Serious attacks of depression involve altered mental, mood and locomotor status and should be worked up as an organic problem that we have not uncovered yet. There is nothing more distressing, more unpleasant, more disabling than a serious attack of depressed mood, depressed cognition and depressed motor activity. The reason depression feels so bad is because the patient is most likely physically ill. This is the reason why organ failure is often accompanied by depression. Organ failure – even early organ failure will affect the brain and the nervous system negatively. Mild cognitive dysfunction is very very very unpleasant. It is truly awful. The patient is unlikely to know what is wrong with them so the doctor should do a careful medical investigation, not a psychiatric one. Paula and I think that all cases of serious depression should be worked up in medical detective clinics or wards. The causes of altered mental, mood and locomotor status are very broad. It may take years to uncover the problem and treat it. We may discover better treatments for organ failure in the future. This too will help alleviate the depression that accompanies being sick.
The assumption in these clinics should be that all cases of a serious depression should be considered as a potentially treatable organic problem and worked up as such. Careful searches for hidden medical emergencies should be conducted by getting the minute volume, pulse, blood pressure and body temperature, as a start. Early organ failure is hard to detect and should be considered frequently as the patient progresses over the years, until helpful treatments can be tried out. The progression of respiratory failure, kidney failure, liver failure and heart failure will most likely involve depression as a complication and successful medical supportive treatments should help to restore baseline mental status whenever possible. Hydration and nutritional status should be assessed, as well as possible blood loss and clotting problems. Organs should be examined with ultrasound and arterial blood gas should be obtained, if necessary.
Birth history, paediatric history, educational history and history of recent physical illness should be obtained from the family. If iron deficiency was a problem at birth and in infancy, it is likely to be a problem during adulthood. If breathing was a problem at birth, as it was for Paula, it is likely to become a problem in adulthood. etc, etc, etc,…. A fast cognitive screening test will uncover “mild” cognitive deficits. Even with a mild cognitive deficit, then the patient should be either admitted and physically cared for or cared for by family after they have been told of the [reversible] deficit.
There are many many causes of acute mental reversible disability, all organic. The first step in the investigation is to look for abnormalities in the vital signs. The pattern of abnormalities will be telling and help to narrow down the causes.
I am sure that many family doctors have uncovered the underlying causes of altered mood, motor and mental status and , with the proper treatment, cured the patient. . In one case, severe visual migraines to the point of being unable to do much of anything was caused by heavy blood loss since the start of menstruation [at least 5 years of heavy monthly blood loss before onset of symptoms] with complications of [A] very low ferric iron [iron deficiency]…causing fatigue and loss of appetite [apparently iron is necessary for digestion of food] and [B] thiamine deficiency [causing episodes of [hidden heart failure, fatigue, mental confusion and depression.] In another case the culprit was celiac disease, which can cause many complications including malnutrition and anaemia, causing severe mood and digestive issues. A different case of tics. muscle stiffness, and distress [anxiety] was much improved with diazepam; [that was all that existed for anxiety in those days].The reason the diazepam worked, in retrospect, was because of this patient’s familial muskuloskeletal disorder, of which the doctor knew nothing. It was just a lucky break. The final case involved a lady who became seriously depressed during menopause and became well after receiving hormone replacement for a few years. Her depression never returned even after weaning herself off the medication. I could go on and on…….. The reason these patients got well is because their doctors took whatever time that was necessary to physically examine their patients and to think of the differential diagnosis of migraine, fatigue, loss of appetite, despair, mental confusion and depressed mood.
Which brings us to Paula. We still do not know what happened to her when she became so sick, disabled and depressed looking with mild undetected retrograde amnesia. The hypothesis we came up with when we discovered her too slow breathing was hypercapnia respiratory failure due to becoming weak after a viral illness. Paxil helped her recover to baseline physical and mental status, although it took way too long [over a year] and had many side effects until she became truly better [and that took over a decade]. Paula was stereotyped as “depressed” and so her vital signs and respiratory rate were not checked and they never uncovered her limited ability to breath, especially during physical illness causing respiratory failure.
Medical detective investigative wards and clinics should replace psychiatric wards and clinics in order to take the time required to look for and potentially cure reversible physical conditions leading to altered mental, motor and mood status. This requires time and knowledge and curiosity and it requires physically examining the patient and knowing their vital signs [including respiratory rate] and their mental status [and their previous mental status]. Those conditions that cannot be cured with present knowledge can be medically re-investigated as medicine continues to grow in knowledge and as new treatments based on results of physical investigations of the whole body continue to be studied.