Masked depression

This is a difficult yet common type of depression in practice and tends to be misdiagnosed. Patients do not complain of the classic symptoms and tend to deny depression, which is perceived as a social stigma and a sign of weakness. They usually have multiple minor complaints of the 'ticket of entry' type. Mood changes may be elicited only after careful questioning.

The classic affective features of depression are masked by a complex of somatic complaints. Such symptoms include fatigue; anorexia; weight loss; menstrual changes; unusual sensations in the abdomen, chest or head; bodily aches and pain; dry mouth; and difficulty in breathing. If depression is not considered many fruitless, expensive and distressing investigations may be performed. According to Davies, 2 nearly half of patients with depressive illness report to the doctor with complaints that suggest physical illness. The family doctor has to suspect masked depression in a patient with a multitude of physical complaints or with complaints that do not fit any definite pattern of organic disease.

The differential diagnoses of depression are presented in Table 16.1 . Table 16.1 Differential diagnoses of depression

Psychiatric conditions

anxiety disorder


• drug and alcohol abuse

Organic disorders malignancy, e.g. lung, pancreas, lymphoma hypothyroidism hyperparathyroidism other endocrine disorders, e.g. Cushing's, Addison's

• anaemia, especially pernicious anaemia

• postinfective states, e.g. Epstein-Barr

• mononucleosis

• cerebrovascular disease

Parkinson's disease

• congestive cardiac failure

systemic lupus erythematosus

• drugs (which may cause depression)

— corticosteroids

— cytotoxic agents

— oral contraceptives/progestogen

An Australian study on masked depression concluded: 3

It must be stressed that the masking of the depressive state occurs on the doctor's side as well as the patient's, and an awareness that this may be so leads us to recommend that, once organic lesions have been excluded, there is a place for the use of an adequate therapeutic trial of antidepressants.

The following additional points were made by a panel of psychiatrists at a symposium entitled 'Depression: Masked or Missed?' in Dallas, Texas: 4

• Some patients dismissed as 'crocks' may go on to suicide if their depression is not treated.

• Masked depression would be missed much less frequently if the physician would look beneath symptoms that do not quite ring true.

• The patient with the 'tired blood syndrome' deserves something other than an iron tonic.

• Depression frequently accompanies organic diseases that are associated with nausea and other illness.

• A complete work-up may help to rule out organic disease but may result in iatrogenic disease if pursued overzealously.

Alcoholism should be suspected as a cause of depression.

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