depression and anxiety in medical setting

7/31/2019 Depression and Anxiety in Medical Setting

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Dr P.KasiKrishnaRaja DPM DNBAsst. Professor of psychiatry

Department of PsychiatryIRT-Perundurai Medical College &

Consultant Psychiatrist-Erode

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Objectives

Epidemiology of depression and anxiety in Medicalillness

Understand the bidirectional effects Know the barriers in recognition and effects of

depression and anxiety on medical illness

Learn how to recognize depression and anxiety &

understand the treatment options

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Depression Epidemiology

Depression is estimated to affect 340 millionpeople globally

Depression is very often a chronic and recurrent

illness Earlier Indian studies have reported prevalence

rates of depression that vary from 2183% inprimary care practices

In the CURES study conducted at chennai,25,455 subjects participated in this study.

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DSM-IV Diagnostic Criteria for Major

Depressive Episode

Presence of at least 5 of the following symptomsduring the same 2-week period that is a change fromprevious functioning: Depressed mood*

Loss of interest or pleasure* Change in appetite and/or weight

Insomnia or hypersomnia

Psychomotor agitation or retardation

Fatigue or loss of energy

Feelings of worthlessness or guilt Poor concentration or indecisiveness

Suicidal ideation

* At least one of the symptoms must be present: 1) depressed mood or 2) loss of interest or pleasure.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, TextRevision. Washington, DC: American Psychiatric Association; 2000. 6


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The global burden of disease, 19902020 Lower Respiratory

Infections

Diarrheal Diseases Perinatal conditions

Depression

Heart Diseases

Cerebrovascular D/O

Heart Diseases

Depression

Traffic accidents Cerebrovascular D/O

COPD

Lower Respiratory

Infections

Lopez et al :Global burden of disease and risk factors, Oxford UniversityPress, New York (2006) 7


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Depression In Primary Care

Prevalence of Affective d/o in Medically ill patientsis twice that of General populations

Medical Disease is a risk factor itself for Depression

Rates of Depression increases with Acuity of carefrom low 9% in general population to 30% inacutely hospitalized patients

Fava: J clin Psych Primary Care Companion 2005

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Likelihood of Depression Increases with No. of

Physical Symptoms at Presentation

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0-1 2 to 3 4 to 5 6 to 8 >9

No. of Physical Symptoms

Depression

Likelihood/Percentage

Series1

Kroenke K, et al. Arch Fam Med 1994 9


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Prevalence of Psychiatric disorder

in different medical conditions

Per cent

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Are Depressed patients more likely to be

medically ill?

1500 Depressed Patientswere evaluated forGeneral MedicalConditions

Total prevalence was 53% Those with older age,

Lower income,unemployment, limited

education and longerduration of depressionwere at higher risk

Disease/ System Prevalence%

Musculo skeletal 43%

Respiratory 32%

Heart 29%

Upper GI 26%

Neurological 25%

Endocrine 24%

Yates et al, Gen Hosp Psych 2004

STAR-D Study 11


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Barriers in Diagnosing Depression in

Medically Ill Patients and families

Physicians

Diagnostic

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Barriers in Diagnosing Depression in Medically Ill

Patients and families

Patient's own belief systems, Knowledge andawareness

Too busy with medical problems Trying to act tough

Not to add burden on family

Do not want to deal with it now

Family minimizing depression

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Barriers in Diagnosing Depression in Medically Ill

Physician factors

Not aware of the pathoplastic effects of depression.

Depression is transient

Depression is secondary to underlying illness /Medications

Patient already has a diagnosis of depression or seeinga MH provider

I need to focus on medical illness first

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Barriers in Diagnosing Depression in

Medically Ill--Diagnostic issues

Overlap of depressive symptoms can be accounted formedical Illness

Negative behaviors may be considered as reaction toillness or rebellious behavior against illness

DSM IV does not give you any guidance

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Causes of Depression in Medical Illness

Psychological: Grief & loss of functioning, disabilityappearance, being a burden, Death anxiety andnarcissistic injury

Social: Financial issues, educational issues, limitedresources

Medical: Bidirectional theory i.e. one illness affectsother, Direct effects of depression on medical

illness, Is depression a common symptoms of serousmedical illness?

Iatrogenic: Medications, Restraints and wrongdoings

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Cost of Depression

Who pays for it? Patients

Families

Health Care Provider System

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Cost of Depression

to Patients Unable to cope effectively

Affects nutrition, Rx adherence, self care

More likely to have adverse reaction to medications Poor physical functioning

Increased Morbidity and mortality

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Cost of Depression

Families Increased burden

Patient being aloof from family causing more guilt andanxiety

Impaired relationship

Increased risk of violence and neglect

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Cost of Depression

Health Care Providers

More likely to order work up

Feelings of detachment

May give up early Feelings of being a failure or not doing enough

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System Increased use of resources

Increased mortality and morbidity

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Increased Use of the Resources

Simmons: Bio. Psychiatry 2003

Comorbid

Illnesses

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Bula, C. J. et al. Arch Intern Med 2001;161:2609-2615.

Average costs per day of follow-up and type of inpatient stay for subjects with depressive symptoms(Geriatric Depression Scale [GDS] >=6) vs without depressive symptoms (GDS,


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Are Depressed Patients Likely to Die Early?

Review of 57 studies showed 52% as positive, 22 %negative and 26% Neutral.

Depression increases death by natural course andCardiovascular Diseases.

Men were at higher risk

Depression does not increase the risk of death by

cancer.

Lawson: Psychosomatic Medicine 1999

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*P< 0.05

Rovner BW, et al. JAMA. 1991;265:993-996.

29.8%

47.4%

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Depressive Disorder No Depressive Disorder

Deaths(%)

n = 57 n = 315

Depression: 1-Year Mortality in

Nursing Home Patients

*

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Depression and Coronary Artery Disease

Depression (Barefoot and Schroll 1996; Ford et al.1998;Lett et al. 2004) and anxiety (Strik et al. 2003) appearto be independent risk factors for the development ofcoronary artery disease.

Subsyndromal depressive symptoms also correlatewith an increased risk of cardiovascular mortality(Frasure-Smith et al.1995).

Even more impressively, negative mood appears to

predict long-term cardiac-related mortality followingmyocardial infarction (MI), independently of cardiacdisease severity (Frasure-Smith and Lesperance 2003a,2003b).

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Prevalence of Depression is Higher

%

Jiang et al AM J Heart 2005

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Pathophysiology of Depression in CAD

Social, Behavioral causes (lifestyle, compliance,smoking, other risks)

Biological: Depression causes increased HPA activationleading to increased Cortisol

Depression lowers heart rate variability due toincreased sympathetic tone

Depression plays a role in subacute inflammatoryprocess : CRP and IL-6

Common link of 3 Omega FA in Depression and CAD

Depression causes platelet activation and aggregation

Jiang et al AM J Heart 2005

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Can Depression in Early Life Lead to CAD?

Most studies sayyes

Ford studied Depression in Medical students for26 years. Study showed that those who were

depressed at some point did have a up to two foldhigher risk of later CAD

In ECA study after 13 years those with depression

had 4.5 times higher risk of developing heartattack. Worse. even those with minor depressionhad same risk.

Ford DE: Arch. Int. Med 1998

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D i d I h i H t Di M t lit E id


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Depression and Ischemic Heart Disease Mortality: Evidence

From the EPIC-Norfolk United Kingdom Prospective Cohort

Study?

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During a total follow-up of 162,974 person-years (the medianfollow-up periodwas 8.5 years), there were 274 deaths fromIHD.

12-month major depression was associatedwith an increased risk of IHDmortality (2=13.2, df=1, p=0.0003,after adjustment for age and sex)

participants who reported an episode of major depression within12 months ofassessment were 2.7 times more likely to die fromIHD over the 8.5-year follow-up period.

a trend in association according to recency of major depression,such that noassociation was observed for episodes that were experienced more than 12months before assessment

a stronger association was

observed for those who reported three or moreepisodes

the association was stronger for participantswho reported episodes of majordepression that lasted on average6 months or more


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Can Depression Cause

Diabetes? Meta-analysis# studies N (est) F/U OR

Knoll 9 173,000 3-16 1.37

Casgrove 11 282,000 3-15.6 1.25

Mezuk 13 6,916 3-15.6 1.60

Knoll et al : Diabetologica 2006Casgrove et al :Occu. Med 2008Mezuc : Diabetes care 2008

Findings varies depending on selectioncriteria, self report vs. exam, medicationsused, sample size

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Can Diabetes Cause Depression?

Kovacs et al (Diabetes care 1997) followed youthswith DM I for 10 years, 27.5% developed depression

Gavard et al (Diabetes care 1993) did the review of 20studies and came to conclusion that prevalence of

depression in diabetics range from 8.5% to 27.3%Anderson et al (Diabetes care 2001) meta-analysis of

21,351 patients . They found that 11% prevalence of

Major Depression (OR=2.0

) among diabetics andprevalence of clinical relevant depression at 31% indiabetics.

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Depression and Diabetes Poor glycemic control

Increased functional disability

Increased cost of care Poor adherence and control

Increased complications

2.5 times likely to die in 8year f/u study

Gonzales 2008; Edege 2001, Edege 2006; Lustman 2000, Groote, 2001,Edege 2005

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Obesity and Depression

20 % of obese boys and 30% of girls havedepression

Recent meta-analysis showed bidirectionalincreased OR of around 1.5 for both obesity and

depression Often weight loss leads to improvement in

mood, at the same time people who undergogastric bypass have higher rates of depression

Antidepressants are known to cause weight gain

Stunkard : Biol. Psych 2003

Luppino : Arch Gen Psych 2010

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Triad of Death

Diabetes

CADDepression

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Depression and CVA

Depression rates vary from 15-35% but latestmeta-analysis estimates it to be between 15-20%

L side lesions can cause Depression and Rsubcorticle more likely to cause Mania

Depressed patients are 2.5 times likely to have aCVA in their life time

Diagnosis is difficult

AD, Stimulants and ECT shows effectiveness

One study showed that SSRI can preventdepression

Evans Biol Psych 2005

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Dementia and Parkinsons Disease

Prevalence is 30-50% in Dementia. Rates

depends upon severity, settings and methods Prevalence in Parkinsons 25-40%

Studies show bidirectional effects i.e. earlyDepression an independent risk factor forcognitive decline.

Treatment is difficult due to side effects andexacerbation of underlying illness

ECT has been used effectively in Parkinson'sand Epilepsy patients

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Depression and Cancer

Likelihood of Depression is 4 times greater and Suicides

rates are twice than that in general population Depression was unrecognized in 50% of hospitalized

cancer patients

Rates of Depression are higher in pancreatic, ENT andBreast cancer

Depressed patients followed for 13 years showed higherincidence of breast cancer but not of other types.

When present for at least 6 years, depression wasassociated with a generally increased risk (RR : 1.88) of

cancer in elderly (Penninx, JNCI 1998) 5/10 studies show positive effects of psychotherapy and

survival ratesDavid Spiegel Biol Psych 2003

Netzel Womans Health Psych 2006

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HIV d D i


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HIV and Depression Rates of depression are two times higher

More in female than male Depression is associated with poor adherence to

treatment and rapid progression of illness Depression might even affect HIV entry &

replication increasing the risk for infection Changes in functioning of Killer Lymphocytes in

depressed patients lead to delaying of symptomspresentations and lowering the CD4 count.

Treatments are effective but drug interactions andchanges in antiviral treatments createscomplications

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Chronic Pain and Depression


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Chronic Pain and Depression

30-40 % have Depression

Pain is closely associated with social stress, monetarygain, personality, and past h/o abuse

These patients are at higher risk for substancedependence

Fibromyalgia and Depression have comorbidity of up to70%

Suicide rates are higher in this population especially ifthey have cancer

Fishbain 1997,1999: Ann Med

Lynch 2001 Jr Psych Neuroscience 41


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Challenges in Diagnosis of Depression Inclusive approach

Exclusive approach

Vegetative vs. Psychological symptoms Scales

Structured Psychiatric Interview

Limitations of DSM IV

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Challenges in Diagnosis of Depression


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Challenges in Diagnosis of Depression

How to make a correct Diagnosis in shortest

period of time?

Are you depressed?

Look for irritability, refusal,sudden mood changes andlack of interest

Hopelessness andSuicidality are not thenorms.

Chochinov: Am J Psych 1997

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Treatment Issues

Be aware

Do not justify and just put the patients shoes bythinking what if I was in this patients situation Iwould.Ask patient, families, nurses and other care givers

Keep your eyes and ears open for risk factors

Give time empathy and show compassion itgives patients opportunity to open up

Yes, It is your job. Depression is part of the severemedical illness.

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Treatment Principles

Watch for risk factors

Consider current medical conditions,

side effects, Medications, social situations andfinances while considering an antidepressant

Continue to evaluate as just starting medicationswill help in only 40% of cases

Get patient some help through social services orcounseling

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Selection of Antidepressants

Select AD based on the co-morbidities likeOCD, Panics, pain,

Anxiety: Paroxetine, Sertraline, EscitalopramWt. Loss: Mirtazepine, TCA, QuetiapineWt. Gain/ Fatigue: Buproprion, Fluoxetine,

Stimulants

Pain: TCA, Duloxetine Fatigue, somnolence: Stimulants for short timeNausea/Vomiting: Mirtazepine, Escitalopram

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Antidepressants classification

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TCA

amitryptylline,imipramine,triimipramine,dosulupine,nortryptylline etc..

SSRIsserrtraline,escitalopram,fluoxetine,fluoxamine,paroxetine,citalopram

SDRIsbupropion

SARIstrazadone,nefazadone

SNRIsvenlafaxine,des-venlafaxine,duloxetine,

SSNRIsmilnacipran

NaSSAmirtazapine

RIMAmoclobemide,broforomine

MAOItranylcypramine,phenelzine

NARI--reboxetine


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Serotonin is released from platelets in response to vascular injury and promotesvasoconstriction and morphological changes in platelets that lead to Aggregation.

Serotonin is a relatively weak platelet aggregator on its own:the presence ofepinephrine, collagen and adenosine diphosphate are required for effective clotting.

Platelets cannot synthesize serotonin

it is taken up by active transport. Selectiveserotonin reuptake inhibitors (SSRIs) inhibit the serotonin transporter, which is

responsible for the uptake of serotonin into platelets.

It might thus be predicted that SSRIs will deplete platelet serotonin, leading to areduced ability to form clots and a subsequent increase in the risk of bleeding.


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Hyponatremia and antidepressants

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Medications that may Cause Depression

Culpepper L: J Clin Psych & Primary care Companion

2005 59

AlcoholAnticonvulsants .BarbituratesBenzodiazepinesBeta-adrenergic blockers

Bromocriptine (Parlodel)Calcium-channel blockersChemotherapeutic agentsAntabuse drugsEstrogensStatins

Interferon alfaNarcoticsNorplant
http://www.medicinenet.com/script/main/art.asp?articlekey=43955http://www.medicinenet.com/script/main/art.asp?articlekey=45293http://www.medicinenet.com/script/main/art.asp?articlekey=43882http://www.medicinenet.com/script/main/art.asp?articlekey=45311http://www.medicinenet.com/script/main/art.asp?articlekey=18510http://www.medicinenet.com/script/main/art.asp?articlekey=9724http://www.medicinenet.com/script/main/art.asp?articlekey=23586http://www.medicinenet.com/script/main/art.asp?articlekey=44991http://www.medicinenet.com/script/main/art.asp?articlekey=44991http://www.medicinenet.com/script/main/art.asp?articlekey=23586http://www.medicinenet.com/script/main/art.asp?articlekey=9724http://www.medicinenet.com/script/main/art.asp?articlekey=18510http://www.medicinenet.com/script/main/art.asp?articlekey=45311http://www.medicinenet.com/script/main/art.asp?articlekey=43882http://www.medicinenet.com/script/main/art.asp?articlekey=45293http://www.medicinenet.com/script/main/art.asp?articlekey=43955


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Selection of Antidepressants

Drug Interaction: Watch for Cytochrome P 450

More likely: Fluoxetine, Paroxetine and Fluvoxamine

In-between: Sertraline, Citalopram, Duloxetine

Less Likely: Escitalopram, Desvenlafaxine, Buproprion

Risky: TCA and MAOI

Suicidal patients : Do not choose TCA , bring them

back early, give small supply under supervision Renal Damage: do not choose Desvenlafaxin

Watch out for serotonin syndrome

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Psychosocial Aspects

Spend Time to Know your patients Make them an informed client and a partner in

treatment Refer to a therapist for issues like guilt, anger, poor

coping, relationship problems,sucidal ideation. Refer to social workers and support services for

help reg: living, home health, job, Insuranceissues, Food stamps.

Watch for familys mental health and always ask:How are you holding/coping it?

Use humor but wisely.

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M di l E i d


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Medical Environment and

anxiety Separated from familiar surroundings

Unfamiliar health care professionals ask a series ofpersonal questions and perform physical examinations

that include uncomfortable and embarrassing probingof orifices.

Simple issues such as cold rooms can enhance anxiety.

needle phobia appearing when blood is drawn. sense of confinement causing an anxiety reaction

during imaging studies, phobic reactions and anxietyare quite common during a medical workup.

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Contd.. If a disease is identified during Gnostic process, it is almost always perceived as

a threat (Imboden and Wise 1984). The patient usually views serious illness as apotential loss. The most basic fear is loss of life.

An individual with a myocardial infarction may find his or her career hopesdashed as a result of the stigma of disease.

A young mother with breast cancer may fear that she will never live to see her

children fully grown.

The coronary care unit (CCU) is a specific medical environment where anxietycan predominate and be a burden to patient recovery.

A patient who is very anxious may constantly call a nurse/doctor shop forreassurance. Anxiety will certainly augment such cravings unless treated.

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Cardiac Disease and Anxiety Oslers descriptions of early-onset angina mayrepresent the first attempt at defining what we havecome to know as type A behavior (Friedman and

Rosenman 1974).Another early observer of the hearts connection to

anxiety was Jacob Mendes DaCosta, who reported oncardiac symptoms of Civil War soldiers for which he

could not identify objective cardiac findings.DaCostas syndrome was further elaborated by SirWilliam Lewis (1918) during World War I, when hecoined the term effort syndrome.

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Contd.. Patients with cardiac symptoms such as chest pain

who have no objective cardiac findings on angiographyhave a high prevalence (between 43% and 61%) of

panic disorder (Beitman et al. 1987; Katon et al. 1988;Zinbarg et al. 1994)

Panic attacks have been demonstrated to impairmyocardial perfusion in patients with cardiac disease,

even when antiarrhythmic cardiac medication isadministered (Fleet et al. 2005).

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Contd.. Other psychophysiological theories have revolved

around the issue of panic disorder and mitral valveprolapse.

Originally, it was thought that because these twodiseases share similar clinical symptoms, demographicfeatures, and prevalence within the generalpopulation, the two may be subsumed within a single

classification of mitral valve prolapse syndrome(Pariser et al. 1978; Savage et al. 1983a; Wooley 1976).

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Medical conditions mimicking or directly resulting ini t


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anxiety

Poor pain controlSuch as ischaemic heart disease, malignantinfiltration

Anaemia

HypoxiaMay be episodic in both asthma and pulmonaryembolus

Hypoglycaemia Hypocapnia-May be due to occult bronchial hyperreactivity

Hyperkalaemia

Central nervous system disorders (structural or epileptic)

Alcohol or drug withdrawal Vertigo

Thyrotoxicosis

Hypercapnia

Hyponatraemia 69


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depression and anxiety in medical setting

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