Reexamining the Elderly Patient's Presentation With Depression

Abstract

Sir: We wish to comment on the well-written and well-designed article by Voils et al.1 In our clinical practice in 2 of the major pain centers in the Midwest, we frequently see patients referred from primary care offices who are allegedly suffering from depression and who present with insomnia, anxiety, somatization, low energy, and some sadness. It is difficult for the patient to articulate the word depression, let alone acknowledge its presence. Anxiety, on the other hand, appears to be less vulnerable to the patients’ self-esteem and easier for them to articulate. Another description manifest by the patient includes “I am under some stress.” Insomnia and somatization, noted on the Hamilton Rating Scale for Depression2 as items 12 and 13, however, are seen prominently in our practice. Following months to years of the existence of depression, characteristics manifest by the patient are somatic and include headaches, neck pain, back pain, shoulder pain, hip pain, leg pain, arm pain, abdominal pain, and chest pain of noncardiac origin. Generally with these complaints, the primary care physician reacts in a diagnostic manner and orders radiographic testing, laboratory testing, and workups, including electromyograms and blood tests, in an attempt to document the physical pathology of pain complaints of the patient and to determine the etiology. Patients often will react in a manner as to protect themselves and will not disclose what is true but will rather disclose that which they perceive would be favorable to the clinicians who will be evaluating the outcome of the structural patient evaluation tools or forms of evaluated tools provided to the patients and/or families. Consequently, an additional medication focused at a new complaint or an attempt to abate the patient's pain complaints is often initiated with futile outcomes. It is not uncommon to see the patient change the somatic complaints from one body organ or system or location to that of another. Clinical judgment provides an index of suspicion to discriminate psychopathology (hopelessness, worthlessness, loss of self-esteem, suicidal ideation, and guilt) from that which is revealed by the elderly patient presenting with disseminated somatic pain complaints. DSM-IV-TR provides multiple diagnoses which are imbedded with somatic complaints that reflect pain and psychiatric complaints. Elderly patients may not vocalize or express the psychiatric events underlying their geriatric presentation. Commonly, elderly patients elect to guise these somatic issues as a mask for their psychiatric issues (depression, anxiety, etc.). This masking presentation of somatic symptoms permits the opportunity for presentation into the health care system. To preserve the patient's self-esteem, we often address with equal vigor both the somatic complaints and the underlying psychiatric basis. Consequently, this joint focus of attention at resolution of both the presenting somatic complaints and the psychiatric basis facilitates a more successful and robust remission in the elderly patient. This effort is in realization that painful physical comorbidity may be less than adequately addressed and opens the patient-provider relationship to decremental changes in both their physical painful comorbidity and the consequent psychiatric sequelae. In our clinical practice, we have noticed that the time when depression may be actually declared by the patient as a comorbidity is after he or she has established a fiduciary relationship of trust and confidence with the clinician. We often advise other clinicians, such as fellows and residents, that they “don't talk to the patients but talk with them, stop hearing them and begin listening to them.” Such a clinical pearl assists in building a relationship of trust and confidence with the patient over time until the disclosure of depression may appear. It is also appropriate to remember that when depression and comorbid anxiety exist, the anxiety may persist after the depression has reached remission. This may also occur with insomnia. Insomnia may not uncommonly coexist but additionally may be independent of depression and must be addressed once depression has achieved remission. These observations are based on the hundreds of patients who are sent to a pain center from primary care physicians who appear to have reached academic and professional frustration in not being able to satisfy the patients’ need for amelioration of their somatic complaints. More often than not, treatment has been focused on duration of somatic complaints as opposed to the patient's psychosocial and emotional issues that may remain undisclosed or disguised. Robert L. Barkin, M.B.A., Pharm.D., F.C.P. Rush Pain Center, Rush University Medical Center, Chicago, Illinois NorthShore Pain Center, Skokie, Illinois Stacy J. Barkin, M.Ed., M.A., Psy.D. Scottsdale, Arizona