Post on 22-Jan-2018
Depression in the Medically Ill
David Straker, D.O., FAPA, FAPM Attending C-L PsychiatryPsychosomatic Medicine Fellowship DirectorNorth Shore-Long Island Jewish Medical Center Attending C-L Psychiatrist, Columbia University Medical Center, Lenox Hill Hospital
Key Points
Many patients are “depressed”. May be an Adjustment disorder or “minor depression”
Often patients in ICU look depressed and actually have hypoactive delirium
Antidepressants take time to work
Rule out Medical Conditions / Drug Induced / Substance Induced
Does patient need a Psych Consult
Does patient need a 1:1
Suicide Assessment
Suicidal ideation, intent or plan
Prior suicide attempts
Command Auditory Hallucinations
Anxiety (psychic), insomnia, panic attacks, Hopelessness
Access to firearms
Chronic Pain
Family History of Suicide
Over 45 years of age
Male, divorced or widowed, unemployed
Substance Use
Borderline Personality Disorder
Treatment of Depression
Discontinue meds that may cause depression
Treat Medical Conditions that cause depression
First Line SSRI’s
Atypical antidepressants
TCA’s / MAO Inhibitors
Combination of Antidepressant Agents : receptors
Augmentation : Lithium / Thyroid
Stimulants – work fast
Electroconvulsive Therapy (ECT)
Folic Acid (Deplin), Vitamin B12
Medical Conditions
Coronary Artery Disease
Cancer
Stroke
Other Neurological Disorders
Hypothyroidism
Diabetes
Coronary Artery Disease
16-23% depressed
Depression is an independent predictor of morbidity and mortality following the onset of CAD
Increased risk of coronary events in patients who are depressed
Higher incidence of depression in patients with CHF, post-MI, post CABG, and post angioplasty
SADHART and ENRICHD trials: modest effects noted. Sertraline safe, but little positive effects on heart. ENRICHD – CBT and social support
Cancer
10-30% prevalence of major and minor depression
Pancreatic #1
Medications: interferon, interleukin, corticosteroids, and vinca alkaloids (vincristine and vinblastine)
Very difficult to distinguish from medical illness (especially fatigue, anorexia)
Neurological Disease
Parkinson’s Disease
Poststroke Depression
Dementia’s
Epilepsy
Multiple sclerosis
Huntington’s Disease
Parkinson’s Disease
50% prevalence of depressive symptoms
Often dysthymic disorder and minor depression rather than MDD
Levo-dopa can cause depression
Very difficult to distinguish from core features of the illness itself. BDI is helpful
Post-Stroke Depression
Major depression ranges from 19.3% (inpatient) to 23.3% (ambulatory)
? Associated with lesions in the left anterior and left basal ganglia regions, although recent meta-analysis failed to show this
Evidence for TCA (nortriptyline) and SSRI (celexa) as treatment
Cardiovascular morbidity and mortality may be reduced with the use of SSRI’s
Dementia
Significant co-morbidity with major depression
20-32% prevalence of MDD in dementia patients
Treatment appears to have minimal positive effects
Epilepsy
20-55% of patients with recurrent seizures but only 3-9% of those with well controlled seizures have major depression
Patients with Complex Partial Seizures have 17x prevalence of MDD than general population
Avoid wellbutrin, maprotiline, and amoxapine as greater risk of seizures
Phenobarbital and keppra can cause depression
Other Neurological Disorders
Multiple sclerosis: up to 50% of patients and those on interferon (40% of patients). Often during an acute exacerbation or as part of chronic progressive course
Huntington’s Disease: MDD in up to 32% of patients
Endocrine Disorders
Diabetes: 2x as common as the general population; often effects the illness, compliance, etc.
Hypothyroidism: leads to depression In patients who are depressed check TSH. Also those on lithium who get depressed; check thyroid
Medications and Depression
See Table
Mostly dose related, but as with interferon at normal doses it is seen
Most common: Accutane, Steroids, Interferon, ? Beta Blockers, and Anticonvulsants
Psychopharmacologic Management
SSRI’s
TCA’s
Other Novel antidepressants
Augmenting Agents
Herbal Meds / Vitamins
SSRI’s
Watch p450 interactions Sedating (paxil) vs. activating (prozac) Paxil – 2D6 Prozac – 2D6 and 2C9/19 Zoloft (high doses) – 2D6 and 2C19 / 3A4 (less) Luvox – 1A2 and 3A4 Lexapro and celexa: minimal to no drug interactions Zoloft: most dopaminergic and highest incidence of diarrhea Paxil inhibits its own metabolism and is the most
anticholinergic of the SSRI’s 4-6 weeks to work
Rare, but Noteworthy Side Effects of Antidepressants
Hyponatremia – SSRI’s (elderly)
Bleeding / Surgery
QTc prolongation – Citalopram, TCA’s
Seizures - Wellbutrin
Liver Dysfunction – nefazodone, duloxetine
Serotonin Syndrome
Other Psychotropics
Bupropion: Activating, work faster? / seizure risk Mirtazapine: good for sleep, helps appetite, helps nausea
(cancer pt.). Comes in dissolvable tablet Venlafaxine: caution with HTN, withdrawal Trazadone: orthostasis. Good for sleep Duloxetine: liver issues (rare) Lamictal: mood stabilizer, good anti-depressant effect.
Chewable tablets. Rash / SJS (rare) Seroquel: approved as augmenting agent Abilify: approved as augmenting agent. Dissolvable TCA’s: co-morbid pain. Side effects problematic, cardiac (QTc) Citalopram: QTc prolonged at high doses
Augmenting Agents
Standard therapy : Lithium, thyroid (T3), pindolol, buspirone
Stimulants (anergic with SSRI’s)
Opiates?
Atypical Antipsychotics (prior slide)
Stimulants
Methylphenidate (2.5 mg to 10mg often in divided doses given early in the day): increase energy, appetite, and elevate mood
Dexedrine, Modafanil (Provigil), etc.
Atypical / retarded depression
Fast onset of action
Stroke, HIV, and Cancer
Mild, dose related side effects are agitation, naseau, and insomnia. Tachycardia, psychosis and hypertension may occur but are rare.
Herbal Medicines and Vitamins
St. John’s Wort
Valerian Root
SAME’s
Omega 3 Fatty Acids
Vitamins: Folic Acid and Vitamin B12
Folate and B12
Should be checked in depressed patients Folic Acid extensively studied since 1940’s and
implicated in depression Low serum blood levels of folate detected in 15 –
38% of adults diagnosed with depressive disorders Study showed enhancement of antidepressant
effect by folic acid (fluoxetine) in a randomized placebo controlled trial vs fluoxetine alone (Coppen JAD 60, 121-130 2000)
Deplin (L-methyl folate) 15 mg a day Vitamin B12 also implicated and should be
measured especially in treatment refractive patients
Other Treatments
Electromagnetic Stimulation (Transcranial MS)
Vagal Nerve Stimulation
ECT (“shock therapy”)
CES (Cranial Electrical Stimulator)
Psychotherapy
Supportive
Psychodynamic
Cognitive Behavioral Therapy
Brief Psychotherapy (at the bedside)