SIN04 - Treatment of Depression In Neurological Disease An Evidence Based Approach (Sept 2004)
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Depression is common in many neurological and medical conditions. It can influence outcomes and prognosis. Treatment requires consideration of issues specific to each condition such as effects on symptoms, cognition, rehabilitation, and mortality. While evidence is limited, antidepressants may benefit conditions like stroke, Parkinson's disease, and multiple sclerosis when used carefully. Future research needs to further evaluate treatments and their impact on overall physical health and quality of life outcomes.
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SIN04 - Treatment of Depression In Neurological Disease An Evidence Based Approach (Sept 2004)
- 1. Alex Mitchell Leicester (UK) Alex Mitchell Leicester (UK) XXXV SIN - Genova, Italy, 2004XXXV SIN - Genova, Italy, 2004Alex.mitchell@leicspart.nhs.uk
- 2. • In Neurology Markus Reuber (Sheffield) Julian Benito-Leon (Madrid) • In Psychiatry RHS Mindham (Leeds) Trevor Friedman (Leicester) Harald Hampel (Munich) Pratibha Nirodi (Harrogate)
- 3. • Part I – Key Issues Features Recognition Aetiology • Part II – Depression in Specific Conditions Background Evidence and guidelines Special issues
- 5. Depressione Apathy Irritability & Anger Mania & Hypomania Emotionalism Dysthymia & Chronic Depression Sub-syndromal Depression Brief Reactive Depression Anxiety
- 6. Depressione Apathy Irritability & Anger Mania & Hypomania Emotionalism Dysthymia & Chronic Depression Sub-syndromal Depression Brief Reactive Depression Anxiety Demenze Morte RISK
- 7. Depression Parkinson’s Disease Cancer Motor System Psychomotor Retardation Bradykinesia Retardation Reduced Blink Rate Mask-like Facies Cachexia Stooped Posture Shuffling Gait Variable Somatic Reduced Energy Reduced Energy Reduced Energy Fatigue Fatigue Fatigue Sleep Disturbance Sleep Disturbance Sleep Disturbance Weight Loss Variable Weight Loss Psychological Loss of Interest Variable Variable Poor Motivation Poor Motivation? Variable Indecisiveness Indecisiveness Variable Cognitive Poor Concentration Poor Concentration Poor Concentration Executive Deficits Executive Deficits Variable Depressive Pseudodementia Parkinson’s Dementia Variable
- 8. Symptoms in Primary vs Post-Stroke DepressionSymptoms in Primary vs Post-Stroke Depression Symptom Clusters in 43 patients with PSD & 43 patients with functional depression Lipsey JR et al. (1986) Am. J. Psychiatry 143: 527
- 10. Common Neurological PresentationsCommon Neurological Presentations • Headache • Alzheimer’s disease • Epilepsy • Tremor • Chronic Fatigue • Multiple Sclerosis • Parkinson’s disease • Head Injury • Stroke / Cerebrovascular disease • After Warlow 2001
- 11. Common Neurological PresentationsCommon Neurological Presentations • Headache • Alzheimer’s disease • Epilepsy • Tremor • Chronic Fatigue • Multiple Sclerosis • Parkinson’s disease • Head Injury • Stroke / Cerebrovascular disease After Warlow 2001
- 12. CNS Disorder Depression (all types) Cognitive Deficits Dementia Psychosis Alcohol 15% 80% 15% 5% Epilepsy 20% Unknown rare 5% Alzheimer’s disease 30% 100% 100% 30% Head Injury 35% 3% Unknown 3% HIV dementia 25% 40% 25% 6% Huntington’s Disease 25% 40% Unknown 8% Multiple Sclerosis 50% 50% 5% 10% Parkinson’s Disease 50% 80% 30% 20% Stroke 50% 50% 20% 5% Subarachnoid Haemorrhage 20% 30% Unknown Unknown Normal Control 10% 5% 2% 1%
- 16. Comorbidity Hypertension PostPost--StrokeStroke DepressionDepression Risk Factors Precipitants Cardiovascular Anomaly Degenerative Change Trauma SmokingLipids &Diet CriticalCritical AnatomicalAnatomical LesionLesion Exercise Social
- 17. Comorbidity Hypertension PostPost--StrokeStroke DepressionDepression Neuromodulators Anterior Frontal lobe Medial Temporal lobe Basal Ganglia Risk Factors Precipitants Cardiovascular Anomaly Functional Disability Pre-Existing Vulnerability Final CommonFinal Common PathwayPathway Degenerative Change Trauma SmokingLipids &Diet Neurobiological Markers Neurological Impairment Neurophysiology Neurotransmitters Neuroendocrinology Handicap (Quality of Life) CriticalCritical AnatomicalAnatomical LesionLesion Social Support Life Events Coping Style Exercise Social Vicious Circle
- 18. Treatment of Post-Stroke DepressionTreatment of Post-Stroke Depression Special Issues • Ischaemic vs Haemorrhagic Stroke SSRIs • Influence on rehabilitation NA vs Serotonin • Influence on Mortality Antidepressants Olanzapine and risperidone (Pettenati – XXXV SIN) Individual Studies • Placebo Controlled Lipsey (1984) n = 34 Reding et al (1986) n= 27 Andersen et al (1994) n=66 Grade et al (1998) n = 21 • Head-to-Head Lauritzen et al (1994) n = 20 Dam et al (1996) n =52 Robinson et al (2000) n = 56 Jorge et al (2003) n=104
- 19. Jorge et al (2003) Am J Psychiatry N=104; 9 year follow up Nortriptyline, fluoxetine, placebo (RCT
- 20. Depression and Prognosis of StrokeDepression and Prognosis of Stroke 626 Patients completed CES-D at one week post stroke Depression, age, medical illness & weakness correlated with functional outcome J Neuropsychiatr Clin Neurosci 10, 26-33. In 60 post-stroke rehabilitation patients, fluoxetine improved neurological deficits at 3months compared with placebo and maprotiline Stroke 27, 1211-1214. In 91 stroke patients, depressed vs non-depressed were twice as likely to die over the next 10 years. Am J Psychiatr 150, 124-129.
- 24. Treatment of Depression in EpilepsyTreatment of Depression in Epilepsy Special Issues • Seizure Threshold MAOIs Low Dose TCAs SSRIs ECT ! Individual Studies • Placebo Controlled Few • Head-to-Head Edwards et al (2001) n=133 Lamotrigine vs valproate Edwards KR, Sackellares JC, Vuong A et al 2001 Lamotrigine monotherapy improves depressive symptoms in epilepsy: a double-blind comparison with valproate. Epil & Beh 2:28–36
- 28. Treatment of Depression in PDTreatment of Depression in PD Special Issues • Movement Disorder Eg Paroxetine Psychosis Eg. memantine Individual Studies • Placebo Controlled Many! • Head-to-Head Few
- 29. Depression & Parkinson’s Disease - CorrelatesDepression & Parkinson’s Disease - Correlates Higher rates of hallucinations, anxiety, cognitive impairment, somatic symptoms Risk Factors Stage of illness Cognitive Impairment Stigma Disability 40% Recovery within one year No Depression 60% Major Depression Minor Depression Major Depression 60% No Depression 10% Minor Depression 30% Major Depression 10% Minor Depression 30% Starkstein et al (1992) JNNP 55, 377-382
- 32. Treatment of Head Injury and DepressionTreatment of Head Injury and Depression Special Issues • PCS vs Apathy • Influence on rehabilitation NA vs Serotonin • Seizures Individual Studies • Placebo Controlled Mooney & Haas (1993) n= 38 Methylphenidate Wroblewski et al 1996) n=10 Head-to-Head None
- 33. +10 Severity 0 Disorientation & PTA Depression & Irritability Apathy Post-Concussion Syndrome Time (weeks-months after head injury)
- 34. +10 Time (weeks-months after head injury) Severity 0 Post-Concussion Syndrome Alone Depression + PCS
- 39. Treatment of MS and DepressionTreatment of MS and Depression Special Issues • Interferon/Steroids • Influence on rehabilitation ? • Cognitive Function/QoL Individual Studies Placebo Controlled Schiffer & Wineman (1990) n=28 desipramine Mohr et al (2000) n= 32 CBT vs usual care Head-to-Head None
- 42. Treatment of Depression in ADTreatment of Depression in AD Special Issues • Stage of Disease • Influence on prognosis • Risk of AD in depression! Individual Studies Placebo Controlled Nyth et al (1992) Volicer et al (1994) Olafsson et al (1992) Reifler et al (1989) Fuchs et al (1993) Head-to-Head None
- 43. The Natural History of Alzheimer’sThe Natural History of Alzheimer’s PRE-SYMPTOMATIC PRE-CLINICAL CLINICAL Pathological Burden Diagnosis DiseaseSeverity Time in Years T 0 T-5 T+1 0 T-10 T+5 Death (BrainVolume/IntracranialVolume) 80% 85% 90% 75% 70% Severe Dementia Moderate Dementia Mild Dementia Mild Cognitive Impairment 23 30 20 12 Diagnosis Death No Depression Depression Modrego PJ & Ferrández,J. (2004). Depression in Patients With Mild Cognitive Impairment Increases the Risk of Developing Dementia of Alzheimer Type A Prospective Cohort Study . Arch Neurology 61:1290-1293.
- 45. Monastero et al (2004) XXXV SIN [Palermo]
- 47. Overview of Recommendations - CochraneOverview of Recommendations - Cochrane • The Cochrane Library, Issue 4, 2003 - Therapies for Depression in Parkinson's Disease (updated 2003) • The Cochrane Library, Issue 4, 2003 - Psychological treatments for epilepsy (2003 updated) • The Cochrane Library, Issue 4, 2003 - Pharmacological management for agitation and aggression in people with acquired brain injury • The Cochrane Library, Issue 4, 2003 - Cognitive behaviour therapy for chronic fatigue syndrome in adults • The Cochrane Library Issue 2, 2004 - Pharmaceutical interventions for depression & emotionalism after stroke • Protocol for a Cochrane Review (2003) - Psychological interventions for multiple sclerosis (Expected 2004) • The Cochrane Library, Issue 4, 2003 - Antidepressants for depression in medical illness (updated 2002)
- 51. • Depression in Physical Illness is Common Under-diagnosed • The mechanisms underlying depression Are poorly understood Complex • The Treatment of Depression Use a Combination Avoid TCAs • The Future Better RCTs Study physical outcomes Better antidepressants Global Outcomes Physical + Somatic Symp Mortality Participation/Concord