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I am male 50years old. About six months ago I started to get back and chest pains. I was tested extensively for heart disease and all tests were negative. But the pain in the chest has persisted. It has reduced but just when I think the worst is over it comes back. It is very debilitating and the doctors cannot give a good explanation.

For the last few months I have lost interest in everything. Every afternoon between 3 and 6pm I feel very depressed and extremly sad, almost in tears. I also have anxiety when the chest pain returns. I feel okay in the evenings. I have been taking St Johns Wort for about a month but that has not helped. Can you please offer an explanation and suggest treatment?

Answered by: Jonathan W. Stewart

It is unusual for depressive illness to first present as pain and only later for low mood and its attendant symptoms to surface. Therefore, it was appropriate for this man to first be worked up for a physical cause. Even though none was found, I would still worry that something was missed. Pancreatic cancer, for example, can present with pain and depression but be difficult to diagnose initially. This is not to say that this man has pancreatic cancer, but more to say it is still possible that his symptoms have a physical cause. Poor thyroid function is another physical cause of depression, though not commonly associated with pain. So, I would first consider a new look at possible physical causes. Assuming the pain and depression are not both symptoms of a physical disorder, a complete psychiatric evaluation is the next step. At this evaluation, the psychiatrist will make a psychiatric diagnosis and suggest possible treatments. Because of the prominent pain, I would recommend a psychiatrist with experience diagnosing psychiatric disorders in medically ill patients, such as one who regularly consults on patients hospitalized for medical or surgical problems.