Depression is common in medically ill patients and can be caused by medical conditions, medications, or substances. It is important to rule out these potential causes and differentiate depression from symptoms of the underlying illness. Treatment involves addressing any contributing factors, using antidepressants such as SSRIs, and providing psychotherapy. Combining medications, therapies, and alternative treatments can effectively treat depression in medically ill patients.

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)

8. Neurological Disease
 Parkinson’s Disease
 Poststroke Depression
 Dementia’s
 Epilepsy
 Multiple sclerosis
 Huntington’s Disease

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

16. Medications and Depression

17. Psychopharmacologic
Management
 SSRI’s
 TCA’s
 Other Novel antidepressants
 Augmenting Agents
 Herbal Meds / Vitamins

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

21. Augmenting Agents
 Standard therapy : Lithium, thyroid
(T3), pindolol, buspirone
 Stimulants (anergic with SSRI’s)
 Opiates?
 Atypical Antipsychotics (prior slide)

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

25. Other Treatments
 Electromagnetic Stimulation
(Transcranial MS)
 Vagal Nerve Stimulation
 ECT (“shock therapy”)
 CES (Cranial Electrical Stimulator)

26. Psychotherapy
 Supportive
 Psychodynamic
 Cognitive Behavioral Therapy
 Brief Psychotherapy (at the bedside)

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