Download Prevalence, Pathogenesis, and Diagnosis of Depressive Disorders

Prevalence, Pathogenesis, and
Diagnosis of Depressive Disorders
in the Medically Ill
Rodolfo Fahrer 1, Francis Creed 2
& Luigi Grassi 3
1 Emeritus Professor, School of Medicine, University of Buenos Aires. Academician of the National Academy of Medicine, Buenos Aires.
Chair of the Department of Psychiatry FLENI. Founder and previous Chair of the WPA Section on Psychiatry, Medicine and Primary Care.
2 Professor of Psychological Medicine, School of Community-based Medicine, University of Manchester, UK; Editor of Journal of
Psychosomatic Research
3 Professor and Chair of Psychiatry, University of Ferrara, Italy; Chair WPA Section on Psycho-Oncology and Palliative Care; Chair IPOS
Federation Psycho-Oncology Societies; Past-President International Psycho-Oncology Society (IPOS)
Copyright © 2011. World Psychiatric Association
The importance of depression in
the medically ill
• Among the most frequent conditions seen in primary care (PC); depression is
more common [22%-33%] in medically ill
• Associated with impairment of patients’ QoL, functional status, and, possibly,
poorer prognosis of medical illness
• Often inadequately managed in PC
– Patients may present with somatic symptoms, which are wrongly attributed to
medical illness. This reduces chance of adequate treatment of the depression.
– General practitioners may have negative attitudes towards mental health
problems, regard depression as “understandable” reaction to medical illness and
feel treatment is not merited.
– They may hesitate to prescribe antidepressants to patients with medical illness,
who take other medications.
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Strategies to improve the approach to depression in
the medically ill
1. Improve and encourage teaching of psychiatry to primary care physicians,
other medical specialists, medical students, and other health workers.
2. Promote methods of observation and training in psychological skills and
techniques enabling physicians to gain a more holistic understanding of
patients with medical illness.
3. Provide improved opportunities for all medical practitioners to acquire a basic
background in psychiatry and a better understanding of the relationship
between physical and psychological disorders.
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Strategies to improve the approach
to depression in the medically ill (cont.)
4. Encourage a more integrative, multidisciplinary teamwork approach to
research, training, and patient care.
5. Develop preventive and therapeutic resources within communities to address
individual, family, and/or group crises.
6. Promote research and teaching concerning diagnostic and therapeutic
methods that can be used in family disturbances and place more emphasis
on the role of the family in promoting mental health in the community.
7. Provide solutions to help clinicians overcome problems in doctor-patient
relationships caused by insurance and prepaid healthcare systems.
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Possible situations in medically ill with depression
1. Medical illness is a risk factor for developing a depressive disorder
2. Depressive disorder may be a risk factor for developing a medical illness
(e.g. heart disease)
3. The medical illness and the depressive disorder may share genetic and/or
environmental risk factors
4. The two disorders may have developed independently of each other
5. With regard to outcome, the effect of the two disorders is additive
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Medical illness as a cause of depressive disorders
• Biological mechanisms
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Impairment of neurochemical pathways and structures that modulate mood states
Endogenous cytokines and compromised immune function
Effects on neurotransmitters
Genetic factors
Disturbances in endocrine function
• Psychological mechanisms
– Onset of physical illness is a negative life event
– Impact of illness/disability on the patient’s mood & self-esteem
– Social support may be reduced
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Depressive disorders as a possible cause of
medical illness
• Depression can be a factor facilitating the onset of physical illness in different
ways:
– Immunological mechanisms: decreased natural killer cell activity or other
physiological changes (eg., hypercortisolemia) may act as an immunosuppressant
– Self-neglect and suicide attempts may have physical consequences and/or
worsen medical illness
– Unhealthy bahaviours (smoking or alcohol use)  medical illness
– Treatment for the depressive disorder itself may cause medical problems (e.g.,
hepatic or cardiac dysfunction)
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Interactions between depressive disorders and
medical illness
Medications that may be associated with depressive symptoms *
Antiarrhythmic Drugs
Antibiotics
• Digitalis
• Procainamide
• Amphotericin B
• Cycloserine
• Dapsone
• Ethionamide
Anticholesterol Drugs
Antinflammatories
• Cholestyramine
• Statins
• NSAIDs
• Interferon
Anticonvulsants
Antihypertensive Agents
• Felbamate
• Phenobarbitone
• Vigabatrin
• Beta blockers (lipophilic)
• Clonidine
• Methyldopa
• Calcium channel blockers
• ACE inhibitors
* Depressive symptoms are not the same as depressive disorders.
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Interactions between depressive disorders and
medical illness (cont.)
Medications that may be associated with depressive symptoms *
Cancer Chemotherapy Agents
H2 Blockers
• Asparaginase
• Methotrexate
• Procarbazine
• Vinblastine
• Cimetidine
Selective Estrogen Receptor
Modulators
Lipid-Lowering Drugs
• Simvastatin
• Tamoxifen
Hormonal Agents (Withdrawal)
Psychotropic Drugs
• Anabolic steroids
• Corticosteroids
• Oral contraceptives
• Benzodiazepines
• Neuroleptics
• Methaqualone
• Stimulants
* Depressive symptoms are not the same as depressive disorders.
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Variables suggesting a depressive disorder in the
medically ill
• Typical psychological or somatic symptoms of depressive disorder, including
self-blaming, suicidal ideation
• Family history of a) mood disorder or b) suicide/suicide attempt
• Previous a) depressive episodes/good response to antidepressants in the
past; or b) manic or hypomanic episodes; or c) suicide attempt(s)
• History of alcoholism or alcohol/substance abuse
• Seasonal variation and/or diurnal variation of depressive symptoms that do
not parallel those of the medical illness
• Worsening of pain/disability or onset of negative attitude to outcome/ refusal
to adhere to medical regimen
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Obstacles to diagnosis
• Medical symptomatology: many symptoms (e.g., fatigue, loss of appetite)
may be common to both
• Denial: depression may be not reported, or suppressed or downplayed on
family’s demand to have an optimistic atmosphere
• Somatisation: Mood can be described in somatic terms.
• Tacit collusion: discussion of depressive symptoms is perceived as being
uncomfortable, stigmatising, too time consuming, or minimized while
attention focused on the medical illness
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Non-drug therapy
• Cognitive-behavioural or interpersonal therapy for patients with mild to
moderate non-psychotic nonsuicidal depressive disorders (alone or in
combination with psychotropic drugs)
• Light (photo) therapy in seasonal affective disorders (alone or combination
with antidepressants)
• ECT when the general medical and cardiovascular condition of the patient
does not contra-indicate use of brief narcosis and muscle relaxation
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When Is referral appropriate?
• Patient seriously depressed and suffering from severe depressive disorder
(e.g. major depression), or psychotic depression and/or presents with
suicidal ideas
• Advice regarding the use of psychotropic medications
• Depressive disorder resistant to antidepressant treatment
• Serious impairment of social functioning
• Patient with a history of sexual abuse or other major trauma
• Patient being treated for another psychiatric disorder,
• Patient not responding to treatment after 4-6 weeks,or a change of ADs,
polypharmacy, or ECT may be needed
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Conclusions
• Depressive symptoms are common in the medically ill
• The likelihood of depressive disorders developing in this population will
increase as life expectancy increases
• Depression co-occurring with medical illness may increase psychosocial
impairment and impair adherence to medical treatment and rehabilitation
• Suicide rates higher among the physically ill than general population (e.g.,
end-stage renal disease, cancer, AIDS)
• Depression in the physically ill can and must be treated whenever it is
diagnosed
• Postponing treatment worsens the prognosis of both the physical illness and
the depressive disorder
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