Treatment Considerations for Depression in Patients with Significant Medical Comorbidity

Treatment Considerations for Depression in Patients with Significant Medical Comorbidity David M. McCoy, MD Nashville, Tennessee In addition to being a strong psychological stressor in favors the use of selective serotonin reuptake inhibitors itself, medical illness is associated with risk factors that and other new antidepressants because they have fewer predispose patients to develop coexisting depression. anticholinergic, cardiac, or cognitive adverse effects. Patients with conditions such as cancer, cardiovascular Depressed medically ill patients clearly benefit from anti disease, and neurologic disorders are particularly prone depressant therapy. Because mental health influences to depression because these illnesses are severe, prognosis and treatment outcome, primary care physi chronic, and often fatal. Because an antidepressant may cians should maintain a high index of suspicion for exacerbate an underlying illness, leading to more seri depression in patients with significant medical illness ous side effects, agents with a poor tolerability profile or and aggressively treat the condition when indicated. that act at multiple receptor sites should be avoided. In many cases, this precludes the use of tricyclic antide KEY WORDS. Depression; comorbidity; drug therapy. J pressants and monoamine oxidase inhibitors, and Fam Pract 1996; 43(suppl):S35-S44 ajor depression is responsible for and treatment of depression in the family medicine more days in nonpsychiatric hospitals setting. and more days home from work than any other chronic illness except for RISK FACTORS severe, unstable coronary artery dis ease.1M Even though at least 8 million people in the Some medical disorders have clearly been associat United States become depressed in any given year,2 ed with higher incidences of depression. These only one third to one half of those with mtyor depres include cancer (1% to 50%),7" stroke (25% to 30%),”" sive disorder are properly diagnosed:' Family physi coronary heart disease (18% to 50%),1214 and cians have an increased burden to care for these Parkinson’s disease (4% to 70%).1WW7 These epi patients because 3 of every 4 mental health visits demiologic data concur with the results from other present initially to the primary care setting.1 studies, demonstrating that severe or chronic dis There is a trend toward increased prevalence of eases are associated with a higher prevalence of major depression in primary care clinics (5% to 10%) depression.618 Medically ill patients who are over 70 and inpatient medical wards (10% to 14%) compared years of age,19 hospitalized,20'21 or institutionalized22 with community samples (2% to 4%) (Figure l).6 In are also more likely to develop depression. view of these statistics, it is not surprising that patients with chronic medical conditions, such as DIAGNOSIS cancer, chronic lung disease, and arthritis, have a sig nificantly higher' lifetime prevalence of psychiatric It is expected that patients will react to a serious medical illness with some degree of demoralization disorders (46% to 60%) compared with patients with or dysphoria. It is important to note, however, that none of these conditions (33%; Pc.001).6 Thus, the noncompliance with or disregard for medical treat prevalence of depression in medically ill primary ment by patients is a significant indicator of depres care patients underscores the need for recognition sion.18 The diagnosis of depression should also be Revised, submitted September 30, 1996. considered when somatic symptoms are out of pro Address correspondence to David M. McCoy, MD, 394 portion to the illness or when the symptoms have a Harding PI, Suite 201, Nashville, TN 37211. The Journal of Family Practice, Vol. 43, No. 6 (Suppl), 199(1 S 35 © 1996 Appleton & Lange/ISSN 0094-3509 DEPRESSION IN PATIENTS WITH MEDICAL COMORBIDITY FIGURE 1 pie, insomnia, anorexia, and fatigue Relationship between the prevalence of depression and medical illness. Based are features that can be attributed to on data from Katon and Schulberg,5 either a medical illness or depres sion.24 Mood Disorder Due to a 15 10%-14% General Medical Condition is a disor der described in the DSM-IV as a per o sistent mood disturbance caused by M<7> the direct physiological effects of a 5%-10% Q.S 10 I general medical condition. Symptoms O Q associated with the mood disturbance o 'ro* may include a depressed mood, 2 diminished interest in activities, or I O<1) 2%-4% elevated or irritable mood.23 Specific _0) symptoms that differentiate depres > sion from manifestations of medical k.o CL illnesses include suicidal feelings, a sense of failure or hopelessness, the Community Primary Care Clinic Inpatient Medical Ward feeling of being punished, diminished social interest, crying, indecision, and dissatisfaction (Table 1).2M7 Psycho significant impact on functional status.18 Somatic motor retardation (with the exception of hypothy complaints that are exaggerated relative to the roidism and Parkinson’s disease) and feelings of guilt patient’s medical illness or that are persistent or and self-reproach are other features of depression unresponsive to treatment are an indication that that are not usual consequences of medical illness depression may underlie the medical illness.20 The es.4' presence of a prior depressive episode or a positive According to DSM-IV, a Substance-Induced Mood family history for affective disorder should also raise Disorder is a persistent mood disturbance that is the level of suspicion for depression. According to associated with the direct physiological effects of a the Diagnostic and Statistical Manual of Mental substance (ie, a drug of abuse, a medication, other Disorders, 4th edition (DSMTV),23 patients may be somatic treatment for depression, or toxin expo diagnosed with a Major Depressive Disorder if at sure).23 Thus, reviewing the medication profile can least five symptoms are present over a 2-week peri uncover potential iatrogenic sources of depression. od. One of the diagnostic symptoms must be either a Although a myriad of drugs have side-effect profiles depressed mood or the loss of interest or pleasure. that resemble depression,28 drugs of abuse (eg, opi Symptoms that may be present nearly every day ate, marijuana, and alcohol), antihypertensives (eg, include a depressed mood, diminished interest or pleasure in most activities, significant weight loss or TABLE 1 weight gain (eg, change of more than 5% of body Discriminators of Depression from Medical Illness weight), insomnia or hypersomnia, psychomotor agi tation or retardation, fatigue or loss of energy, feel • Guilt and self-reproach ings of worthlessness or inappropriate guilt, • Psychomotor retardation decreased ability to think or concentrate, or recur • Recurrent suicidal thoughts (except for dialysis and HIV) rent thoughts of death or suicidal ideation. • Sense of failure • Loss of social interest • Feeling punished D ifferential D ia g n o s is Depression may coexist with medical illness. • Persistent dissatisfaction • Indecision However, depression may also be a psychological • Recurrent or persistent episodes of crying response or a direct effect of a physical illness. Diagnosing depression in medically ill patients is fur HIV denotes human immunodeficiency virus. Based on data from ther complicated by medication side effects or symp Camaron25; Cassem26; and Clark, Cavanaugh, Gibbons.27 toms of the illness that mimic depression. For exarn- S 3 6 The Journal of Family Practice, Vol. 43, No. 6 (Suppl), 1996 d e p r essio n in pa tien ts w ith m e d ic a l comorbidity - TABLE 2 _______ _______________ reserpine, propranolol, and methyl- dopa), and corticosteroids are fre Medications That May Induce Depression quently implicated (Table 2). If drug- induced depression is suspected, Cardiovascular drugs Sedatives/tranquilizers a-methylclopa Barbiturates substituting an alternative agent or Reserpine discontinuing the drug altogether Benzodiazepines Propranolol Ethanol will quickly uncover a drug-related Guanethidine Major and minor side effect.29 C lonidine Age may be helpful in determin Thiazide diuretics Anti-inflammatory/ D igitalis ing whether depression or a physi anti-infective agents Hydralazine Nonsteroidal anti-inflammatory agents cal illness is the primary disorder. Procainamide Ampicillin Depression is more likely to devel Cycloserine op in patients who are young (usu Antineoplastics Dapsone ally in their third decade of life) Azathioprine Griseofulvin 6-Azouridine Isoniazid compared with older patients who L-asparaginase Co-trimoxazole develop medical illnesses (usually Bleom ycin Ethambutol in their fifth decade of life).25 C isplatin Disulfiram Depression and medical illness may Cyclophosphamide Sulfonamides develop concurrently, but it is also Doxorubicin Metoclopramide Mithramycin Metronidazole possible that depression is masking Vinblastine Nalidixic acid a newly developing medical condi Vincristine tranquilizers Nitrofurantoin tion, such as Huntington’s disease, Procaine penicillin multiple sclerosis, Cushing’s dis Anti-Parldnsonian drugs Streptomycin Tetracycline ease, Parkinson’s disease, systemic Amantadine Bromocriptine lupus, and human immunodeficien Levodopa Stimulants cy virus (HIV) encephalopathy.26 Amphetamines (withdrawal) For example, spontaneous crying is Antipsychotic drugs Caffeine indicative of severe depression, but Haloperidol Cocaine (withdrawal) Methylphenidate it can also be a manifestation of Fluphenazine neurologic disease.30 To reduce

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