Another concern is failing to recognize immediate human suffering for what it is. Hospitals and doctors’ offices are places of pain and loss as patients encounter morbidity and mortality in themselves and their loved ones. Rushing to pathologize the psychological or social manifestations of this pain can be invalidating to patients and may impair the doctor-patient relationship.
The 8 Ds
To determine what these “depression lookalike” syndromes could be, we identified 100 consecutive consultations to our adult inpatient psychiatry consultation-liaison team with a question of “depression.” We reviewed each patient’s chart, and recorded the diagnosis the psychiatrist gave to explain the patient’s depressed appearance. Data were recorded without patient identifiers, and the Mayo Clinic institutional review board (IRB) determined this study was exempt from IRB review.
Our sample included 45 men and 55 women with an average age of 48 (range: 18 to 91). On evaluation, 3 patients were given no psychiatric diagnosis, 29 were categorized as depressed, and 68 fell into one of 7 other “D” categories we describe below.
Depressed. These patients met criteria for a MDE in the context of major depressive disorder (MDD) or bipolar disorder, dysthymic disorder, mood disorder due to a general medical condition, substance-induced mood disorder, or depressive disorder not otherwise specified.
Demoralized. Patients who had difficulty adjusting to or coping with illness, and received a DSM-IV-TR diagnosis of adjustment disorder with the illness as the inciting stressor were placed in this category. Consistent with adjustment disorder criteria, these patients did not have depressive symptoms of sufficient intensity or duration to meet criteria for MDD or another primary mood disorder.
Difficult. For these patients, the primary issue was a breakdown in the therapeutic alliance with their treatment team. They received DSM-IV-TR diagnoses of personality disorder, noncompliance with treatment, or adult antisocial behavior.
Drugged. Patients in this category appeared depressed as a result of illicit substance use or misuse of alcohol or pharmaceuticals. DSM-IV-TR diagnoses included substance intoxication or withdrawal and substance abuse or dependence.
Delirious. This group consisted of patients with acute disruption in attention and level of consciousness that met DSM-IV-TR criteria for delirium. Patients whose delirious appearance was the result of illicit substance use or pharmaceutical misuse were categorized as “Drugged” rather than “Delirious.”
Disaffiliated. Patients in this category had dysphoria not commensurate with a full-blown mood disorder but attributable to grief from losing a major relationship to death, separation, or divorce. These patients received a DSM-IV-TR diagnosis of bereavement or a partner relational problem.
Delusional. These patients demonstrated amotivation and affective blunting as a result of a primary psychotic disorder such as schizophrenia. In preparation for emergent surgery, these patients had been prevented from taking anything orally, including antipsychotics, and their antipsychotics had not been restarted, which precipitated a gradual return of psychotic symptoms in the days after surgery.
Dulled. Two patients in our sample had irreversible cognitive deficits that explained their withdrawal and blunted affect; 1 had dementia and the other had mental retardation.
Managing the other Ds
In our sample, the most commonly misdiagnosed patients were those having difficulty adjusting to illness (Demoralized) or to other life events (Disaffiliated) (Table 1). In these cases, misdiagnosis has substantial treatment implications because these patients are better served by acute, illness-specific interventions that bolster coping skills, rather than pharmacotherapy or psychotherapy that targets entrenched depressive symptoms. For these patients, psychiatrists may “prescribe” interventions such as visits with a chaplain or other spiritual advisor, telephone calls or visits from family, friends, and other social supports, participation in physical or occupational therapy to improve adaptive functioning, or connecting with other patients in similar situations. Often, the key with these patients is to identify ways they have managed previous stressors and creatively use those resources to adapt to their new situation.
A second large group in our sample consisted of patients actively or passively fighting with their treatment team—the Difficult (Table 2). The treatment team or the patient’s caregivers and loved ones often are more distressed by the “difficult” patient’s symptoms than the patient, who may instead focus on his or her disappointment with caregivers who are unable to meet the patient’s unreasonable expectations. These challenges typically can be addressed by clarifying the salient issues for both the patient and team and establishing a liaison between patient and team to improve communication among all parties. Multidisciplinary care conferences can be an excellent way to ensure that the care team provides the patient with consistent communication and care.