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Section Seven - Assessment of the Client with Medical Illness

Section VII: Assessment of the Client with Medical Illness

For the clinician who must evaluate the medically ill patient in whom psychiatric symptoms develop, it is almost impossible to determine if these symptoms are the result of psychobiologic changes brought on with the illness. Where there is family or personal history of mental illness or if the client is experiencing psychological problems at the time of the medical illness, the risks of depression with the medical illness are obvious.

The type of symptom is often useful to distinguish primary from secondary anxiety and depression. In severe medical illness, fatigue, apathy, and resignation may point to a somatic origin, whereas depressed mood, concentration difficulties and suicidal ideation may suggest a psychological response to being severely ill. (15)

The goal of the clinician is to determine which signs and symptoms are due to the medical illness and its treatment and which signify a psychological disorder. Some factors to consider in diagnosing depression in medical patients include:

- The presence of one or more specific medical illnesses
- The presence of DSM criteria for one of the depressive syndromes
- Family history of affective disorder
- Past psychiatric history of the client
- Client response to treatment of prior depressive episodes
- Sex of client
- Age at the onset of depression
- Duration of the depressive symptoms
- The presence of psychosocial precipitants that precede the onset of depression
- Depression which preceded the medical illness
- Biological markers for depression
- Frequency the diagnosis in general population
- Diagnosis by commission, not omission i.e. suicidal behaviors

There are several cognitive-affective symptoms that best differentiate the effects of depression from those of medical illness. These include:

- Feelings of failure
- Low self-esteem
- Guilt feelings
- Loss of interest in people
- Dissatisfaction
- Difficulty with decisions
- Feelings of being punished
- Suicidal ideation
- Crying

The vegetative symptoms of depression increase in severity as the depressive disorder increases. They also increase with the severity of the medical illness. Loss of energy, decreased appetite and sleep disturbances are not considered to indicate depression in medical patients as these are common in medical illnesses.

Psychosis and suidical thoughts are two problems of special significance. The clients with these issues are at greater risk for suicide attempts or more likely to resist treatment for this reason. They may have difficulty with following the treatment regimen for their medical condition as a result of their delusions or hallucinations.

A clinician must evaluate the client’s ability to make competent decisions. It may be necessary to decide if the client is competent to refuse treatment or is depressed and wants to die. (8)

Biopsychosocial Psychiatric Assessment

Biologic factors

- Present and past health status, to include any history of cardiac problems, respiratory problems, endocrine disorders, neurologic problems, immune disorders, hospitalizations and operations; use, exposure, abuse or dependence on substances including alcohol, tobacco, prescription drugs and illegal drugs
- Results of physical exam from primary physician or by client report to include medications, weight or other medical issues; a review of body systems; neurologic status including head trauma, hypertension, speech; laboratory results ideally detailed by PCP.
- Physical functions such as elimination, activity, exercise, sleep, appetite, nutrition, hydration, sexuality, self-care
Psychological factors

- Responses to mental health problems
- Mental status exam
- General observations
- Orientation
- Mood and affect
- Thought processes
- Cognition and intellectual performance
- Attention and concentration
- Abstract reasoning and comprehension
- Memory
- Insight and judgment
- Behavior
- Self-concept
- Body image
- Self-esteem
- Personal identity
- Stress and coping patterns
- Risk assessment
- Suicidal ideation
- Assaultive or homicidal ideation

Social factors

- Functional status
- Social and family systems
- Cultural assessment
- Community support and resources
- Spiritual assessment
- Occupational status
- Economic status
- Legal status
- Quality of life

Summary

There are numerous factors to consider in making an accurate mental health evaluation. These are complicated when there is a medical illness. The clinician who is aware of these possibilities is less likely to ignore a physical basis for symptoms. The effectiveness of treatment begins with an accurate diagnosis.