Abstract
The term masked depression is a long-recognised entity where a patient is depressed but does not complain of a disturbed mood. Kielholz [1] defined masked depression as a depression in which physical manifestation conceals the psychopathological symptomology. He stressed that the term denotes a phenomenological but not nosological diagnosis. The diagnosis is suspected from the vagueness of the symptom, the failure to conform to an organic disease, the unresponsiveness to therapies that would normally be effective in that particular illness and/or the presence of psychological stress. Patients deny any feeling of depression or anxiety but blame these kind of feelings on the ‘physical’ illness that they had.
A short report below demonstrates the diversity of the presenting symptoms and lack of objective criteria to diagnose masked depression.
A 45-year-old housewife was referred from the orthopedic clinic with the complaint of backache and generalised body ache for 9 months. She had visited several general practitioners and traditional healers prior to this. However, no significant improvement was noted. Since the illness, her usual routine and social activities were disturbed. She was noticed to be more irritable and easily became fatigued. There was no change in her biological (vital) functions. She was convinced that she was suffering from a physical illness. There was no disturbance in her mood. No physical problems were found despite thorough examination. All the results of relevant investigations were normal.
The negative physical finding, withdrawal from routine activities, irritability and fatigue were the clues to a psychiatric diagnosis, namely masked depression. She received supportive psychotherapy in addition to antidepressants. The backache and vague somatic symptoms disappeared after 6 weeks of treatment with dothiepin. She maintained the improvement when she was seen 6 months later.
It is clear from the above report that no list of criteria could be used to diagnose masked depression. Any list of criteria can be only suggestive and indirect. The diagnosis of masked depression should not be confused with depressive illness presenting with prominent somatic symptom of anxiety which is masking the underlying depressive symptomology [2]. Masked depression is not a unique type of disease or a syndrome, but a state or a stage of the depressive syndrome. There is no list of symptoms which has enough specificity, reliability and validity that can be drawn on in order to describe this state. Whatever argument against the term, the author feels that the term masked depression deserves to be recognised because it has a special meaning which is communicable among physicians. However, it should be reserved for a small group of depressed patients.