Date: 7/4/2016 By: Mahmoud Mostafa

Contents : Why Physicians should be conscious ? Somatisation Pain Psycho Somatic

Contents : Psycho Somatic IBS Post Stroke Depression Diabetes Migraine Why Physicians should be conscious ?

Recognition of general practice patients Up to 50% of general practice patients may have some depressive symptoms. Approximately 5% of these will have major depression defined by DSM-III-R criteria. Freeling and Tylee (1992); Regier et al (1988); Vazquez-Barquero et al (1987)

How the Mood disorder patients present in the clinic Somatisation How the Mood disorder patients present in the clinic

90% of Mood disorder patients reported primarily somatic symptoms

General practice patients and recognised major depression How do patients with major depression usually present in primary care? Patients with major depression often present with predominantly physical (somatic) symptoms such as: significant weight loss, or gain insomnia or hypersomnia agitation or retardation fatigue or loss of energy The presence of physical symptoms reduces the likelihood of diagnosis by the GP. Many patients with major depression also have a physical illness. Blacker and Clare (1987); Bridges et al (1991); Freeling et al (1985)

Psycho Somatic disorder

Definition The co morbidity between chronic medical illness and depression or anxiety The first complain is the medical disease then symptoms of depression and anxiety appear As far as depression is there , the prognosis and treatment of medical illness will delay

The association between depression and medical illness Depression is associated with disability caused by a variety of diseases. Stroke Alzheimer’s disease Parkinson’s disease CNS Pulmonary Chronic obstructive pulmonary disease Cardiac Myocardial infarction Rheumatic Arthritis Gurland et al (1988)

IBS

World Wide IBS Prevalence ` 9-23% of worldwide patients suffering from IBS 12% of total visits of primary care providers due to IBS Women are 2.5 times more common to suffer than men 20-75% of individuals with IBS symptoms seek medical care for their symptoms Ref: International foundation for functional Gastrointestinal disorders IBS article by LIN Chang 2008 (1) Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi:10.1053/gast.2002.32392. PMID 11910364 (2)

World Wide IBS Prevalence ` 9-23% of worldwide patients suffering from IBS 12% of total visits of primary care providers due to IBS Women are 2.5 times more common to suffer than men Ref: International foundation for functional Gastrointestinal disorders IBS article by LIN Chang 2008 (1) Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi:10.1053/gast.2002.32392. PMID 11910364 (2)

IBS Co Morbid with Psychiatric Disorders psychiatric disorders were found to occur in 50-94% of IBS patients Rates of IBS in 60% of outpatients with dysthymia and in 27% with major depressive disorder Prevalence of co morbid IBS with Anxiety 39.2% & with Depression 42% Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi:10.1053/gast.2002.32392. PMID 11910364 (2) J Clin Psychiatry. 1995;56(8):363-367 (3)

IBS Co Morbid with Psychiatric Disorders psychiatric disorders were found to occur in 50-94% of IBS patients Prevalence of co morbid IBS with Anxiety 39.2% & with Depression 42% Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi:10.1053/gast.2002.32392. PMID 11910364 (2) J Clin Psychiatry. 1995;56(8):363-367 (3)

Co morbid IBS with Anxiety & Depression Abdominal Pain or discomfort Headache Pain Sharp dull gas-like Fatigue Backache Bloating Sleep problems Gut movement Palpitation Anxiety Depressed mood Ref: International foundation for functional Gastrointestinal disorders IBS article by LIN Chang 2008

Reason For Co Morbidity

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Choosing an Anti-depressant Considering drug profile. Considering patient profile.

Considering drug profile Efficacy of drug in treating the condition both acute & long term. Efficacy in treating any co-morbid conditions eg: anxiety ,panic….etc. Tolerability of the drug. Safety in overdose.

Cipriani Et Al Independently funded meta-analysis that compared the efficacy and patient acceptability of 12 antidepressants 117 randomised clinical trials (25 928 participants) from 1991 - 30th Nov. 2007 Included bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine Cipriani et al. Lancet 2009; 373 (9665): 746–758

Cipriani Et al Cont. Only assessed the acute treatment phase (first 8 weeks of treatment) in adults with unipolar major depressive disorder Side-effects, toxic effects, discontinuation symptoms, social functioning and cost-effectiveness were not considered Fluoxetine was used as the reference drug Cipriani et al. Lancet 2009; 373 (9665): 746–758

Primary outcome measures Response (proportion of patients who had a reduction of at least 50% from baseline on Hamilton depression rating scale or Montgomery-Åsberg depression rating scale or Who scored much improved or very much improved on the clinical global impression at 8 weeks) Acceptability (number of patients who terminated the study early for any reason during the first 8 weeks) Cipriani et al. Lancet 2009; 373 (9665): 746–758

Acceptability also differs between antidepressants Adapted from Cipriani et al. Lancet 2009; 373 (9665): 746–758 (Source: Patrick et al. J Fam Pract 2009; 58 (7): 365–369) OR=odds ratio, using fluoxetine as the reference medication

Post Stroke Depression

Depression increased mortality rate when associated with post stroke

Cipralex Enhances positive recovery from stroke

Diabetes

Depression as a Co morbidity to Diabetes: Implications for Management Diabetes and depression are debilitating conditions that are associated with significant morbidity, mortality, and healthcare costs. Coexisting depression in people with diabetes is associated with : Decreased adherence to treatment. Poor metabolic control. Higher complication rates. Decreased quality of life. Increased healthcare use and cost. Increased disability and lost productivity. Increased risk of death. diabetes research and clinical practice 87 (2010) 302–312 30

Depression affects negatively the glycemic control diabetes research and clinical practice 87 (2010) 302–312

Depression as a Co morbidity to Diabetes: Implications for Management overall people with type 2 diabetes have a 24% increased risk of incident depression compared with people without diabetes. Only 25% to 50% of diabetic patients with depression are identified in primary care. Diabetologia (2010) 53:2480–2486 2485 diabetes research and clinical practice 87 (2010) 302–312

Depression as a Co morbidity to Diabetes: Implications for Management diabetes research and clinical practice 87 (2010) 302–312

ADA Recommendations. The American Diabetes Association (2008) Advises regular screening for Depression throughout the course of diabetes management: at diagnosis, routine management visits, hospitalizations, when complications develop, or when problems with glucose control, quality of life, or adherence to self-care are identified.

Controlling depression improve all the diabetes related symptoms

Cipralex shows unsurpassed efficacy in treating comorbid depression and anxiety patients Vs Paroxetine. Boulenger et al. Curr Med Res Opin 2010; 26 (3): 605–614

Reaching complete remission with high baseline anxiety levels 10 20 30 40 50 60 70 80 90 100 Complete remission (MADRS ≤5) rate (%) Baseline HAM-A total score * ** Escitalopram Paroxetine All (n=451) >20 (n=280) ≥22 (n=254) ≥24 (n=201) ≥26 (n=166) ≥28 (n=120) ≥30 (n=84) ≥32 (n=67) *p<0.05; **p<0.01 (Fisher’s Exact test); LOCF Boulenger et al. Curr Med Res Opin 2010; 26 (3): 605–614

Cipralex® is better tolerated than Paroxetine †Incidence based on male patients only ‡Incidence based on female patients only ‡ † #p ≤0.05; ##p ≤0.01 # ## More patients treated with Paroxetine withdrew from the study due to adverse events three times than did patients treated with Cipralex13 Bielski et al. Poster presented at ADAA, 2004 38

Migraine

Cipralex Enhances the relief from headache

Drug-drug interaction: Interactions may arise when SSRIs are administrated with other drugs that share a common metabolic pathway via the Cytochrome P450 isoenzyme system. Many psychotropics – including SSRIs - inhibit to varying degrees specific Cytochrom P450 isoenzymes involved in the elimination of drugs. Escitalopram has a very low potential for drug-drug interactions, mainly because of the absent or very low inhibition of the Cytochrom P450 isoenzymes. (Speaker note: Regarding CYP 2D6 – in vitro data did not reveal an inhibitory effect of escitalopram. However, there are limited in vivo data suggesting a modest CYP2D6 inhibitory effect for escitalopram 20 mg/day.)

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