Consult Liaison Psychiatry: Comorbidity & interrelations of depression & medical illnesses

Transcription

1 Consult Liaison Psychiatry: Comorbidity & interrelations of depression & medical illnesses Dr. Lyndal Petit, MD, FRCPC, D.ABPN Assistant Professor, University of Ottawa CL Lead, Ottawa Hospital General Site Review Course: February 10 th 2015

2 Objective To discuss the comorbidity & interrelations of depression & medical illnesses.

3 Interrelation between Medical Illness and Depression

4 Interrelation between Medical Illness and Depression Depression and Medical Illness Interrelation Through: Mutual Etiological Mechanisms. Mutual and Reciprocal Risk Factors. Medication Factors. Psychosocial and Behavioral Factors. Common Predisposing Factors. Ramasubbu et al. (2012)

5 Interrelation between Medical Illness and Depression 1. Etiological Mechanisms: K&S (2009); Nemeroff and Sadek (2014); Ramasubbu et al. (2012) Common Etiological Factor - Heightened Stress Response HPA activation HPA hyperactivity causes/seen in depression. Depression associated with CRH and Cortisol. Immune system activation Inflammatory markers in depression (eg IL-1,6; acute phase reactants). Cytokines may induce/mediate affective sx similar to depression. Altered immune function in depression. Interferon (Immune mediated tx for Hepatitis/CA) causes depression.

6 Interrelation between Medical Illness and Depression 1. Etiological Mechanisms: Common Etiological Factor - Sympathetic Activity Depression and some medical illnesses increase sympathetic stimulation. Ramasubbu et al. (2012)

7 Interrelation between Medical Illness and Depression 2. Medical Illness is a risk factor for and can cause depression: Illness Specific Factor - Eg Neurotransmitters: Eg: Parkinson s Disease: Loss of DA neurons % develop a mood d/o, most commonly depression. Depression can be the first presenting sx. Illness Specific Factor - Eg CNS Damage: Eg: Demyelination: MS or B12 deficiency. Post-stroke: Up to 70% depressive sx, especially L frontal stroke. Nemeroff and Sadek (2014); K&S (2009)

8 Interrelation between Medical Illness and Depression 3. Depression is a risk factor for medical illness: Medical Illness CAD/Ischemic Heart Disease Ischemic Stroke Epilepsy Alzheimer s Depression increases the risk by: 1.5 to 2 fold. 1.8 fold. 4 to 6 fold. 2.1 fold. Diabetes Mellitus (type II) 60%. Ramasubbu et al. (2012) Cancer HIV 1.35 to 1.88 fold. Bipolar spectrum may increase HIV risk.

9 Interrelation between Medical Illness and Depression 4. Depression is a risk factor for worsening medical illness: Medical Illness Depression.. Ramasubbu et al. (2012) Cardiovascular Disease Stroke Epilepsy Diabetes Mellitus Cancer HIV Increases cardiac mortality fold. Predicts poor prognosis in CAD. Increases mortality by 3.4 fold. Adversely affect functional recovery. Increases burden from seizures. Decreases quality of life. Increase onset of vascular complications, functional disability, death. Increases mortality by 2.6 fold. Associated with illness progression to AIDS. Higher mortality rates.

10 Interrelation between Medical Illness and Depression 5. Medications Psychiatric Medications Medical Illness Eg: SSRI GI bleeds; SIADH. TCA QT prolongation Valproic Acid PCOS Non-Psychiatric Medications Psychiatric Illness Eg: Steroids Depression; Psychosis Chemotherapy agents (eg Interferon; Tamoxifen) Depression Ramasubbu et al. (2012)

11 Interrelation between Medical Illness and Depression 6. Psychosocial and Behavioral Factors: Lifestyle Factors Eg: Sedentary Lifestyle. Obesity. Smoking. Treatment Non-adhrence. Chronic Illness Burden Eg: Functional impairment. Loss of autonomy. Risk of death. Disability. Change in relationships. Role change. Financial problems. Ramasubbu et al. (2012)

12 Interrelation between Medical Illness and Depression 7. Common Predisposing Factors: Early adverse psychosocial events + perinatal problems risk for depression and comorbid medical illnesses. Ramasubbu et al. (2012)

13 Depressive D/O due to another medical condition

14 DSM V Depressive D/O Due to Another Medical Condition A. Prominent and persistent period of depressed mood or markedly diminished interest/pleasure in all/almost all, activities - predominates clinical picture. B. Evidence from Hx, P&E or Labs Disturbance is the direct pathophysiological consequence of another medical condition. C. Not better explained by another mental d/o. D. Not only during a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

15 Specifiers Depressive D/O Due to Another Medical Condition With depressive features Not meeting full MDE criteria. With major depressive-like episodes Meeting full MDE criteria (except for criteria C). With mixed features Sx of mania or hypomania present but do not predominate the clinical picture. DSM V

16 Approach to Diagnosis Depressive D/O due to another medical condition: Consider this if... Timing, exacerbation and remittance of dep sx relates to the medical illness. Etiology supports a link. Multiple medical illnesses. Findings on physical exam and on labs suggestive of the medical illness. Family hx of medical illnesses linked to depression. Atypical clinical picture: Onset > 40 yr old; Cog impairment; Personality changes; Emotional syndromes (eg emotionalism or catastrophic reactions). Neurovegetative symptoms present. Poor response to antidepressant treatment. No past MDD. No family hx of MDD. DSM V; Ramasubbu et al. (2012)

17 Approach to Diagnosis Do a good medical history: LOC, TBI or Falls, Seizures, Stroke Sleep Apnea/Snoring Infection history: Mono, Sexual Hx: HIV, Hep B/C, Syphilis. Nutritional status and Blood Problems, Anemia Thyroid Problems or other endocrine illnesses. Cardiac, Resp, GI, Neuro Cancer Family hx of degenerative or inheritable diseases - Huntington, PD. And do a physical exam!

18 Approach to Diagnosis - DSMV MDD, MDE: Consider this if MDE sx are not judged to be directly caused by a medical condition. Do not include sx clearly due to another medical condition. Assess non-vegetative sx with particular care. Ex: Dysphoria, anhedonia, guilt/worthlessness, impaired concentration or indecision and SI. Guilt, worthlessness and suicidal ideation more common in MDD. Personal or family history of MDD. DSM V

19 Approach to Diagnosis Relevance of a Primary vs Secondary Depression? Ultimately, the clinical presentation and course are similar. Common etiological mechanisms exist. They represent a continuum of depressive diathesis. Consideration for depression with comorbid medical illness. Ramasubbu et al. (2012)

20 Approach to Diagnosis - CANMAT Diagnostic Challenge Inclusive: Include all symptoms: False Positives. Best for Clinical Setting Exclusive: Take out somatic sx from criteria: False Negatives. Etiological: Including sx only if clearly not due to a medical condition: False Negatives. Substitutive: Substitute psychological sx for the somatic ones. Example: Replace: Fatigue, Sleep disturbance, Appetite/Weight change, Concentration problems With: Depressed appearance, social withdrawal, brooding, self-pity, pessimism and anhedonia. K&S (2009); Ramasubbu et al. (2012)

21 Differential Depressive D/O Due to another medical condition Primary Depressive Disorders Adjustment D/O, with depressed mood Consider pervasiveness of sx; # and quality of sx; MSE; Strength of link to the medical condition. Medication/Substance induce Depressive Disorder Clinical judgement based on evidence and on what is more important. May not be clear. Delirium or Dementia DSM V

22 Some Causes of Secondary Mood D/O Drug Intoxication Alcohol or sedative-hypnotics Antipsychotics Antidepressants Metoclopramide, H 2 -receptor blockers Antihypertensives (especially centrally acting agents, e.g., methyldopa, clonidine, reserpine) Sex steroids (e.g., oral contraceptives, anabolic steroids) Glucocorticoids Levodopa Bromocriptine Drug Withdrawal Nicotine, caffeine, alcohol or sedative-hypnotics, cocaine, amphetamines Infection Cerebral (e.g., meningitis, encephalitis, HIV, syphilis) Systemic (e.g., sepsis, urinary tract infection, pneumonia) Cardiac and Vascular Cerebrovascular (e.g., infarcts, hemorrhage, vasculitis) Cardiovascular (e.g., low-output states, CHF, shock) Physiological or Metabolic Hypoxemia, electrolyte disturbances renal or hepatic failure, hypo- or hyperglycemia, postictal states Endocrine Thyroid/glucocorticoid disturbances Nutritional Vitamin B 12, folate deficiency Tumor Primary cerebral Systemic neoplasm Trauma Cerebral contusion Subdural hematoma Demyelinating Multiple sclerosis Neurodegenerative Parkinson's disease, Huntington's disease K&S (2007)

23 Course Depressive D/O Due to Another Medical Condition Course is dependent Underlying Medical Condition Psychiatric Intervention Prognosis Dependent on the underlying medical condition. Best if reversible. May respond poorly to antidepressants and relapses more common. Suicide likely Primary depressive d/os. Ramasubbu et al. (2012)

24 Treatment Depressive D/O Due to Another Medical Condition 1. Treat medical cause. If possible, modify drugs that maybe contributing. Proper pain management. If the medical illness is chronic/not reversible Psychiatric Tx. 2. Select antidepressant on level 1 or 2 evidence. Document safety and efficacy of the antidepressant in the medical illness. If the level evidence is inadequate/inconclusive counsel the patient re this. Then select a medication following general guidelines. Ramasubbu et al. (2012)

25 Treatment Depressive D/O Due to Another Medical Condition 3. Avoid drugs with: Significant Drug Interactions 2D6 inh and some antiarrhythmics (mexiletine) Toxic antiarrhythmic levels. SSRI and ASA, Coumadin or NSAID Bleed. P-glycoprotein inh (Sertraline; Paroxetine) & Digoxin/Anticancer Toxic levels Interaction with medical illness TCA and heart block. Medication clearance in Renal and Hepatic Failure. QTc prolongation Eg: Ziprasidone Problematic Side-Effects Eg: Anticholinergic Drugs Ramasubbu et al. (2012)

26 Treatment Depressive D/O Due to Another Medical Condition 4. Match the drug with problematic neurovegetative sx. Pain: Action 5HT/NE: Duloxetine, Venlafaxine, Mirtazapine; Amitriptyline (low dose); Other: Gabapentin or Pregabalin. Poor appetite: Mirtazapine, Olanzapine, Quetiapine. Sleep problems: Mirtazapine, Seroquel, Trazodone. Energy poor, Apathy: Psychostimulants. Seizure: Lamotrigine if seizure and depression. 5. Start low and go slow. Ramasubbu et al. (2012)

27 Treatment Depressive D/O Due to Another Medical Condition Stimulants: Effect within 2-3d. Mainly Inhibits DA reuptake. Also some NE reuptake and 5HT effects. Often for Anergia or Apathy Methylphenidate: Usual dose is 5-10mg/d to a max of 30-40mg/d. Dextroamphetamine: Usual dose is 5-20mg/d (divided) Associated with motivation and collaboration with therapy.

28 Side Effects Relative Contraindications Action CVS: Incr. BP (slightly only) & HR Rare: HTN, Stroke GI: Wt Loss; Abd pain Anorexia Psych: Irritability, Labile Mood, Insomnia, Tics Rare: Psychosis, Mania, Dep. Other: Headache, Seizures, Incr. spasticity of upper motor neuron dz. Contraindicated: Symptomatic CVD. Mod-Severe/Uncontrolled HTN Advanced arteriosclerosis. Arrhythmia; Tachyarrhythmias Recent MI or angina Cardiac abnormalities/cvd Eating D/O Psychosis BAD I Contraindication: Hypersensitivity, Marked anxiety; Agitation; Glaucoma; Pheochromocytoma; Subs use d/o; Hyperthyroidism; Hx or Family Hx of Tourettes (Can worsen tics); MAOI use; Halogenated Anesthetics. Baseline BP. Monitor BP/HR EKG - if cardiac hx. Cardiology if: SOBOE, Syncope, Palpitations, Hx Cardiac dz, Fam hx sudden death. Monitor Ht, Wt; Take w/ food to avoid duodenal spasm. Monitor for mood and behaviour change. Check for drug-drug interactions before use. eg: SNRI, TCA, MAOI, AP, Warfarin

29 Treatment Depressive D/O Due to Another Medical Condition 4. ECT: Safe and highly effective. Consider especially for: Medication nonresponsiveness. Malnourished/dehydrated. MDD with psychosis Catatonia Previous good ECT response No absolute contraindications. Relative contraindications exist. Assess each case individually. K&S (2009)

30 Treatment Depressive D/O Due to Another Medical Condition 5. Psychotherapy Focus: Life Transition and loss of autonomy. Psychoeducation: On the relationship b/w medical illness and depression. Intrapsychic, interpersonal and familial issues addressed prn. RCT indicate psychotherapy is effective in: Cancer, HIV, CVD, Post-stroke. Outpatient: CBT (found effective post MI), IPT, Problems Solving Therapy (found effective post stroke). Ramasubbu et al. (2012); K&S (2009)

31 References Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. APA Arlington VA. Kaplan and Sadock. Kaplan and Sadock Comprehensive Textbook of Psychiatry. (2009). Kaplan and Sadock. Kaplan and Sadock s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. (2007). Nemeroff, C. & Sadek, N. Update on the Neurobiology of Depression. Medscape Psychiatry and Mental Health. Downloaded Jan Philbrick et al. Clinical Manual of Psychosomatic Medicine. A Guide to Consultation Liaison Psychiatry. Second Edition. APA. (2012). Arlington VA. Ramasubbu, et al. (2012). The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid metabolic disorders. Annals of Clinical Psychiatry 24: No