Dr Paul Gill
The Longley Hospital, Sheffield

The emotional response of patients to chronic illness initially follows the same pattern as the response to acute illness, which is a wish for relief of symptoms, such as headaches and nausea, fear and anxiety, feeling generally sorry for themselves and then anger and frustration. This moves on to irritability, boredom, depression and the expectation of recovery. Chronically ill patients still expect to recover so an adjustment period is therefore necessary, during which both patients and the people around them acknowledge their situation.

Chronic illnesses are associated with higher rates of depression and anxiety compared with the general population. This may be the result of treatment or an integral part of a patient's condition. Some common psychiatric problems are anxiety (especially by family members less well informed than the patients) and self-image problems, resulting from changes in a patient's appearance or how they sound or smell. Others include depression and apathy, impairment of brain function and memory, confusion, delirium and in some cases psychosis.

Pituitary Cushing's

Psychiatric problems are much more common with this condition than with adrenal Cushing's and patients may present with severe depression. Different studies suggest that between 35% and 86% of patients with pituitary Cushing's have psychiatric symptoms, suggesting that there may be links between the condition and depressive illness and that these symptoms may in fact be part of the disease process. Memory problems are quite common, cognitive impairment less so and often resolves when treated, and depressive psychosis with paranoid features may occur. If Cushing's is not treated there tends to be a poor response to antidepressant drugs but primary treatment, e.g. hypophysectomy, usually leads to complete remission of these symptoms.

Acromegaly

There have been many reports of personality changes, such as egocentricity, depression and mood swings. More careful studies suggest that the incidence of psychiatric disorder is no higher in acromegalics than in the general population with chronic illnesses, but the question of whether personality changes can be attributed to personal responses to illness or caused by the illness itself remain unanswered.

Hyperprolactinaemia

Higher levels of anxiety and depression have been recorded in women than in men, which may be explained by the interaction of Sex hormones. Patients tend to have poor responses to antidepressants and good responses to Bromocriptine treatment and surgery to reduce Prolactin levels.

Hypopituitarism

Psychiatric symptoms, depression, apathy, inertia, memory problems and cognitive impairment are all common with this condition. If the condition remains untreated there is a poor response to antidepressants but when treated with replacement therapy there is a good response and antidepressants become more effective. Hypopituitarism is not always recognised immediately as symptoms are common with many conditions and it may take months or years for a full recovery.

Diabetes Insipidus

This condition has not been associated with an increased incidence of psychiatric problems.

In assessments of psychiatric responses to treatment, high doses of bromocriptine, used to treat hypoprolactinaemia, can cause psychosis as a direct result of increased levels of dopamine in the brain. Anxiety and depression have been recorded in patients undergoing Cortisol replacement therapy and could be caused by the fixed regime of therapy. When a person with an intact Endocrine system experiences stress, they respond by producing cortisol. Patients on replacement therapy have a gap between when their bodies expect a cortisol response and when they receive their dose, possibly causing their anxiety.

There is a higher incidence of post-treatment psychiatric problems than has previously been recognised. However, health psychology and liaison psychiatry services are only available at some hospitals and are often not specialised for pituitary/chronic conditions. Many hospitals simply do not have the resources and pressure is required from patient and carer groups, as well as health care professionals, to improve these services.