Depression: misleading or masked forms

 

Depression: misleading or masked formsA depressive state in which somatic phenomena dominate, in such a way as to completely camouflage the depressive background. Called also latent depression, occult depression or currently equivalent depressive, it is, in the experience of all practitioners and especially in general medicine, an indisputable clinical reality.

CLINIC:

What are the most common somatic symptoms?

All devices may be affected, but more frequently:

• Algebraic phenomena: headaches are frequent, diffuse, often affecting the neck and accompanied by anxiety disorders, even phobic (fear of diseases …); other painful sites: joint, spinal, lumbar and sciatic pain, dental neuralgia and glossodynia;

• Digestive symptoms are common with, in particular, anorexia which can look like anorexia nervosa. Other digestive signs may be abdominal pain with vomiting, or even gastric intolerance;

• other devices: cardio-vascular, respiratory, genito-urinary …

What are the elements that lead to a masked depression?

• The inaccuracy of the description sometimes contrasts with the richness of the details given.

• The evolution is chronic.

• The relative ineffectiveness of symptomatic treatments.

• The repercussions on the general state with the notion of fatigue, often predominantly morning, which can lead to an alteration of the social and professional functioning.

Paradoxically, the psychic signs are practically absent, difficult to highlight, when they are not denied by the patient.Among these :

– anxiety, which can be manifested by hypersensitivity to stimulation, hyperexcitability;

– and all the somatic signs of anxiety: palpitations, chest pains, feeling of choking and general malaise, complete the table of complaints.

Depressive signs are sometimes present at least:

– psychomotor retardation is to be found in mimicry, attitude, speech (verbal flow, fluence of ideas, perception of past time); it is an excellent indicator of a depressive disorder, especially since the alteration of the mood is not very apparent;

– the sleep can be disturbed, one often finds an insomnia of falling asleep with early morning awakenings.

Family history of severe mood disorders are important.

DIFFERENTIAL DIAGNOSIS:

Hidden depressions are difficult to diagnose for the somatic doctor and the psychiatrist.

Often unknown, the identification time is longer than in the classic forms of depression (two years for six months). This delay is not without consequence on the prognosis, and the more the disorder is old, the more random is the treatment. Masked depression is at the edge of other psychiatric disorders, including somatisations, hypochondriacal disorders, and persistent pain syndromes.

Eliminating an authentically organic cause is important, and these patients have often benefited from many complementary explorations. However, one should not multiply the investigations because one is exposed to iatrogenic complications by the risks of certain examinations, and by the fact that one maintains the idea of ​​an organicity in a patient who has difficulty to recognize the psychic origin of his troubles.

TREATMENT:

It must be as early as possible. The response to antidepressant treatment is an argument in favor of the diagnosis of masked depression.

Therapeutic families are the same as for classic depressive episodes:

– tricyclics, MAOIs (not widely used in France as first aid because of their difficult handling);

Other antidepressants, including serotonin reuptake inhibitors, are easier to use.

The delay of action of the treatment is generally of eight to fifteen days; Do not stop treatment after two days, saying it is ineffective. It is important to consider the side effects of these drugs, which may initially interfere with somatic symptoms and lead to worsening of the disorder and premature discontinuation of therapy.

The duration of treatment is at least six months to prevent relapse or recurrence.

In addition to drug treatment, a psychotherapeutic approach is sometimes necessary.

 Hidden depressions or depressive equivalents are clinical realities that are part of our practice. In front of any atypical somatic clinical syndrome, of more or less torpid and fluctuating evolution without clear explanation, it is important to think about a hidden depression, to look for the signs and especially to treat it with antidepressants with effective dose and during a enough time.

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