Physical illness in old age, particularly if it results in long-term disability, is associated with a higher than average prevalence of anxiety and depression. In addition, depression is the commonest mental illness causing physical complaints. Professor John Wattis and Professor Steve Curran discuss the management of patients with persistent physical symptoms related to mental health.

The relationship between physical and mental health is complicated. Unfortunately, the predominant cultural view that mind and body are somehow separate does not help us in dealing with these complexities. Older patients in particular often seem to prefer to present physical rather than psychological symptoms. Often, they are not 'psychologically minded'. Nor are they often short of physical problems to complain about. Medical training means doctors are more likely to exclude physical causes before considering psychological explanations. Again we are trapped in a false dichotomy between body and mind. Yet, with increasing knowledge, it seems that many mental and neurological illnesses previously labelled as 'functional' do in fact have a basis in the structure or biochemistry of the brain. This paper explores the relationship between physical and psychological symptoms and suggests strategies for helping patients with persistent physical symptoms related to mental ill-health.

A two-way interaction

Physical illness in old age, particularly if it results in long-term disability, is associated with a higher than average prevalence of anxiety and depression. In many disorders, patients with depression have a prognosis for recovery from physical illness that is worse than that of patients who are not depressed. Acute physical illness also often produces delirium. In hospital populations around a quarter of old people with acute physical illness have significant depression and a third to two thirds have some degree of delirium. Depression is found in around 11 per cent of the older community-based population, but is more common in selected populations such as those who repeatedly present at GP surgeries, those with physical disabilities and social isolation, and those in residential care. Disorders where physical complaints arise in the absence of other psychiatric illness are classified as 'somatoform' and include the diagnostic term 'hypochondriasis'.

Learned illness behaviour

Most episodes of illness are the end result of interactions between genetic risks, current environment, physiological factors and specific causative agents. How the disease presents will also depend on learned patterns of response. Physical discomfort and symptoms are common, but we normally dismiss the aches and pains of everyday life without a second thought. Three out of four people of all ages will have symptoms in any given month, which lead them to take action such as self-medication, bed-rest or consulting their GP. How we react to perceived illness will depend on the nature of the symptoms, our life circumstances and our attitudes to, and beliefs about, illness. The reactions of those around us (including our doctors) may also shape our response. The presence of depressed mood or an anxious personality will colour our perceptions. All these factors need to be taken into account when assessing the diagnostic significance of physical symptoms in an individual patient. Often they also need to be included in the plan of management. For example patients who have catastrophic fears about the significance of a particular symptom may need reassurance and inappropriate reactions from relatives and carers may have to be dealt with.

Assessment and management

Making an appropriate assessment

The significance of symptoms to the patient can be explored by questions like 'What do you think is the matter?' Often, in primary care the patient's and family's attitudes to illness will already be understood, but issues such as 'secondary gain' from being in the sickness role may need to be considered. The patient's mood should be assessed and questions can be supplemented by simple brief self-rating scales like the Hospital Anxiety and Depression Scale (HADS)¹ or the Geriatric Depression Scale (GDS)^2,3.

Dealing with the obvious - delirium

Occasionally, delirium is missed in community patients, particularly where there is pre-existing cognitive impairment. Relatives and carers of people with dementia should always be warned to consider the possibility of physical illness if a patient with dementia suddenly gets worse. Delirium is also often missed in hospital. About half of delirious patients have 'florid delirium' with behavioural disturbance and (usually visual) hallucinations. These are least likely to be missed. The other half have 'quiet delirium'. They tend to be withdrawn and, on a busy ward, the fact that they are confused can be missed. Sometimes the withdrawal is misinterpreted as a sign of depression. Treatment is directed at the underlying cause of the delirium, at nursing the patient in as familiar an environment as possible, and providing reassurance and re-orientation to help the patient keep a grip on reality. Sometimes, low doses of antipsychotics are useful. Risperidone is probably the drug most used in these cases. Haloperidol can also be useful, but carries increased risks of extrapyramidal side effects.

Significant physical illness

Physical conditions such as hypothyroidism, vitamin B12 deficiency, hyponatraemia and anaemia may present with tiredness and apparent depression. Such conditions should be excluded in older patients presenting for the first time with depression and, when present, should be treated. On the other hand, physical symptoms are often proffered to the doctor by the patient who is depressed. We all know the story of the little boy who cried 'wolf' and one pitfall to avoid in the patient who habitually complains of physical symptoms is that of missing a new and significant episode of physical illness. New physical complaints should be taken seriously, especially if persistent. At the same time, psychologically determined physical symptoms can be made worse by over-investigation, leading the patient to think that the doctor believes there really is something seriously wrong. Difficult clinical judgements have to be made about how far to investigate each individual symptom, especially in the patient who presents with one complaint after another. The possible risks and benefits of investigation should be discussed with the patient, but in the end the doctor has to make a judgement balancing risks and benefits as well as ethical principles such as patient autonomy and acting in the patient's best interest. This is not always an easy task.

Depressive illness and anxiety

This is often not a question of either physical illness or mood disturbance. The two commonly co-exist. Heart disease, chronic lung disease and other causes of disability are associated with depressive symptoms and anxiety. Depression and anxiety may amplify the patient's experience of pain and depressive symptoms affect the mortality and morbidity associated with physical illness. In patients with depressive symptoms and chronic physical illness, depressed mood and disability tend to vary together. Three to four months after ischaemic stroke, four out of ten people have depressive illness and treating depression after stroke appears to improve the physical prognosis. It is not only the person who has the stroke who suffers increased risk of depression. Caregivers are also more likely to be depressed, particularly if the stroke victim is severely dependent or depressed.

Though large-scale specific clinical trials of antidepressants in depressed elderly cardiac patients or carers are not available, there is every reason to believe that these patients will respond to such treatment. On the whole more modern non-cardiotoxic antidepressants such as the selective serotonin reuptake inhibitors (SSRls) are to be preferred in such patients though, in common with other antidepressants, they may cause hyponatraemia with resulting physical symptoms.

There is even a putative physiological link between depression and heart disease as platelets are rich in serotonin and SSRIs may reduce platelet stickiness, one of the risk factors for cardiovascular disease. Most doctors will also have come across cases where the depressive illness appears to be primary and the physical complaints, sometimes of delusional intensity, are secondary. The case history in Box 1 describes such a patient. Though fictional, this case history contains features often found in patients presenting with physical complaints as a result of depression:
A history of recurrent depression
A change in circumstances resulting in inappropriate physical investigation
The patient was convinced that a physical illness was being missed
The patient refused to take an antidepressant (or complied poorly)
Later episodes were more severe and difficult to treat
The delay in antidepressant treatment contributed to management difficulties.

Many such patients will have thick medical files as a result of repeated investigation of apparent physical complaints. Often they will have a number of 'genuine' chronic physical health problems and their doctor may be reluctant to further complicate an already complicated regime of medical treatment by adding an antidepressant. Sometimes, however, an adequate dose of antidepressant for an adequate length of time may result in such improvement that the other medications can be reduced.

Although in hospital practice depressive illness and various forms of anxiety disorder are often seen as separate conditions, most psychiatrists and GPs are very familiar with the patient who is depressed, but who also suffers anxiety symptoms that seem to vary with the depression. The physical accompaniments of anxiety may be interpreted as signs of physical disease by the patient or the anxiety may manifest as unwarranted concern about what seem to others to be relatively trivial symptoms. Some SSRIs and venlafaxine may be particularly useful where anxiety is prominent.

Long-standing physical complaints

Even in the absence of physical pathology to explain the complaints, and when there is not a treatable depressive illness or anxiety state, some patients still make repeated complaints about physical symptoms. They are often people for whom physical symptoms are a maladaptive way of coping with the stresses and strains of everyday life. Doctors may have inadvertently reinforced the complaining behaviour over the years by inappropriate investigation or symptomatic treatment. If the complaints are interfering with the patient's capacity to live a full life, then referral for specialist treatment may be appropriate. This is often best delivered by involving a psychologist to work with the patient, but also to suggest strategies to health-care staff for dealing with physical symptoms in a way that does not reinforce complaining behaviour. Careful coordination of management is called for to ensure the patient does not, for example, attend several different partners in a practice in the hope that one will 'take his/her complaints seriously' and refer for further physical investigations. This coordination role may be taken by the psychologist, by a partner in the practice or by a member of the community mental health team. Sometimes a similar approach may be needed in patients who have persistent physical complaints in the context of depression or anxiety disorder.

Conclusion

The relationship between physical illness and mental health problems, particularly depression and anxiety, is strong in older people. Depression may cause physical complaints or be caused by them. Treatment requires careful analysis of the problem, use of medication where appropriate and a psychological management plan. Never forget that even the habitual complainer may have a new and important cause for complaint. At the same time try not to reinforce complaining behaviour by inappropriate investigation or symptomatic treatment. In cases of severe depression or persistent unfounded health complaints the specialist services should be involved. Specialist psychologists, often working as part of a multi-disciplinary mental-health team, are particularly useful in managing and coordinating management of patients with persistent physical complaints in the absence of treatable physical illness or depression.

John Wattis is a Professor of Old Age Psychiatry and Steve Curran is a Professor of Old Age Psychopharmacology, Ageing and Mental Health Research Group, School of Human and Health Sciences, University of Huddersfield, Queensgate

References

1. Kenn CH, Wood M, Kucyj JP, Wattis J, Cunane J. Validation of the Hospital Anxiety and Depression Rating Scale (HADS) in an elderly psychiatric population: International. Journal of Geriatric Psychiatry, 1987; 2: 189-93

2. Yesavage J. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clinical Gerontology 1986; 9: 165-73

3. Montorio I, Izal M. The Geriatric Depression Scale: a review of its development and utility: International Psychogeriatrics, 1996; 8: 103-12

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