Lecture to Medical Residents at Long Island Jewish Medical Center

1. Depression
in the Medically Ill
David Straker, D.O., FAPA, FAPM
Attending C-L Psychiatry
Psychosomatic Medicine Fellowship Director
North Shore-Long Island Jewish Medical Center
Attending C-L Psychiatrist,
Columbia University Medical Center, Lenox Hill Hospital

2. Key Points
 Many patients are “depressed”. May be an
Adjustment disorder or “minor depression”
 Often patients in ICU look depressed and
actually have hypoactive delirium
 Antidepressants take time to work
 Rule out Medical Conditions / Drug Induced
/ Substance Induced
 Does patient need a Psych Consult
 Does patient need a 1:1

3. Suicide Assessment
 Suicidal ideation, intent or plan
 Prior suicide attempts
 Command Auditory Hallucinations
 Anxiety (psychic), insomnia, panic attacks, Hopelessness
 Access to firearms
 Chronic Pain
 Family History of Suicide
 Over 45 years of age
 Male, divorced or widowed, unemployed
 Substance Use
 Borderline Personality Disorder

4. Treatment of Depression
 Discontinue meds that may cause depression
 Treat Medical Conditions that cause depression
 First Line SSRI’s
 Atypical antidepressants
 TCA’s / MAO Inhibitors
 Combination of Antidepressant Agents : receptors
 Augmentation : Lithium / Thyroid
 Stimulants – work fast
 Electroconvulsive Therapy (ECT)
 Folic Acid (Deplin), Vitamin B12

5. Medical Conditions
 Coronary Artery Disease
 Cancer
 Stroke
 Other Neurological Disorders
 Hypothyroidism
 Diabetes

6. Coronary Artery Disease
 16-23% depressed
 Depression is an independent predictor of morbidity
and mortality following the onset of CAD
 Increased risk of coronary events in patients who
are depressed
 Higher incidence of depression in patients with
CHF, post-MI, post CABG, and post angioplasty
 SADHART and ENRICHD trials: modest effects
noted. Sertraline safe, but little positive effects on
heart. ENRICHD – CBT and social support

7. Cancer
 10-30% prevalence of major and minor
depression
 Pancreatic #1
 Medications: interferon, interleukin,
corticosteroids, and vinca alkaloids
(vincristine and vinblastine)
 Very difficult to distinguish from medical
illness (especially fatigue, anorexia)

8. Neurological Disease
 Parkinson’s Disease
 Poststroke Depression
 Dementia’s
 Epilepsy
 Multiple sclerosis
 Huntington’s Disease

9. Parkinson’s Disease
 50% prevalence of depressive
symptoms
 Often dysthymic disorder and minor
depression rather than MDD
 Levo-dopa can cause depression
 Very difficult to distinguish from core
features of the illness itself. BDI is
helpful

10. Post-Stroke Depression
 Major depression ranges from 19.3%
(inpatient) to 23.3% (ambulatory)
 ? Associated with lesions in the left anterior
and left basal ganglia regions, although
recent meta-analysis failed to show this
 Evidence for TCA (nortriptyline) and SSRI
(celexa) as treatment
 Cardiovascular morbidity and mortality may
be reduced with the use of SSRI’s

11. Dementia
 Significant co-morbidity with major
depression
 20-32% prevalence of MDD in
dementia patients
 Treatment appears to have minimal
positive effects

12. Epilepsy
 20-55% of patients with recurrent seizures
but only 3-9% of those with well controlled
seizures have major depression
 Patients with Complex Partial Seizures have
17x prevalence of MDD than general
population
 Avoid wellbutrin, maprotiline, and
amoxapine as greater risk of seizures
 Phenobarbital and keppra can cause
depression

13. Other Neurological Disorders
 Multiple sclerosis: up to 50% of
patients and those on interferon (40%
of patients). Often during an acute
exacerbation or as part of chronic
progressive course
 Huntington’s Disease: MDD in up to
32% of patients

14. Endocrine Disorders
 Diabetes: 2x as common as the
general population; often effects the
illness, compliance, etc.
 Hypothyroidism: leads to depression
In patients who are depressed check
TSH. Also those on lithium who get
depressed; check thyroid

15. Medications and Depression
 See Table
 Mostly dose related, but as with
interferon at normal doses it is seen
 Most common: Accutane, Steroids,
Interferon, ? Beta Blockers, and
Anticonvulsants

16. Medications and Depression

17. Psychopharmacologic
Management
 SSRI’s
 TCA’s
 Other Novel antidepressants
 Augmenting Agents
 Herbal Meds / Vitamins

18. SSRI’s
 Watch p450 interactions
 Sedating (paxil) vs. activating (prozac)
 Paxil – 2D6
 Prozac – 2D6 and 2C9/19
 Zoloft (high doses) – 2D6 and 2C19 / 3A4 (less)
 Luvox – 1A2 and 3A4
 Lexapro and celexa: minimal to no drug interactions
 Zoloft: most dopaminergic and highest incidence of diarrhea
 Paxil inhibits its own metabolism and is the most
anticholinergic of the SSRI’s
 4-6 weeks to work

19. Rare, but Noteworthy Side
Effects of Antidepressants
 Hyponatremia – SSRI’s (elderly)
 Bleeding / Surgery
 QTc prolongation – Citalopram, TCA’s
 Seizures - Wellbutrin
 Liver Dysfunction – nefazodone,
duloxetine
 Serotonin Syndrome

20. Other Psychotropics
 Bupropion: Activating, work faster? / seizure risk
 Mirtazapine: good for sleep, helps appetite, helps nausea
(cancer pt.). Comes in dissolvable tablet
 Venlafaxine: caution with HTN, withdrawal
 Trazadone: orthostasis. Good for sleep
 Duloxetine: liver issues (rare)
 Lamictal: mood stabilizer, good anti-depressant effect.
Chewable tablets. Rash / SJS (rare)
 Seroquel: approved as augmenting agent
 Abilify: approved as augmenting agent. Dissolvable
 TCA’s: co-morbid pain. Side effects problematic, cardiac (QTc)
 Citalopram: QTc prolonged at high doses

21. Augmenting Agents
 Standard therapy : Lithium, thyroid
(T3), pindolol, buspirone
 Stimulants (anergic with SSRI’s)
 Opiates?
 Atypical Antipsychotics (prior slide)

22. Stimulants
 Methylphenidate (2.5 mg to 10mg often in divided
doses given early in the day): increase energy,
appetite, and elevate mood
 Dexedrine, Modafanil (Provigil), etc.
 Atypical / retarded depression
 Fast onset of action
 Stroke, HIV, and Cancer
 Mild, dose related side effects are agitation,
naseau, and insomnia. Tachycardia, psychosis and
hypertension may occur but are rare.

23. Herbal Medicines and
Vitamins
 St. John’s Wort
 Valerian Root
 SAME’s
 Omega 3 Fatty Acids
 Vitamins: Folic Acid and Vitamin B12

24. Folate and B12
 Should be checked in depressed patients
 Folic Acid extensively studied since 1940’s and
implicated in depression
 Low serum blood levels of folate detected in 15 –
38% of adults diagnosed with depressive disorders
 Study showed enhancement of antidepressant
effect by folic acid (fluoxetine) in a randomized
placebo controlled trial vs fluoxetine alone (Coppen
JAD 60, 121-130 2000)
 Deplin (L-methyl folate) 15 mg a day
 Vitamin B12 also implicated and should be
measured especially in treatment refractive patients

25. Other Treatments
 Electromagnetic Stimulation
(Transcranial MS)
 Vagal Nerve Stimulation
 ECT (“shock therapy”)
 CES (Cranial Electrical Stimulator)

26. Psychotherapy
 Supportive
 Psychodynamic
 Cognitive Behavioral Therapy
 Brief Psychotherapy (at the bedside)

27. Summary
 Rule out Medical Conditions
 Check Medication List
 R/O substance induced disorders
 Differentiate depression from neuro-
vegetative signs of medical illness
 Treat aggressively with medications,
therapy and use alternative /
complementary treatments when indicated