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Medicine Conference - Depression
1. Depression
in the Medically Ill
David Straker, D.O., FAPA, FAPM
Attending C-L Psychiatry
Psychosomatic Medicine Fellowship Director
North Shore-Long Island Jewish Medical Center
Attending C-L Psychiatrist,
Columbia University Medical Center, Lenox Hill Hospital
2. 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
3. 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
4. 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
5. Medical Conditions
Coronary Artery Disease
Cancer
Stroke
Other Neurological Disorders
Hypothyroidism
Diabetes
6. 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
7. 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)
9. 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
10. 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
11. Dementia
Significant co-morbidity with major
depression
20-32% prevalence of MDD in
dementia patients
Treatment appears to have minimal
positive effects
12. 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
13. 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
14. 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
15. 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
18. 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
19. 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
20. 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
22. 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.
23. Herbal Medicines and
Vitamins
St. John’s Wort
Valerian Root
SAME’s
Omega 3 Fatty Acids
Vitamins: Folic Acid and Vitamin B12
24. 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
27. 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