Chronic illnesses and depression, when present together, lead to worst clinical outcomes.
Because of the close interrelationship between depression and medical illnesses, it is very important to recognize and treat depressive symptoms in medically ill patients and vice versa.
What is depression?
The cardinal features of depression is a low mood. This is manifested by a loss of interest in people or activities of daily life that persists over a period of at least two weeks. Low mood is accompanied by a constellation of other depressive symptoms such as suicidal ideation, hopelessness, fatigue and altered eating and sleeping patterns. Somatic symptoms may be seen in depressed patients and are sometimes the presenting complaints.
Definition of Depression:
The American psychiatric association defines depression ( DSM IV) as follows:
A Major depressive episode:
- At least five of the following symptoms have been present during the same two weeks time and represent a change from previous functioning; at least one of the symptom is either 1) depressed mood or 2) loss of interest or pleasure
- Depressed mood most of the day
- Marked diminished interest or pleasure in activities most of the day
- Significant weight loss or weight gain or decrease/ increase in appetite nearly every day.
- Insomnia/ hypersomnia
- Psychomotor agitation/ retardation
- Fatigue or loss of energy
- A feeling of worthlessness or guilt
- Inability to concentrate and indecisiveness
- The recurrent thought of death or suicidal ideation
- The symptoms do not meet criteria for a mixed episode
- The symptoms cause significant functional, occupational and social deterioration
- Symptoms of the patient are not due to a direct or indirect effect of a drug or another medical condition
- The symptoms are not accounted for by bereavement
- There has never been a mixed episode
Major depressive disorder, recurrent:
- Presence of two or more major depressive episode separated at least two months apart
- The major depressive episodes are not better accounted for by schizoaffective or schizophreniform disorder, a delusional or psychotic disorder not otherwise specified.
- There has never been a maniac, hypomanic or a mixed disorder.
Natural history and course of Depression:
A depressive disorder may begin at any age although the age of onset is usually postpuberty. Symptoms develop over days to weeks.
Prodromal symptoms may occur over the preceding several months. These include generalized anxiety, phobias, panic attacks or depressive symptoms not meeting the criterion threshold.
In some individuals, the major depressive disorder may develop suddenly due to severe psychosocial stress.
Duration of a depressive episode varies and a subset of patients may eventually have a maniac or a hypomanic episode as well.
Recurrence in major depression:
Recurrence in major depressive disorder is about 35%. Patients who have more than three episodes of major depression, the recurrence rate approaches 100%.
Patients may return to their premorbid functional status between episodes but about one-third of the patients have residual symptoms mostly in the form of anxiety and somatic symptoms leading to some functional and occupational limitations.
How depression affects an individual:
Depression adversely affects the patient as well as the family, colleagues, friends and all individuals in the patients social ( including marital and parental) and occupational circle. The most serious complication of a major depressive disorder is suicide. Associated medical conditions are also associated with significant comorbidities and recovery from a medical condition in patients with depression is usually delayed and complicated.
The disorder if recurrent can have adverse outcomes on the family and children with depressed parents have an increased likelihood of becoming depressed as well.
Prognosis of the major depressive disorder depends on many factors including support from the family and friends, concurrent medical conditions, chronicity of the symptoms and treatment status. With proper treatment, the prognosis is generally good.
Treatment of Depression:
Treatment of patients with depression involves a number of steps which include:
It is further subdivided into a broad array of interventions that psychiatrists should initiate, continue and maintain throughout the duration of illness. These include:
- Establish and maintain a therapeutic alliance
- Complete psychiatric assessment
- Evaluate the safety of the patient
- Establish an appropriate setting for the patient
- Evaluate functional impairment and quality of life
- Coordinate the patient’s care with other clinicians
- Monitor the patients psychiatric status
- Integrate measurements into psychiatric management127
- Enhance treatment adherence
- Provide education to the patient and the family
The acute phase of therapy:
The aim of the initial phase of therapy should be to induce remission and full return of the baseline functional status. Antidepressant medication is recommended as the initial treatment of choice. SSRIs, SNRIs, mirtazapine or bupropion are the initial drugs of choice for most patients because of their acceptable side effect profiles and greater patients adherence in the long run.
Patients should be monitored for side effects regularly. In patients who develop side effects dose of antidepressants should be adjusted and patients may also be shifted to another class of drugs. In patients who have psychotic or catatonic features or patients who fail pharmacotherapy and in those where an urgent response is required as in patients with suicidal ideation, ECT may be helpful.
For mild to moderate disease psychotherapy may be helpful alone or in conjunction with pharmacotherapy. Patients response to the therapy should be assessed after an interval of four to eight weeks.
Continuation phase of therapy:
Patients should be assessed for a possible relapse during the continuation phase. Monitoring for side effects, treatment adherence, and functional status should also be regularly assessed. Treatment should be continued for four to nine months.
Discontinuation of treatment:
To discontinue drugs, it is better to taper off antidepressants over a course of several weeks. Patients should be monitored over the next several months for a possible relapse.
Chronic illnesses and Depression:
There is a high prevalence of co-occurring chronic illnesses and depression. Furthermore, the outcome of co-occurring medical conditions is poor in patients with depression. Medical conditions may have altered mood as a part of their clinical presentation or may act as persistent stressors that may provoke a depressive episode.
Because of the close interrelationship between depression and medical illness, it is very important to recognize and treat depressive symptoms in medically ill patients and vice versa. Furthermore, drug interactions should always be kept in mind and drug dosages adjusted accordingly.
Hypertension and depression:
Hypertension may influence the choice of antidepressants. Selective norepinephrine reuptake inhibitors ( duloxetine, venlafaxine) may have a dose-dependent effect on raising blood pressure.
The effect of alpha blockers ( prazosin) may be enhanced by tricyclic anti-depressants (notable trazodone). Similarly, tricyclic antidepressants may antagonize the actions of clonidine and methyldopa.
Furthermore, side effects of antihypertensives like beta blockers may confound the depressive symptoms in some patients.
Cardiac diseases and depression:
Reason for high mortality in these patients has been associated with lower heart rate variability.
Furthermore, Special precautions should be taken by psychiatrists when using tricyclic antidepressants in patients with a previous history of ventricular arrhythmias, subclinical sinus node dysfunction, conduction defects, prolonged QT intervals or a recent history of myocardial infarction as these drugs are associated with prolonged QT interval and arrhythmias.
Stroke and depression:
Depression has been observed in about half of post-stroke patients. Depression after stroke has detrimental effects on the quality of life of these patients.
Treating depression in post-stroke patients have deduced variable results but a trial of antidepressants should be tried.
Selective serotonin reuptake inhibitors (SSRIs) are well tolerated and have fewer interactions with other drugs. However, the potential for increased bleeding risk due to drugs interaction should be recognized in patients on warfarin, clopidogrel, aspirin, and dipyridamole.
Parkinson’s disease and depression:
The major depressive disorder is very common in patients with Parkinson’s disease. SSRIs have been shown to be efficacious but there is some risk of worsening of Parkinson’s disease especially with agents that are primarily serotonergic.
Bupropion has been shown to be beneficial both for depression and Parkinson’ disease but it may also induce psychotic symptoms.
SNRIs may also be preferable to SSRIs. MAOs may adversely interact with L-dopa products.
Electroconvulsive therapy also exerts a transient beneficial effect on the symptoms of idiopathic Parkinson’s but it might occasionally worsen L-dopa induced dyskinesis and induce a transient interictal delirium.
Epilepsy and depression:
The prevalence of major depression appears to be increased in patients with epilepsy. On the other hand, major depressive disorder significantly increases the risk of unprovoked seizures.
In addition TCAs and bupropion lower seizure thresholds. SSRIs and SNRIs can be safely used. Valproate, carbamazepine, and lamotrigine appear useful for the treatment of mood disorders apart from their role as anticonvulsants.
Diabetes and depression:
However, depression in diabetics results in reduced diet and medications adherence. Whether antidepressants have any role in achieving glycemic control in depressed patients is not yet known.
SSRIs rather than TCAs may be preferable in diabetics because TCAs have been associated with a worsened glycemic control.
HIV(Human Immunodeficiency Virus) and hepatitis C infections and depression:
Rates of major depression are increased among individuals with HIV compared to HIV negative individuals.
Other psychiatric illnesses like substance abuse can be present simultaneously in these patients. Potential drug interactions are common.
SSRIs may be useful apart from group psychotherapies, interpersonal and cognitive behavioral therapies. Coinfections with hepatitis C is also common. Individuals with hepatitis C are at increased risk of major depression.
Furthermore, interferon is associated with a further increased risk of depression. SSRIs can be used to treat these patients and depression should not be considered a contraindication to the treatment of hepatitis C.
Arthritis and depression:
Like other chronic illnesses, people living in pain, arthritis or disabilities have a higher prevalence of depression and anxiety. More than 20% of the adults with arthritis have anxiety and 12% report depression.
Symptoms of anxiety and depression are more common in patients who are young, can not work and have disabilities. When symptoms of depression and anxiety are present in patients with arthritis, they may become less adherent to their medications.
A vicious cycle of more severe pain and greater depressive symptoms and non-compliance may begin.
Both the conditions should be treated simultaneously. Left untreated, depression in people with arthritis may result in:
- Greater pain
- Greater risk of cardiovascular disease and heart attacks
- Loss of productivity at work
- Increased risk of economic hardship
- Deterioration of relationships with friends and family
- Sexual dysfunction