International Journal of Psychiatry in Clinical Practice, 2009; 13(3): 223
228

ORIGINAL ARTICLE

What is the ‘‘mask’’ of depressed inpatients from the viewpoint of surgeons and internal medicine physicians?

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JIAN-AN SU1,2,4, CHEE-JEN CHANG2,3 & SHIH-YONG CHOU1,2,4 1

Department of Psychiatry, Chang Gung Memorial Hospital, Chiayi, Taiwan, 2Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan, 3Resources Center for Clinical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan, 4Chang Gung Institute of Technology, Taoyuan, Taiwan

Abstract Objective. Depressed inpatients are easily misrecognized by general hospital physicians. Therefore, our study aimed to examine the following issues: (1) how primary care doctors recognize depressed inpatients; (2) if there are any differences between internal medicine physicians and surgeons with regard to this recognition; (3) the factors associated with the accurate recognition of depression. Methods. Four hundred and twenty-five consecutive patients from internal medical or surgical wards who had been diagnosed with depression were enrolled in this study. The reasons for referral were recorded from the referral sheet. Accurate recognition of depression was defined as depressive disorder or depressed core symptoms, which were the reasons for referral. Results. The rate of correct recognition of depression was the same for both physicians and surgeons. Depressed inpatients from the internal medicine wards were referred more commonly for suicide problems and unexplained physical symptoms, while a greater number of depressed patients from the surgical wards were referred for insomnia, agitation/irritability, cognitive impairment, and past psychiatric history. Multiple physical comorbidities, depression treatment history, and depression of a higher severity were independent factors associated with accurate recognition. Conclusions. Postgraduate education is still needed with regarded to understanding depression. The educational content should be specific to the different specialties and the patient characteristics in different wards

Key Words: Recognition, presentation, depression, consultation-liaison, reasons for referral, difference

Introduction Depression is a very common psychiatric morbidity among general hospital inpatients. The prevalence of various depressive disorders, as reported in the literature, is from 11.3 to 20% [1
5]. Patients with comorbid depression may be associated with a poor treatment outcome and higher mortality [6
9]. If adequate treatment is not provided, depression can cause significant impairments in daily life activities and decrease the quality of life [10]. However, general hospital physicians find it difficult to diagnose depression, hence it is very easily under-detected or misdiagnosed in clinical practice [8,11]. The rate of accurate detection of depressed inpatients reported in the literature varies. Balestrieri et al. found that among depressed inpatients, only 32.5% were assessed as depressed

[5]. A study by Dilts et al. indicated that only 53.6% of inpatients whose primary care doctors consulted psychiatrists for possible depression in their patients were finally diagnosed as depressed [12]. A survey conducted in a medical oncology ward revealed that doctors and nurses recognized only 49% of the depressed inpatients [13]. Further, Wancata et al. reported that diagnostic sensitivity differed depending upon the severity of depression; sensitivity for major depression was 61.5%, and for minor depression, 41% [3]. A large-scale survey conducted in an outpatient department in China revealed that only 4% of depressed outpatients were correctly identified by general practitioners [14]. A similar study conducted in the U.K. reported a 36.1% rate of diagnosis and also suggested that more severe depression was more easily recognized [15]. In short, the overall rate of accurate diagnoses

Correspondence: Chee-Jen Chang, Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan. Tel:886 5 362 1000 ext. 2313. Fax: 886 5 362 1100 ext. 2312. E-mail: [email protected]

(Received 21 October 2008; accepted 11 February 2009) ISSN 1365-1501 print/ISSN 1471-1788 online # 2009 Informa UK Ltd. DOI: 10.1080/13651500902815228

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of depression by family physicians was from 30 to 40% [16]. Several factors that are associated with the accuracy of diagnosis by primary care doctors have also been reported when encountering depressed inpatients. Factors such as female gender, unemployment, past psychiatric history, older age, poor physical condition, and severe depressive symptoms increase the probability of recognizing depression accurately [2,15
19]. In addition, a doctor’s attitude, knowledge, experience, and interview skills are key factors that influence the recognition of depression [2,16,20]. Interestingly, different medical backgrounds were also found to be influential, in that internal medicine physicians were more competent at recognizing depression than surgeons [5]. Therefore, this study aimed to determine how primary care physicians recognize depressed inpatients and what clinical variables are associated with the accurate recognition. Three hypotheses were used here: firstly, the accurate recognition rate was different between internal medicine physicians and surgeons; secondly, the presentations of depression among inpatients were different between the internal medicine and surgical wards; thirdly, some factors, such as differences in age, gender, multiple physical conditions, severity and treatment history of depression were associated with accurate recognition. Materials and methods Our study was conducted in a 700-bed general hospital. The number of beds in the internal medicine wards outnumbered those in the surgical wards. The psychiatric services in this hospital included outpatient services, day-care ward rehabilitation, and consultation-liaison services for inpatients. There were no acute or chronic wards for psychiatric inpatients. Our subjects were 425 consecutive internal medical or surgical inpatients who had been referred for psychiatric consultation between January 2002 and March 2007, and who were finally diagnosed as having depression by psychiatrists; the diagnoses of these patients included major depressive disorder and dysthymic disorder. The need of inpatients for psychiatric consultations was evaluated and requested by the primary care doctors, either residential or visiting staff. Then, they had to key in to the computer a physical condition summary, brief past history and reason for referral, and print this information out as a formal referral sheet. One staff member at the station would inform the psychiatrists by beeper during working hours in the daytime. The psychiatric consultation service was conducted by three boardcertified psychiatrists, and diagnosis was made on the basis of the diagnostic criteria of the Diagnostic and

Statistical Manual of Mental Disorders, 4th edition (DSM-IV). After consultation, the same referral sheet with diagnoses and recommendations written on the back was immediately sent to the primary care doctors. The regular consultation generally was finished within 24 h. The primary care doctors’ evaluation and perspective on the depressed inpatients was gathered from their record of reasons for referral. The classification of the referral items is shown in Table I. Besides the referral reasons, we collected other variables, including demographic data, the origin of the referral from the department, the severity of depression, and comorbidity with other physical problems. Treatment history for depression was recorded if it was mentioned by the consultee on the referral sheet. Accurate recognition of depression was defined as either the impression of a depressive disorder or if core symptoms associated with depression, such as depressive mood, low mood, crying, lack of interest, and negative thoughts, were elaborated as referral reasons. This study was approved by the Ethics Committee of Chang Gung Memorial Hospital, Taiwan. In statistical analysis, the accurate recognition rate (proportion of referral reasons as depression) was calculated. Descriptive analyses and independent sample t-tests were performed for some variables. Categorical variables were analyzed using the chisquare test to determine if the reasons for referral differed among physicians and surgeons. The data were adjusted by Fisher’s exact test if the number of cases was less than 5. The patients were divided into two groups: one comprised patients who were recognized as depressed and the other group was composed of those who were not recognized as depressed by primary care doctors. Multivariate logistic regression was used to determine the factors associated with an accurate recognition by their primary care doctors. Results During the study period, 1775 inpatients were referred for psychiatric consultation. After undergoing psychiatric evaluation, 425 depressed inpatients from the internal medicine and surgical wards were enrolled into the study. The mean age was 56.8 (SD: 16.9) years, and male patients comprised 45.2% of the subjects. Further, there was no significant difference in the mean age and sex distribution between subjects from the internal medical and surgical wards. The referral reasons are elaborated in Table I. One hundred and twenty-five cases were correctly identified on the basis of the reasons for referral. The overall rate of accurate recognition was 29.4% (125/425). In addition to depression, suicide risk evaluation, sleep

The mask of depressed inpatients 225 Table I. Reasons for referral of depressed inpatients from the internal medicine and surgical departments.

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Total N425 (%) Depression Suicidality* Sleep problems* Unexplained physical symptoms* Anxiety Past psychiatric history* Irritability/agitation* Cognitive impairment* Psychotic symptoms Behavioral problems (uncooperative or violent) Substance use problems Others (family’s request, major life event, etc.)

125 113 52 37 28 16 14 11 6 6 9 8

(29.4) (26.6) (12.2) (8.7) (6.6) (3.8) (3.3) (2.6) (1.4) (1.4) (2.1) (1.9)

Internal Medicine N309 95 92 30 32 21 8 6 5 5 5 4 6

Surgical Department N116 30 21 23 5 7 8 8 6 1 1 5 2

Statistics ns 0.015 0.009 0.049 ns 0.038 0.011 0.040 ns ns ns ns

ns, not significant. *Statistical significance (PB0.05).

problems, unexplained physical symptoms, and anxiety were the most common overall referral reasons for the depressed inpatients. The rate of accurate recognition was higher among internal medicine inpatients than that among surgical inpatients; however, this difference was not statistically significant. (30.7 vs. 25.9%, P 0.325). Besides depression, common reasons for referral among medical inpatients were suicide risk evaluation and unexplained physical symptoms. In contrast, the common reasons for referral among surgical inpatients were sleep problems, agitation/irritability, cognitive impairment, Table II. Factors associated with the rate of correct diagnosis, as analyzed by logistic regression.

and past psychiatric history. There was a significant difference in the abovementioned reasons for referral between the internal medicine and surgical inpatients. In order to determine the factors associated with the recognition of depression, multivariate logistic regression analysis was performed. From the information presented in Table II, it can be concluded that depressed inpatients with multiple physical problems, a history of treatment for depression, and severe symptoms of depression tended to be identified correctly and were referred to psychiatrists. However, differences in age and gender were not associated with the rate of recognition. Discussion

Identified and referred for depression OR (95%CI) Department Internal Medicine Surgical

0.87 (0.53
1.44)

Age B65 ]65

1.21 (0.76
1.93)

Gender Female Male

0.71 (0.45
1.10)

Physical condition Single illness Multiple illness

2.36 (1.45
3.84)*

Depression treatment history Without With

2.17 (1.34
3.50)*

Severity Dysthymic disorder Major depression

1.71 (1.09
2.68)*

*P B0.05. OR, odds ratio; CI, confidence interval.

Only 24.9% of referred depressed inpatients were correctly recognized by primary care doctors. Unlike our study, most studies emphasized the sensitivity rate (the proportion of all depressed inpatients that is recognized as having depression). Here, we used the reasons for referral as evidence of the recognition of depressed inpatients. Using this study design, the rate of accurate recognition, 29.4%, was not exactly the same as the sensitivity rate. We did not screen all the inpatients, and only those with depression who were referred for psychiatric consultation were enrolled as subjects. Therefore, no sensitivity rate, and only a recognition rate, was available in our study. The subjects recruited for this study were inpatients referred for psychiatric consultation. This implied that doctors had identified these patients as mentally ill and requiring psychiatric intervention. The fact that doctors could propose psychiatric consultations and not ignore patients’ mental problems is a good development in itself. Therefore, the accuracy of recognition might not matter too much if

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the psychiatric consultation-liaison is immediately available. However, it would be better if the doctors had more understanding of depression, because consultation services are not available in every general hospital. Physicians sometimes have to deal with psychiatric problems independently; therefore, more understanding about depression is essential for the further application of effective treatment. Nonpsychiatric physicians need to learn more about depression, and psychiatrists have an important role in teaching and educating doctors. Some depressed inpatients are referred for reasons such as suicide risk, sleep problems, anxiety, irritability/agitation, cognitive impairment, and unexplained physical symptoms. Considering these reasons for referral, it is clear that primary care physicians need to be provided with education that not only emphasizes the DMS-IV criteria of depressive disorders, but also the common comorbidities, such as anxiety disorders. In addition, it is important to emphasize other atypical subtypes of depression, such as agitated depression, and the concept of pseudodementia, in which patients manifest memory or cognitive impairment due to depression. Moreover, depressed patients often present with multiple somatic discomforts, such as back pain, headache, joint pain, chest tightness or gastrointestinal problems that are not mentioned in the DSM-IV criteria [21]; these somatic symptoms are often medically unexplained [22] and the more the physical symptoms, the greater the likelihood of coexisting depressive disorders [23]. Somatic presentations easily mask concurrent depression and are considered to be one of the main reasons for the low rates of recognition in the medical care system [17,21]. Therefore, it is important that physicians consider depression as a possible diagnosis for patients presenting with a variety of medically unexplained somatic symptoms. Some reports have indicated that physicians have higher sensitivity and accuracy rates of recognizing depression than surgeons [3,5], but the accuracy rate of recognition of the two groups was the same in our study. However, there remained some differences.In the internal medicine wards, there were higher numbers of consultations for suicide risk and unexplained somatic symptoms. This revealed a pattern among medical inpatients, because many of them were admitted for the purpose of an etiological survey. Psychiatrists were to be consulted if the subjective complaints were not compatible with the objective findings. On the other hand, the considerable physical morbidity caused by the attempted suicide, using means such as a drug overdose or carbon monoxide (CO) intoxication, was treated by physicians. A routine consultation is required for

those who attempt suicide. In the surgical ward, a large number of patients suffered from wound pain after operation or accident trauma, which resulted in agitation/irritability and insomnia. Interestingly, the interaction between pain and depression is reciprocal, in that pain will cause depression and depression will amplify discomforting physical sensations, including pain [24]. Many studies have emphasized the importance of education that involves knowledge of depression [17,25]. However, Thompson et al. indicated there has been no obvious improvement in the ability of physicians to recognize depression after education [26]. To improve this situation, the National Institute for Clinical Excellence (NICE) recommended guidelines for primary care physicians to identify and manage depression [25]. On the basis of different training backgrounds and patient patterns, educational programs designed to fulfill the needs of doctors in the context of their specialty are required. We have suggested a few focal points for the teaching programs for physicians or surgeons in Table III. Besides the abovementioned factors associated with doctors, there are some factors associated with patients that also interfere with the accurate recognition of depression. In our study, comorbidities along with a number of physical problems, a history of treatment for depression, and severer symptoms of depression were associated with a more accurate recognition; this result was the same as that of other studies [3,15,20,27]. However, some studies have shown that severe physical problems undermine the detection of depression [17,28,29]. This difference may be due to the different subject source, since most of those studies were conducted with patients from outpatient departments. In the case of doctors, inpatients presenting with comorbidity along with a number of physical problems are visited more frequently and given more attention. Thus, depression might be easily noted. Other studies indicated that several factors, such as differences in gender and age, were associated with the rate of recognizing Table III. Suggestions for education on depression for primary care physicians. 1. 2. 3. 4. 5. a

The close relationship between suicidea/insomniab and depression. Common psychiatric comorbidities in depression, for example, anxiety disorder. Common somatic symptoms, both painful and non-painful, in depressiona. Cognitive impairment in depression, for example, the concept of pseudodementiab. The subtype of depression, for example, agitated depressionb.

Should be addressed more for medical physicians. Should be emphasized more for surgeons.

b

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The mask of depressed inpatients 227 depression [15]; however, this was not the case in our study. In addition, all the recruited subjects were ethnic Chinese, who tend to deny depression or express it somatically [30]. These are potential difficulties hampering the diagnosis of depression. There are some limitations to this study. First, the recognition rate may be underestimated, since we did not ask the primary care doctors directly about their impression, and made use of referral sheets only. Second, the results were related to patients from a single hospital, therefore they cannot be generalized. Third, the subjects in our study were only those who were referred for consultation, and did not include all the depressed patients in the ward. Hence, the results of this study should be interpreted cautiously. In conclusion, only one-third of referred depressed inpatients was correctly identified. Postgraduate education, either clinical pathological conferences, or combined meetings or workshops focusing on depression should be implemented in hospitals. Although the rate of accurate recognition of depression was the same for both internal medicine physicians and surgeons, there remained some significant differences between them with regard to assessing these patients on the basis of the reasons for referral. In order to improve educational effectiveness, educational content may be adjusted based on an individual’s background and the patient characteristics. For internal medicine physicians, the somatic symptoms seen in depression and knowledge of suicide evaluation should be emphasized, while for surgeons, the comorbidity of insomnia in depression, the concept of pseudodementia, and the subtype of agitated depression should be stressed. Key points

Statement of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.

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Acknowledgements

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We are very grateful to our psychiatric team for their dedication to consultation-liaison service and research and for the grants from the Chang-Gung Medical Research Program (CMRPG 660341).

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. The presentations of depression among inpatients were different between the internal medicine and surgical wards . Postgraduate education is still needed with regard to understanding depression and the educational content should be specific to the different specialties and the patient characteristics in different wards

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