Depression and Medical Illnesses

Depression Plus Medical Illness

Is it serious?

Poor outcomes of the medical illness
Increased mortality in cardiovascular disease, stroke, diabetes, and ?cancer
Chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.
Worse adherence to medical regimens, tobacco smoking, sedentary lifestyle, and overeating.
Increased functional disability, decreased self-care.
Four to five times greater levels of morbidity, premature mortality, health services use and health care expenditures compared to non-depressed patients with no GMC.

Lin EH. Et al. Gen Hosp Psychiatry. 2006;28:482-486

4 of the following (3 with both depressed mood and loss of interest or pleasure)

Physical
1. Sleep disorder
2. Appetite/weight change
3. Fatigue
4. Psychomotor retardation/agitation
Psychological
1. Low self-esteem/guilt
2. Poor concentration/indecisiveness
3. Thoughts of death/suicidal ideation
4. Depressed mood
5. Loss of interest/pleasure

Inclusion approach: “count” all physical symptoms as part of depression even if possibly explained by the medical illness (to give patients, the benefit of doubt, by treating serious disabling illness like depression).
Etiological approach: exclude symptoms if physically-based
Substitutive approach: modify criteria
Exclusion approach: used in research setting.

Depressive disorder due to another medical condition.
Substance-induced depressive disorder, iatrogenic versus other illicit substances.
Bipolar I/II disorder, most recent episode depressed.
Major depressive disorder (unipolar).
Persistent depressive disorder (Dysthymia).
Adjustment disorder with depressed mood (common in medical setting).

Historically, depression in the medically ill was often considered a natural and expected response to medical illness.
Treatment of depression was often considered secondary to treatment of the medical illness, if the depression was even treated at all.
Today, this perspective can no longer be accepted.
Depression is a systemic disease.
The effect of depression on the course of medical illness is multifaceted because there are systemic pathophysiologic implications, as well as psychological and behavioral ramifications.
The accurate diagnosis and appropriate treatment of depression in the medically ill improves quality of life, enhances the patient’s ability to be actively engaged in his or her treatment, decreases symptom quantity and severity, and decreases cost utilization.
Most important, it decreases morbidity and mortality.

Most psychotropic tx are fat soluble, easily pass the BBB, not dialyzable, metabolized primarily by the liver, and excreted mainly in bile.
Monitor decline in renal function, especially in elderly; CKD progression is often non-linear.
Try to avoid nephrotoxic drugs in CKD patients (e.g. lithium).
Start at a low dose and increase slowly.
Majority of patients with ESRD both tolerate and require ordinary doses of most psychotropic tx.
Try to avoid long-acting drugs (e.g. depot), polypharmacy, tx with anticholinergic effects, prolong QTc.
Monitor weight carefully.
Be vigilant for serotonin syndrome and NMS; as rhabdomyolysis can cause renal failure.

The Maudsley Prescribing Guidelines in Psychiatry, 14th edition, 2021

To guide pharmacotherapy in liver disease, use Childs-Pugh scores with closer monitoring to help to increase safety and tolerability.
Prescribe as few drugs as possible (monitor drug interactions).
Start at a low dose and increase slowly and stop at lower doses as most psych tx are extensively hepatically metabolized.
Consider the implications of low albumin on highly protein-bound drugs, and ascites on water-soluble drugs.
Avoid long-half life tx, pro-drugs, sedative/constipating (risk of hepatic encephalopathy), hepatotoxic tx.
Choose a low-risk drug and monitor LFTs initially weekly.

The Maudsley Prescribing Guidelines in Psychiatry, 14th edition, 2021