Charlie S. was 76 when his wife, Mary, died. The couple had been married for more than 50 years, and while they had no children, their many nieces and nephews were their family. Throughout their marriage, Charlie played the "macho man" role—Mary was always the nurturing partner.

However, when Mary died, his tough faade crumbled and he was devastated. But with the help of friends and relatives, Charlie dealt with his grief and adjusted to his loss. In good health, he continued to live alone, drive his car and maintain a fairly active lifestyle.

Six years later, when he was 82, Charlie was diagnosed and treated for a bilateral retinal disorder. For a year, the disease was fairly stable, but then it progressed rapidly until he was legally blind. An avid reader, Charlie used a magnifying glass to compensate for his decreased vision. But eventually he could no longer read, drive or maintain his independence. He began to show signs and symptoms of depression—decreased eating, sleep difficulties, increased physical complaints, reclusiveness.

A gregarious person all his life, Charlie was encouraged by relatives and friends to check out the new assisted-living facility down the street. But he wouldn't consider it. He resisted seeking treatment for depression when it was suggested. Real men don't get depressed, he maintained. Depression was an admitted sign of weakness. Instead, he self-medicated himself with prescribed pain pills. Two years after he lost his eyesight, Charlie died of a broken heart—a myocardial infarction.

Comorbidities Increase
After Charlie was diagnosed with the retinal disorder, a medical problem, he developed a comorbid condition—depression. In fact, the cardiac condition that resulted in his death was probably linked to the depression; it was a medical comorbidity, according to several research studies.

Psychiatric comorbidities are seen in clinical practice and have been reported in the literature more frequently in recent years. However, there are still many unanswered questions related to causes, risk factors, financial costs, protective factors and prevention. To address these concerns, the National Institute of Mental Health (NIMH) in 1999 issued a program announcement to encourage additional NIMH-supported research studies on comorbid disorders.

The call for research abstracts stated, "An abundance of epidemiologic data has established that mental disorders, substance abuse and other medical conditions (including HIV disease) are frequently comorbid. Sometimes these disorders co-occur and have equally devastating impact on an individual while at other times one disorder is clearly secondary to another; for example when depression develops as the result of a life-threatening physical disease."

An individual's illness and prognosis as well as the cost to the nation in lost productivity and health expenditures is magnified well beyond the suffering and costs associated with one disorder, according to NIMH data. It is hoped that additional research can shed light on how to reduce the incidence and prevalence of the various comorbid disorders.

Chronic Illness
Psychiatric comorbidities are seen most frequently in those experiencing chronic illnesses, i.e., rheumatoid arthritis, multiple sclerosis, HIV and cancer. Most of these individuals present with depression and anxiety, according to Sally Corbo, EdS, RN, president, Epicare Associates, West Caldwell, NJ. "It is estimated that more than 50 percent of patients suffering from chronic neurological diseases develop psychiatric comorbidities," she said.

Up to 60 percent of patients affected with a cerebrovascular accident (CVA) become depressed, according to Frieda Vandegaer, MS, RN, CS, psychiatric liaison nurse, Visiting Nurses Association of Greater Philadelphia. In many of these patients, there may be a direct physiological cause for the depression depending on the area of the brain involved. Lesions of the frontal lobes, especially the left frontal lobe, are more commonly associated with depression than in some other brain regions, wrote Lenore Kurlowicz, PhD, RN, CS, in "Depression in hospitalized medically ill elders: Evolution of the concept" (Archives of Psychiatric Nursing, 1994). Also, an individual's inability to cope with the functional losses of his illness may trigger the mood disorder.

Regardless of the cause, when a CVA patient is depressed, his recovery process slows. However, these patients are often not treated for the depression as quickly as they should be, according to Vandegaer.

"I have been called into rehab facilities to see CVA patients who are depressed," she explained. "It's not unusual to see a therapist trying in vain to provide therapy to the patient. It makes much more sense to treat the patient's depression first, before beginning therapy." The CVA patients she treats usually have a positive response to the prescribed selective serotonin reuptake inhibitors (SSRIs), she reported.

The Medically Ill Elderly
In recent years, psychiatric comorbidities in older adults have been studied, diagnosed and treated more frequently than in the past. Enlightened primary care providers now understand that depression is not part of the normal aging process. However, it has been well documented in numerous research studies that the prevalence rates of depression in elderly patients who are hospitalized with medical illnesses are consistently high.

Dr. Kurlowicz, assistant professor at the University of Pennsylvania School of Nursing and psychiatric nurse liaison at the Hospital of the University of Pennsylvania in Philadelphia, estimated in 1994 that major depression was seen in 12 to 16 percent of the elderly medically ill, with an additional 20 to 30 percent suffering appreciable depressive symptoms.

More recently, at the annual meeting of the American Psychiatric Association in May 2000, Rangai Krishnan, MD, of Duke University Medical Center in Durham, NC, reported that "the rate of depression in the elderly population increases significantly when there is a comorbid physical condition." He cited a study that showed a seven- to 12-fold increase in the risk of ischemic heart disease in those with depression. And, 45 percent of the patients studied who were post-myocardial infarction were diagnosed with major depression.

Precipitating Factors
"Frequently, it is difficult to determine whether symptoms of depression represent a direct manifestation of physical illness, a psychological response to physical illness, or are part of an ongoing or coexistent psychological disorder," wrote Dr. Kurlowicz. "The specific influence of age-related bio-psychosocial factors in the development of depression is not clear."

Multiple precipitating factors have been linked to the onset of depression in the elderly. For example, any medical condition associated with systemic involvement and metabolic disturbances can produce profound mental changes, the most common being fever, dehydration, decreased cardiac output, electrolyte disturbances and hypoxia.

With a slowly developing illness, the elderly individual may have more time to adjust and suffer less intense symptoms than if the onset of illness is abrupt. Illnesses associated with prominent changes in body image, such as amputations and CVAs, and those that increase the possibility of disability and death, such as cancer and MI, generally produce more acute symptoms.

Sensory deprivation (such as Charlie's loss of vision) and immobilization, including the use of restraints, can trigger depression. In the elderly who commit suicide, many have an active physical illness; in 70 percent of reported cases, the illness was believed to contribute to the suicide.

Depression in the medically ill can also be triggered or exacerbated by a number of medications such as anti-hypertensives, narcotic analgesics, digitalis, steroids, and major and minor tranquilizers. When an older adult seeks treatment for a medical condition or even depression from a primary care provider, often the presenting symptom is generalized anxiety. Far too frequently, the person is not properly diagnosed and benzodiazepines are prescribed, according to the psychiatric nurse therapists interviewed by ADVANCE.

In her private practice, Corbo frequently sees elderly patients who are on benzodiazepines. "These individuals are at high risk for falls and hip fractures," she noted. "Also, many of the medications that elderly patients are prescribed cause orthostatic hypotension. Safety concerns must be a top priority when drugs are prescribed for the elderly."

A Therapeutic Milieu
With more knowledge about depression in the elderly, health care providers now refer more patients, like Charlie, to mental health clinicians. A growing number of inpatient psychiatric facilities now have dedicated units for older adults.

At Sheppard Pratt Health System, Towson, MD, older adults—60 years and older—who require inpatient psychiatric care are admitted to the 34-bed psychogeriatric unit. Depression and other affective disorders are the most frequent admitting diagnoses for both groups of patients, according to Ruth Jordan, MS, RN, CSP, the unit's director.

When patients are admitted to the psychogeriatric unit, their psychiatric problem is their primary diagnosis and the medical problems their comorbidities. It's not unusual for these patients to have several comorbidities, according to Jordan.

Polypharmacy is a potential problem for geriatric patients being treated for psychiatric and medical problems concurrently. Jordan reported that the average number of medications prescribed for patients on her unit is 10. Obviously, communication between the pharmacist, physician and nurse is essential to prevent potential serious drug interactions.

Psychiatric comorbidities provide diagnostic and treatment challenges for health care providers. Recent research studies have provided much useful data as far as prevalence, risk factors and treatment. With additional data and treatment models, patients with comorbid conditions can be diagnosed more quickly and receive better care. And, maybe patients like Charlie can receive treatment for depression—and not die from broken hearts or other medical problems.

Kay Bensing is a psychiatric nurse and senior staff nurse consultant at ADVANCE.