Mohammed T. Abou-Saleh

PHYSICAL ILLNESS AND DEPRESSION 423Physical Illness and Depression: a Number of ConundrumsM. Robin EastwoodFormerly at St Louis University Medical School, MO, USAOne of the clinical conundrums in modern medicine is thatpsychiatric patients complain frequently in somatic terms and yettruly suffer from an excess of physical illness 1 . In a reviewconducted as part of a European Science Foundation Study(EMRC), Hafner and Bickel 2 concluded that ‘‘Studies ofmortality in mental patients have shown that . . . these patientsstill have an excess risk for natural causes of death which is notrestricted to patients or to certain diagnostic groups . . . However,the evidence for specific associations between psychiatric diagnosisand natural causes of death is not yet conclusive’’. In acommentary, Rorsman 3 said that two out of three majorlongitudinal studies indicate, at least in men, that mental illnessstrongly affects the risk of dying from natural causes. Murphy etal. 4 , from the Stirling County study, found death to besignificantly associated with affective, not physical disorder, anddepression, not anxiety. Rorsman et al. 5 , from the Lundby study,found that psychiatric patients have a significantly increasednatural death risk, and untreated psychiatric males in particular.An issue of the International Journal of Geriatric Psychiatry 6dealt with physical illness and depression in the elderly. Burvill,from Australia, pointed out that physical illness worsens theprognosis of depressive illness in the elderly. Lindesay, from theGuy’s/Age Concern Survey in the UK, found that 70% ofdepressed subjects reported one or more serious physicalproblems. Sadavoy et al., from Canada, found that about 75%of the elderly with chronic physical illness had cognitiveimpairment and 35% were depressed. There was a significantcorrelation between cognitive deficit and depression.Eastwood and Corbin 7 , in a review of the connection betweendepression and physical illness in the elderly, addressed anotherconundrum. While physical disease increases with age, depressionmay not do so. In community surveys of the elderly, fewer than25% are disease-free and over 50% have at least one activitylimitingdisorder 8 . While the findings are disputed, depressiveillness apparently declines with age, while depressive symptomsincrease. Snowdon 9 argued that depressive symptoms andsyndromes are difficult to distinguish in the medically ill. Hethought that, since conditions which significantly correlate withdepression, such as dementia, physical disability, physical illness,bereavement and so on, increase with age, then so mustdepression. Recently, Mann 10 argued that, ‘‘if other depressive,diagnostic terms are included—‘minor depression’, ‘subthresholdsyndrome’ or ‘depressive symptoms’—then the total rate ofdepression is, in fact, higher than in the younger age groups’’.The truth probably lies in some complex multivariate relationship.Notwithstanding, there are some fascinating and relatively directrelationships, such as stroke causing depression 11 and griefcausing increased coronary heart disease 12 . Fascinatingly, Glassmanand Shapiro 13 consider that we have reached the point wherewe can state that depression is an independent risk factor forcoronary heart disease. While taking this as an interestingpostulate, it has to be remembered that atherosclerosis could bea cause of both depression and heart disease. At this stage we donot know whether intervention with antidepressants would reducethe risk of depression on heart disease.Finally, as Hafner and Bickel suggest, prospective studies withdisease registers will help sort out general and specific relationshipsand direct and indirect risk factors, and help confirmRorsman’s statement, that this all means that psychiatry is abranch of medicine.REFERENCES1. Eastwood MR. The relationship between physical and psychologicalmorbidity. In Williams P, Wilkinson G, Rawnsley K, eds, The Scopeof Epidemiological Psychiatry—Essays in Honour of MichaelShepherd. London: Routledge, 1989.2. Hafner H, Bickel H. Physical morbidity and mortality in psychiatricpatients. In Vhman R et al., eds, Interaction between Mental andPhysical Illness: Needed Areas of Research. Berlin: Springer-Verlag,1989.3. Rorsman B. Discussion in connection with Hafner and Bickel’s paper.Physical mortality and morbidity in psychiatric patients. In Vhman Ret al., eds, Interaction between Mental and Physical Illness: NeededAreas of Research. Berlin: Springer-Verlag, 1989.4. Murphy JM, Monson RR, Olivier DC et al. Affective disorders andmortality. A general population study. Arch Gen Psychiat 1987; 44:473–80.5. Rorsman B, Hagnell O, Lanke J. Mortality and hidden mentaldisorder in the Lundby study. Age-standardized death rates amongmentally ill ‘‘non-patients’’ in a total population observed during a25-year period. Neuropsychobiology 1983; 10: 83–9.6. Special Issue. Int J Geriat Psychiat 1990; 5(3).7. Eastwood MR, Corbin SL. The relationship between physical illnessand depression in old age. In Murphy E, ed., Affective Disorders in theElderly. London: Churchill Livingstone, 1986.8. Jarvik L, Perl M. Overview of physiologic dysfunctions related topsychiatric problems in the elderly. In Levenson AJ, Hall RCW, eds,Neuropsychiatric Manifestations of Physical Disease in the Elderly.New York: Raven, 1981.9. Snowden J. Editorial: the prevalence of depression in old age. Int JGeriat Psychiat 1990; 5: 141–4.10. Mann A. Old age disorders in primary care. In Tansella M,Thornicroft G, eds, Common Mental Disorders in Primary Care.London: Routledge, 1999.11. Robinson R, Starkstein S. Current research in affective disordersfollowing stroke. J Neuropsychiat 1990; 2(1): 1–14.12. Parkes CM, Benjamin B, Fitzgerald RG. Broken heart: a statisticalstudy of increased mortality among widowers. Br Med J 1969; 1: 740.13. Glassman AH, Shapiro PA. Depression and the course of coronaryartery disease. Am J Psychiat 1998; 155(1): 4–10.