorders in the medically ill the same or different from that seen in psychiatric populations? Persons who are medically depressed are less likely than those who are psychiatrically depressed to have a personal or family history of depression,20 (although medically depressed persons are more likely than nondepressed medical patients to have a personal or family history of depression).24-26 Although stress may play a major role in the onset of depression in a psychiatric population, stress plays a much more significant role in the onset of depressive disorders in the medically ill. Moffic and Paykel 2 found that depression antedated the physical illness in onequarter of medically ill patients, while depression occurred after the medical illness in the remaining three-quarters. Research in the last 15 years has shown that the stressors such as severity of illness, disability, pain, discomfort, and more recent time since diagnosis significantly affects the depth of depression. 2.5.27 There is ample evidence that the biological changes resulting from stress can lead to the final common pathway of depression. Robert Post,28 in a most elegant article, described the transduction of psychosocial stress into the neurobiology of affective disorder. The work of Fritz Henn's PSYCHOSOMATICS
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group29 is particularly interesting here. Henn's group has developed an animal model demonstrating that both environmental events and genetic predisposition can lead to the rat equivalent of depression, "helplessness." The researchers, using the Weiss model, tail shocked two categories of rats, "executive" and "passive" rats. The executive rat was able to stop the shock for both himself and the passive rat by pushing a button, while the passive rat, who was housed separately, had no button and depended on the executive rat to stop the shock. As a result, 20% of the passive rats became helpless. When these helpless rats were killed, changes were found in their 5-HTz receptors. When the helpless rats were retrained, by giving them executive button-pushing privileges to stop tail shock, many were able to reverse the 5-HTz receptor changes. When the helpless rats were bred, a pure strain of helpless rats were produced that showed evidence of changes in the 5-HTz receptors, which the researchers attributed to genetic transmission. This animal model provides an interesting paradigm for the contribution of stress and genetic predisposition to depressive disorders. The issue of how to proceed if a medical condition or treatment is present that might lead to a depressive disorder is a complicated one. Certainly, illness or medications can lead to a depressive disorder phenomenology indistinguishable from those not caused by illness or drugs. Ideally, removal of the factor known to cause depression, with subsequent reevaluation of the depressive disorder, is ideal (e.g., stopping methyldopa, reversing uremia with dialysis, or treatment of hypothyroidism). But in many cases, the medication or treatment cannot be stopped, nor can treatment wait until illness remission. As a result, depression must be empirically treated in spite of these medical conditions or treatments that might be etiologically related. To further complicate matters, many medical conditions, medications, or conditions that cause depressions will respond to classic biological treatments used for psychiatric patients. For example, the depression associated with stroke and Parkinson's disease respond to fluoxetine and nortriptyline,3o.31 and depression caused by hypothyroidism, in VOLUME 36· NUMBER I • JANUARY - FEBRUARY 1995
some cases, will require antidepressants or ECT in addition to thyroid replacement for complete remission. 3z Regarding treatment, most would agree that once a diagnosis of major depressive disorder has been made that biological treatments are in order. But are these treatments the same or different from those used for psychiatric populations? Medications such as psychostimulants are more efficacious in medical populations,33 particularly if a dementia is present. On the other hand, in a retrospective study by Popkin et al.;14 it was suggested that persons who are medically depressed might be less responsive to tricyclics, although these results might be partially explained by the high incidence of side effects, which interrupt tricyclic treatment. In a small sample of depressed medically ill patients, Mitchell et al.·15 reported a 30% response rate to fluoxetine, which is well below that seen in psychiatric populations. It is unknown whetherthese differences in antidepressant response rate are attributable to inaccurate diagnosis before treatment, other etiological factors such as a medical illness or medical treatment contributing to the depressive syndrome, or a lower genetic loading for depression. As with psychiatric patients, psychotherapy is very important in conjunction with biological treatments in treating depressed medically ill patients. Given the high incidence of stress in the etiology of depressive disorder in the medically ill, is psychotherapy or cognitive therapy more efficacious or necessary for a full response to biological treatments in the medically ill than in psychiatric patients? The answers to these questions bear investigation, but studies cannot be easily carried out until valid descriptive criteria are developed for depressive disorders in the medically ill. Cohen-Cole and Stoudemire 36 discussed the approaches to diagnostic criteria in the medically ill. In the "inclusion" approach, symptoms are counted whether or not they are caused by a physical illness or treatments. Such an approach clearly and falsely increases the prevalence of major depressive disorder. In the "etiological" approach, a symptom is included only if it is not 51
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caused by a physical treatment or illness. Strictly adhered to, this could result in an underreporting of major depressive disorder because illness or treatments can partially contribute to somatic or vegetative symptoms. In the "substitutive" approach, criteria are modified or substituted. This approach hampers communication if the diagnostic criteria are too different from established criteria. In the "exclusive" approach, criteria, such as fatigue or anorexia in cancer patients, are deleted. 6 Such a deletion is useful in patients with cancer but would hamper diagnostic validity in patients with cardiovascular disease. 37 Clearly, what diagnostic criteria we use is critical for research. In addition, a framework of diagnosis using DSM-IV is essential for our clinical work, not only for communication, but also for choosing treatment strategies. But the confounding variables mentioned before cannot be dismissed. DSM-IV criteria will need to be modified and clarified to increase diagnostic validity for depressive disorders in the medically ill. RESEARCH Although many authors might disagree, it appears that a large heterogeneous medically ill population should be studied to answer our questions of diagnostic validity. Investigators have examined depressive disorders in homogeneous diagnostic groups. Results from their studies have been very helpful when applied to the same diagnostic group studied but are less valid when applied to other disease categories. The more homogeneous a group, the easier it is to control confounding variables, but the less the group resembles that of typical patients seen in medical or surgical settings. To establish face and descriptive validity four groups should be studied: I) a non-ill epidemiological population, 2) a randomly selected medically ill population, 3) consecutive or randomly selected psychiatric consultations, and 4) a group of psychiatric patients with depressive disorders. Patients would best be assessed by two independent senior clinicians and a structured interview tool, such as the Schedule for Affective Disorders and Schizophrenia, (SADSi 8 and ad52
ditional questions to help clarify psychiatric symptomatology, administered by a rater blind to the clinician's diagnosis. Such a design using appropriate statistics, including latent trait and latent class analyses, would first help differentiate "normal" low-level depressive symptomatology from the depressive symptomatology seen in depressive disorders in the medically ill. Second, the issue of depressive severity or categorical diagnoses could be clarified. For example, is major depressive disorder categorically different from adjustment disorder with depressed mood, or does it just represent increasing numbers and severity of depressive symptoms? Third, the effect of other comorbid conditions such as dementia on depressive symptoms could be understood. Finally, the differences and similarities between psychiatrically and medically depressed persons could be examined. Such a study is now being completed at our facility, Rush-Presbyterian St. Luke's Medical Center. Project data will be forthcoming in the next few years. Nonetheless. a great deal of descriptive data has been gathered from a comparison of the SADS·18 and additional questions to help clarify psychiatric symptomatology in the medically ill with skilled clinician's interviews. TOWARD A RATIONAL CLINICAL DIAGNOSIS OF DEPRESSIVE DISORDERS IN THE MEDICALLY ILL USING THE DSM-IV At the risk of being presumptuous, it appears that past research, our recent preliminary finding, and the collective wisdom in our field-better known as face validity--could result in some recommendations on how the DSM-IV could be used to diagnose depressive disorders in the medically ill. Tables 1-5 show DSM-IV criteria J9 with additional clarifying comments to make these criteria useful with the medically ill (criteria reprinted with permission). It would be preferable to dispense with adjustment disorder with depressed mood and replace it with a subsyndromal depressive disorder or a minor depressive c1assiPSYCHOSOMATICS
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TABLE I.
Major depressive episode: modified DSM-IV criteria
A. Five of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is present: I) depressed mood or 2) loss of interest or pleasure. or 3) hopelessness. helplessness. not caring anymore. \. depn:ssed mood most of the day. nearly every day. as indicated by either subjective repon (e.g.• feels sad or emply) or observalion made by others (e.g.. appears tearful). 2. markedly diminished interest or pleasure in all. or almost all. activities most of the day. nearly every day (as indicaled either by subjective account or observation made by olhers. panicularly loss of interest in people) 3. feelings of wonhlessness (feels bad about self. not situation) or excessive inappropriate guilt (feeling that illness is a punishment for wrongdoing). nearly every day (I/O/merely self-reproach or guilt about beil/g sick) 4. diminished ability tothink or concentrate (nol easily explained by delirium. dementia. physical illness. or treatments) or indecisiveness. nearly every day (either by subjeclive accounl or as observed by others) 5. recurrent thoughts of death (not jusl fear of dying). recurrent suicidal ideation wilhoul a specific plan. or a suicide altemptor a specific plan forcommilling suicide (nol wishing to be dead to end physical suffering) MUST BE TEMPORALLY RELATED TO AFFECTIVE AND COGNITIVE SYMPTOMS OF DEPRESSION. NO/e:
Unmarked texl
6. significant weight loss or weighl gain when nOl dieting (e.g.• more than 5% of body weight in a month). or decrease or increase in appetite nearly every day. not easily explained by physical illness. lreatments. or hospital environmenl 7. psychomotor agitation or retardation nearly every day (observable by others. not merely subjective feelings of restlessness or being slowed down). not easily explainable by delirium. dementia. physical illness. or treatments 8. insomnia or hypersomnia nearly every day (nol easily explainable by physical illness.treatmentSOr hospilal environment) 9. fatigue or loss of energy nearly every day (not easily explainable by physical illness or treatments) B. The symptoms cause clinically significant distress or impairment in social. occupational. or other imponant areas of functioning. (Not due to illness or treatment.) Patient is not panicipating in medical care. in spile of ability 10 do so. is not progressing despite improved medical condition and/or is functioning at a lower level lhan lhe medical condition warrants. C. NOI allributable to direcl physiological effects of a substance (e.g.. drugs of abuse. medication) or a general medical condition (e.g.. hypothyroidism). D. The symptoms are not belter accounted for by bereavement. that is. after lhe loss of a loved one. the symptoms persist for longer than 2 months or are characterized by marked functional impairment. morbid preoccupation with wonhlessness. suicidal ideation. psychotic symptoms. or psychomotor retardation.
=DSM-IV criteria: Underline =suggested addition; Italics =DSM-IV criteria deleted.
fication, but for the sake of communication, this diagnostic category is reluctantly included. DSM-III, DSM-III-R, and DSM-IV have been a valuable contribution to diagnostic nosology in psychiatry. Unfortunately, they have also fostered a mindless counting of symptoms. To make diagnoses in this manner decreases diagnostic validity. Diagnostic criteria are guidelines, not a substitute for good clinical skills and judgment. For example, most patients 2 weeks after a bone marrow transplant would erroneously meet criteria for major depressive disorder ifthe symptoms were just blindly counted. Likewise, an elderly patient with severe and persistent depressed mood and anhedonia, with no other reported associated symptoms, would not be VOLUME 36· NUMBER 1 • JANUARY - FEBRUARY 1995
diagnosed as having a major depressive disorder and might not receive antidepressant treatment. As with all other diagnostic endeavors, accurate diagnosis of depressive disorders in the medically iII begins with a good history, including a collateral history from family and medical staff. Because many of these patients are elderly with delirium, dementia, or other cognitive disorders and/or are severely ill, they are often unable to accurately remember the progression of their depressive symptoms. Given all the variables that affect the evaluation of depressive symptoms, tracking out the depressive symptoms is essential. First, it is important to observe depressive symptoms over time, particularly depression and anhedonia. Un53
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TABLE 2.
Mood disorder with depressed features due to a general medical condition: DSM-IV criteria
A. A prominent and persistent disturbance in mood predominates the clinical picture and is characterized by the following: depressed mood or markedly diminished interest or pleasure in all, or almost all. activities. B. There is evidence from the history, physical examination. or laboratory findings of a general medical condition judged to be etiologically related to the disturbance.
TABLE 4.
Dysthymic disorder: modified DSM-IV criteria
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation made by others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following: I. feelings of hopelessness (not demoralization or discouragement related to the reality of the medical illness) 2. low self-esteem (feeling bad about self, not situation)
C. The disturbance is not better accounted for by another mental disorder (e.g.• adjustment disorder with depressed mood. in response to the stress of having a general medical condition).
3. diminished ability to think or concentrate (not related to delirium, dementia, physical i1lness:o.: treatments) or difficulty making decisions
D. The disturbance does not occur exclusively during the course of delirium or dementia.
4. poor appetite or overeating (not easily explained by physical illness, treatments, or hospital environment)
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other importanl areas of functioning.
5. insomnia or hypersomnia (not easily explainable by illness, treatments or, hospital environment) 6. low energy or fatigue (not easily explainable by physical illness or treatments)
TABLE 3.
Substance-induced mood disorder with depressed features
A. A predominant and persistent disturbance in mood predominates the clinical picture and is characterized by the following: depressed mood or marked diminished interest or pleasure in all, or almost all, activities.
B. There is evidence from history, physical examination, or laboratory findings of either: I. the symptoms in criterion A developed during, or within a month, of substance intoxication or withdrawal 2. medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a mood disorder that is not substance induced.
D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significanl distress or impairment in social, occupational, or other important areas of functioning.
fortunately, hospital stays are so short that this represents a challenge, In an academic setting visits from the resident, medical student, and the attending physician at various times during the day is helpful. In other situations, the patient is reevaluated in the outpatienl clinic after returning home. Next. the time course of the mood and
C. During the 2-year period of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.
D. No major depressive episode has been presenl during the first 2 years of the disturbance, that is, not better accounted for by chronic major depressive disorder. or major depressive disorder in partial remission. E. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance does not occur exclusively during the course of achronic psychotic disorder, such as schizophrenia or delusional disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition (e.g.. hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (not due to illness or treatment) Note: Unmarked text suggested addition.
=DSM-IV criteria; Underline =
associaled symptoms of depression should be evaluated. Are depressive symptoms persistent over time? Do the mood symptoms and associated symptoms of depression co-vary in the same time period? Also, the severity of the depressive symptoms is important. DSM III, III-R, and IV PSYCHOSOMATICS
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TABLE S.
Adjostmenet disorder with depressed mood: modified DSM-IV criteria
A. The development ofdepressed mood in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). (Stressor may be illness or treatment.) B. The depressed mood is clinically significant as evidenced by either of the following: I. marked distress that is in excess of what would be expected from exposure to the stressor (rarely with medical illness is the distress considered in excess of the stressor) 2. significant impairment in social or occupational (academic) functioning (not due to illness or treatment) 3. treatment is recommended C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. (Does not meet criteria for major depressive disorder. dysthymia. or mood disorder with depressed features due to a general medical condition or substance ). D. The symptoms do not represent bereavement. E. Once the stressor (or its consequences) has terminated. the symptoms do not persist for morc than an additional 6 months. Specify if: Acutc: if the symptoms havc persisted for Icss than 6 months Chronic: if the symptoms have persisted for 6 months or longer. Note: Unmarked text suggestcd addition.
=DSM-IV critcria; Undcrline =
do not define the severity of the depressive symptoms. Given the high incidence of mild mood symptoms in this population, at least a moderate level of symptom intensity as defined by the Research Diagnostic Criteria (RDC)2J is important in diagnosing major depressive disorder. Finally, events that make the depressive symptoms worse or better, such as effects of illness, medications, treatment, and hospital environment, should be evaluated with every symptom. EVALUATING THE SYMPTOMS As mentioned earlier, all symptoms used to make a diagnosis of depression can be confounded by medical illness, treatments, hospital environVOLUME 36· NUMBER I • JANUARY - FEBRUARY 1995
ment, delirium, dementia, other cognitive disorders, stress, loss, and character pathology. The accurate clinician rules these variables in and out with investigation of each depressive symptom. Because the affective and cognitive symptoms of depression are least affected by the aforementioned variables (except character pathology), they bear the most careful evaluation. DEPRESSED MOOD AND ANHEDONIA Depressed mood for the patient with major depressive disorder is persistent, pervasive, and at least at a moderate level of symptom intensity, that is, the patient feels depressed most of the time..w The mood has little reactivity and improves little with positive events:") for example, improved medical condition and support from family, friends, and medical staff. The patient brightens little with discussion of pleasant topics in the interview. Psychotherapy may only briefly help improve the mood or have no effect at all. Depressed mood for the patient with dysthymia may be at a lower level ofsymptom intensity than for the patient with major depressive disorder, but the mood persists nearly every day for 2 years. The depressed mood for a patient with a mood disorder caused by a general medical condition or substance may be at a lower level of symptom intensity than major depressive disorder, but the mood is also predominant and persistent. The onset of the depressed mood coincides with the onset of the medical disorder or treatment and is not a response to the stress of medical illness. For the patient with an "adjustment disorder with depressed mood," the dysphoric mood is variable..w The patient has periods when he/she is not depressed. The patient's mood is depressed, and the patient thinks about and discusses painful topics and negative events. The patient's mood is reactive, however, and improves with discussion of positive topics or events in the person's life. Mood also brightens with improvement in the medical condition, support from family and friends, and psychotherapy. Because a clinical or subclinical delirium can cause depressed mood, a diagnosis of depression cannot be made until such conditions remit. 55
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Also, diffuse or focal frontal lobe dysfunction or disease can cause affective lability. This can be confused with the crying associated with depressed mood. The patient with major depression has a loss of interest and pleasure that is persistent and at a moderate level of symptom intensity (most activities are less interesting and pleasurable).4O Assessment of interest and pleasure in the ill patient is difficult. Some mild decrease in enjoyment in usual activities is present in nondepressed medically ill patients. 4o For many patients usual pleasurable activities may not be possible because of the illness or hospital environment. Others may have never obtained pleasure from passive activities such as reading and television. Last, a patient's interest in activities may be blunted by fatigue, illness, or treatment. The most reliable indicator of loss of interest or pleasure for the ill patient with a major depressive disorder is loss of interest in or pleasure from family or friends. On the other hand, the patient with an adjustment disorder is pleased to see family and friends. Elderly patients may deny depressed mood or anhedonia but may be hopeless, helpless, or state "I don't care anymore." Hopelessness and helplessness should be considered the equivalent of depressed mood in the elderly.4O Such patients may also demonstrate the behavioral manifestation of loss of interest or pleasure. The patient may withdraw, show loss of interest in self-care, and show little interest in friends or other activities. Again, this should be considered the behavioral equivalent of anhedonia. 4O Regardless of whether the patient admits to depressed mood or anhedonia, the hopelessness, helplessness, and pessimism of a patient with a major depressive disorder is different from that seen in a patient with an adjustment disorder with depressed mood. The patient with major depressive disorder who states ''I'm not worth it," "don't bother with me," "it's hopeless to try," "there is nothing I can do," "no one can help me," or "nothing can improve" is quite different than the patient with an adjustment disorder who may be demoralized and discouraged about the illness situation but has not given up. 56
FEELINGS OF WORTHLESSNESS OR EXCESSIVE OR INAPPROPRIATE GUILT Many patients with character pathology will report feelings of worthlessness or inappropriate guilt that have been present off and on throughout their lives. For feelings of worthlessness or excessive or inappropriate guilt to be included as an associated symptoms of major depressive disorder, these cognitive symptoms of depression should have started or intensified with the onset of the depressed mood and/or anhedonia. The DSM-IV makes the comment that the excessive or inappropriate is "not merely self-reproach or guilt about being sick." That comment is vague and does not directly deal with the issue of self-worth or inappropriate guilt. The patient with these cognitive symptoms of depression feels bad about self rather than the situation K•4O ; the patient expresses feelings of worthlessness by the comments "I'm no good," or "I don't feel good about myself'; self-reproach may be expressed by "I'm no good because I'm a burden"; excessive or inappropriate guilt by "I'm a bad person because I'm ill"; and sense of punishment by "my illness is a punishment." Conversely, the ill patient who does not feel worthless or does not have excessive or inappropriate guilt may feel bad about the situation but not self. The patient may feel bad about being a burden, changes in body image, loss of function and role, loss of independence, loss of control over body and life, and not knowing why he/she has been chosen to be ill. The person may also have a mild loss of self-esteem, but when directly asked about "how do you feel about yourself as a person" the patient answers "I basically feel good about myself," "I'm a good person," or "I' m doing the best I can." When asked if the patient feels loved, the person will state "my family loves me," and if the patient is religious, "God loves me." Because many medical patients have sustained significant losses, Freud's concept of "mourning" and "melancholia'>-ll is relevant here. With mourning the patient has a positive selfconcept, whereas with melancholia the patient has a poor self-image. PSYCHOSOMATICS
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SUICIDAL IDEATION For suicidal ideation to be counted as a symptom of major depressive disorder, the patient should have recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, suicidal attempt or specific plan to kill him or herself. On the other hand, the critically ill patient may wish to die to end suffering. Wishing to be dead should not be considered suicidal ideation when the following conditions are met: I) the patient's suffering is so bad that death is a reasonable option; 2) the choice appears logical to the family and medical staff; and 3) the wish to die is not due to a clinical depression. DIMINISHED ABILITY TO THINK OR CONCENTRATE OR INDECISIVENESS Because 28% of all hospitalized patients have a score on the Mini-Mental State Exam of less than 23,12 it is important to assess whether the diminished ability to concentrate is caused by the illness, medication, or treatments. Mild indecisiveness is common in nondepressed medical patients. 4.K Indecisiveness at least at a moderate level of symptom intensity (unable to make decisions or decision making takes so long as to cause difficulties) supports a diagnosis of major depressive disorder. K SOMATIC AND VEGETATIVE SYMPTOMS Because vegetative symptoms are present in 41 % to 81 % of medically ill patients, the evaluation of these symptoms is difficult. 7.K In a previous study, the author found that the number of vegetative symptoms increases little with increasing levels of depressive severity, but the severity of the vegetative symptoms increases as the depressive severity increases. K Vegetative symptoms are useful in supporting a diagnosis of a major depressive disorder if I) the symptoms are at least at a moderate level of symptom intensity; 2) the onset of the symptoms coincides or intensifies with the onset of depressed mood or anhedonia; 3) the symptoms are not be easily explained by the illness, medications, treatments, or hospital VOLUME 36· NUMBER I • JANUARY - FEBRUARY 1995
environment; and 4) the symptoms are out of proportion to that expected by the illness, medications, treatment, or hospital environment. 4o PSYCHOMOTOR AGITATION OR RETARDATION At least 81 % of medically ill patients have mild psychomotor retardation. 7 Differentiating moderate-to-severe psychomotor retardation caused by depression from that caused by medical illness is difficult even for the skilled clinician. Psychomotor retardation cannot be accurately assessed if the patient has Parkinson's disease; delirium; dementia or other neurological conditions causing increased speech latency, slowed movements, or apathy; renal failure; liver failure; or critical illness. 4o Likewise, psychomotor agitation may be caused by delirium or other medical conditions or treatments (i.e., anoxia, hyperthyroidism, and corticosteroids) and cannot be accurately assessed until such organic causes are ruled out. WEIGHT LOSS OR GAIN AND ANOREXIA Fifty-eight percent of medically ill hospitalized patients lose weight. K To support a diagnosis of major depressive disorder the weight loss cannot be easily explained or is out of proportion to that expected by medical illness, medication, or treatments (rule out occult carcinoma, which frequently causes massive weight loss). Further, the weight loss cannot be explained by dieting or inability to obtain, cook, or eat food, which is commonly seen in the elderly patient without adequate environmental support. Forty-one percent of medically ill patients report anorexia. K The nondepressed medically ill patient associates anorexia with chemotherapy, illness, medications, and hospital food. On the other hand, the patient with major depressive disorder and anorexia will comment ''I'm not interested in food," "I'm just not hungry," "it's related to the depression," or "I don't know why I don't eat." Forthe patient with major depressive disorder. appetite will be poor when presented with favorite food. The patient makes minimal 57
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effort to eat, although the person knows eating is important to improved medical condition. Elderly patients may deny anorexia or weight loss, but a collateral history from the family or staff can often reveal that the patient eats poorly.40 SLEEP DISTURBANCE Fifty-four percent of medically ill patients report sleep disturbance. S The nondepressed medical patient is able to pinpoint why. "They wake me up all night to take my vital signs," "my roommate moans all night," "I was worried about the bone marrow test tomorrow," "I sleep fine at home," "I'm just uneasy in the hospital," or "the pain wakes me up at night." Many ill patients may have a change in their sleep-wake pattern. Patients who sleep during the day may have difficulty sleeping at night. Others will have brief periods of sleep during the day and night, and as a result they appear to have early morning awakening. On the other hand, patients with a major depressive disorder have considerable difficulty sleeping, which is not easily explained or is out of proportion to that expected by illness, treatments, discomfort, or hospital environment. A sleep record is important in documenting the nature of the sleep disturbance in the medically iII.40 FATIGUE OR LOSS OF ENERGY Seventy-seven percent of all hospitalized medically ill patients have loss of energy or fatigue. s In a previous study, fatigue was not found to be useful as a symptom of depression in the medically iII. s If the fatigue, however, worsens with
the onset of the affective symptoms, or is out of proportion to that expected by illness or treatments, the symptom supports a diagnosis of major depressive disorder. 40 CRITERIONC In OSM_ly 39 a new criterion has been added that is present in the ROC criteria for major depressive disorder, "The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." It is important to note that this impairment is not directly related to physical illness, treatment, or hospitalization. In the medically ill patient with a major depressive disorder, this impairment is usually manifested by the patient's decreased participation in medical care and greater disability than the medical condition warrants. In the patient with dysthymia, mood disorder with depressed features due to a general medical condition or substance, or an adjustment with depressed mood, this impairment (decreased participation in medical care and greater disability than the medical condition warrants) is variable. CONCLUSIONS It is hoped that these guidelines for using the OSM-IY to diagnose depression in the medically ill patients will be helpful forconsultation-liaison psychiatrists. Further clinical observations and research are needed to confirm the usefulness of these guidelines and their validity as diagnostic criteria.
References I. Akiskal HS: The classification of mental disorders. Chapter II, in Comprehensive Textbook of Psychiatry. 5th Edition. edited by Kaplan HI. Sadock BJ. Baltimore. MD. Williams & Wilkins. 1989. pp 583-598 2. Moffic HS. Paykel ES: Depression in medical inpatients. Br J Psychiatry 1975; 126:346-353 3. Stewart M. Drake F. Winokur G: Depression among medically ill patients. Diseases of the Nervous System 1965; 26:47~85
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4. Clark D. Cavanaugh SvA. Gibbons RD: The core symptoms of depression in medical and psychiatric patients. J Nerv Ment Dis 1983; 171:705-713 5. Rodin G. Cravens J. Liulefield C (eds): Depression in the Medically III: An Integrated Approach. New York. BrunnerlMazel. 1991, pp 3-53 6. Plumb M. Holland J: Comparative studies of psychological function in patients with advanced cancer. I. Self-reported depressive symptoms. Psychosom Med 1977;
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39:264-276 7. Schwab JJ. Bialow M. Brown. JM. et al: Diagnosing depression in medical inpatients. Ann Intern Med 1967: 64:695-707 8. Cavanaugh S. Clark D. Gibbons R: Diagnosing depression in the hospitalized medically ill. Psychosomatics 1983: 24:809-815 9. Boland RJ: Requests to evaluate "depression" in the general hospital. Proceedings of the 40th Annual Meeting of the Academy of Psychosomatic Medicine. New Orleans. LA. 1993. P 3 10. Cavanaugh S. Wellstein R: Prevalence of psychiatric morbidity in medical populations. in Psychiatric Update. The American Psychiatric Annual Review. Vol III. edited by Grinspoon L. Washington. DC, American Psychiatric Press. 1984. pp 187-215 II. Robins LN. Helzer J. Weissman M. et al: Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry 1984: 41 :949-958 12. Cavanaugh S: The prevalence of emotional and cognitive dysfunction in a general medical population. using the MMSE. GHQ. and BDI. Gen Hosp Psychiatry 1983: 5:15-24 13. Herridge CF: Physical disorders in physical illness: a study of 209 consecuti ve admissions. Lancet 1960: 2:949-951 14. Davies DW: Physical illness in psychiatric outpatients. Br J Psychiatry 1965: II 1:27-33 15. Koranyi EK: Physical health and illness in a psychiatric outpatient department population. Canadian Psychiatric Association Journal (suppl) I 7: 1972: 109-116 16. Hall RCW: Depression. in Psychiatric Presentations of Medical Illness: Somato and Psychiatric Disorder. edited by Hall RC. New York. Spectrum Publications. Inc.. 1980. pp 37--63 17.0rmel J. Oldehinket T. Brilman E. et al: Outcome of depression and anxiety in primary care. Arch Gen Psychiatry 1993: 59:759-766 18. Saravay SM. Lavin M: Psychologic co-morbidity and length of stay in the general hospital. Am J Psychiatry 1991: 148:324-329 19. Schlessinger HJ. Mumford E. Glass GV: Mental health treatment and medical care utilization in a fee-for-service system: outpatient mental treatment following the onset of chronic disease. Am J Public Health 1983: 74:422-429 20. WinokurG. Black DW. Nasrallah A: Depressions secondary to other psychiatric disorders and medical illness. Am J Psychiatry 1988: 145:233-237 21. Frasure-Smith N. Lesperance F. Talajic J: Depression following myocardial infarction. JAMA 1993: 27: 18191825 22. Morrow GR. Chiarello. RJ. Derogatis. LR: A new scale for assessing patients' psychosocial adjustment to medical illness. Psychol Med 1978: 8:605--610 23. Spitzer RL. Endicoll J. Robins E: Research diagnostic criteria. rational and reliability. Arch Gen Psychiatry 1978: 35:773-782
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24. Carney RM. Rick MW.teVelde A. et al: Majordepressive disorder in coronary artery disease. Am J Cardiol 1987: 60:1273-1275 25. Craven JL. Rodin GM. Johnson L. et al: The diagnosis of major depression in renal dialysis patients. Psychosom Med 1987: 49:482-492 26. Feldman E. Mayou R. Hawton. K. et al: Psychiatric disorder in medical inpatients. Q J Med 1987: 63:405-412 27. Cassileth BR. Lusk EJ. Strouse TB. et al: Psychosocial status in chronic illness: a comparative analysis of six diagnostic groups. N Engl J Med 1984: 311 :506-511 28. Post RM: Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. Am J Psychiatry 1991: 149:999-1010 29. Edwards E. Harkins K. Wright G. et al: The modulation of 13H)paroxetine binding to the 5-hydroxytryptamine uptake site in an animal model of depression. J Neurochem 1991:56:1581-1586 30. Fedroff J. Robinson RG: Tricyclic antidepressants in the treatment of post-stroke depression. J Clin Psychiatry 1989: (suppl)50: 18-23 31. Cummings JL: Depression and Parkinson' s disease: a review. Am J Psychiatry 1992: 149:443-454 32. Extein J. Gold MS: Psychiatric application of thyroid tests. J Clin Psychiatry 1986: 47: 13-16 33. Satel SL. Nelson JC: Stimulants in the treatment of depression: a critical overview. J Clin Psychiatry 1989: 50:241-249 34. Popkin MK. Callies AL. Mackenzie TB: The outcome of antidepressant use in the medically ill. Arch Gen Psychiatry 1985:42:1160-1163 35. Mitchell KE. Popkin MK. Kallie AL: The outcome of depressed medically ill patients treated wilh fluoxeline. Proceedings of the 40th Annual Meeting of the Academy of Psychosomatic Medicine. New Orleans. LA. 1993. P 13 36. Cohen-Cole SA. Stoudemire A: Major depression and physical illness. consultation-liaison psychiatry. PsychiatrClin North Am 1987: Hl:I-17 37. Koenig HG. O'Connor CM. Guarisco SA: Depressive disorder in older medical inpatients on general medicine and cardiology services at a university teaching hospital. Am J Geriatr Psychiatry 1993: I: 197-210 38. Robins LN. Heltzer JE. Croughan J. et al: Nalional institute of mental health diagnostic inlerview schedule. its history. characteristics. and validity. Arch Gen Psychiatry 1981: 38:381-389 39. American Psychiatric Association: Diagnostic and Statislical Manual. 4th Edition. Washington. DC. American Psychiatric Press. 1994 40. Cavanaugh S: Depression in the medically ill. in Handbook of Studies on General Hospital Psychialry. edited by Judd FK. Burrows GD. Lipsin DR. Amsterdam. The Netherlands. Elsevier Science Publishers. B. V. (Biomedical Di vision l. 1991. pp 283-303 41. Freud S: Mourning and Melancholia. edited by Strachey 1. Toronlo. Canada. Hogarth Press. 1957. p 243
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M.D.
Diagnosing depression in the medically ill is a difficult diagnostic task that will not be clarified appreciably by DSM-IV. The author reviews diagnostic validity as it relates to depressive disorders in the medically ill. Suggested guidelines for using the DSM-IV to diagnose depressive disorders in the medically ill also are reviewed. (Psychosomatics 1995; 36:48-59)
T
Received January 27. 1994; revised March 9. 1994; accepted April 7. 1994. From the Depanment of Psychiatry, Rush-Presbyterian 51. Luke's Medical Center. Chicago. IL. Address reprint requests to Dr. Cavanaugh. Depanment of Psychiatry. Rush-Presbyterian 51. Luke's Medical Center. 1753 W. Congress Pkwy., Chicago, IL 60612. Copyright © 1995 The Academy of Psychosomatic Medicine.
48
he first step in establishing diagnostic validity is called "face validity."1 Face validity is the extent to which, on the face of it, clinicians agree that a particular syndrome or pattern of clinical features describes a mental disorder. "Descriptive validity"! is the degree to which the characteristics of a particular mental disorder are unique to that disorder. Several assumptions are made about descriptive validity. First, the mental disorder is a distinct group of symptoms rarely seen in other groups of mental disorders. Second, the disorder is a discrete entity with discontinuity between it and other disorders. Third, the characteristic features are always present. Fourth,joint occurrence of these symptoms is rare if the disorder is not present. Finally, when the symptoms occur together, they are considered abnormal and indicative of a mental disorder. Most of the research thus far has attempted to establish descriptive validity for depressive disorders in the medically ill. In this endeavor, several problems have been encountered. The first is determining whether the characteristics of depressive disorders seen in the medically ill are the same or different from those seen in psychiatric populations. Moffic and Paykel,2 Stewart et al,,3 and Clark et al. 4 have shown that the symptom profile for persons who are medically depressed may be different than that seen in those who are psychiatrically depressed. This is probably because of the covariance of other emotional, mental, and physical disorders in the medically ill, which may obscure or alter diagnostic criteria. First, the stress and loss associated with medical illness PSYCHOSOMATICS
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may result in depressive symptomatology. Also, each disease category leaves its own imprint on the signs and symptoms of depressive disorders. 5 Further, physical illness can produce the somatic or vegetative symptoms of depression.6--K In addition, delirium and dementia may produce symptoms that can be confused with those seen in depressive disorders. Boland9 reported that an organic disorder was diagnosed in 54% of consultation requests for evaluation of depression. Finally, as with psychiatric patients, character pathology and cognitive style can make the evaluation of depressive symptoms difficult. The second problem is defining what depressive symptomatology is indicative of a depressive disorder in the medically ill and what represents a normal reaction to medical illness. If an epidemiological population is compared to a medically ill population, a much higher prevalence of depressive symptomatology is reported in the medically ill population. K.IO . 11 Although it is estimated that 10-20% of patients will have a depressive disorder that requires intervention,5.JO 30% or more of medically ill patients have depressive symptomatology, depending on what diagnostic instrument is used. 5.JO.11 Approximately 6-17%5.10 of medically ill patients have a major depressive disorder, depending on the diagnostic criteria used. This represents an only slightly higher prevalence than is seen in epidemiological populations. I I Likewise, dysthymic disorders are found at only slightly higher levels than those found in community samples. 5.1O•11 Although it is estimated that one-third or more of medically ill patients have a medical condition or are receiving a medication or treatment might contribute to the depressive disorder, the prevalence of a disorder solely caused by a physical illness or treatments is much 10wer. 13- lb The remainder of depressive disorders and depressive symptomatology in medically ill patients consists of patients with an adjustment disorder with depressed mood or a life-circumstance problem. It is this group that accounts for the difference between the 10-20% that have a depressive disorder requiring intervention and the remaining 10-20% with "normal" depressive symptomatology. For example, irritability, crying, mild depressive symptoms, discouragement with future, mild difficulty with decisions, and mild anhedonia are found in one-third of all medically ill patients and might be considered a "normal" reaction to medical iIIness.s Most of these reactions are mild and remit without treatment as the patient adjusts to the illness, leaves the hospital, finishes unpleasant treatments, or improves physically. But those with more severe depressive symptomatology require intervention and carry much the same risk as those with dysthymia and major depressive disorder, that is, decreased quality of life, less participation in life and medical care, increased disability,l7 increased utilization of health care services,IK.19 and increased medVOLUME 36· NUMBER 1• JANUARY - FEBRUARY 1995
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ical morbidity and mortality.2o.21 DSM-III-R and DSM-IV do little to help us with these significant but subsyndromal minor depressions that do not meet criteria for major depressive disorder, dysthymic disorder, and organic mood disorder, which are usually called adjustment disorder with depressed mood. Several problems ensue from using this diagnostic category with medically ill patients. First, adjustment disorder with depressed mood in the medically ill is rarely considered by the patient, family, or medical staff to be in excess of the stressor of medical illness and its concomitants. Second, because of the confounding variable of medical illness, it is difficult to evaluate social or occupational functioning unless a detailed and lengthy instrument such as the Psychological Adjustment to Illness Scale 22 quantifies these parameters. Unfortunately, adjustment disorder in the medically ill has become a wastebasket term for a significant depression that does not meet criteria for other depressive disorders. In many cases a diagnosis of a life-circumstance problem might be more appropriate, but in practice the diagnosis is rarely made because it is not reimbursable or does not reflect the severity of the depressive disorder being considered. Perhaps a diagnosis of minor 3 or subsyndromal depression, rather than adjustment disorder with depressed mood, would be more appropriate and would reflect the syndrome's severity and treatment need. Another problem is determining whether depressive disorders in the medically ill are distinct categories or represent a continuum of severity. DSM-IV is categorical. For example, are adjustment disorder with depressed mood and major depressive disorder a continuum of increasing severity and numbers of symptoms, or are they distinct diagnoses? The distinction between the two diagnoses becomes particularly confusing if the medical diagnosis prevents accurate assessment of somatic or vegetative symptoms. As a result, if the somatic symptoms are counted, a diagnosis of major depressive disorder is established. If, however, the somatic or vegetative symptoms are not counted, a diagnosis of adjustment disorder with depressed mood would be made. 50
After face and descriptive validity are determined, the next step is to establish predictive and construct validity. "Predictive validity'" is the degree to which a particular diagnosis predicts the course of the illness, treatment, and complications. "Construct validity'" is the extent to which evidence supports a theory that is helpful in explaining the etiology of a disorder and the specific pathophysiological process. The DSMIII-R and DSM-IV have attempted to move away from etiology and toward description of phenomenology only. This is a departure from the medical tradition in which understanding etiology is helpful in treatment. As with medical disorders, one would hope that a DSM-III-R or DSM-IV diagnosis of a mental disorder would suggest a particular treatment strategy. In examining depressive disorders in the medically ill, two issues continue to plague us regarding predictive and construct validity. Specifically, is the etiology and treatment of depressive disorders in the medically ill the same or different from that seen in psychiatric populations? Persons who are medically depressed are less likely than those who are psychiatrically depressed to have a personal or family history of depression,20 (although medically depressed persons are more likely than nondepressed medical patients to have a personal or family history of depression).24-26 Although stress may play a major role in the onset of depression in a psychiatric population, stress plays a much more significant role in the onset of depressive disorders in the medically ill. Moffic and Paykel 2 found that depression antedated the physical illness in onequarter of medically ill patients, while depression occurred after the medical illness in the remaining three-quarters. Research in the last 15 years has shown that the stressors such as severity of illness, disability, pain, discomfort, and more recent time since diagnosis significantly affects the depth of depression. 2.5.27 There is ample evidence that the biological changes resulting from stress can lead to the final common pathway of depression. Robert Post,28 in a most elegant article, described the transduction of psychosocial stress into the neurobiology of affective disorder. The work of Fritz Henn's PSYCHOSOMATICS
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group29 is particularly interesting here. Henn's group has developed an animal model demonstrating that both environmental events and genetic predisposition can lead to the rat equivalent of depression, "helplessness." The researchers, using the Weiss model, tail shocked two categories of rats, "executive" and "passive" rats. The executive rat was able to stop the shock for both himself and the passive rat by pushing a button, while the passive rat, who was housed separately, had no button and depended on the executive rat to stop the shock. As a result, 20% of the passive rats became helpless. When these helpless rats were killed, changes were found in their 5-HTz receptors. When the helpless rats were retrained, by giving them executive button-pushing privileges to stop tail shock, many were able to reverse the 5-HTz receptor changes. When the helpless rats were bred, a pure strain of helpless rats were produced that showed evidence of changes in the 5-HTz receptors, which the researchers attributed to genetic transmission. This animal model provides an interesting paradigm for the contribution of stress and genetic predisposition to depressive disorders. The issue of how to proceed if a medical condition or treatment is present that might lead to a depressive disorder is a complicated one. Certainly, illness or medications can lead to a depressive disorder phenomenology indistinguishable from those not caused by illness or drugs. Ideally, removal of the factor known to cause depression, with subsequent reevaluation of the depressive disorder, is ideal (e.g., stopping methyldopa, reversing uremia with dialysis, or treatment of hypothyroidism). But in many cases, the medication or treatment cannot be stopped, nor can treatment wait until illness remission. As a result, depression must be empirically treated in spite of these medical conditions or treatments that might be etiologically related. To further complicate matters, many medical conditions, medications, or conditions that cause depressions will respond to classic biological treatments used for psychiatric patients. For example, the depression associated with stroke and Parkinson's disease respond to fluoxetine and nortriptyline,3o.31 and depression caused by hypothyroidism, in VOLUME 36· NUMBER I • JANUARY - FEBRUARY 1995
some cases, will require antidepressants or ECT in addition to thyroid replacement for complete remission. 3z Regarding treatment, most would agree that once a diagnosis of major depressive disorder has been made that biological treatments are in order. But are these treatments the same or different from those used for psychiatric populations? Medications such as psychostimulants are more efficacious in medical populations,33 particularly if a dementia is present. On the other hand, in a retrospective study by Popkin et al.;14 it was suggested that persons who are medically depressed might be less responsive to tricyclics, although these results might be partially explained by the high incidence of side effects, which interrupt tricyclic treatment. In a small sample of depressed medically ill patients, Mitchell et al.·15 reported a 30% response rate to fluoxetine, which is well below that seen in psychiatric populations. It is unknown whetherthese differences in antidepressant response rate are attributable to inaccurate diagnosis before treatment, other etiological factors such as a medical illness or medical treatment contributing to the depressive syndrome, or a lower genetic loading for depression. As with psychiatric patients, psychotherapy is very important in conjunction with biological treatments in treating depressed medically ill patients. Given the high incidence of stress in the etiology of depressive disorder in the medically ill, is psychotherapy or cognitive therapy more efficacious or necessary for a full response to biological treatments in the medically ill than in psychiatric patients? The answers to these questions bear investigation, but studies cannot be easily carried out until valid descriptive criteria are developed for depressive disorders in the medically ill. Cohen-Cole and Stoudemire 36 discussed the approaches to diagnostic criteria in the medically ill. In the "inclusion" approach, symptoms are counted whether or not they are caused by a physical illness or treatments. Such an approach clearly and falsely increases the prevalence of major depressive disorder. In the "etiological" approach, a symptom is included only if it is not 51
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caused by a physical treatment or illness. Strictly adhered to, this could result in an underreporting of major depressive disorder because illness or treatments can partially contribute to somatic or vegetative symptoms. In the "substitutive" approach, criteria are modified or substituted. This approach hampers communication if the diagnostic criteria are too different from established criteria. In the "exclusive" approach, criteria, such as fatigue or anorexia in cancer patients, are deleted. 6 Such a deletion is useful in patients with cancer but would hamper diagnostic validity in patients with cardiovascular disease. 37 Clearly, what diagnostic criteria we use is critical for research. In addition, a framework of diagnosis using DSM-IV is essential for our clinical work, not only for communication, but also for choosing treatment strategies. But the confounding variables mentioned before cannot be dismissed. DSM-IV criteria will need to be modified and clarified to increase diagnostic validity for depressive disorders in the medically ill. RESEARCH Although many authors might disagree, it appears that a large heterogeneous medically ill population should be studied to answer our questions of diagnostic validity. Investigators have examined depressive disorders in homogeneous diagnostic groups. Results from their studies have been very helpful when applied to the same diagnostic group studied but are less valid when applied to other disease categories. The more homogeneous a group, the easier it is to control confounding variables, but the less the group resembles that of typical patients seen in medical or surgical settings. To establish face and descriptive validity four groups should be studied: I) a non-ill epidemiological population, 2) a randomly selected medically ill population, 3) consecutive or randomly selected psychiatric consultations, and 4) a group of psychiatric patients with depressive disorders. Patients would best be assessed by two independent senior clinicians and a structured interview tool, such as the Schedule for Affective Disorders and Schizophrenia, (SADSi 8 and ad52
ditional questions to help clarify psychiatric symptomatology, administered by a rater blind to the clinician's diagnosis. Such a design using appropriate statistics, including latent trait and latent class analyses, would first help differentiate "normal" low-level depressive symptomatology from the depressive symptomatology seen in depressive disorders in the medically ill. Second, the issue of depressive severity or categorical diagnoses could be clarified. For example, is major depressive disorder categorically different from adjustment disorder with depressed mood, or does it just represent increasing numbers and severity of depressive symptoms? Third, the effect of other comorbid conditions such as dementia on depressive symptoms could be understood. Finally, the differences and similarities between psychiatrically and medically depressed persons could be examined. Such a study is now being completed at our facility, Rush-Presbyterian St. Luke's Medical Center. Project data will be forthcoming in the next few years. Nonetheless. a great deal of descriptive data has been gathered from a comparison of the SADS·18 and additional questions to help clarify psychiatric symptomatology in the medically ill with skilled clinician's interviews. TOWARD A RATIONAL CLINICAL DIAGNOSIS OF DEPRESSIVE DISORDERS IN THE MEDICALLY ILL USING THE DSM-IV At the risk of being presumptuous, it appears that past research, our recent preliminary finding, and the collective wisdom in our field-better known as face validity--could result in some recommendations on how the DSM-IV could be used to diagnose depressive disorders in the medically ill. Tables 1-5 show DSM-IV criteria J9 with additional clarifying comments to make these criteria useful with the medically ill (criteria reprinted with permission). It would be preferable to dispense with adjustment disorder with depressed mood and replace it with a subsyndromal depressive disorder or a minor depressive c1assiPSYCHOSOMATICS
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TABLE I.
Major depressive episode: modified DSM-IV criteria
A. Five of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is present: I) depressed mood or 2) loss of interest or pleasure. or 3) hopelessness. helplessness. not caring anymore. \. depn:ssed mood most of the day. nearly every day. as indicated by either subjective repon (e.g.• feels sad or emply) or observalion made by others (e.g.. appears tearful). 2. markedly diminished interest or pleasure in all. or almost all. activities most of the day. nearly every day (as indicaled either by subjective account or observation made by olhers. panicularly loss of interest in people) 3. feelings of wonhlessness (feels bad about self. not situation) or excessive inappropriate guilt (feeling that illness is a punishment for wrongdoing). nearly every day (I/O/merely self-reproach or guilt about beil/g sick) 4. diminished ability tothink or concentrate (nol easily explained by delirium. dementia. physical illness. or treatments) or indecisiveness. nearly every day (either by subjeclive accounl or as observed by others) 5. recurrent thoughts of death (not jusl fear of dying). recurrent suicidal ideation wilhoul a specific plan. or a suicide altemptor a specific plan forcommilling suicide (nol wishing to be dead to end physical suffering) MUST BE TEMPORALLY RELATED TO AFFECTIVE AND COGNITIVE SYMPTOMS OF DEPRESSION. NO/e:
Unmarked texl
6. significant weight loss or weighl gain when nOl dieting (e.g.• more than 5% of body weight in a month). or decrease or increase in appetite nearly every day. not easily explained by physical illness. lreatments. or hospital environmenl 7. psychomotor agitation or retardation nearly every day (observable by others. not merely subjective feelings of restlessness or being slowed down). not easily explainable by delirium. dementia. physical illness. or treatments 8. insomnia or hypersomnia nearly every day (nol easily explainable by physical illness.treatmentSOr hospilal environment) 9. fatigue or loss of energy nearly every day (not easily explainable by physical illness or treatments) B. The symptoms cause clinically significant distress or impairment in social. occupational. or other imponant areas of functioning. (Not due to illness or treatment.) Patient is not panicipating in medical care. in spile of ability 10 do so. is not progressing despite improved medical condition and/or is functioning at a lower level lhan lhe medical condition warrants. C. NOI allributable to direcl physiological effects of a substance (e.g.. drugs of abuse. medication) or a general medical condition (e.g.. hypothyroidism). D. The symptoms are not belter accounted for by bereavement. that is. after lhe loss of a loved one. the symptoms persist for longer than 2 months or are characterized by marked functional impairment. morbid preoccupation with wonhlessness. suicidal ideation. psychotic symptoms. or psychomotor retardation.
=DSM-IV criteria: Underline =suggested addition; Italics =DSM-IV criteria deleted.
fication, but for the sake of communication, this diagnostic category is reluctantly included. DSM-III, DSM-III-R, and DSM-IV have been a valuable contribution to diagnostic nosology in psychiatry. Unfortunately, they have also fostered a mindless counting of symptoms. To make diagnoses in this manner decreases diagnostic validity. Diagnostic criteria are guidelines, not a substitute for good clinical skills and judgment. For example, most patients 2 weeks after a bone marrow transplant would erroneously meet criteria for major depressive disorder ifthe symptoms were just blindly counted. Likewise, an elderly patient with severe and persistent depressed mood and anhedonia, with no other reported associated symptoms, would not be VOLUME 36· NUMBER 1 • JANUARY - FEBRUARY 1995
diagnosed as having a major depressive disorder and might not receive antidepressant treatment. As with all other diagnostic endeavors, accurate diagnosis of depressive disorders in the medically iII begins with a good history, including a collateral history from family and medical staff. Because many of these patients are elderly with delirium, dementia, or other cognitive disorders and/or are severely ill, they are often unable to accurately remember the progression of their depressive symptoms. Given all the variables that affect the evaluation of depressive symptoms, tracking out the depressive symptoms is essential. First, it is important to observe depressive symptoms over time, particularly depression and anhedonia. Un53
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TABLE 2.
Mood disorder with depressed features due to a general medical condition: DSM-IV criteria
A. A prominent and persistent disturbance in mood predominates the clinical picture and is characterized by the following: depressed mood or markedly diminished interest or pleasure in all, or almost all. activities. B. There is evidence from the history, physical examination. or laboratory findings of a general medical condition judged to be etiologically related to the disturbance.
TABLE 4.
Dysthymic disorder: modified DSM-IV criteria
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation made by others, for at least 2 years.
B. Presence, while depressed, of two (or more) of the following: I. feelings of hopelessness (not demoralization or discouragement related to the reality of the medical illness) 2. low self-esteem (feeling bad about self, not situation)
C. The disturbance is not better accounted for by another mental disorder (e.g.• adjustment disorder with depressed mood. in response to the stress of having a general medical condition).
3. diminished ability to think or concentrate (not related to delirium, dementia, physical i1lness:o.: treatments) or difficulty making decisions
D. The disturbance does not occur exclusively during the course of delirium or dementia.
4. poor appetite or overeating (not easily explained by physical illness, treatments, or hospital environment)
E. The symptoms cause clinically significant distress or impairment in social, occupational, or other importanl areas of functioning.
5. insomnia or hypersomnia (not easily explainable by illness, treatments or, hospital environment) 6. low energy or fatigue (not easily explainable by physical illness or treatments)
TABLE 3.
Substance-induced mood disorder with depressed features
A. A predominant and persistent disturbance in mood predominates the clinical picture and is characterized by the following: depressed mood or marked diminished interest or pleasure in all, or almost all, activities.
B. There is evidence from history, physical examination, or laboratory findings of either: I. the symptoms in criterion A developed during, or within a month, of substance intoxication or withdrawal 2. medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a mood disorder that is not substance induced.
D. The disturbance does not occur exclusively during the course of a delirium. E. The symptoms cause clinically significanl distress or impairment in social, occupational, or other important areas of functioning.
fortunately, hospital stays are so short that this represents a challenge, In an academic setting visits from the resident, medical student, and the attending physician at various times during the day is helpful. In other situations, the patient is reevaluated in the outpatienl clinic after returning home. Next. the time course of the mood and
C. During the 2-year period of the disturbance, the person has never been without the symptoms in criteria A and B for more than 2 months at a time.
D. No major depressive episode has been presenl during the first 2 years of the disturbance, that is, not better accounted for by chronic major depressive disorder. or major depressive disorder in partial remission. E. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance does not occur exclusively during the course of achronic psychotic disorder, such as schizophrenia or delusional disorder.
G. The symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition (e.g.. hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. (not due to illness or treatment) Note: Unmarked text suggested addition.
=DSM-IV criteria; Underline =
associaled symptoms of depression should be evaluated. Are depressive symptoms persistent over time? Do the mood symptoms and associated symptoms of depression co-vary in the same time period? Also, the severity of the depressive symptoms is important. DSM III, III-R, and IV PSYCHOSOMATICS
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TABLE S.
Adjostmenet disorder with depressed mood: modified DSM-IV criteria
A. The development ofdepressed mood in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). (Stressor may be illness or treatment.) B. The depressed mood is clinically significant as evidenced by either of the following: I. marked distress that is in excess of what would be expected from exposure to the stressor (rarely with medical illness is the distress considered in excess of the stressor) 2. significant impairment in social or occupational (academic) functioning (not due to illness or treatment) 3. treatment is recommended C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder. (Does not meet criteria for major depressive disorder. dysthymia. or mood disorder with depressed features due to a general medical condition or substance ). D. The symptoms do not represent bereavement. E. Once the stressor (or its consequences) has terminated. the symptoms do not persist for morc than an additional 6 months. Specify if: Acutc: if the symptoms havc persisted for Icss than 6 months Chronic: if the symptoms have persisted for 6 months or longer. Note: Unmarked text suggestcd addition.
=DSM-IV critcria; Undcrline =
do not define the severity of the depressive symptoms. Given the high incidence of mild mood symptoms in this population, at least a moderate level of symptom intensity as defined by the Research Diagnostic Criteria (RDC)2J is important in diagnosing major depressive disorder. Finally, events that make the depressive symptoms worse or better, such as effects of illness, medications, treatment, and hospital environment, should be evaluated with every symptom. EVALUATING THE SYMPTOMS As mentioned earlier, all symptoms used to make a diagnosis of depression can be confounded by medical illness, treatments, hospital environVOLUME 36· NUMBER I • JANUARY - FEBRUARY 1995
ment, delirium, dementia, other cognitive disorders, stress, loss, and character pathology. The accurate clinician rules these variables in and out with investigation of each depressive symptom. Because the affective and cognitive symptoms of depression are least affected by the aforementioned variables (except character pathology), they bear the most careful evaluation. DEPRESSED MOOD AND ANHEDONIA Depressed mood for the patient with major depressive disorder is persistent, pervasive, and at least at a moderate level of symptom intensity, that is, the patient feels depressed most of the time..w The mood has little reactivity and improves little with positive events:") for example, improved medical condition and support from family, friends, and medical staff. The patient brightens little with discussion of pleasant topics in the interview. Psychotherapy may only briefly help improve the mood or have no effect at all. Depressed mood for the patient with dysthymia may be at a lower level ofsymptom intensity than for the patient with major depressive disorder, but the mood persists nearly every day for 2 years. The depressed mood for a patient with a mood disorder caused by a general medical condition or substance may be at a lower level of symptom intensity than major depressive disorder, but the mood is also predominant and persistent. The onset of the depressed mood coincides with the onset of the medical disorder or treatment and is not a response to the stress of medical illness. For the patient with an "adjustment disorder with depressed mood," the dysphoric mood is variable..w The patient has periods when he/she is not depressed. The patient's mood is depressed, and the patient thinks about and discusses painful topics and negative events. The patient's mood is reactive, however, and improves with discussion of positive topics or events in the person's life. Mood also brightens with improvement in the medical condition, support from family and friends, and psychotherapy. Because a clinical or subclinical delirium can cause depressed mood, a diagnosis of depression cannot be made until such conditions remit. 55
Depression in the Medically III
Also, diffuse or focal frontal lobe dysfunction or disease can cause affective lability. This can be confused with the crying associated with depressed mood. The patient with major depression has a loss of interest and pleasure that is persistent and at a moderate level of symptom intensity (most activities are less interesting and pleasurable).4O Assessment of interest and pleasure in the ill patient is difficult. Some mild decrease in enjoyment in usual activities is present in nondepressed medically ill patients. 4o For many patients usual pleasurable activities may not be possible because of the illness or hospital environment. Others may have never obtained pleasure from passive activities such as reading and television. Last, a patient's interest in activities may be blunted by fatigue, illness, or treatment. The most reliable indicator of loss of interest or pleasure for the ill patient with a major depressive disorder is loss of interest in or pleasure from family or friends. On the other hand, the patient with an adjustment disorder is pleased to see family and friends. Elderly patients may deny depressed mood or anhedonia but may be hopeless, helpless, or state "I don't care anymore." Hopelessness and helplessness should be considered the equivalent of depressed mood in the elderly.4O Such patients may also demonstrate the behavioral manifestation of loss of interest or pleasure. The patient may withdraw, show loss of interest in self-care, and show little interest in friends or other activities. Again, this should be considered the behavioral equivalent of anhedonia. 4O Regardless of whether the patient admits to depressed mood or anhedonia, the hopelessness, helplessness, and pessimism of a patient with a major depressive disorder is different from that seen in a patient with an adjustment disorder with depressed mood. The patient with major depressive disorder who states ''I'm not worth it," "don't bother with me," "it's hopeless to try," "there is nothing I can do," "no one can help me," or "nothing can improve" is quite different than the patient with an adjustment disorder who may be demoralized and discouraged about the illness situation but has not given up. 56
FEELINGS OF WORTHLESSNESS OR EXCESSIVE OR INAPPROPRIATE GUILT Many patients with character pathology will report feelings of worthlessness or inappropriate guilt that have been present off and on throughout their lives. For feelings of worthlessness or excessive or inappropriate guilt to be included as an associated symptoms of major depressive disorder, these cognitive symptoms of depression should have started or intensified with the onset of the depressed mood and/or anhedonia. The DSM-IV makes the comment that the excessive or inappropriate is "not merely self-reproach or guilt about being sick." That comment is vague and does not directly deal with the issue of self-worth or inappropriate guilt. The patient with these cognitive symptoms of depression feels bad about self rather than the situation K•4O ; the patient expresses feelings of worthlessness by the comments "I'm no good," or "I don't feel good about myself'; self-reproach may be expressed by "I'm no good because I'm a burden"; excessive or inappropriate guilt by "I'm a bad person because I'm ill"; and sense of punishment by "my illness is a punishment." Conversely, the ill patient who does not feel worthless or does not have excessive or inappropriate guilt may feel bad about the situation but not self. The patient may feel bad about being a burden, changes in body image, loss of function and role, loss of independence, loss of control over body and life, and not knowing why he/she has been chosen to be ill. The person may also have a mild loss of self-esteem, but when directly asked about "how do you feel about yourself as a person" the patient answers "I basically feel good about myself," "I'm a good person," or "I' m doing the best I can." When asked if the patient feels loved, the person will state "my family loves me," and if the patient is religious, "God loves me." Because many medical patients have sustained significant losses, Freud's concept of "mourning" and "melancholia'>-ll is relevant here. With mourning the patient has a positive selfconcept, whereas with melancholia the patient has a poor self-image. PSYCHOSOMATICS
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SUICIDAL IDEATION For suicidal ideation to be counted as a symptom of major depressive disorder, the patient should have recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation, suicidal attempt or specific plan to kill him or herself. On the other hand, the critically ill patient may wish to die to end suffering. Wishing to be dead should not be considered suicidal ideation when the following conditions are met: I) the patient's suffering is so bad that death is a reasonable option; 2) the choice appears logical to the family and medical staff; and 3) the wish to die is not due to a clinical depression. DIMINISHED ABILITY TO THINK OR CONCENTRATE OR INDECISIVENESS Because 28% of all hospitalized patients have a score on the Mini-Mental State Exam of less than 23,12 it is important to assess whether the diminished ability to concentrate is caused by the illness, medication, or treatments. Mild indecisiveness is common in nondepressed medical patients. 4.K Indecisiveness at least at a moderate level of symptom intensity (unable to make decisions or decision making takes so long as to cause difficulties) supports a diagnosis of major depressive disorder. K SOMATIC AND VEGETATIVE SYMPTOMS Because vegetative symptoms are present in 41 % to 81 % of medically ill patients, the evaluation of these symptoms is difficult. 7.K In a previous study, the author found that the number of vegetative symptoms increases little with increasing levels of depressive severity, but the severity of the vegetative symptoms increases as the depressive severity increases. K Vegetative symptoms are useful in supporting a diagnosis of a major depressive disorder if I) the symptoms are at least at a moderate level of symptom intensity; 2) the onset of the symptoms coincides or intensifies with the onset of depressed mood or anhedonia; 3) the symptoms are not be easily explained by the illness, medications, treatments, or hospital VOLUME 36· NUMBER I • JANUARY - FEBRUARY 1995
environment; and 4) the symptoms are out of proportion to that expected by the illness, medications, treatment, or hospital environment. 4o PSYCHOMOTOR AGITATION OR RETARDATION At least 81 % of medically ill patients have mild psychomotor retardation. 7 Differentiating moderate-to-severe psychomotor retardation caused by depression from that caused by medical illness is difficult even for the skilled clinician. Psychomotor retardation cannot be accurately assessed if the patient has Parkinson's disease; delirium; dementia or other neurological conditions causing increased speech latency, slowed movements, or apathy; renal failure; liver failure; or critical illness. 4o Likewise, psychomotor agitation may be caused by delirium or other medical conditions or treatments (i.e., anoxia, hyperthyroidism, and corticosteroids) and cannot be accurately assessed until such organic causes are ruled out. WEIGHT LOSS OR GAIN AND ANOREXIA Fifty-eight percent of medically ill hospitalized patients lose weight. K To support a diagnosis of major depressive disorder the weight loss cannot be easily explained or is out of proportion to that expected by medical illness, medication, or treatments (rule out occult carcinoma, which frequently causes massive weight loss). Further, the weight loss cannot be explained by dieting or inability to obtain, cook, or eat food, which is commonly seen in the elderly patient without adequate environmental support. Forty-one percent of medically ill patients report anorexia. K The nondepressed medically ill patient associates anorexia with chemotherapy, illness, medications, and hospital food. On the other hand, the patient with major depressive disorder and anorexia will comment ''I'm not interested in food," "I'm just not hungry," "it's related to the depression," or "I don't know why I don't eat." Forthe patient with major depressive disorder. appetite will be poor when presented with favorite food. The patient makes minimal 57
Depression in the Medically III
effort to eat, although the person knows eating is important to improved medical condition. Elderly patients may deny anorexia or weight loss, but a collateral history from the family or staff can often reveal that the patient eats poorly.40 SLEEP DISTURBANCE Fifty-four percent of medically ill patients report sleep disturbance. S The nondepressed medical patient is able to pinpoint why. "They wake me up all night to take my vital signs," "my roommate moans all night," "I was worried about the bone marrow test tomorrow," "I sleep fine at home," "I'm just uneasy in the hospital," or "the pain wakes me up at night." Many ill patients may have a change in their sleep-wake pattern. Patients who sleep during the day may have difficulty sleeping at night. Others will have brief periods of sleep during the day and night, and as a result they appear to have early morning awakening. On the other hand, patients with a major depressive disorder have considerable difficulty sleeping, which is not easily explained or is out of proportion to that expected by illness, treatments, discomfort, or hospital environment. A sleep record is important in documenting the nature of the sleep disturbance in the medically iII.40 FATIGUE OR LOSS OF ENERGY Seventy-seven percent of all hospitalized medically ill patients have loss of energy or fatigue. s In a previous study, fatigue was not found to be useful as a symptom of depression in the medically iII. s If the fatigue, however, worsens with
the onset of the affective symptoms, or is out of proportion to that expected by illness or treatments, the symptom supports a diagnosis of major depressive disorder. 40 CRITERIONC In OSM_ly 39 a new criterion has been added that is present in the ROC criteria for major depressive disorder, "The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." It is important to note that this impairment is not directly related to physical illness, treatment, or hospitalization. In the medically ill patient with a major depressive disorder, this impairment is usually manifested by the patient's decreased participation in medical care and greater disability than the medical condition warrants. In the patient with dysthymia, mood disorder with depressed features due to a general medical condition or substance, or an adjustment with depressed mood, this impairment (decreased participation in medical care and greater disability than the medical condition warrants) is variable. CONCLUSIONS It is hoped that these guidelines for using the OSM-IY to diagnose depression in the medically ill patients will be helpful forconsultation-liaison psychiatrists. Further clinical observations and research are needed to confirm the usefulness of these guidelines and their validity as diagnostic criteria.
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