Special Problems: Dual Diagnosis, Refractory Depression, and Suicide
Depression and other disorders of mood are usually discussed as if they occurred independently of other conditions or problems. Very often, however, depression coexists with other psychological or behavioral problems, which can obscure the diagnostic picture and complicate treatment planning. In reality, patients often present with many problems, of which depression may be but one. Although depression can coexist with any other nonmood disorder (unless precluded by the diagnostic definitions in DSM-IV; e.g., a major depressive disorder that might be better accounted for by the diagnosis of a schizoaffective disorder), there are some diagnoses which are seen more frequently with depression than others. Anxiety disorders, personality disorders (including obsessive-compulsive personality), somatization disorders, alcohol-and substance-use problems, and eating disorders are commonly seen in depressed patients. While a thorough discussion of these disorders is certainly beyond the scope of this book, we will review some of the more common ones as they affect depression and conclude with some thoughts about treatment approaches in dual diagnosis. In managed care, conditions may be treated sequentially, rather than simultaneously,
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for effective management of resources. Particular approaches for a patient with a dual diagnosis are appropriate.