Depression is an unpleasant experience of sadness and misery, accompanied by a loss of interest and a decreased capacity for enjoyment or productive work. The depressed patient appears gloomy. He may be tearful and may have difficulty sleeping. He reports that he has little appetite and has lost weight. His behavior reflects his pervading gloom. He may be preoccupied with feelings of guilt based on trivial transgressions. He may attempt suicide.
Predisposing And Precipitating Factors
The mood of depression, like that of anxiety, is an experience known to everyone as the accompaniment of unhappy events like the death of cherished relatives. Depression in such circumstances takes a rather predictable course, the intense feelings of loss and misery gradually lessening with time. Although depression can be a natural response, it may appear in an intensity that seems exaggerated and prolonged, or it may occur without obvious immediate precipitation. Explanations for more unusual depressive reactions must be sought by a closer examination of the patient and his situation.
Some people with a pessimistic cast of personality have a tendency to react in a depressed way to any disruptive difficulty Certain physical illnesses frequently are accompanied by mild to severe depressive states. Common among these are influenza, hepatitis, and the endocrine disturbances, particularly hyperadrenocorticism, hyperparathyroidism, and the postpartum state. A depression can be the first manifestation of certain diseases of the brain, such as the cerebral atrophies or brain tumors, particularly brain tumors situated in the frontal area. Depression is the outstanding feature of the depressive psychosis (see the article on Psychoses).
Depression In The Dying Patient
Depression is a frequent emotional response in patients with a fatal disease. The impressive study of Hinton revealed that almost 50 per cent of a large group of fatally ill patients were experiencing a distressing degree of depression. Depression was directly correlated with the duration of illness, the degree of physical distress suffered, and awareness by the patient of the possibility that he might die. Although depression is common and distressfully severe in such ill patients, it may be overlooked by physicians because a depressed patient may be quiet and unobtrusive. His depression may not be distinguished from the general exhaustion of his illness.
Since the knowledge that one is dying commonly produces a depression, what should dying people be told? This question has no easy answer and remains a perennial problem. It does lose some of its force from Hinton’s data demonstrating that three fourths of his patients were already aware of the probability that they had a fatal illness, although no specific information had been given them. Thus, the problem of what to tell a patient resolves itself into discovering just how much the patient already knows and how much more he actually wants to know.
It is not wise to supply gratuitous information by rushing into a full definition of the disease and its inevitable outcome in response to rather vague inquiries by the patient about himself. This action is often regretted by both patient and doctor because it almost always produces emotional distress that might at least be postponed. Most persons do not ask delving questions about their chances of survival.
There are, however, some patients who are able to formulate specific and searching questions about the nature of their illness and its prognosis. For such people, to be answered by prevarication or an empty reassurance will only increase feelings of anxiety,, distrust, and isolation. An honest answer, particularly if it can be given along with a description of the plan of treatment that can hold the patient’s attention, usually will not increase his distress, but may aid him as he finds in the physician a friend with whom to face the future. An excellent paper by Abrams (see references) provides a more detailed consideration of this problem.
How Depression Is Diagnosed, Being A Doctor You Must Know
Depression is easily recognized. The symptoms of sadness and misery are usually unmistakable. The patient looks sad and complains that he is “blue” and has lost his interest and energy. The major issue is not the diagnosis but the estimate of how severe the depression is and, particularly, whether it is so severe as to carry a risk of suicide. Although suicide is usually the act of a severely depressed person, there can be no certain estimate of the suicide risk in any one case. All depressed patients, regardless of the cause of their depression, should be specifically asked about suicidal thoughts; any evasiveness in reply is cause for concern and calls for increased supervision of the patient. Many suicides appear to be sudden and impulsive rather than well- planned and organized acts. Therefore, lethal instruments, drugs, or open windows should not be accessible to the patient. Imposed obstacles to finding a method for self-destruction often block the intention.
Management and Treatment of Depression.
Direct treatment of depression in sick and dying patients is possible but often neglected. Considerable emotional and psychologic support can be given to these patients by just allowing them to talk with a sympathetic listener who need do no more than accept and understand. Late in the course of a terminal illness, patients often are overcome with a feeling of loneliness and abandonment. Physicians can give great help at this time by simply continuing to visit these patients regularly.
The patients come to depend on the physician as their link with the living, and a failure by the physician to see these patients because “I have nothing further to offer’’ will add considerable suffering to then final days Similarly, physicians should encourage visitors to such patients in an effort to combat this loneliness The observation that a significant number of mortal ill patients consider suicide indicates that vigorous treatment of symptoms of depression is needed for the sick Since physical discomfort is an important cause of depression, a meticulous effort to keep the patient free of pain should always be made.
All physicians need skill in the use of opium derivatives.These medicines are remarkable foi their control of pain and simultaneous reduction of anxiety and depression. Any program intended to control pain and bring comfort to a patient must be carefully attended, repeatedly scrutinized, and revised to meet changing conditions. Also, direct pharmacotherapy\ of the depressive symptoms should not be neglected for patients who are sick or dying. Often they can be comforted with imipramine, 25 to 50 mg. three times a day.
