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Depression in Medical Patients

Dr. A/Moneim Al Hakam Consultant Psychiatrist Alkhor Hospital - HMC

Common

2nd most important of disability worldwide Life time prevalence 1:20 1/3 of physically ill
WHO

Life threatening or chronic illness

Unpleasant or demanding treatment


Low social support Personal or family vulnerability

Alcoholism and substance abuse


Drug induced

Classification
A spectrum of mood disturbance

Adjustment disorder
Major depressive disorder

Dysthymia
Manic depressive illness

Criteria for major depression


Five or more of the following symptoms during the same two week period representing a change from normal
Depressed mood Substantial weight loss or weight gain Insomnia or hypersomnia Decreased interest or pleasure Psychomotor retardation or agitation Fatigue or loss of energy

Feelings of worthlessness or Diminished ability to think or concentrate inappropriate guilt Recurrent thoughts of death or suicide or suicide attempt

Risk Factors
Biopsychosocial

Direction of causality
Stroke, multiple sclorsis, parkinsonism, cancer pancreas.

Recognition & Diagnosis


Under diagnosed Under treated (?)

Difficulty distinguishing psychological symptoms of depression, such as sadness and loss of interest, from a "realistic" response to stressful physical illness Confusion over whether physical symptoms of depression are due to an underlying medical condition Negative attitudes to diagnosis of depression Unsuitability of clinical setting for discussion of personal and emotional matters Patients' unwillingness to report symptoms of depression

Liaison Psychiatry Health Psychology


Focus

Hospital patients
particularly those experiencing psychological difficulties in the face of a physical health problem.

on

Healthy and ill populations and on the psychological processes that influence their level of health or their degree of adaptation to disease.

Concerned with
The diagnosis and treatment of either unexplained symptoms or psychiatric disorders occuring in people with medical conditions.

Developing theoretically based explanations for health related and illness related behaviour.

Behavioural factors influencing health


Health

protective Health-risk

stress personality life style factors

Stress and health


Stress: Situations in which individuals
are faced with demands that exceed their immediate ability to cope.

Stressful situations:
novel

unpredictable
un-controllable those involving change or loss

adverse physiological & psychological

changes. disease

Stress is associated with the development of illness:


Indirect

effects: Levels of risk behaviour Direct effects: physiological mechanisms (BP) suppression of the immune system triggering a disease process in vulnerable individuals.

Cope with stressful situations

autonomic
neuro-endocrine immunological changes

Personality and health


Type A personality and coronary heart disease
competitiveness time urgency hostility

Anger and hostility are pathogenic


Physiological reactivity to environmental demands engage in unhealthy behaviours

Type A Personality

Health protective personality variables

Hardiness:

personal control over events


sense of commitments see environmental demands as challenges less affected by stress

Optimism

tendency towards positive expectations

Concept of Hardiness

Lifestyle and health


Health -risk behaviours
Start as: ways of coping with stress peer pressure pleasure, etc., Maintained by : psychological, social biological factors.

Depression & Cardiovascular diseases

Depression is a risk factor in the survival of cardiovascular disease, Has an unfavourable evolution in diagnosed heart disease, Is an independent prognostic factor in cardiac mortality.

Epidemiology

Depression in the coronary patient often follows a prolonged course, which distinguishes it from a simple reactive depression.

Incidence of severe depression in patients suffering from heart disease.

Study

Number & type of patients Diagnostic method


283 patients hospitalized for myocardial infarction 103 patients suffering from heart failure confirmed by angiography 222 patients hospitalized for myocardial infarction SADS

Incidence of severe depression (%)


18

Schleifer et al (1989) Carney et al (1993) Frasure-Smith et al (1993)

DIS

18

DIS

16

Gonzalez et al 99 patients hospitalized for (1996) coronary heart disease Hance et al (1996) Koenig (1998) 200 coronary patients eligible for angiography 107 elderly patients (>60 years) with heart failure

DIS DIS DIS

23 17 36.5

SADS = Schedule for Affective Disorders and Schizophrenia DIS = Diagnostic Interview Schedule

Depression, a risk factor in cardiovascular morbidity and mortality


1. Depression: a risk factor in heart disease

Epidemiological studies have shown an increase in cardiovascular morbidity and mortality in patients with depression (Anda et al, 1993). In the absence of antidepressant treatment, the increase in cardiac risk appears to be correlated with the severity of symptoms of depression and seems to be noticeably prolonged and stable over time (Barefoot et al, 1996).

2. Depression, a poor prognostic factor


HT

(hypertension): depression is associated with an increased risk of the target organs being affected (heart, brain)
Simon Sick et al, 1995. Stroke 2.3 -2.7 times greater in HTN with depression

Unstable

angina: associated depression (BDI score 10) considerably increases the risk of infarction in the following year (p<0.001) (Frasure-Smith et al, JAMA 1995).

3. Depression, an independent predictor of cardiac mortality


Frasure-Smith et al,1995. Depression and 18 months prognosis after MI

Post-infarction,

depression is an independent predictor of cardiac mortality in the short and long term. of the depression at the outset is a major prognostic factor in the cardiac mortality risk at 5 years.

Severity

Pathophysiology
1. Psychological factors
Depression causes a number of psychological problems which may be involved in an unfavourable evolution of the coronary heart disease:

- it affects ones ability to face the illness; - it reduces compliance with drug treatment and
rehabilitation;

- it increases medical comorbidity, particularly by


contributing to a reduction in physical activity and maintenance of addictive habits (alcohol, smoking etc,).

2. Hyperactivity of the hypothalamohypophyso-suprarenal axis and sympathomimetic hyperactivity

Hyperactivity of the sympathetic nervous system is one of the somatic markers of depression

3.Hypertension

Symptoms of depression are associated with the development of HT and complications arising from this myocardial infarction

4. Change in heart rate variability


Abnormalities

of cardiac rhythm which accompany depression expose patients to the risk of serious ventricular arrhythmia.

Clinical considerations
1. Clinical screening
A series of symptoms will indicate depression in patients suffering from ischemic heart disease : unusual fatigue anxiety irritability sleeping disorders difficulty coping with everyday stress unusual somatic symptoms, in particular atypical precordial pain difficulty rehabilitating difficulty complying with treatments and lifestyle changes

During hospitalization, the nursing staff must remain vigilant to symptoms of depression. Depression is often underestimated as it is considered to be normal when recovering from an acute cardiac event.

2. Systematic screening

The HAD scale might be especially appropriate in screening depression in the context of acute care units since this simple questionnaire, which is filled in by the patient, evaluates symptoms of depression as well as anxiety.

Psychological Consequences of Physical Illness


Adjustment disorder Phobic anxiety disorders Post Traumatic Stress Disorder (PTSD) Depressive episodes Organic mood disorders Acute and Transient Psychotic Disorders Other behavioural syndromes Brittle Diabetes Eating Disorders (Anorexia, bulimia)

Diabetes and Depression


Cohort studies indicate a high prevalence of depression in patients with diabetes mellitus: Despite numerous investigations, the underlying pathophysiologies of the metabolic abnormalities are poorly understood. A possible role play: 1. the increased counter regulatory hormone release involved in glucose homeostasis 2. Alterations in the glucose transport function and 3. Increased inflammatory activation triggered by depression.
(Dtsch Med Wochenschr 2005 April 29; 130 (17) = 1097

Depression increases mortality risk in Diabetes

Depression should be considered a target for Diabetes management interventions.


The prevalence of centers for Epidemiological studies Depression (CES D) scores > 16, was higher in the Diabetic than in the nondiabetic cohort ( 26-3% vs 15.8%) Diabetes with CES-D scores of > 16 had 54% greater mortality than those with CES D scores > 16

No significant association between Depression and mortality in the non-diabetic population


Am J Epidemiol 2005; 161 = 652 - 660

Depressive symptomatology and Coronary Heart Disease in Type 1 Diabetes Mellitus

Recent evidence has suggested that Depressive symptomatology is a risk factor for the development of coronary heart disease (CHD) in patients with diabetes mellitus, although little is understood about mechanisms that may explain this association. Epidemiological studies show participants who reported the fewest depressive symptoms on the Beck Depression inventory at baseline examination were least likely to develop CHD over 10 years.
Health psychol. 2002; 21: 543-552

Treatment of Depression in Diabetes: Impact on Mood and Medical outcome


The efficacy of depression treatment with either pharmacological agents or psychotherapy has been demonstrated in the few available controlled trials. Depression has been associated with poor glycaemic control and with accelerated rates of coronary heart disease in diabetic patients. Reported depression treatment trials demonstrate benefits of depression remission on glycaemic control as well as mood and the potential for improvement in the course and outcome of diabetes. J Psychosom Res.2002; 53 : 917-924

Clinical assessment of suicidal intent

Low level risk


Clinical picture Suicidal ideation but no suicide attempts Action Consider referral to mental health professional for routine appointment (not always necessary)

Supportive environment Physically healthy No history of psychiatric illness

Clinical assessment of suicidal intent

Moderate level risk


Clinical picture
Low lethality suicide attempt (patient's perception of lethality) Frequent thoughts of suicide

Action
Refer to mental health professional, to be seen as soon as possible

Previous suicide attempts


Persistent depressive symptoms Serious medical illness Inadequate social support History of psychiatric illness

Therapeutic approach
Effective

treatment of depression is associated with a reduction in the high cardiac mortality.

1.Choice of treatment

Psychotherapy

Drug treatments

Criteria when choosing antidepressant medications.


1. 2.

3. 4.

5.

efficacy cardiac side effects e.g. tricyclic antidepressants weight gain anxiolytic action (Benzodiazepines ?!! ) SSRIs
hyponatremia hemorrhage interference of some cytochrome P450 isoenzymes

Evidence based summary


Depressive illness is an important cause of morbidity and disability in physically ill patients All patients with depression should be examined for suicidal ideation Depression is treatable in physically ill patients.

THANK YOU

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