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Depression in Medically Ill Patients
Sandra Rackley, MDa,b, J. Michael Bostwick, MDc,*

KEYWORDS • Depression • Adjustment disorder • Differential diagnosis • Medical illness • Antidepressant medication • Psychotherapy

“Depression” in medically ill patients is first and foremost a phenotype. Many underlying etiologies may take a final common pathway of producing such a phenotype, but have divergent implications for prognosis and management. Thus appropriate management requires first establishing the most likely diagnosis that has caused depression to be considered. This article reviews common etiologies for a “depressed” appearance in medically ill patients and proposes management strategies in each sphere of the bio-psycho-social-spiritual model.
UNIQUE CHALLENGES IN ASSESSING DEPRESSION IN MEDICALLY ILL PATIENTS

Working with medically ill patients routinely poses pragmatic challenges not typically encountered in general psychiatric practice. Hospitalized patients are rarely afforded rest and privacy. Many evaluations are conducted with no more privacy than a curtain between patients and their roommates. Interruptions are common from nursing staff, other consulting services, technicians performing bedside tests, and transporters trying to whisk patients off to remote procedures. Illness-related fatigue or medication side effects may challenge the patient’s ability to tolerate a standard diagnostic interview, with the result that evaluations may need to be broken up into several brief sessions rather than a single extended one. Many medical illnesses and medications can impair cognition on physiologic grounds, and the psychological impact of facing a life-limiting illness can dim patients’ memory of less emotionally salient information. Astute clinicians will be mindful of these factors during assessment and modify their approaches as indicated— by abbreviating an interview and returning later, gently
The authors have nothing to disclose. a Departments of