Social Work in Health Care

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Understanding Depression in Medical Patients Part I Margaret S. Wool ACSW, PhD To cite this article: Margaret S. Wool ACSW, PhD (1990) Understanding Depression in Medical Patients Part I, Social Work in Health Care, 14:4, 25-38, DOI: 10.1300/J010v14n04_04 To link to this article: http://dx.doi.org/10.1300/J010v14n04_04

Published online: 26 Oct 2008.

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Understanding Depression in Medical Patients Part I: Diagnostic Considerations Downloaded by [NUS National University of Singapore] at 14:40 06 November 2015

Margaret S. Wool, ACSW, P h D

ABSTRACT. Little attention has been devoted to integrating theo-

retical conceptions of depression when considering patients with medical illness. This is more true of the social work hterature than the psychiatric, in which medical formulations and treatment of depression gain primary focus. This paper presents an approach for understanding the phenomenon of depression in medical patients. It incorporates a theoretical perspective on the mechanism of depression relevant to social work intervention. Topics reviewed include diagnostic criteria for depression in the medically ill, organic factors in depression, and psychosocial theory of depression applied to medical patients. A second part of this paper will provide case examples and recommendations for social work intervention.

INTRODUCTION Depression is one of the most common yet underdiagnosed conditions among medical patients (Goldberg, 1988; Saltz & Magruder-Habib, 1985). Existing literature on depression focuses predominantly o n medically healthy individuals (Beckham & Leber, 1985). Less attention has been devoted to integrating existing conceptions of depression when considering patients with medical illMargaret S. Wool is Clinical Assistant Professor of Psychiatry and Human Behavior, Department of Psychiatry, Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. Social Work in Health Care, Vol. 14(4) 1990 25 O 1990 by The Haworth Press, Inc. All rights resewed.

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ness. This is more true of the social work literature than the psychiatric, in which the medical treatment of depression gains primary focus (Bieliauskas & Garron, 1982; Cohen-Cole & Harpe, 1987; Holland, 1987; Massie & Holland 1984). It is the intent of this paper to present an approach for understanding the phenomenon of depression in medical patients that incorporates a theoretical perspective on the mechanism of depression relevant to social work intervention. This is the first of a two-part article. The second part will present cases which illustrate the theoretical points considered here, and will offer recommendations for social work intervention. DMGNOSTIC CRITERIA FOR DEPRESSION IN THE CONTEXT OF MEDICAL ILLNESS The word "depression" is used to describe a number of different states and conditions from ordinary unhappiness, to bereavement, to psychiatric disorders. In the vernacular, depression refers to some state of sadness or despair. There is public consensual validation for this use of the term. Another definition would be an operational one, as in the use of a depression inventory or research instrument in which a cut-off score indicates the presence of depression (Snaith, 1987; Holland, 1987). The differences among these definitions become particularly relevant when estimating the prevalence of depression. DSM-111-R (1987) outlines the criteria for diagnosis of adjustment disorders, abnormal grief reactions, and affective mental disorders. Each of these diagnoses can be characterized by depressed mood. With medical patients, a major diagnostic complication is the overlap of somatic symptoms of physical illness and possible side effects of treatment with neurovegetative symptoms of depression. In addition, some medical conditions cause organic mental disorders characterized by depressed mood. This paper will focus primarily on the DSM-111-R definition of depression as a major affective disorder or "Major Depression." The criteria for diagnosing depression can be divided into two major categories of deprcssive symptomatology: psychological and ncurovegetative. Psychological symptoms include: feelings of

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worthlessness, helplessness, guilt, anhedonia, and preoccupation . with death or suicide. The principle neurovegetative signs are loss of appetite, sleep disturbance, diminished ability to concentrate, fatigue and weight loss. These signs are rarely useful in diagnosing medical patients because they often overlap with common symptoms of serious illnesses and medical treatments (Snaith, 1987). Studies have correlated depression with low functional status, suggesting that people with more advanced illness score higher on depression scales due to an overlap of physical symptoms with signs of depression (Bukberg, Penman & Holland, 1984). Two behavioral symptoms can be useful in making the diagnosis of depression in the medically ill: agitation with inability to relax (which must be in the absence of pain) and extreme slowness of movement and thinking. Early morning awakening, insomnia and poor concentration can also have validity in aiding the diagnosis of depression in medically ill patients (Gorzynski & Massie, 1981). The evaluation of depression in medical patients requires strategies that do not depend on rigid adherence to the list of criteria from DSM-111-R, and clearly distinguish between the psychologic and neurovegetative symptoms. This means that the clinician must address existential concerns and personal meaning in interviewing the patient, rather than focusing on the documentation of a typical symptom complex. In addition, realities of the illness experience must be factored into the equation. For example, a patient preoccupied with death following the recent diagnosis of a life threatening illness would not be considered abnormal. Other evidence of psychopathology must be sought to document a major depression. These could include persistent evidence of guilt, feelings of worthlessness, and the behavioral symptoms noted above.

THE PREVALENCE OF DEPRESSION In the general population, 9-20% score depressed on self report scales. In diagnostic interviews 3% of men and 4-9% of women were diagnosed as depressed (Glass, 1983). Depression among the medically ill is even more prevalent (Saltz & Magruder-Habib, 1985). Ten studies of depression in medical out-patients found a range from 5.8% to 25%. Similar studies which focus on in-patients

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found the prevalence of depression to be between 20-33% (Katon, 1987). The prevalence of depression in large community samples of elderly have been rcported at 13-18%, and prevalence among elderly medical in-patients appears to be even higher (Fogel & Fretwell, 1985). In cancer patients the general estimates for depression rates are 17-25%. These numbers are thought to be about the same for hospitalized and ambulatory patients, and patients with other medical illnesses. Peck conducted a study of cancer patients and distinguished those with depressed mood from those with a full depressive syndrome (Petty and Noyes, 1981). In this random sample of 50 ambulatory cancer patients only one was found to have a clear depressive syndrome. Depressed mood was found in 37 of the 50 patients, giving a figure of 74% for this less disabling condition. Petty and Noyes (1981) cited depression as the most common reason for requests for psychiatric consultation for cancer patients. They asserted that as many as one fourth of hospitalized cancer patients have depressive symptoms severe enough to require intervention. To summarize this confusing information with a cautionary note, thc problems with statistics on prevalence of depression in medical patients include heterogeneity of samples, the varied ways depression is defined and measured, difficulty finding comparison populations, and inconsistency in dcscribing the intensity of depressive symptoms across studies (Petty & Noyes, 1981; Glass, 1983; Bukberg, Penman 81 I-Iolland, 1984). Consequently, it is difficult to assess precisely the magnitude of the problem of depression in medical patients. The studies presented would suggest a conservative prevalence rate ranging between 5 and 20%. The problem of measurement of depression in the face of medical illness, which contributes so much to the uncertainty of these prevalence estimates, has not yet been resolved (Snaith, 1987). ~ e s ~ i -the t e evidence of how common depression is, it is often misdiagnosed by physicians (Goldberg, 1988). This is partly due to patients' tendencies to report physical rather than affective or emotional complaints to their doctors-and doctors' expectation that depression will be reported as a mood rather than a somatic problem. Katon (1987) found that primary care physicians missed the

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diagnosis of depression in 50% of cases. Social work clinicians may aid by playing a pivotal role in making links between somatic complaints and psychosocial events in their evaluations of medical patients (Saltz & Magruder-Habib, 1985). The complexity of the mind-body interaction is ubiquitous in the practice of social work in the medical context. One way to frame the problem with regard to diagnosing depression is to characterize the symptoms as stemming from either endogenous or reactive origins. Endogenous, used here in a broad sense, comprises innate vulnerability due to developmental and/or genetic factors. It could also be conceived of as including the presence of a medical condition which generates depression through "endogenous" organic means. This dimension will be discussed in the following pages.

REACTWE VERSUS ENDOGENOUS DEPRESSION A common way of conceptualizing types of depression is whether it is reactive or endogenous. This is a particularly loaded question in thinking about medical patients when the diagnosis itself is a very conspicuous event to which patients react. Reactive depression and endogenous depression could be viewed as lying on a continuum based upon the severity of an external precipitating factor. A reactive depression would rely heavily on a significant external blow, while an endogenous depression may emerge in the absence of an obvious insult. The greater the role of a conspicuous external event in the onset of a depression, the better the prognosis for a given patient. Substantial differences in the stability of personality organization and ego strength are implied in the relationship between depressive symptoms and external precipitating factors. Patients with strong internal resources cope well with significant illness and maintain normal functioning to the degree that they are physically able. Those who are derailed by an illness have a predisposition due to developmental and psychosocial vulnerabilities. The individual with a clearly reactive depression may be expected to return to his or her baseline of normal functioning more fully and more quickly than someone whose depression developed without an obvious precipitant. In medical patients, most depressions are thought to be reactive

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rather than cndogcnous. Hall (1980) lists twenty-three conditions that are. associated with reactive depression. They include myocardial infarction, spinal cord injuries, arthritis, cancer, epilepsy, and diabetes mellitus. Hackett asserts that reactive or "homecoming depression" is virtually universal among patients following myocardial infarction (1985). The onset of a reactive depression is often associated with certain points in the experience of serious illness. These include diagnosis, recurrence, loss of functions or body part due to the illness or its treatment, medical complications, withdrawal of treatment which has become invested with a sense of security and caretaking, failure of social support, the death of other patients that have become familiar in the waiting room during ongoing treatment experiences, or deaths of friends or acquaintances from a similar illness. In addition, patients with a previous history of depression are more likely to become depressed in response to illness (Gorzynski and Massie, 1981). In such cases, one could hypothesize a more serious depression due to a presumed history of endogenous depressive episodes. A careful history seeking evidence of precipitants to previous episodes, is an important component of the biopsychosocial assessment.

THEORETICAL MODEL OF DEPRESSION One of the classic papers on depression is Freud's "Mourning and Melancholia" (1948). It is aptly suited to the present topic because mourning is such an integral part of the experience of serious illness. Freud's objective was to use mourning as a model from which to better understand melancholia or depression. In looking at the psychodynamics of depression, the central message conveyed in Freud's formulation is that melancholia is a form of pathological mourning. The mechanism of depression, or melancholia, is a kind of grief reaction complicated by feelings of unacknowledged or unconscious ambivalence toward the lost object. A predominance of aggressive feclings is directed against the internalized image of the object within the self, producing depression. In both mourning and melancholia a principle task is withdrawal of libido from a loved object-or the giving up of an attachment. In normal mourning, "grief work" involves the progressive letting go of a lost object and the gradual readiness to invest one's self in other

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interests, activities, and relationships again. Vaillant (1986) points out that the letting go is not an elimination of the attachment to the loved person. He says "grief work leads to remembering, not forgetting; it is a process of internalizing, not extruding" (p. 15). Depression, in the classical psychodynamic sense, is understood to involve the loss-real or symbolic-of an ambivalently regarded object. In the present context, it is useful also to consider qualities toward which there are conflicted feelings. Personal qualities are usually associated with a significant other in the form of an internalization. For example, since in illness the loss for the patient may be a personal ability or physical disfigurement, the dynamic meaning of the particular skill or of beauty must be understood. Using physical appearance as a paradigm, an identification with the parent may have been linked to the child being admired for attractiveness rather than deeper personal qualities. This could yield narcissistic investment in beauty as well as an insecure belief in onc's inner value. Physical changes resulting from serious illness can prompt such a response: loss of attractiveness is equated with loss of worthiness. Freud postulated internalization of the lost object - those loved qualities and the desire to be like the parent-and a focusing of aggressive affect on the internalized object. He expressed it with this imagery: "thus the shadow of the object fell upon the ego, so that the latter could henceforth be criticized . . . , like the forsaken object" (1948, p. 159). However, Vaillant points out, Admittedly, it is often painful to the point of mental illness to lose someone whom we have loved a little and hated a lot. But . . . the source of psychopathology is that we forget the love and remember the hate. We deny gratitude and amplify envy.

(1986, p. 13) The psychoanalytic model described above could be characterized as a conflict model, focusing on drives or wishes and defenses against them. Later theory, moving to a focus on ego psychology, centered attention on the ego functions rather than id functions or drives. The organizing ability of the ego is derived from a number of separate functions. They can be categorized in different ways, but a sample would be cognition, perception, memory, reality test-

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ing, regulation of affects, and object relations capacity (Bellak, Hurvich & Gediman, 1973). Object relations theorists believe that ego functions and personality characteristics are acquired in the context of the relationship with the primary caretaker (Horner, 1979). From this perspective, one's ability to function well, be emotionally stable, and have satisfying relationships is predominantly a result of the nature of early developmental experiences. The infant passes through the phases of separation-individuation, what Mahler, Pine and Bergman (1975) call "psychological birth," and gradually internalizes the mothering functions. When this is successfully accomplished, the growing child (and later adult) will have the capacity to tolerate frustration, maintain a sense of selfesteem, and have mutually rewarding rather than dependent needoriented relationships. If, however, the early mothering experience includes significant inconsistency, frequent separations or permanent loss, the child's ability to internalize significant objects and develop stable ego functions will be compromised (Mahler, Pine, & Bergman, 1975; Bowlby, 1979). This would be conceived of as a deficit model. For example, a so-called anaclitic depression would result from loss or excessive separation at a point when the child is developmentally very dependent. The word anaclitic, which means to lean upon, emphasizes that state of dependency. Deficits in the supportive nurturing maternal functions leave the child prone to depression or even more severe psychopathology. Between the early deprivation that would contribute to severe ego deficits, and oedipal conflict which could result in vulnerability to depressive neurosis, trauma or threat may take on different tone and intensity. The resulting psychopathology would vary accordingly in severity and pervasiveness. In each phase, the increasing consolidation of ego functions brings greater stability and independence from significant others to maintain psychological and emotional well-being (Horner, 1979). DISTINGUISHING GRIEF FROM DEPRESSION

There are a number of common features shared between grief and depression, and some important differences. Loss is a feature in both grief and depression, and sadness, disrupted sleep patterns,

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appetite disturbance, and trouble concentrating are seen in both (Bowlby, 1979). Mourning is viewed as a normal condition, however, and expected to resolve on its own. Treatment is generally not sought or advised for normal grief. A major symptomatic difference between mourning and melancholia is loss of self-esteem. A bereaved person will be painfully sad, but in normal grief will generally not suffer loss of self-esteem. In depression, by contrast, this is a hallmark symptom. This focus on the sense of self can be seen in another aspect, by looking further at the nature of the loss in depression as compared with mourning. In mourning the loss is known to consciousness - it is concrete and as a result the world, for the self-limited period of bereavement, is experienced as empty. In depression, the loss is often not clearly apparent and is often not conscious. For the person experiencing depression, it is the self that feels empty. George Vaillant (1986) stated, Much of the literature on loss is in fact about attachment. But since we have no adequate language for internalization, we need metaphor. Thus, the discussion of grief, loss, and separation provides patients and therapists, alike, a metaphor for discussing attachment and the peopk who live on within us. (P. 11) Some of the features that led Freud to use mourning states to learn more about the mechanism of depression are precisely what complicate the situation in evaluating medical patients. "Loss" is not simply loss through death. The loss conceived of as triggering a depressive reaction could be loss of functioning, loss of role as breadwinner, andlor loss of physical attractiveness, which may represent a narcissistic iniury to some individuals. Loss of ~roximitvto loved ones through h6sphalization could precipitate an baclitiidepression due to a developmental vulnerability related to separations. Medical patients are confronted with an assault to physical health and sometimes threat to survival. Functional status may be significantly compromised. Numerous changes in sense of self, role, values and other existential matters will take on, perhaps only temporarily, a compelling significance. What the DSM-111-R calls an

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adjustment reaction would be viewed as normal under these circumstances and would not constitute major depression. In addition, the experience of anticipaiory grief is genuine for manv ~atientsand families. The issues involved in discriminatine bekeen normal grief reaction and major depression, and the din: cal significance of that discrimination, include the intensity and pervasiveness of symptoms. Both grief and depression are intense, but depression tends to be more pervasive and affect one's view of everything. Duration is also a significant factor: the acute symptoms of bereavement resolve more quickly than depression. Finally, the degree and type of dysfunction differ between the two conditions. Major depression tends to be more disabling and interfere with functioning more substantially than normal bereavement, and also carries the risk for suicide. Of course, bereaved people can become depressed, or have other forms of unresolved or pathological grief. Those individuals may need treatment to facilitate the grieving process, come to terms with the loss, and move on.

ORGANIC FACTORS IN DEPRESSION The presence of medical symptoms complicating the diagnosis of depression among hospital patients has been noted. Often overlooked is the fact that certain illnesses can actually cause depressive symptoms. Social workers, particularly those practicing in the medical setting, must consider the possibility that depression in a patient may be due to an organic mental disorder rather than psychosocial or psychodynamic factors (Hall, 1980; Goldberg, 1980). Hall (1980) lists twenty-five illnesses that often induce depression, including multiple sclerosis, cirrhosis, thyroid conditions, and ulcerative colitis. Some tumors influence mood state through hormone secretion or location in the brain or other areas that affect mental state. Cancer is sometimes first manifested through changes in emotional state, including symptoms that appear to be a depressive syndrome. Those cancers most likely to be preceded by psychiatric symptoms are brain tumors-particularly in the frontal, temporal, or parietal lobes - endocrine or hormone secreting tumors, and tumors of the pancreas. The most prevalent psychiatric condi-

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tions accompanying malignancies are affective disorders or organic mental disorders. (Peterson & Perl, 1982, p. 789) Many patients, particularly the elderly, have several medical problems and therefore several areas of vulnerability to emotional effects of physiological conditions. It is important, therefore, to know the natural history and symptom complex of psychiatric disorders so that the index of suspicion will be sensitive when the pattern doesn't fit. For example, an episode of depression longer than 6-9 months and weight loss of more than 20 pounds would be atypical (Hall, 1980; Goldberg, 1980). Ruling out organic mental disorder involves a review of medical information. Discussion of these approaches is not meant to suggest that social workers should be involved in the patient's medical care. Some knowledge, however, of areas in which organic factors are associated with changes in mood, thought and behavior are invaluable to the assessment process, and enhance the social worker's capacity to collaborate in the health care team. Some areas of common knowledge are essential to the integration of multidisciplinary services. For the social worker, reviewing aspects of mental status related to organic disorders facilitates the process of determining when to request a medical-psychiatric consultation. DLAGNOSIS OF ORGANIC MENTAL DISORDER

Major features of a delirium or organic mental disorder include (DSM-111-R, 1987):

1. Clouding of consciousness, trouble shifting sets, focusing, and sustaining attention. 2. At least two of the following: perceptual problems, incoherent speech at times, disturbed sleeplwake cycle, increased or decreased motor activity, disorientation and impaired memory. 3. Acute onset.

To evaluate these symptoms, a mental status examination must review judgment, orientation, intellect, memory, affect, and object relations (Sullivan & Fogel, 1986). Among the tests, one should include orientation, registration of information, attention, calculation, recall, language (reading and writing), and drawing (Folstein,

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Folstein & McHugh, 1975; Goldberg, 1980; Folstein, Felting, Lobo, Niaz, & Capozzoli, 1984). With some practice, these assessments can be artfully incorporated into an initial interview. Drawing is usually the least familiar part of the mental status examination for social workers. Simple drawing exercises, such as constructing a clock face or copying a geometric figure, require different cognitive capacities and engage different parts of the brain than those used in verbal activities. A patient might appear normal on other measures, or appear to have a straightforward depression, and then demonstrate gross abnormalities in attempting a simple drawing. A patient demonstrating this symptom would be a candidate for a medical-psychiatric work-up. From this summary it should be evident that medical patients are at risk, for a variety of reasons, of experiencing symptoms of affective disorder. Once the problem of an organic component has been settled, it is appropriate to consider depression from a more psychotherapeutic perspective oriented toward social work intervention.

PSYCHOSOCLAL THEORY OF DEPRESSION APPLIED T O MEDICAL PATIENTS What is the relevance of this multidimensional approach for understanding depression in the medically ill? Medical illness is an "equal opportunity employer" and individuals with the full range of personal and emotional resources are afflicted with serious conditions. Consistent with the above formulations, a person with a developmental vulnerability to depression is at considerable risk when faced with serious medical illness. The ability to assess a patient's psychological and emotional level of development is an asset to successful intervention. Many factors must be considered and assessed in diagnosing and planning treatment strategies for depressed individuals with medical illness. Organic and theoretical factors have been discussed. Part I1 of this article will offer case examples illustrating the points described above, and outline principles for successful therapeutic intervention.

Margaret

.$.Wool

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REFERENCES Beckham, E. E. & Leber, W. R. (Eds.). (1985). Handbook of Depression: Treatment, Assessment, and Research. Homewood, Illinois: The Dorsey Press. Bellak, L.; Huwich, M. & Gediman, H. (1973). Ego Functions in Schizophrenics, Neurotics, and Normah. New York: John Wiley and Sons. Bieliauskas L. A. & Garron, D. C. (1982). Psychological depression and cancer. General Hospifal Psychiarry, 4, 187-195. Bowlby, J. (1979). The Making and Breaking of Aflecfional Bonds. London: Tavistock Publications. Bukberg, I.; Penman, D.; Holland J. C. (1984). Depression in hospitalized cancer patients. Psychosomatic Medicine, 46(3), 199-212. Cohen-Cole, S . A. & Harpe, C. (1987). Diagnostic assessment of deprcssion in the medically ill. In A. Stoudemire & B. S. Fogel (Eds.), Principles of Medical Psychiatry (pp. 23-36). New York: Gmne & Stratton. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. (1987). Washington, D. C.: American Psychiatric Association. Fogel, B. S. & Fretwell, M. (1985). Reclassification of depression in the medi. cally ill elderly. Journal of the American Cenafrics Society, 33(6), 446-448. Folstein, M. F.; Fetting, J. H.; Lobo, A,; Niaz, U. & Capozzoli, K. D. (1984). Cognitive assessment of cancer patients. Cancer, 53(10), 2250-2257. Folstcin, M. F.; Folstein, S. E. & McHugh, P. R. (1975). "Mini-Mental Stale," a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Freud, S. (1948) Mourning and melancholia. In Ernest Jones (Ed.), Collecfed Papers (Vol. IV, pp. 152-170). The International Psycho-Analytical Library, London: The Hogarth Press. (Original work published 1917). Glass, R. (1983). Psychiatric disorders among cancer patients. Journal oJ fhe American Medical Associafion, 249(6), 782-783. Goldberg, R. J. (1980). Sfrafegies in Psychiatry for fhe Primary Physician. Darien, Conn.: Patient Care Publications, Inc. Goldberg, R. J. (1988). Depression in primary care: DSM-111 diagnioses and other depressive syndromes. Journal of General Inlernal Medicine, 3(Septl Oct), 491-497. Gorzynski J. G. & Massie M. J. (1981). How to manage Ihe depression of cancer. Your Parient and Cancer, 8, 25-30. Hackett, T. P. (1985). Depression following myocardial infarction. Psychoson~arics, 26(11) (supplement), 23-28. Hall, R. C. W. (Ed.). (1980). Psychiatric Presentations oJMedica1 Illness: Sonlatopsychic Disorders. New York: S P Medical and Scientific Books. Holland, J. C. (1987). Managing dcpression in the patient with canczr. CA-A Cancer Journal for Clinicians, 37(6), 366-371. Horner, A. (1979). Object Relafionr and the Developing Ego in Therapy. New York: Jason Aronson.

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Katon, W. (1987). The epidemiology of depression in medical care. international Journal of Psychiatry in Medicine, 17, 93-1 12. Mahler, M. S.; Pine, F. & Bergman, A. (1975). The Psychological Birth of fhe Human Infant. Ncw York: Basic Books. Massie, M. J. & Holland J. C. (1964). Diagnosis and treatment of depression in the cancer patient. Journal of Clinical Psychology, 45, 25-28. Peterson. L. Ci. & Perl M. (1982). Psvchiatric oresentations of cancer. Psvchosonlatic;, 23(6), 601-604. Pettv. F. & Noves. R. Jr. (1981). Deoression secondarv to cancer. Biolo~icol &chiafry, iqiq, 1203:1220: ' Saltz, C. C. & Magruder-Habib, K. (1985). Recognizing depression in patients receiving medical care. Health and Social Work, 10(1), 15-22. Snaith, R. P. (1987). The concepts and assessment of depression in oncology. Journal of Psychosocial Oncology, 5(3), 133-139. Sullivan, N. & Fogel, R. (1986). Could this be delirium? American Journal of Nursing, December, 1359-1363. Vaillant, G. E. (1986). Attachment, loss and rediscovery. The Psychiatric Times, M(8), 1,10-16. \

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Understanding depression in medical patients. Part I: Diagnostic considerations.

Little attention has been devoted to integrating theoretical conceptions of depression when considering patients with medical illness. This is more tr...
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