Problems in Family Practice The Depressed Patient David W. Krueger, MD Houston, Texas Sadness and normal grief are distinguished from pathological grief and depression by intensity, duration, precipitating events, and the quality of psychopathological features. De­ pression is evaluated as a final common pathway of potential psychodynamic, genetic, psychosocial, physiological, and personality characteristics or events. The clinical entity of depression is diagnosed by describing some of each of the affective, behavioral, and cognitive changes concomitant with depression. The clinical entity of depression is further differentiated for purposes of treatment into the categories of bipolar depression (manic-depressive ill­ ness), unipolar depression (psychotic depressive reaction or involutional melancholia), neurotic depression, and secondary depression (secondary to somatic disease, drugs, or to other psychiatric disorders). The immediate treatment depends on the type of depression diagnosed. Unipolar and bipolar depressions respond to spe­ cific pharmacologic therapy and supportive care. Neurotic and characterologic depressions respond to supportive or insight psychotherapy with possible brief adjunctive anti-anxiety or hypnotic medication. All of the treatment modalities, with the possible exception of insight psychotherapy, can be effected very adequately by the primary care physician who is given clear diagnostic and assessment guidelines with specific treat­ ment approaches. Depression has been estimated to be the most may be difficult to recognize masked depression, common clinical condition that causes people to in which symptoms of hypochondriasis, psycho­ seek medical attention.1 The majority of clinical somatic problems, anxiety, addictions, and/or depressions are treated by the family physician. acting-out behavior mask an underlying depres­ One primary and continuing problem in treating sion. Once the clinical entity of depression is rec­ depression is adequate and precise diagnosis. It ognized, the next problem is how to classify and treat it. An overview of the differentiation of nor­ mal sadness and grief from pathological grief and From the Baylor Psychiatry Clinic and the Department of Psychiatry, Baylor College of Medicine, Houston, Texas. depression will be presented, as well as criteria by Requests for reprints should be addressed to Dr. David W. which to recognize each of the types of depression Krueger, Department of Psychiatry, Baylor College of Medicine, 1200 Moursund Avenue, Houston, TX 77030. and what to do about each. 0094-3509/79/020363-08$02.00 ® 1979 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 2: 363-370, 1979 363 DEPRESSED PA T/ENT Table 1 A Comparison of Normal and Pathological Grief Normal Grief Pathological Grief Intensity Sensations of somatic Acquisition of the symptoms distress. of the last illness of the deceased. Change in conduct patterns: restlessness, inability Behavior destructive of to organize activities patient's interest: foolish or carry out social business deals or generosity, pleasantries. agitated depression. Duration Up to 4 or 8 weeks. Longer than 6 m onths Precipitating Loss; preoccupation with Loss w hich is denied; Events image of deceased. overactivity without a sense of loss. Quality of Hostility toward others Marked hostility w ith o u t Psychopathologic (or physician). grief. Features Guilt feelings; bereaved Apathy. accuses himself of negligence. Definitions cians and others, and even a change in conduct Sadness is a response to external events, par­ patterns including restlessness and inability to or­ ticularly the reaction to unhappy events close to ganize activity or to carry out social pleasantries.2 our personal lives. Sadness is appropriate when The average period of acute grief lasts four to eight reactive to specific events, especially those involv­ weeks. ing some type of loss, and is something everyone With sadness and grief, there are no distortions experiences from time to time. of events or persons, and thought centers around Normal grief is the acute affect or feelings the actual loss which gradually is accepted. A re­ experienced concomitant with a significant loss. action of grief has been associated with physical Grief is not to be confused with mourning, the illness3 and mutilating surgery4 as well as with the psychological work of gradually untying the emo­ loss of a significant person. tional bonds to the lost person and making a mem­ Pathological grief reactions indicate that for ory of the relationship and all its meaning. Grief is some psychological reasons the person is unwill usually precipitated by a specific loss and accom­ ing or unable to “give up” the lost or deceased panied by a preoccupation with an image of the person, refuses to commit him/her to memory, and deceased. Possible manifestations of normal grief engages in a pathological process around the loss. include sensations of somatic distress, guilt feel­ The precipitating event is usually a loss which is ings with the bereaved accusing himself of negli­ denied and around which there is little or no grief, gence, perhaps hostility feelings toward physi­ with marked hostility or apathy in its stead. Con- 364 THE JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 2, 1979 DEPRESSED PA TIENT comitant with pathological grief may be the acqui­ Table 2. The Diagnosis of The Clinical Entity of sition of the symptoms of the last illness of the Depression deceased. The patient may engage in behavior de­ structive of his interest, such as foolish business 1. Affect deals, unwarranted generosity, or agitation.5 Sad with or without crying Normal grief may extend to six months; pathologi­ Discouraged cal grief, eventuating in depression, usually lasts Irritable much beyond six months. 2. Behavior Sadness and normal grief are distinguished from Anorexia and/or weight-loss pathological grief and depression by intensity, du­ Sleep disturbances (specifically, terminal ration, precipitating events, and quality of insomnia) psychopathologic features (Table l).6 Diurnal mood swing Loss of energy and fatigue Decreased libido Multiple somatic complaints Alcohol and drug abuse Loss of interest in usual activities Etiology of Depressive Disorders Loss of gratification from usual roles The physician must evaluate the physiological, 3. Cognition psychological, and social components of any dis­ Hopelessness and helplessness Poor concentration ease entity whether the disease is primarily or­ Decreased self-esteem ganic or psychological. The following factors are Guilt and self-reproach considered important both etiologically and in Suicidal thoughts considering the multiplicity of factors which form Paranoid ideation the clinical entity of depression.7 Loss of interest in usual activities Psychodynamic: Early life experiences predis­ Viewing of one's accomplishments as pose a person to being sensitive to loss; for exam­ meaningless ple, the early loss of a parent before development Delusions, specifically of a hypochondriacal, is complete may sensitize to further loss and may guilty, or impoverished nature. develop a proneness to depression on separation or other loss. Genetic: Genetically determined hereditary predispositions have been specifically demon­ strated in both bipolar and unipolar depression. Psychosocial: Events in an adult life which overwhelm coping mechanisms either by the magnitude of the stressing factors or the di­ of the above five factors, with depression being a minished coping ability at a particular time in the heterogeneous group of syndromes with multiple individual have been shown to cause or worsen a causations. Depressive illness is thus seen as a depressive illness. psychobiological final common pathway.7 Physiological: Stressors of a physiological na­ ture, such as medical illness, childbirth, or drugs, may increase susceptibility or cause a secondary depression. Personality: Certain character traits, specific­ ally those found in hysterical and obsessive- Diagnosis compulsive personalities, determine or modify the reaction of a person to stress. The Clinical Depressed State The most significant factor accounting for de­ pression in an adult is the previous position or By describing some of each of the following vulnerability of the person based on a composite changes of affect, behavior, and cognition, a treat- THE JOURNAL OF FAMILY PRACTICE, VOL. 8, NO. 2, 1979 365 DEPRESSED PA VENT Table 3. Clinical Depressed State Primary Affective Disorder Neurotic Depression Secondary Affective Disorder Unipolar Bipolar Other Systemic Psychiatric Diseases Disorder An episode of Evidence of Reactive Depression (a) Alcoholism (a) Central nervous significant depression current or past (b) Schizophrenia system disorders without evidence of manic episode (b) Drugs any manic episode (reserpine, birth control pills, steroids) (c) Endocrine disorders (d) Viral diseases (e) Postpartum depressions (f) Anemia (g) Organic brain disease able clinical entity of depression is delineated (Ta­ well as loss of interest in usual activities. Suicidal ble 2). thoughts and paranoid ideation may be present The affect is usually that of depression or ir­ here as well as in the more serious psychotic de­ ritability. The person may feel discouraged and pression where there may be delusions of a irritable or sad, with or without crying. hypochondriacal, guilty, or impoverished nature. The psychomotor or behavioral changes con­ After the above present illness is elaborated, comitant with depression