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 19 June 2018

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Bernard Maroy How to recognize depression in gastroenterological practice
Bernard Maroy, 15 January 2009

This article details the conclusions I have reached after analyzing the somatic features of depression over 30 years.

I am a hepatologist who has practiced alcohology since 1979, and aims to understand and treat the main cause of relapsing liver disease. It quickly became clear that depression was a very important component of craving for alcohol. I, therefore, progressively developed algorithms of diagnosis and treatment.

I found that my criteria for depression were validated for several reasons:

  • Firstly, because they were statistically-associated with classical psychic signs of depression;
  • Secondly, some had been described previously;
  • And thirdly, because they disappeared following anti-depressive treatment, relapsing when this was stopped, and disappearing again with further treatment.

The first sign was coccygodynia and pain elicited by rectal touch. I succeed to publish this sign, but as I discovered many further signs it became too long to publish my studies, mainly because publications dealing with depression are rarely accepted. Moreover, it was boring to work hard to publish on out-dated features, when I was far ahead at that moment.

The basis of my work is that depression is a neuro-biochemical syndrome leading to multisystemic dysfuctions and. by no means, a merely psychic disease.

Suspecting depression?

Various digestive signs may be encountered. The most indicative feature is the intermittent appearance of symptoms with fluctuating intensity.

Starting with the mouth - dry or (rarely) excessive salivation, anomaly of taste (mainly abnormal spontaneous taste of any kind). Burning tongue or mouth without any local lesion.

Next the pharynx - globus, sensation of foreign body, frequently on a single side. Characteristic is improvement by or lack of deglutition effect.

Retrosternal pain is typically parasternal, often left-sided. It can realize (improvement after sipping water) a more or less typical reflux syndrome.

Epigastric pain is typically soon after a meal, or non-influenced by it as a heaviness associated with dyspepsia, early satiety, bloating and intestinal noises.

Nausea and vomiting are especially indicative, especially in the morning or when triggered by smell, as is travel sickness in adults. Nauseous reflex can be increased when brushing teeth, swallowing a tablet, during dentistry or upper endoscopy. This dyspepsia worsens with large fatty meals and during purgation for colonoscopy.

The liver can be tender - in part or whole - with a normal consistency, blood tests and ultrasound. It seems to me that depression can be a direct factor of fatty liver.

Depression is an important component of biliary-pancreatic sphincter dyskinesia.

At a colonic level, pain is frequent, usually diurnal, and alleviated by lying down. It is typical if burning or cold, as if owing to the quantitative or qualitative dysfunction of neuronal filters. Mucus can be wet or dry. Diarrhoea is typical if it is irregular, preceded by hard stools, urgent, of a low volume, decreases during the day, and occurs mainly during the morning and after meals, but rarely in the evening.

Constipation is typically propulsive with an empty rectum, even in case of urgency. Stools are rare, frequently small, due to hyperdigestion and difficult to pass, even if soft, owing to insufficient propulsion.

At the anal level, depression can cause various pains, more or less typical, from proctalgia fugax to coccygodynia. Depression is more frequent among fissure patients than among haemorrhoids or abscess patients. Localized pain can be due to peri-anal metameric syndrome, mainly S4.

How to confirm depression when it is suspected?

The first thing to do is to notice if presentation face mobility is normal and whether the hands are wet, then search for allodynia (pain elicited by a normally painless stimulation). Start on spontaneously painful locations, explore successively the different planes: skin (rarely), subcutaneous tissue by pinching or rolling; muscular tensing increases pain and deep planes like bones and insertions.

The search on elective locations: vertex, middle of sternum, xyphoid appendix, extremity of the last ribs, subcutaneous tissue and muscles of abdomen, lateral muscles by pinching, pubis, pubic spines, adductors of thigh, insertions of biceps on tibia and posterior spine joints. These pains can predominate over one or more hemi-dermatomes, frequently bilateral and asymmetric. It can be "all over" and then on the same side on face and body, contrary to organic pains. It seems to be due to an abnormal central treatment of normal afferent pain. Tickling or itching have the same value as pain. The first is a qualitative and the second a quantitative abnormality of central sensation modulation.

Ask the patient these questions:

  • Do you wake up during night, even for voiding?
  • Do you fall asleep easily?
  • Are you tired, especially in the morning?
  • Do you have difficulty starting the day?
  • Do you feel sleepy during day, especially after meals or driving?
  • How is your appetite?
  • Has your weight changed?
  • Do you have neuro-vegetative signs: instability, frequent voiding, itching, excessive sweating, spontaneous or evocated by exercise or eating, sexual, memory problems, nightmares?
  • Are you abnormally nervous, anxious, irritable, pessimistic? If possible, ask the patient's spouse.
  • Do you have any problem with alcohol?

Once these questions have been asked then decide whether a treatment is warranted. It depends of the perception of impediment by the patient and of his or her vision of the treatment.

This treatment is based on antidepressants adjusted by the "try and failure" method. It is better to start with a relatively low dosage, supra-liminar but infra-optimal (For example, 50 mg of tricyclics reached in a few days).

In the case of poor tolerance, stop the treatment because the medication is not going to be effective. If there is no effect, stop treatment for between 2 and 6 weeks, depending on the urgency of treatment, the number of medications tested and of earlier failures.

Wait until effect is maximal, then increase by steps until effect decreases. Hence, back to earlier dosage. If effect is only fair then begin again. If it is absolutely perfect, continue 6 months at full dosage, then diminish by prudent 2 months steps. Sometimes, a maintenance treatment is necessary.

If the result is good but not perfect, test an association with another antidepressant, preferably of another family, and so on…

Never forget that after stopping a medication its later effect will be frequently less. The curve dose-effect is not linear - flat for subliminar dosage, climbing if efficient and then declining over optimal dosage. These values vary from one patient to another.

Two illnesses can be associated, either because it causes depression or by chance because depression is very frequent all over the world.

Be careful before ascribing a recent pain to depression, even associated with an overlying allodynia.

Finally, the only way to make sure the exclusive responsibility of depression is to cure the patient with an effective treatment.

Further details about signs dealing with digestion and other systems, especially alcoholism, are detailed in English in my website and in my French language book La Dépression et Son Traitement: Aspects Méconnus. 2005 L’Harmattan, Paris.

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