Post on 05-Apr-2018
transcript
7/31/2019 Depression and Anxiety in Medical Setting
1/72
Dr P.KasiKrishnaRaja DPM DNBAsst. Professor of psychiatry
Department of PsychiatryIRT-Perundurai Medical College &
Consultant Psychiatrist-Erode
1
7/31/2019 Depression and Anxiety in Medical Setting
2/72
Objectives
Epidemiology of depression and anxiety in Medicalillness
Understand the bidirectional effects Know the barriers in recognition and effects of
depression and anxiety on medical illness
Learn how to recognize depression and anxiety &
understand the treatment options
2
7/31/2019 Depression and Anxiety in Medical Setting
3/72
Depression Epidemiology
Depression is estimated to affect 340 millionpeople globally
Depression is very often a chronic and recurrent
illness Earlier Indian studies have reported prevalence
rates of depression that vary from 2183% inprimary care practices
In the CURES study conducted at chennai,25,455 subjects participated in this study.
3
7/31/2019 Depression and Anxiety in Medical Setting
4/72
4
7/31/2019 Depression and Anxiety in Medical Setting
5/72
5
7/31/2019 Depression and Anxiety in Medical Setting
6/72
DSM-IV Diagnostic Criteria for Major
Depressive Episode
Presence of at least 5 of the following symptomsduring the same 2-week period that is a change fromprevious functioning: Depressed mood*
Loss of interest or pleasure* Change in appetite and/or weight
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt Poor concentration or indecisiveness
Suicidal ideation
* At least one of the symptoms must be present: 1) depressed mood or 2) loss of interest or pleasure.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed, TextRevision. Washington, DC: American Psychiatric Association; 2000. 6
7/31/2019 Depression and Anxiety in Medical Setting
7/72
The global burden of disease, 19902020 Lower Respiratory
Infections
Diarrheal Diseases Perinatal conditions
Depression
Heart Diseases
Cerebrovascular D/O
Heart Diseases
Depression
Traffic accidents Cerebrovascular D/O
COPD
Lower Respiratory
Infections
Lopez et al :Global burden of disease and risk factors, Oxford UniversityPress, New York (2006) 7
7/31/2019 Depression and Anxiety in Medical Setting
8/72
Depression In Primary Care
Prevalence of Affective d/o in Medically ill patientsis twice that of General populations
Medical Disease is a risk factor itself for Depression
Rates of Depression increases with Acuity of carefrom low 9% in general population to 30% inacutely hospitalized patients
Fava: J clin Psych Primary Care Companion 2005
8
7/31/2019 Depression and Anxiety in Medical Setting
9/72
Likelihood of Depression Increases with No. of
Physical Symptoms at Presentation
0
10
20
30
40
50
60
70
0-1 2 to 3 4 to 5 6 to 8 >9
No. of Physical Symptoms
Depression
Likelihood/Percentage
Series1
Kroenke K, et al. Arch Fam Med 1994 9
7/31/2019 Depression and Anxiety in Medical Setting
10/72
Prevalence of Psychiatric disorder
in different medical conditions
Per cent
10
7/31/2019 Depression and Anxiety in Medical Setting
11/72
Are Depressed patients more likely to be
medically ill?
1500 Depressed Patientswere evaluated forGeneral MedicalConditions
Total prevalence was 53% Those with older age,
Lower income,unemployment, limited
education and longerduration of depressionwere at higher risk
Disease/ System Prevalence%
Musculo skeletal 43%
Respiratory 32%
Heart 29%
Upper GI 26%
Neurological 25%
Endocrine 24%
Yates et al, Gen Hosp Psych 2004
STAR-D Study 11
7/31/2019 Depression and Anxiety in Medical Setting
12/72
Barriers in Diagnosing Depression in
Medically Ill Patients and families
Physicians
Diagnostic
12
7/31/2019 Depression and Anxiety in Medical Setting
13/72
Barriers in Diagnosing Depression in Medically Ill
Patients and families
Patient's own belief systems, Knowledge andawareness
Too busy with medical problems Trying to act tough
Not to add burden on family
Do not want to deal with it now
Family minimizing depression
13
7/31/2019 Depression and Anxiety in Medical Setting
14/72
Barriers in Diagnosing Depression in Medically Ill
Physician factors
Not aware of the pathoplastic effects of depression.
Depression is transient
Depression is secondary to underlying illness /Medications
Patient already has a diagnosis of depression or seeinga MH provider
I need to focus on medical illness first
14
7/31/2019 Depression and Anxiety in Medical Setting
15/72
Barriers in Diagnosing Depression in
Medically Ill--Diagnostic issues
Overlap of depressive symptoms can be accounted formedical Illness
Negative behaviors may be considered as reaction toillness or rebellious behavior against illness
DSM IV does not give you any guidance
15
7/31/2019 Depression and Anxiety in Medical Setting
16/72
Causes of Depression in Medical Illness
Psychological: Grief & loss of functioning, disabilityappearance, being a burden, Death anxiety andnarcissistic injury
Social: Financial issues, educational issues, limitedresources
Medical: Bidirectional theory i.e. one illness affectsother, Direct effects of depression on medical
illness, Is depression a common symptoms of serousmedical illness?
Iatrogenic: Medications, Restraints and wrongdoings
16
7/31/2019 Depression and Anxiety in Medical Setting
17/72
Cost of Depression
Who pays for it? Patients
Families
Health Care Provider System
17
7/31/2019 Depression and Anxiety in Medical Setting
18/72
Cost of Depression
to Patients Unable to cope effectively
Affects nutrition, Rx adherence, self care
More likely to have adverse reaction to medications Poor physical functioning
Increased Morbidity and mortality
18
7/31/2019 Depression and Anxiety in Medical Setting
19/72
Cost of Depression
Families Increased burden
Patient being aloof from family causing more guilt andanxiety
Impaired relationship
Increased risk of violence and neglect
19
7/31/2019 Depression and Anxiety in Medical Setting
20/72
Cost of Depression
Health Care Providers
More likely to order work up
Feelings of detachment
May give up early Feelings of being a failure or not doing enough
20
7/31/2019 Depression and Anxiety in Medical Setting
21/72
System Increased use of resources
Increased mortality and morbidity
21
7/31/2019 Depression and Anxiety in Medical Setting
22/72
Increased Use of the Resources
Simmons: Bio. Psychiatry 2003
Comorbid
Illnesses
22
7/31/2019 Depression and Anxiety in Medical Setting
23/72
Bula, C. J. et al. Arch Intern Med 2001;161:2609-2615.
Average costs per day of follow-up and type of inpatient stay for subjects with depressive symptoms(Geriatric Depression Scale [GDS] >=6) vs without depressive symptoms (GDS,
7/31/2019 Depression and Anxiety in Medical Setting
24/72
Are Depressed Patients Likely to Die Early?
Review of 57 studies showed 52% as positive, 22 %negative and 26% Neutral.
Depression increases death by natural course andCardiovascular Diseases.
Men were at higher risk
Depression does not increase the risk of death by
cancer.
Lawson: Psychosomatic Medicine 1999
24
7/31/2019 Depression and Anxiety in Medical Setting
25/72
*P< 0.05
Rovner BW, et al. JAMA. 1991;265:993-996.
29.8%
47.4%
0
10
20
30
40
50
60
70
Depressive Disorder No Depressive Disorder
Deaths(%)
n = 57 n = 315
Depression: 1-Year Mortality in
Nursing Home Patients
*
25
7/31/2019 Depression and Anxiety in Medical Setting
26/72
Depression and Coronary Artery Disease
Depression (Barefoot and Schroll 1996; Ford et al.1998;Lett et al. 2004) and anxiety (Strik et al. 2003) appearto be independent risk factors for the development ofcoronary artery disease.
Subsyndromal depressive symptoms also correlatewith an increased risk of cardiovascular mortality(Frasure-Smith et al.1995).
Even more impressively, negative mood appears to
predict long-term cardiac-related mortality followingmyocardial infarction (MI), independently of cardiacdisease severity (Frasure-Smith and Lesperance 2003a,2003b).
26
7/31/2019 Depression and Anxiety in Medical Setting
27/72
Prevalence of Depression is Higher
%
Jiang et al AM J Heart 2005
27
7/31/2019 Depression and Anxiety in Medical Setting
28/72
Pathophysiology of Depression in CAD
Social, Behavioral causes (lifestyle, compliance,smoking, other risks)
Biological: Depression causes increased HPA activationleading to increased Cortisol
Depression lowers heart rate variability due toincreased sympathetic tone
Depression plays a role in subacute inflammatoryprocess : CRP and IL-6
Common link of 3 Omega FA in Depression and CAD
Depression causes platelet activation and aggregation
Jiang et al AM J Heart 2005
28
7/31/2019 Depression and Anxiety in Medical Setting
29/72
Can Depression in Early Life Lead to CAD?
Most studies sayyes
Ford studied Depression in Medical students for26 years. Study showed that those who were
depressed at some point did have a up to two foldhigher risk of later CAD
In ECA study after 13 years those with depression
had 4.5 times higher risk of developing heartattack. Worse. even those with minor depressionhad same risk.
Ford DE: Arch. Int. Med 1998
29
D i d I h i H t Di M t lit E id
7/31/2019 Depression and Anxiety in Medical Setting
30/72
Depression and Ischemic Heart Disease Mortality: Evidence
From the EPIC-Norfolk United Kingdom Prospective Cohort
Study?
30
During a total follow-up of 162,974 person-years (the medianfollow-up periodwas 8.5 years), there were 274 deaths fromIHD.
12-month major depression was associatedwith an increased risk of IHDmortality (2=13.2, df=1, p=0.0003,after adjustment for age and sex)
participants who reported an episode of major depression within12 months ofassessment were 2.7 times more likely to die fromIHD over the 8.5-year follow-up period.
a trend in association according to recency of major depression,such that noassociation was observed for episodes that were experienced more than 12months before assessment
a stronger association was
observed for those who reported three or moreepisodes
the association was stronger for participantswho reported episodes of majordepression that lasted on average6 months or more
7/31/2019 Depression and Anxiety in Medical Setting
31/72
31
7/31/2019 Depression and Anxiety in Medical Setting
32/72
Can Depression Cause
Diabetes? Meta-analysis# studies N (est) F/U OR
Knoll 9 173,000 3-16 1.37
Casgrove 11 282,000 3-15.6 1.25
Mezuk 13 6,916 3-15.6 1.60
Knoll et al : Diabetologica 2006Casgrove et al :Occu. Med 2008Mezuc : Diabetes care 2008
Findings varies depending on selectioncriteria, self report vs. exam, medicationsused, sample size
32
7/31/2019 Depression and Anxiety in Medical Setting
33/72
Can Diabetes Cause Depression?
Kovacs et al (Diabetes care 1997) followed youthswith DM I for 10 years, 27.5% developed depression
Gavard et al (Diabetes care 1993) did the review of 20studies and came to conclusion that prevalence of
depression in diabetics range from 8.5% to 27.3%Anderson et al (Diabetes care 2001) meta-analysis of
21,351 patients . They found that 11% prevalence of
Major Depression (OR=2.0
) among diabetics andprevalence of clinical relevant depression at 31% indiabetics.
33
7/31/2019 Depression and Anxiety in Medical Setting
34/72
Depression and Diabetes Poor glycemic control
Increased functional disability
Increased cost of care Poor adherence and control
Increased complications
2.5 times likely to die in 8year f/u study
Gonzales 2008; Edege 2001, Edege 2006; Lustman 2000, Groote, 2001,Edege 2005
34
7/31/2019 Depression and Anxiety in Medical Setting
35/72
Obesity and Depression
20 % of obese boys and 30% of girls havedepression
Recent meta-analysis showed bidirectionalincreased OR of around 1.5 for both obesity and
depression Often weight loss leads to improvement in
mood, at the same time people who undergogastric bypass have higher rates of depression
Antidepressants are known to cause weight gain
Stunkard : Biol. Psych 2003
Luppino : Arch Gen Psych 2010
35
7/31/2019 Depression and Anxiety in Medical Setting
36/72
Triad of Death
Diabetes
CADDepression
36
7/31/2019 Depression and Anxiety in Medical Setting
37/72
Depression and CVA
Depression rates vary from 15-35% but latestmeta-analysis estimates it to be between 15-20%
L side lesions can cause Depression and Rsubcorticle more likely to cause Mania
Depressed patients are 2.5 times likely to have aCVA in their life time
Diagnosis is difficult
AD, Stimulants and ECT shows effectiveness
One study showed that SSRI can preventdepression
Evans Biol Psych 2005
37
7/31/2019 Depression and Anxiety in Medical Setting
38/72
Dementia and Parkinsons Disease
Prevalence is 30-50% in Dementia. Rates
depends upon severity, settings and methods Prevalence in Parkinsons 25-40%
Studies show bidirectional effects i.e. earlyDepression an independent risk factor forcognitive decline.
Treatment is difficult due to side effects andexacerbation of underlying illness
ECT has been used effectively in Parkinson'sand Epilepsy patients
38
7/31/2019 Depression and Anxiety in Medical Setting
39/72
Depression and Cancer
Likelihood of Depression is 4 times greater and Suicides
rates are twice than that in general population Depression was unrecognized in 50% of hospitalized
cancer patients
Rates of Depression are higher in pancreatic, ENT andBreast cancer
Depressed patients followed for 13 years showed higherincidence of breast cancer but not of other types.
When present for at least 6 years, depression wasassociated with a generally increased risk (RR : 1.88) of
cancer in elderly (Penninx, JNCI 1998) 5/10 studies show positive effects of psychotherapy and
survival ratesDavid Spiegel Biol Psych 2003
Netzel Womans Health Psych 2006
39
HIV d D i
7/31/2019 Depression and Anxiety in Medical Setting
40/72
HIV and Depression Rates of depression are two times higher
More in female than male Depression is associated with poor adherence to
treatment and rapid progression of illness Depression might even affect HIV entry &
replication increasing the risk for infection Changes in functioning of Killer Lymphocytes in
depressed patients lead to delaying of symptomspresentations and lowering the CD4 count.
Treatments are effective but drug interactions andchanges in antiviral treatments createscomplications
40
Chronic Pain and Depression
7/31/2019 Depression and Anxiety in Medical Setting
41/72
Chronic Pain and Depression
30-40 % have Depression
Pain is closely associated with social stress, monetarygain, personality, and past h/o abuse
These patients are at higher risk for substancedependence
Fibromyalgia and Depression have comorbidity of up to70%
Suicide rates are higher in this population especially ifthey have cancer
Fishbain 1997,1999: Ann Med
Lynch 2001 Jr Psych Neuroscience 41
7/31/2019 Depression and Anxiety in Medical Setting
42/72
Challenges in Diagnosis of Depression Inclusive approach
Exclusive approach
Vegetative vs. Psychological symptoms Scales
Structured Psychiatric Interview
Limitations of DSM IV
42
Challenges in Diagnosis of Depression
7/31/2019 Depression and Anxiety in Medical Setting
43/72
Challenges in Diagnosis of Depression
How to make a correct Diagnosis in shortest
period of time?
Are you depressed?
Look for irritability, refusal,sudden mood changes andlack of interest
Hopelessness andSuicidality are not thenorms.
Chochinov: Am J Psych 1997
43
7/31/2019 Depression and Anxiety in Medical Setting
44/72
Treatment Issues
Be aware
Do not justify and just put the patients shoes bythinking what if I was in this patients situation Iwould.Ask patient, families, nurses and other care givers
Keep your eyes and ears open for risk factors
Give time empathy and show compassion itgives patients opportunity to open up
Yes, It is your job. Depression is part of the severemedical illness.
44
7/31/2019 Depression and Anxiety in Medical Setting
45/72
Treatment Principles
Watch for risk factors
Consider current medical conditions,
side effects, Medications, social situations andfinances while considering an antidepressant
Continue to evaluate as just starting medicationswill help in only 40% of cases
Get patient some help through social services orcounseling
45
7/31/2019 Depression and Anxiety in Medical Setting
46/72
Selection of Antidepressants
Select AD based on the co-morbidities likeOCD, Panics, pain,
Anxiety: Paroxetine, Sertraline, EscitalopramWt. Loss: Mirtazepine, TCA, QuetiapineWt. Gain/ Fatigue: Buproprion, Fluoxetine,
Stimulants
Pain: TCA, Duloxetine Fatigue, somnolence: Stimulants for short timeNausea/Vomiting: Mirtazepine, Escitalopram
46
7/31/2019 Depression and Anxiety in Medical Setting
47/72
Antidepressants classification
47
TCA
amitryptylline,imipramine,triimipramine,dosulupine,nortryptylline etc..
SSRIsserrtraline,escitalopram,fluoxetine,fluoxamine,paroxetine,citalopram
SDRIsbupropion
SARIstrazadone,nefazadone
SNRIsvenlafaxine,des-venlafaxine,duloxetine,
SSNRIsmilnacipran
NaSSAmirtazapine
RIMAmoclobemide,broforomine
MAOItranylcypramine,phenelzine
NARI--reboxetine
7/31/2019 Depression and Anxiety in Medical Setting
48/72
48
7/31/2019 Depression and Anxiety in Medical Setting
49/72
49
7/31/2019 Depression and Anxiety in Medical Setting
50/72
50
7/31/2019 Depression and Anxiety in Medical Setting
51/72
51
7/31/2019 Depression and Anxiety in Medical Setting
52/72
52
7/31/2019 Depression and Anxiety in Medical Setting
53/72
53
Serotonin is released from platelets in response to vascular injury and promotesvasoconstriction and morphological changes in platelets that lead to Aggregation.
Serotonin is a relatively weak platelet aggregator on its own:the presence ofepinephrine, collagen and adenosine diphosphate are required for effective clotting.
Platelets cannot synthesize serotonin
it is taken up by active transport. Selectiveserotonin reuptake inhibitors (SSRIs) inhibit the serotonin transporter, which is
responsible for the uptake of serotonin into platelets.
It might thus be predicted that SSRIs will deplete platelet serotonin, leading to areduced ability to form clots and a subsequent increase in the risk of bleeding.
7/31/2019 Depression and Anxiety in Medical Setting
54/72
54
7/31/2019 Depression and Anxiety in Medical Setting
55/72
55
7/31/2019 Depression and Anxiety in Medical Setting
56/72
Hyponatremia and antidepressants
56
7/31/2019 Depression and Anxiety in Medical Setting
57/72
57
7/31/2019 Depression and Anxiety in Medical Setting
58/72
58
7/31/2019 Depression and Anxiety in Medical Setting
59/72
Medications that may Cause Depression
Culpepper L: J Clin Psych & Primary care Companion
2005 59
AlcoholAnticonvulsants .BarbituratesBenzodiazepinesBeta-adrenergic blockers
Bromocriptine (Parlodel)Calcium-channel blockersChemotherapeutic agentsAntabuse drugsEstrogensStatins
Interferon alfaNarcoticsNorplant
http://www.medicinenet.com/script/main/art.asp?articlekey=43955http://www.medicinenet.com/script/main/art.asp?articlekey=45293http://www.medicinenet.com/script/main/art.asp?articlekey=43882http://www.medicinenet.com/script/main/art.asp?articlekey=45311http://www.medicinenet.com/script/main/art.asp?articlekey=18510http://www.medicinenet.com/script/main/art.asp?articlekey=9724http://www.medicinenet.com/script/main/art.asp?articlekey=23586http://www.medicinenet.com/script/main/art.asp?articlekey=44991http://www.medicinenet.com/script/main/art.asp?articlekey=44991http://www.medicinenet.com/script/main/art.asp?articlekey=23586http://www.medicinenet.com/script/main/art.asp?articlekey=9724http://www.medicinenet.com/script/main/art.asp?articlekey=18510http://www.medicinenet.com/script/main/art.asp?articlekey=45311http://www.medicinenet.com/script/main/art.asp?articlekey=43882http://www.medicinenet.com/script/main/art.asp?articlekey=45293http://www.medicinenet.com/script/main/art.asp?articlekey=439557/31/2019 Depression and Anxiety in Medical Setting
60/72
Selection of Antidepressants
Drug Interaction: Watch for Cytochrome P 450
More likely: Fluoxetine, Paroxetine and Fluvoxamine
In-between: Sertraline, Citalopram, Duloxetine
Less Likely: Escitalopram, Desvenlafaxine, Buproprion
Risky: TCA and MAOI
Suicidal patients : Do not choose TCA , bring them
back early, give small supply under supervision Renal Damage: do not choose Desvenlafaxin
Watch out for serotonin syndrome
60
7/31/2019 Depression and Anxiety in Medical Setting
61/72
Psychosocial Aspects
Spend Time to Know your patients Make them an informed client and a partner in
treatment Refer to a therapist for issues like guilt, anger, poor
coping, relationship problems,sucidal ideation. Refer to social workers and support services for
help reg: living, home health, job, Insuranceissues, Food stamps.
Watch for familys mental health and always ask:How are you holding/coping it?
Use humor but wisely.
61
7/31/2019 Depression and Anxiety in Medical Setting
62/72
62
M di l E i d
7/31/2019 Depression and Anxiety in Medical Setting
63/72
Medical Environment and
anxiety Separated from familiar surroundings
Unfamiliar health care professionals ask a series ofpersonal questions and perform physical examinations
that include uncomfortable and embarrassing probingof orifices.
Simple issues such as cold rooms can enhance anxiety.
needle phobia appearing when blood is drawn. sense of confinement causing an anxiety reaction
during imaging studies, phobic reactions and anxietyare quite common during a medical workup.
63
7/31/2019 Depression and Anxiety in Medical Setting
64/72
Contd.. If a disease is identified during Gnostic process, it is almost always perceived as
a threat (Imboden and Wise 1984). The patient usually views serious illness as apotential loss. The most basic fear is loss of life.
An individual with a myocardial infarction may find his or her career hopesdashed as a result of the stigma of disease.
A young mother with breast cancer may fear that she will never live to see her
children fully grown.
The coronary care unit (CCU) is a specific medical environment where anxietycan predominate and be a burden to patient recovery.
A patient who is very anxious may constantly call a nurse/doctor shop forreassurance. Anxiety will certainly augment such cravings unless treated.
64
7/31/2019 Depression and Anxiety in Medical Setting
65/72
Cardiac Disease and Anxiety Oslers descriptions of early-onset angina mayrepresent the first attempt at defining what we havecome to know as type A behavior (Friedman and
Rosenman 1974).Another early observer of the hearts connection to
anxiety was Jacob Mendes DaCosta, who reported oncardiac symptoms of Civil War soldiers for which he
could not identify objective cardiac findings.DaCostas syndrome was further elaborated by SirWilliam Lewis (1918) during World War I, when hecoined the term effort syndrome.
65
7/31/2019 Depression and Anxiety in Medical Setting
66/72
Contd.. Patients with cardiac symptoms such as chest pain
who have no objective cardiac findings on angiographyhave a high prevalence (between 43% and 61%) of
panic disorder (Beitman et al. 1987; Katon et al. 1988;Zinbarg et al. 1994)
Panic attacks have been demonstrated to impairmyocardial perfusion in patients with cardiac disease,
even when antiarrhythmic cardiac medication isadministered (Fleet et al. 2005).
66
7/31/2019 Depression and Anxiety in Medical Setting
67/72
Contd.. Other psychophysiological theories have revolved
around the issue of panic disorder and mitral valveprolapse.
Originally, it was thought that because these twodiseases share similar clinical symptoms, demographicfeatures, and prevalence within the generalpopulation, the two may be subsumed within a single
classification of mitral valve prolapse syndrome(Pariser et al. 1978; Savage et al. 1983a; Wooley 1976).
67
7/31/2019 Depression and Anxiety in Medical Setting
68/72
68
Medical conditions mimicking or directly resulting ini t
7/31/2019 Depression and Anxiety in Medical Setting
69/72
anxiety
Poor pain controlSuch as ischaemic heart disease, malignantinfiltration
Anaemia
HypoxiaMay be episodic in both asthma and pulmonaryembolus
Hypoglycaemia Hypocapnia-May be due to occult bronchial hyperreactivity
Hyperkalaemia
Central nervous system disorders (structural or epileptic)
Alcohol or drug withdrawal Vertigo
Thyrotoxicosis
Hypercapnia
Hyponatraemia 69
7/31/2019 Depression and Anxiety in Medical Setting
70/72
70
7/31/2019 Depression and Anxiety in Medical Setting
71/72
71
7/31/2019 Depression and Anxiety in Medical Setting
72/72