Marcia Kaplan, M.D

Volunteer Professor of Psychiatry UC Dept. of Psychiatry

Faculty, Cincinnati Psychoanalytic institute

Unofficial psychiatrist UC Dept. of Neurology

Update on Depression, Anxiety and Update on Depression, Anxiety and Psychosomatic Pain DisordersPsychosomatic Pain Disorders

Dr. Kaplan has no conflicts to report.Dr. Kaplan has no conflicts to report.In the past 12 months, Dr. Privitera has received:In the past 12 months, Dr. Privitera has received:

research funding from NIH, American Epilepsy research funding from NIH, American Epilepsy Society, UCB, and Johnson & Johnson Society, UCB, and Johnson & Johnson consulting fees from Johnson & Johnson, Glaxo consulting fees from Johnson & Johnson, Glaxo Smith Kline, UCBSmith Kline, UCBhonoraria for speaking from Johnson & Johnson, honoraria for speaking from Johnson & Johnson, Glaxo Smith Kline, Pfizer and UCBGlaxo Smith Kline, Pfizer and UCB

Disclosures Disclosures

DSM-V Diagnostic Criteria forMajor Depression

• Depressed mood / anhedonia, plus– Sleep disturbance– Difficulty concentrating– Significant appetite/weight change– Psychomotor agitation/retardation– Pervasive loss of energy/fatigue– Feeling worthless; excessive or inappropriate guilt– Recurrent thoughts of death/suicide

• Symptoms present for 2 weeks

Always or often

Sometimes Rarely Never

Everything is a struggle 4 3 2 1

Nothing I do is right 4 3 2 1

Feel guilty 4 3 2 1

I’d be better off dead 4 3 2 1

Frustrated 4 3 2 1

Difficulty finding pleasure 4 3 2 1

Score >15 indicates depression

Single episode vs. chronic, recurrent, severe Single episode vs. chronic, recurrent, severe Bipolar DepressionBipolar Depression

Early onsetEarly onset Prominent sleep problems lifelongProminent sleep problems lifelong Family history of mood problems and alcohol abuseFamily history of mood problems and alcohol abuse Unusual response to antidepressantsUnusual response to antidepressants

DysthymiaDysthymia Grief Grief External life eventsExternal life events

Differential Diagnosis of DepressionDifferential Diagnosis of Depression

DSM-V Anxiety Disorders

Separation anxiety disorder Generalized anxiety disorder Panic disorder Agoraphobia Social anxiety disorder

Obsessive-compulsive disorderObsessive-compulsive disorder Body Dysmorphic disorderBody Dysmorphic disorder Hoarding disorderHoarding disorder TrichotillomaniaTrichotillomania Excoriation - Skin pickingExcoriation - Skin picking

Obsessive Compulsive DisordersObsessive Compulsive Disorders

Post-traumatic stress disorderPost-traumatic stress disorder Acute stress disorderAcute stress disorder Adjustment disorderAdjustment disorder

Trauma and Stressor related disordersTrauma and Stressor related disorders

DSM-V Somatoform Disorders

• Somatic Symptom Disorder = somatization

•Includes “with predominant pain” = former pain disorder

• Conversion Disorder

• Illness anxiety disorder = hypochondriasis

• Psychological factors affecting other medical conditions

How Much History Do You Need?

• eliciting a history of childhood (or adult) neglect/abuse helps

establish a rationale for psychiatric referral

• psychiatric consultation for patients with somatic symptom

disorder reduces subsequent health care expenditures

without changing patients’ satisfaction with their health status

Smith et al, New Eng J Med 1986

How Can Psychiatric Consultation Help Patients with Chronic Pain?

• acknowledgement of the patient’s suffering, loss, and limitations

• establishment of accurate picture of patient’s daily routine, important relationships, sources of financial and emotional support

• referral to appropriate type of psychotherapy

• improve medication management

• address patient’s need for attention from primary care physician, “run interference” with health professionals involved in patient’s care

Conscious or Unconscious?

• Unconscious symptom production and motivation:

• somatization disorder

• conversion disorder

• hypochondriasis

• Conscious symptom production and unconscious motivation:

• factitious disorder

• Conscious symptom production and motivation:

• malingering

Look for Co-Morbidities

• Important to consider with every patient, since these factors complicate dx and tx

• alcohol abuse/dependence

• narcotic abuse/dependence

• post-traumatic stress disorder

•“survivor triad”: insomnia, nightmares, GI distress

• Depressive disorders

• Anxiety disorders

Medication Treatment

• First line: SSRIs

• fluoxetine

• sertraline

• paroxetine

• citalopram, escitalopram

Medication Treatment

• Escitalopram/citalopram• Dose range 10 – 40 mg qd (20-80 for

citalopram)

•start with 5 - 10 mg in anxious pts

• Most selective for 5-HT1 presynaptic receptor

• minimal agitation, insomnia

• CYP 450 inhibition minimal

Medication Treatment

• SNRIs: • Venlafaxine: qd - Effexor XR, Venlafaxine ER. Pristiq;

venlafaxine IR t.i.d.

• Duloxetine: Cymbalta • Milnacipran (Savella) now marketed for fibromyalgia

• 5HT2A/ SRI: nefazodone, trazodone

• Alpha 2 antagonist, HT-3 SRI, antihistaminic: mirtazapine

• NDRI: bupropion

• NRI: desipramine, nortriptyline, protriptyline,

Medication Treatment

• Venlafaxine• SRI at low doses, NRI at higher doses

• Dose range 37.5 to 375

• BP elevation at doses >150 mg

• Insomnia,

• Sexual inhibition

• Sweating, decreases hot flashes

• Discontinuation syndrome• CYP 450 minimal inhibition

Medication Treatment

• Bupropion – SR or XL• NRI, DRI

• Dose range 100 – 450 mg, qd or bid dosing

• Activating, not anxiolytic

• Less risk of sexual inhibition or weight gain

• Smoking cessation utility

• Elevated risk of seizures in female binge eaters

• CYP 450 minimal inhibition

Medication Treatment

• Mirtazapine• Alpha 2, 5HT2A, HT3, H1 antagonism

• Dose range 15 – 90 mg

• Anxiolytic, sedation, weight gain

• No sexual inhibition

• CYP 450 minimal inhibition

Tricyclics and MAOIs

• First antidepressants with effectiveness well established, probably through enhancement of 5-HT and NT transmission

• many side effects: histaminic, alpha-adrenergic, and cholinergic blockade;

• drug and food interactions for MAOIs

Medication Management of Chronic Pain

• Antidepressants:• TCAs

• SNRIs – venlafaxine, duloxetine

• antiepileptic drugs:

• Gabapentin

• Pregabalin

• Valproate

• Carbamazepine

• Second generation antipsychoticsSecond generation antipsychotics

• Check blood sugar, weight and cholesterol, TGs at outsetCheck blood sugar, weight and cholesterol, TGs at outset

• BenzodiazepinesBenzodiazepines

• Use for back-up, not foundation of treatment Use for back-up, not foundation of treatment

• OpiatesOpiates

• Obvious problems with addiction, unintended mood Obvious problems with addiction, unintended mood effectseffects

Problematic (but sometimes useful) in Problematic (but sometimes useful) in Medication Management of Chronic PainMedication Management of Chronic Pain

Treatment Algorithm

• Rule out thyroid abnormality

• Baseline liver functions

• Ask about alcohol and drug use

• Pregnant, or trying to be?

• Family history of affective illness?

Treatment Algorithm

• Begin with SSRI at usual starting dose (or half for severe anxiety, hx of side effects)

• Monitor progress at 4 weeks (have pt. call if problems)

• If some improvement, optimize dose

• If no improvement, switch medication

Treatment Algorithm

• If escitalopram 5 mg -> 10 mg for at least 3 weeks fails…• Mirtazapine

• for severe anxiety, insomnia, anorexia • 15 mg q PM, increase as tolerated

• Venlafaxine

• For depressed mood, poor concentration and motivation, not good for agitation

• 37.5 mg in AM with food, increase as tolerated – ideal at 150 mg

BupropionBupropion best for hypersomnia, psychomotor slowing, low best for hypersomnia, psychomotor slowing, low

motivation, concerns about weight gain and sexual motivation, concerns about weight gain and sexual inhibitioninhibition

Not ideal for agitated or anxious patientsNot ideal for agitated or anxious patients IR form 75 mg in AM, increase as toleratedIR form 75 mg in AM, increase as tolerated SR form 100 mg in AM, increase as toleratedSR form 100 mg in AM, increase as tolerated XL form 150 mg in AM, increase as toleratedXL form 150 mg in AM, increase as tolerated

Treatment AlgorithmTreatment Algorithm

Second generation antipsychotics for Second generation antipsychotics for augmentationaugmentation

AripiprazoleAripiprazole (Abilify) for poor concentration, (Abilify) for poor concentration, impaired motivation impaired motivation half of 2 mg pill in AM, increase as toleratedhalf of 2 mg pill in AM, increase as tolerated

QuetiapineQuetiapine (Seroquel) for insomnia, (Seroquel) for insomnia, agitation, anxietyagitation, anxiety 25 mg in evening, increase as tolerated25 mg in evening, increase as tolerated

OlanzapineOlanzapine (Zyprexa) for resistant (Zyprexa) for resistant depression, anxietydepression, anxiety 2.5 mg in evening, increase as tolerated2.5 mg in evening, increase as tolerated

Treatment AlgorithmTreatment Algorithm

Assessing Response

• Immediate improvement: placebo response

• Some improvement by 2 weeks- continue

• No better in 4 weeks: raise dose or change Rx

• Response ok, remission better

When to Refer

• Refractory depression

• Actively suicidal or homicidal

• Severe anxiety, agitation

• New onset mania, psychosis or personality change

• Significant work, relationship problems