A third group had potentially life-threatening conditions such as substance abuse/withdrawal or delirium as the cause of their “depressive” symptoms—the Drugged and the Delirious (Table 3). Recognizing an organic etiology of mood or behavioral symptoms is important because managing the underlying problem is the primary treatment strategy, not psychopharmacologic or psychotherapeutic intervention. Early identification and appropriate management of these patients could prevent further deterioration, improve medical outcomes, and shorten length of hospital stay.
A final group of patients was those whose chronic psychiatric and cognitive issues may go unrecognized or unappreciated until they interfere with the patient’s medical care—the Delusional and the Dulled (Table 2). In these cases, the correct diagnosis often hinges on obtaining a thorough history through collateral sources. The consulting psychiatrist can be crucial in co-managing these patients by establishing a liaison with outpatient providers, suggesting in-hospital management strategies such as alternate routes of administration of antipsychotics for patients with psychotic disorders, and connecting patients with outpatient supports after hospitalization. Continuity between inpatient and outpatient management is necessary to ensure a successful medical and psychiatric outcome.
Our 8 Ds are limited to the subset of patients referred by their medical teams with a question of depression. These referrals may have been motivated by a variety of patient, family, and team factors above and beyond the categories discussed in this article, and therefore may not accurately represent all patients who present with depressive symptoms in an inpatient setting. However, we hope that providing a mnemonic that suggests an extensive differential for a depressed phenotype may improve identification and management of these issues.
Table 1
Psychological crises that may look like depression
| Category | Percentage of our sample | Distinguishing features | Suggested interventions |
|---|---|---|---|
| “Depressed” patients met DSM-IV-TR criteria for a depressive disorder | 29% | Emotional symptoms: Depressed mood, anhedonia Cognitive symptoms: concentration problems, indecisiveness, negative thoughts, irrational guilt Physical symptoms: changes in sleep, appetite, energy | Initiate psychotherapy with or without antidepressants |
| “Demoralized” patients had difficulty coping with a medical illness | 23% | Close temporal association with illness. Few neurovegetative symptoms. Able to maintain future orientation/hope | Provide compassion, recognition, and normalization. Connect patients with illness-specific supports (groups, social work, chaplaincy). Implement interventions to improve functioning (eg, PT/OT). Encourage patients to engage in activities that have helped them cope in the past |
| “Disaffiliated” patients had dysphoria attributable to grief from losing a major relationship | 3% | Few neurovegetative symptoms. Able to maintain future orientation/hope. Improvement typical as time since loss increases | Encourage patients to connect with other supportive relationships. Refer patients to grief resources (eg, hospice, spiritual supports) |
| OT: occupational therapy; PT: physical therapy | |||
Table 2
Differentiating patients with social challenges from those with depression
| Category | Percentage of our sample | Distinguishing features | Suggested interventions |
|---|---|---|---|
| “Difficult” patients have a breakdown in the therapeutic alliance with their treatment team | 15% | Mood changes often intense, immediate, and reactive to situation. Frequent breakdowns in communication with care team. Care team more distressed by patient’s symptoms than the patient | Establish frequent communication among care team members. Use multidisciplinary care conferences to clarify salient issues for patients and their team. Provide patients with consistent information and expectations |
| “Delusional” patients had affective blunting as a result of a psychotic disorder | 2% | Suspicious about care team/procedures. Seems frightened or scans the room. On antipsychotics at admission. Slowly developing symptoms over several days after home medications are held | Acquire collateral history (an assigned community case manager or social worker can be an important source). Establish a plan for administering psychotropics in chronically mentally ill patients; consider IM or orally disintegrating formulations |
| “Dulled” patients had irreversible cognitive deficits | 2% | Baseline impairments in memory and/or independent functioning | Acquire collateral history. Perform a safety assessment of home environment with attention to need for additional supports |
| IM: intramuscular | |||
Table 3
Substance abuse and delirium can mimic depression
| Category | Percentage of our sample | Distinguishing features | Suggested interventions |
|---|---|---|---|
| “Drugged” patients appeared depressed as a result of substance use/ withdrawal | 12% | Acute presentation closely mimicking mood, anxiety, or psychotic disorders. Emotional symptoms present when intoxicated or withdrawing and resolved during sobriety | Implement safety interventions to prevent self-harm or aggression during acute phase. Support and monitor withdrawal as indicated. Reassess mood state and symptoms once the patient is sober. Refer for chemical dependency evaluation |
| “Delirious” patients met DSM-IV-TR criteria for delirium | 11% | Disoriented and inattentive. Onset over hours to days. Waxing and waning throughout the day. Possible hallucinations (often visual or tactile) | Identify and correct underlying medical cause(s). Restore the patient’s sleep-wake cycle. Provide frequent reorientation and reassurance |
Related Resources
- Stern TA, Fricchione GL, Cassem NH, et al, eds. Massachusetts General Hospital handbook of general hospital psychiatry, 6th ed. Philadelphia, PA: Saunders Elsevier; 2010.
- Levenson JL, ed. The American Psychiatric Publishing textbook of psychosomatic medicine. 2nd ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2011.
- Academy of Psychosomatic Medicine. www.apm.org.
- Caplan JP, Stern TA. Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis. Current Psychiatry. 2008;7(10):27-33.