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

Medications and Depression

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)

Summary

Rule out Medical Conditions

Check Medication List

R/O substance induced disorders

Differentiate depression from neuro-vegetative signs of medical illness

Treat aggressively with medications, therapy and use alternative / complementary treatments when indicated