Depressão e comorbilidade: um caso clínico*

 

Teresa Ventura**

*Os nomes referidos no relato de caso são fictícios.

**Chefe de Serviço/Assistente Graduada Sénior do Centro de Saúde Santo Condestável. Assistente Convidada do Departamento de Medicina Geral e Familiar da Faculdade de Ciências Médicas da Universidade Nova de Lisboa.

 

Correspondência

 

Resumo

Introdução: É frequente a coexistência de depressão com doenças crónicas. Esta associação leva a pior evolução, tanto do quadro psiquiátrico, como da doença crónica. Contudo, nem sempre o diagnóstico da depressão é evidente e, mesmo quando correctamente identificada, muitas vezes é subtratada, quer por razões imputáveis ao médico, quer por má adesão do doente à terapêutica.

Descrição do caso: Maria é grande utilizadora da consulta, a que recorre por tonturas, acufenos, fadiga e dores osteoarticulares. Os problemas de saúde identificados incluem entidades com potencial papel etiológico nestes sintomas, que a doente hipervaloriza. No entanto, esta cumpria irregularmente a terapêutica farmacológica e mantinha hábitos de vida prejudiciais ao controlo desses problemas de saúde.

Após múltiplas consultas de padrão semelhante, admitiu, quando questionada, irritabilidade, anedonia, tendência para o isolamento social, hipersónia e humor depressivo que atribuía ao sofrimento físico.

Após várias tentativas de introdução de terapêutica antidepressiva, que a doente abandonava após escassos dias alegando efeitos secundários, a marcação de consultas quinzenais resultou em maior adesão à terapêutica, antidepressiva e outra, menos queixas e melhor controlo das suas doenças crónicas.

Comentário: A ênfase nos sintomas somáticos e o facto de serem explicáveis no contexto da comorbilidade da doente e, assim, retirados como critérios de suspeição de depressão, levaram a que esta se mantivesse mascarada ao longo do tempo.

O médico deve ter presente a frequência da depressão associada a doenças crónicas, de modo a conseguir melhor acuidade diagnóstica. A abordagem inclusiva, que contabiliza sintomas independentemente de serem explicáveis pela patologia coexistente, diminui o risco de não se diagnosticar um quadro depressivo oligossintomático, não obstante poder gerar falsos-positivos. Pelo contrário, a abordagem excludente utilizada durante algum tempo, adiou o diagnóstico (falso-negativo) e o tratamento, com repercussões no controlo da globalidade dos problemas de saúde e na qualidade de vida da doente.

Palavras-chave: Depressão; Doença Crónica.

 

Abstract

Depression and co-morbidity: Case Report

Introduction: The co-existence of depression and chronic disease is frequent. This association leads to a worse evolution, of both the psychiatric framework and the chronic disease. However, the depression diagnosis is not always evident and even when it is identified correctly it is often under-treated, either for reasons imputable to the doctor or due to the patient’s poor adhesion to the therapeutics.

Description of the case: Maria frequently attends medical appointments complaining of dizziness, tinnitus, fatigue and bone and joint pains. The identified health problems include entities with a potential aetiological role in these symptoms, which are overvalued by the patient. However, the latter complied only irregularly with the pharmaceutical therapeutics and kept lifestyle detrimental to the control of such health problems.

After multiple appointments of similar pattern she admitted, upon questioning, irritability, anhedonia, tendency for social isolation, hypersomnia and depressive humour, which she attributed to her physical aflictions.

After several attempts to introduce anti-depressive medication, which the patient waived a few days later, alleging side effects, medical appointments at fortnight intervals resulted in a better compliance with the therapeutics, both anti-depressive and other, less complaints and better control of her chronic diseases.

Comment: The emphasis on the somatic symptoms and the fact that they could be explained within the context of the patient’s co-morbidity, therefore withdrawn as criteria of depression suspicion, led to the masking of the latter over time. The doctor must always consider the frequency of depression associated with chronic diseases, in order to achieve better diagnosis acuity. The inclusive approach, accounting for symptoms that are irrespective of being explained by the coexisting pathology, lessens the risk of not diagnosing an oligosymptomatic depressive framework, notwithstanding the fact that it may generate false-positive features. On the contrary, the excluding approach used for some time retarded the (false-negative) diagnosis and the treatment, with repercussions on the control of the whole health problems and on the patient’s quality of life.

Keywords: Depression; Chronic Disease.

 

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CONFLITOS DE INTERESSE

Declaro não ter interesses financeiros, ligações pessoais ou outros conflitos de interesse que possam enviesar o presente trabalho.

 

Endereço para Correspondência

Teresa Ventura

Rua Joaquim Quirino, n.^o 6 – 11.^o Direito

2770-089, Paço d’Arcos, Oeiras

E-mail: theresa.v@sapo.pt

 

Recebido em 15/12/2010

Aceite para publicação em 03/01/2011