Diagnostic dilemmas in psychiatric consultation/liaison: the problem of depression

We use the case of a 62-year-old retired widow, referred for psychiatric evaluation by the internal medicine house staff, to illustrate the complexities of diagnosing depressive syndromes in medically ill patients. The patient's presenting symptoms included diarrhea, severe weight loss, and abdominal pain. She appeared cachectic, but diagnostic findings did not account sufficiently for the degree of weight loss observed. When symptoms failed to resolve, the psychiatric consultation was requested. Chronic cognitive symptoms, including feelings of guilt, anhedonia, and hopelessness, were noted. These symptoms had been present since the death of the patient's sister 2 years earlier. This case shows the importance of processing clinical data carefully to include both medical and psychiatric symptoms. It also reveals the need for an ongoing evaluation to gather significant information so the diagnosis can be solidified, allowing more specificity in planning treatment.