Prevalence, Pathogenesis, and Diagnosis of Depressive Disorders in the Medically Ill Rodolfo Fahrer 1, Francis Creed 2 & Luigi Grassi 3 Copyright © 2011.

Prevalence, Pathogenesis, andDiagnosis of Depressive Disordersin the Medically Ill

Rodolfo Fahrer 1, Francis Creed 2 & Luigi Grassi 3

Copyright © 2011. World Psychiatric Association

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)

2 Professor of Psychological Medicine, School of Community-based Medicine, University of Manchester, UK; Editor of Journal of Psychosomatic Research

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.

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.

Copyright © 2011. World Psychiatric Association 2

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.


Strategies to improve the approachto 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.


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


Medical illness as a cause of depressive disorders

• Biological mechanisms– 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


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)


Interactions between depressive disorders and medical illness

Medications that may be associated with depressive symptoms *

* Depressive symptoms are not the same as depressive disorders.


Antiarrhythmic Drugs• Digitalis• Procainamide

Antibiotics• Amphotericin B• Cycloserine• Dapsone• Ethionamide

Anticholesterol Drugs• Cholestyramine• Statins

Antinflammatories• NSAIDs• Interferon

Anticonvulsants• Felbamate• Phenobarbitone• Vigabatrin

Antihypertensive Agents• Beta blockers (lipophilic)• Clonidine• Methyldopa• Calcium channel blockers• ACE inhibitors

8

Interactions between depressive disorders and medical illness (cont.)

Medications that may be associated with depressive symptoms *

* Depressive symptoms are not the same as depressive disorders.


Cancer Chemotherapy Agents• Asparaginase• Methotrexate• Procarbazine• Vinblastine

H2 Blockers• Cimetidine

Selective Estrogen Receptor Modulators• Tamoxifen

Lipid-Lowering Drugs• Simvastatin

Hormonal Agents (Withdrawal)• Anabolic steroids• Corticosteroids• Oral contraceptives

Psychotropic Drugs• Benzodiazepines• Neuroleptics• Methaqualone• Stimulants

9

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


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


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


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


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


Prevalence, Pathogenesis, and Diagnosis of Depressive Disorders in the Medically Ill Rodolfo Fahrer 1, Francis Creed 2 & Luigi Grassi 3 Copyright © 2011.

Documents

medical practitioners

chair of psychiatry

medical specialists

medical students

regard depression

primary care pc depression

approachto depression

school of medicine