Demoralization in the medical setting

Typical consult question “He's depressed.…but I don't know what you can do about it.” The patient, Mr. A., is a fifty year old married male with a functional gastroparesis due to a five-year course of high-volume peritoneal dialysis. The current admission was the tenth in the past year for dehydration, as the patient could not maintain adequate fluid intake because of his gastroparesis. The surgeon who requested the consultation noted, “We can't really do much for him except wait and hope he gets better. Of course, he's depressed.” Mr. A. described his struggles with nausea, vomiting, and pain and became tearful when he reflected on how long he had suffered from this disease process. However, his major complaint was the time he spent away from his wife and seven year old daughter. On a follow-up visit, he seemed surprisingly upbeat one afternoon. He gestured to his iPod and told me, “This is my antidepressant. My wife downloaded the video of our daughter's dance recital and I've been watching it all day.” Background How do we explain the above case? Individuals with physical disorders are often depressed. So why would he be so animated for a protracted time after seeing his daughter's video? The concept of demoralization may offer an answer. A challenge in identifying demoralized patients is the lack of consensus on how to define demoralization in the medically ill.