26.3.4 Low mood 6462 Jane Walker

26.3.4 Low mood 6462 Jane Walker

section 26  Psychiatric and drug-related disorders 6462 Physical examination Even if symptoms are suspected to be medically unexplained, it is useful to physically examine the patient. This may not only reveal unsuspected clinical signs but also helps to reassure the patient that their complaints have been taken seriously and properly assessed. Investigation Investigations are important. However, a balance must be struck be- tween the risk of missing disease and the potential iatrogenic psy- chological harm in increasing the patient’s fear of disease that can result from excessive and unnecessary investigation. Asking about fears and beliefs It is particularly important to find out what the patent thinks or fears is wrong with them. This can reveal why they have presented (e.g. ‘I am worried that it could be cancer’). In some cases anxiety about a specific disease may be the main reason for presentation. If this is severe and persistent, the diagnosis may be one of health anxiety (hypochondriasis). If bizarre and fixed, it may indicate a delusion. Asking about psychological symptoms Asking about the additional psychological symptoms may indicate one of the treatable psychiatric diagnoses listed in the differential just mentioned. However, care must be taken with asking about psy- chological symptoms such as depressed and anxious mood as this may give the patient the impression that their concerns about phys- ical disease have been prematurely dismissed. Consequently, such enquiry is often best done only after taking a history of the physical symptoms when they can be asked about as understandable conse- quences of the symptoms themselves. Management The management will depend on the diagnosis, but there are general principles: • First, patients need to know that the doctor believes them. Symptoms are subjective phenomena and the lack of disease does not mean that their suffering is in some way inauthentic. It often helps to spell this out: ‘I appreciate that you have had some very troublesome and distressing symptoms’. • Second, they need a clear message that no serious disease has been found. However, this needs to be worded carefully. Simply saying ‘there is nothing wrong’ can be heard by the patient as being dismis- sive of their symptoms. Rather it may be better to say: ‘I am pleased to be able to tell you that, despite how troubling these symptoms have been, they do not indicate a serious medical disease.’ • Third, patients need a positive plan. This may include follow up from the physician, referral to a colleague, or a recommenda- tion to the primary care physician. This can be explained as fol- lows: ‘I do hope that your symptoms will improve. They often do. However, in case they do not I will see you again/​ask your primary care physician to review you in a month’s time to review the need for treatment’. The specific treatment will depend on the diagnosis. When there is evidence of a depressive or anxiety disorder, this can be explained as follows: ‘Having physical symptoms can lead to depression and anxiety; these in turn can make the symptoms worse—​ a vicious circle. I suggest that we treat the depression/​anxiety and see if the physical symptoms improve. In my experience they often do.’ When the diagnosis is somatic symptom disorder, so-​called ‘anti- depressant drugs’ and specific forms of cognitive behaviour therapy (CBT) can be helpful. When available there are specific services and teams, for example, pain teams and liaison psychiatric services for patients with severe and chronic symptoms. Complex cases may need case conferences and a multidisciplinary management plan. Prognosis Most medically unexplained symptoms presenting to primary care resolve, but those who are referred to secondary care are more likely to persist. These patients are at risk of iatrogenic harm from exces- sive investigation and unhelpful medical and surgical treatment. FURTHER READING Creed F, et al. (2010). Is there a better term than ‘medically unex- plained symptoms’? J Psychosom Res, 68, 5–​8. Hatcher S, Arrol B (2008). Assessment and management of medically unexplained symptoms. BMJ, 336, 1124–​8. Sharpe M, Carson A (2001). ‘Unexplained’ somatic symptoms, func- tional syndromes, and somatization: do we need a paradigm shift? Ann Int Med, 134, 926–​30. Wessely S, Nimnuan C, Sharpe M (1999). Functional somatic syn- dromes: one or many? Lancet, 354, 936. 26.3.4  Low mood Jane Walker ESSENTIALS Low mood is a very common symptom that is often considered a normal, understandable reaction to serious, disabling, or disfiguring illnesses or treatment. While low mood may indeed be part of the adjustment to adverse circumstances, it may also be the presen- tation of serious psychiatric and medical illnesses requiring active treatment. The most common of these is major depressive disorder, which is a complicating illness in about 10% of patients with chronic medical conditions. Simple questioning can clarify the diagnosis, but sometimes a more detailed psychiatric and medical assessment is required so that the appropriate treatment can be provided. Introduction Low mood is a common symptom in patients with medical illnesses. Despite its prevalence and negative effects, low mood is often over- looked in the medically ill. There are several reasons for this. Patients

26.3.4  Low mood 6463 often assume that it is normal to feel low in the context of a medical illness; they may not wish to burden their doctor with something they consider untreatable; and they may believe that admitting to low mood might be taken as a sign of ‘not coping’, leading to a dis- continuation of their treatment. Clinicians, for their part, often lack confidence in how to assess low mood. Common scenarios Case 1. A 68-​year-​old, previously fit, man presented to his pri- mary care physician with shortness of breath on exertion. Following investigations he was diagnosed with metastatic lung adenocarcinoma with a prognosis of approximately 12 months. At his chemotherapy appointment he described losing interest in golf and DIY, which he was still physically capable of doing. He felt restless and unable to look forward to anything. The differential diagnosis of the low mood includes adjustment disorder, side ef- fects of chemotherapy, major depressive disorder, and developing organic brain syndrome. Case 2. An 85-​year-​old woman was admitted to a medical ward with loss of appetite, fatigue, and urinary incontinence. She appeared withdrawn, refused medications, and was reluctant to get out of bed. She responded only minimally during attempts to converse with her. The differential diagnosis of the low mood includes hypoactive de- lirium, dementia, and severe major depressive disorder. Differential diagnosis While the most obvious psychiatric disorder associated with low mood is major depression, other diagnoses must be considered. Major depression is characterized by pervasive low mood that has persisted for at least two weeks, loss of enjoyment, or motivation, and other symptoms including changes in sleep and appetite. Depression may be a consequence of medical illness, a cause of it, or the two may coexist as a result of common aetiological factors. Occasionally fur- ther assessment will indicate a history of episodes of elevated mood or mania, suggesting a bipolar mood disorder. The main differential diagnosis is that of adjustment disorder. This is a diagnosis used to describe the time-limited psychological symp- toms, including low mood, that occur during adjustment to a diffi- culty such as a new and unpleasant illness. As the term suggests, the symptoms only last while the stressor is present and are neither per- sistent nor severe enough to justify a diagnosis of major depression. However, adjustment disorders can develop into depressive illness and monitoring of the patient’s mood is important. Other psychiatric disorders to bear in mind in the differential diagnosis of low mood are alcohol and substance misuse, dementia, and delirium (particularly hypoactive delirium). In addition to the psychiatric disorders just described, several other medical illnesses and their treatments can cause low mood and should be considered when the symptom is interfering with the patient’s ability to function (Box 26.3.4.1). The most common of these is thyroid dysfunction, in particular hypothyroidism. Some pharmacological treatments have also been associated with low mood (Box 26.3.4.2). Assessment Assessment should focus on: (a) evaluating the nature and severity of the low mood; (b) determining the presence or absence of psychi- atric disorders; (c) considering other possible medical causes. Starting the conversation Patients may not divulge that they are feeling low, just as they may not report being in pain unless prompted to do so. The clinician therefore needs to have a few stock phrases that they can use to open a conversation about low mood. Open questions such as ‘how have you been feeling in yourself/​your spirits/​your mood?’ can be a good way to begin. Patients may, however, be unfamiliar with questions about their emotional well-​being and respond with a description of their physical health. In this instance, a closed question about the presence of low mood may be required, for example, ‘when patients have this medical problem it can often make them feel down or low, have you found that?’ Assessing the nature and severity of low mood It is important to assess whether the patient’s low mood is persistent and how severe it is. Having established that the patient feels low or down some of the time, the clinician can go on to ask, ‘what is that like for you?’ or ‘what does it feel like when you get low?’ Using the patient’s own words for their feelings, even if these are not part Box 26.3.4.1  Common differential diagnoses for patients presenting with low mood Major depression (which may be part of bipolar disorder) Chronic depression Adjustment disorder Alcohol and substance misuse Delirium Dementia Side effects of medication Direct result of medical illness (e.g. hypothyroidism, brain injury) Personality disorder Box 26.3.4.2  Commonly prescribed medications that have been reported to cause low mood ACE inhibitors Anticonvulsants Methyldopa Thiazides Amphotericin Ethionamide Metronidazole Some anticancer drugs β-blockers Calcium channel blockers Corticosteroids Oestrogens Interferon Isotretinoin Metoclopramide Indomethacin Statins Sedative hypnotics

section 26  Psychiatric and drug-related disorders 6464 of the clinician’s usual vocabulary, can make the assessment more comfortable for the patient, who will often be explaining how they feel for the first time. How persistent the low mood is can be estab- lished by asking how long the periods of low mood last; in a de- pressive disorder, the mood will be low most of the time. Severity can be assessed using simple questions such as ‘how bad does it get when you feel like this?’ and by asking the patient how their life has been affected by their low mood—​have they stopped doing things they usually would, or stopped enjoying them. Patient-​rated ques- tionnaires, such as the PHQ-​9, can be used to identify patients with probable major depression or to monitor the severity of a patient’s low mood, but a questionnaire is never a proper substitute for a clin- ical assessment. Assessing mood when communication is difficult Assessing whether patients have low mood and (if so) how severe that is usually involves a conversation, as described previously. However, there are situations when this can be difficult to achieve, for example, when patients are unable to speak due to a neuro- logical disorder, or when their cognitive impairment prevents them from communicating verbally. In these cases, observation of the patient’s appearance and behaviour is essential. The clinician’s observations should be supplemented with information from a relative, friend, carer, or the patient’s usual clinician. Behaviour such as poor eye contact, tearfulness, and lack of interest in per- sonal appearance suggest a diagnosis of depression, whereas fluctuating consciousness and a fearful appearance may be indi- cators of delirium. Suicide risk assessment If the patient has severe low mood it is necessary to also ask ques- tions about suicidal thoughts. There is no evidence that encouraging patients to talk about such thoughts increases the risk of suicide. Suicide risk assessment should start with a question about the patient’s desire for death, for example, ‘sometimes when people feel low like this, they can start to think that they might be better off dead; do you ever feel like that?’ If the patient denies any wish to die, the as- sessment can stop. However if they agree that, at times they wish they were not alive, the clinician should go on to enquire about thoughts of actively ending their life. An affirmative answer to this question should lead to further enquiry to establish the likelihood of suicidal actions and the factors that may reduce the patient’s risk of suicide. Management The management of low mood depends on the cause. Antidepressant medication, for example, is useful when the patient has major de- pression but there is little evidence for its value in patients with simple low mood. Patients should not be subjected to the potential adverse effects of such drugs if the chance of benefitting is low. There are, however, strategies that may be useful for low mood whatever its cause, such as increasing activity, social engagement, and talking treatment. FURTHER READING Allan C, Ebmeier K (2013). Review of treatment for late-​life depres- sion. BJPsych Advances, 19, 302–​9. Gilbody S, Sheldon T, Wessely S (2006). Should we screen for depres- sion? Br Med J, 332, 1027–​30. Simon GE, Von Korff M (2006). Medical co-​morbidity and validity of DSM-​IV depression criteria. Psychol Med, 36, 27–​36.