1. The Impact of Clinical Depression On Chronic Medical Conditions Stephen W. Robinson, MD Assistant Professor Clerkship Director and Inpatient Director Department of Psychiatry SIU School of Medicine July 7, 2009

2. “I’m sorry I failed”

3. “What is Clinical Depression?” It’s not “Having a bad day” It’s not “A sign of weakness” It’s not “Something to talk yourself out of” You can’t “Just get over it!!”

4. DSM-IV TR *Depressed Mood or *Anhedonia Weight change (5% of BW in one month) Sleep disturbance (increase or decrease) Motor disturbance (agitation v. retardation) Fatigue Worthlessness or excessive/inappropriate guilt Impaired concentration, indecisiveness Recurrent thoughts of death, SI, or suicide attempt

5. What Do We Know? CVD risk factors: HTN, DM, Smoking, FH, Males, Hyperlipidemia We know that depression is an independent risk factor for development of CVD and mortality in those with CAD and CHF –ANS dysfunction? Hyperactive Hypotham-pit axis? inflammation cytokines? 20-30% acute coronary events triggered by acute emotional states –PLT activation and Endothelial Dysfunction: can be ppt by emotional states as well S/P MI: Depression rates range 25-31%

6. What Do We Know? 30-50% Post Stroke develop depression Left sided CVAs (prefrontal and basal ganglia) associated with depression (“Left laughs”) 50% Outpatient visits for physical sxs not fully explained by medical causes 50% time Severity of physical sxs impacted by psychological factors, behavioral factors, personality->Type A in CHD

7. “The Association of Depression and Anxiety with Medical Symptom Burden in Patients with Chronic Medical Illness” Studied impact of depression and anxiety comorbidity with chronic medical disorders MEDLINE search 1966-2006 DM, CAD, CHF, COPD/Asthma. Osteoarthritis, and Rheumatoid Arthritis 31 studies approx 17K patients Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

8. General Methods for Depression and Anxiety Assessment Screening and Assessment tools, for depression and anxiety: Hamilton Scales for Anxiety and Depression HAM-D/ HAM- A, Hospital Anxiety and Depression Scale, Arthritis Impact Measurement Scales Structured Interviews Chart reviews DSM-IV TR Criteria

9. Medical Symptom Assessment CAD: Seattle Angina Questionnaire (SAQ) –Ejection fraction; Ischemia with stress tests –Multidimensional Pain Inventory (MPI) DM: Symptoms of Illness Scale (SOI) –Diabetes Scale CHF: Kansas City Cardiomyopathy Questionnaire RA: ESR, C-reactive protein, joint inflammation Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

10. Diabetes > 1 depression or anxiety disorder->Twice as many sxs of diabetes Depression independent risk factor for more DM complications –So as depression sxs increase, # of sxs increase. DM sxs tracked for 1 yr those with baseline depression->”sig higher number of sxs” DM self care significantly impacted by depression Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

11. Asthma/COPD Child Study –> 1 DSM disorder for depression or anxiety v. Asthma alone-> more asthma sxs over prior two week period and overall more respiratory sxs Adult Study –Measured asthma with spirometry found those with depression had greater dyspnea COPD: had similar findings; but found dyspnea related to degree of depression and not lung function on spirometry Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

12. COPD Comorbid depression associated with decreased physical sx burden When treated with nortriptyline had general improvement in somatic sxs but not dyspnea Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

13. CAD Stable CAD with comorbid depression-> more angina frequency and Greater sxs of depression increased angina frequency Angina was as strongly related to depression as exercise capacity with stress testing Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

14. CAD 6 Month F/U CABG and/or Valve operations Patients with pre-op depression and anxiety had greater cardiac sxs @ 6 months than those without Katon,Lin, Kroenke General Hospital Psychiatry 29(2007) 147-55

15. Arthritis Most studies focus on level of pain in association with depression and anxiety One study found that pain severity was more directly related to depression followed by number of inflamed joints Another: Depression and anxiety correlated with increased joint pain Third: Pain, fatigue correlated with increasing levels of depression

16. May 2009 APA Preliminary research from Michigan State University (D’Mello, Hawkins, et al) Response rates to antidepressants and CV risk? Compared CV risk in patient hospitalized with MDD and patients treated with ECT due to refractory to multiple medications with controls

17. May 2009 APA Smoking, Obesity, HTN Dyslipidemia, and DM were all higher than controls Those with Obesity, HTN Dyslipidemia, DM were twice as likely to be unresponsive to antidepressants Those with CV disease had later onset depression and had likely been refractory to many antidepressant medications Healthy lifestyle impact? Self-report and not peer-reviewed for publication

18. American Heart Association June 2009 Publication (“Circulation”) Ischemic heart disease with comorbid depression and anxiety more likely to suffer chest pain than those without 4wk F/U:Seattle Angina Ques.& Self Assessment scales for depression/anxiety Anxiety->4 times likely to have angina Depression->3 times likely –Depression and anxiety cause a reduction in inhibitory pain pathways? Monitor angina pts for depression/anxiety possibly related to frequency of CP

19. Management Issues Other Psychological/ Psychiatric Issues “Anti-Medicine” Noncompliance Education Issues: Technology; side effects Family Dynamics Psychotic Disorders Reducing risk of underlying depression –PCPs: Assess for these disorders!! –Medications –(i.e. Nortriptyline most studied; poss. more effective? SSRIs effective and safer) –Psychiatric Consultation –Therapy: CBT, Supportive, Interpersonal