The most important concern in patients with midand late-life depression is suicide, a topic addressed again further on. Because many of these individuals have reputations for being sound, dependable, and stable and deny being depressed, one’s inclination is to doubt the possibility of self-destruction. Such patients should nonetheless be questioned forthrightly on this subject: Do they feel that life is not worthwhile? Have there been thoughts of suicide? Do they think themselves capable of committing suicide? Have they made such plans or made suicide attempts before? Is there a family history of suicide? Do they own a firearm? Are they fearful of dying? Do they have a strongly held religious view that proscribes suicide? These questions relate to features that have been shown to put depressed individuals at risk (or less risk) of suicide but none are infallible guides to the risk of suicide. If, from their answers, they are judged to carry an imminent risk of suicide, they should be directed to a psychiatrist and generally admitted to a hospital. In recent years, it has come to be appreciated that the elderly are increasingly prone to suicide and that older white men have the highest rates of completed suicides (mainly with firearms).
In some depressions, hypochondriacal preoccupation with bowel and digestive functions accounts for repeated visits to the physician. In one study, 21 of 120 such patients were subsequently diagnosed as being depressed. Persistent insomnia may be the major complaint of the depressed patient. Early awakening is typical, and the morning hours are then the worst period of the day for the low emotional state. Other patients have difficulty falling asleep, especially if there is an associated anxiety state. A complaint in the male of loss of libido and erectile dysfunction is another monosymptomatic presentation; only with probing inquiry about other disturbances common to depression will the diagnosis become evident.
Adherence to the aforementioned or similar diagnostic criteria (see Table 48-1) undoubtedly facilitates diagnosis, but not infrequently a single one of these symptoms so dominates the clinical picture as to suggest the diagnosis of another disease state and obscure the presence of an underlying depression. As mentioned earlier, depressed patients who are referred to the neurologist tend to complain inordinately of physical and cognitive symptoms and to minimize or deny the emotional ones. Complaints of fatigue, weakness, malaise, or widespread aches and pains, for example, suggest a variety of medical diseases, such as anemia, Addison disease, hypothyroidism, chronic infection, polymyositis, or early rheumatoid arthritis. Quite often the fatigue state is misinterpreted as muscular weakness, and this directs a medical search for neuromuscular disease. Similarly, complaints of persistent headache may suggest the presence of intracranial disease. Complaints of poor memory, inability to concentrate, and other cognitive impairments raise the question of a dementia until it is found, by careful examination, that mental competence belies the patient’s appraisal of his own defects.
A number of psychologic scales are used to score the severity of depression. Although they are of value mainly for clinical studies, several of them can be helpful in clinical work since they are sensitive to one or another aspect of depression. They do not supplant the clinical examination in determining if an individual is depressed or suicidal but they may be helpful in differentiating depression from dementia and in detecting depression in cases where physical complaints are more prominent than psychic ones. The tests most familiar to neurologists are the Hamilton and the Beck scales, but others are as valid and widely used.