Depression is a major problem in primary care. At least 30% of patients attending clinic have major depression. However, majority of them are unrecognized or inappropriately treated leading to loss of productivity, functional decline and increased mortality. Diagnosing depression can be difficult as patients rarely present with symptoms that fit neatly into diagnostic taxonomies. Patients in medical settings usually present with physical, social and psychological problems along with somatic symptoms and the consulting doctor has to find out depressive illness from the above mentioned presenting problems. Consulting styles also influence whether depression is recognized. It has been found that doctors who ask open question initially (like enquiring about sleep pattern, mood etc.), give more time, are more empathetic, make more eye contact and interrupt less, are more likely to detect depression.
When to consider depression in the differential diagnosis?
The patients usually complain of depressed mood, diminished interest or pleasure in all activities, unintentional weight loss or weight gain, insomnia or hypersomnia nearly every day, early morning waking or interrupted sleep, feeling of guilt, worthlessness, loss of energy, lack of concentration and in severe cases, thoughts of death and suicide. In addition, there are certain co-morbid medical conditions, where depression is common and the clinician should positively look for evidence of depression if suggestive symptoms are present in such cases. These conditions are.
- Parkinson disease
- Cerebrovascular accidents
- Old Ml, chronic pain
- Diabetes mellitus
- Old age
Anxiety disorder like a phobia, panic disorder, obsessive-compulsive state, generalized severe anxiety is quite common presentations in general practice. These patients are also more vulnerable to depression and the clinician should be aware of this. Somatization is also an integral part of the presentation in depression. As the psychiatric definition of depression does not take into account somatic presentation, an astute clinician should be
aware of this fact and try to find out whether depression is the underlying cause for the somatization.
Majority of the depressive illness can be treated at primary care level (if the clinician is willing). However, some alarm signs should prompt the physicians for a prompt psychiatric referral.
If used appropriately, drugs are successful in more than 70% of cases. However, selection of medication is important. It was recognized in the 50’s that the depression was mediated mainly by the deficiency of monoamine neurotransmitters like serotonin, noradrenaline and dopamine. The major pharmacological manoeuvre involves increasing the level of these monoamines in the brain by either inhibiting the enzyme monoamine oxidase, blockage of autoreceptors that generate negative feedback on the release of neurotransmitters and blockage of the reuptake of the transmitter back into the nerve cell.
Monoamine oxidase inhibitors:
The initial drugs were monoamine oxidase inhibitors. However because of their side effect profile and drug interactions they are not used at least at the primary care level.
Nonselective serotonin and noradrenaline reuptake inhibitors:
The second group of drugs to come was tricyclic anti-depressant (non-selective serotonin and nor-adrenaline uptake inhibitors) which is being still used very commonly in the clinical practice. The problem with them is the non-selective nature of their receptor blockage and the resultant side effect profile. Commonly used drugs are:
- Amitriptyline – special indication if there is associated insomnia, chronic pain, migraine, postherpetic neuralgia.
- Imipramine – Enuresis, insomnia, panic disorder, post traumatic stress disorder, obsessive, compulsive state.
These drugs have an adverse effect on cardiac function and should be avoided in patients with cardiac problems. They have prominent anti-cholinergic side effects.
Selective serotonin and noradrenaline uptake inhibitors: Venlafaxine:
This is a comparatively new class of drug – devoid of cardiac side effects and has quick onset of action. This is also emerging as an effective treatment for anxiety disorder (so commonly associated with depression). Special indications: Anxiety, neuropathic pain, obsessive compulsive disorder. It can cause sedation and anti-cholinergic side effects but are less common.
Selective serotonin reuptake inhibitors (SERI):
- Citalopram – particularly helpful in post-CVA depression, diabetic neuropathy panic disorder, obsessive-compulsive disorders.
- Escitalopram – It is a comparatively new drug (isomer of citalopram) and has a very quick onset of action (compared to citalopram).
- Paroxetine – Post traumatic stress disorder, panic disorder.
They usually do not cause sedation. This group of drugs can cause both weight loss and weight gain. These are cardiac friendly drugs and can be safely prescribed in cardiac patients.
Mirtazapine – This is particularly helpful in anxiety and insomnia. It can also cause weight gain. It has got sedative potential.
Noradrenaline and dopamine reuptake inhibitors:
Bupropion – Particularly helpful in smoking cessation and post-traumatic stress disorder.
Serotonin antagonist and reuptake inhibitors:
Nefazodone – Panic disorder
Trazodone – Post-traumatic stress disorder, insomnia.
Common side effects of antidepressants:
TCA anticholinergic symptoms, weight gain, G.I. symptoms, sedation.
SSRI – insomnia, G.I. symptoms, Anorgasmia, SIADH. Trazodone – sedation, weight gain.
Mirtazapine – sedation.
Duloxetine – insomnia, G.I symptoms.
Bupropion – insomnia.
Sedative Properties of mirtazapine and trazodone may be used therapeutically in patients with insomnia while bupropion may be used additionally in patients with anorgasmia.
The use of antidepressants (SSRI) is controversial and their use should be individualized in patients with depression, the risk for suicide should be assessed and in risk patients, urgent referral to a psychiatrist should be done.
Few points to remember:
- Antidepressants will be effective in approximately 70% of cases.
- It may take 4-6 weeks before it may be fully effective.
- If within 6 weeks therapy there is no appreciable change, one drug can be substituted for another.(Failure of one drug does not necessarily mean that the other drug of the same group may not be effective).
- Wash out period is not necessary while changing from SSRI to another drug like venlafaxine or mirtazapine. (However abrupt withdrawal of SSRI may cause symptoms).
- SSRI should not be co-prescribed with sibutramine (appetite suppressants).
- All anti-depressants should be used with caution in hepatic disorders.
- If no appreciable change is noted with the 2nd drug, psychiatric opinion will be In anxiety disorders, although benzodiazepines are the most effective drugs, they should only be used for a very brief period because of dependence potential. One of the antidepressants with prominent anti anxiety effect should therefore be chosen for long term treatment of primary anxiety disorders.
When to refer to a Psychiatrist?
- If the patient needs specific therapy like prolonged counseling, conditioned behavior therapy then opinion of a psychiatrist should be taken
- If the patient is not responding to the use of two successive antidepressants over a period of 2-3 months.
- If the patients have evidence of psychosis like hearing voice or visual hallucination, have manic symptoms or judged to have high risk for suicide. Once the treatment has been successfully instituted, it should be carried out for at least 6 months. If thepatient has a high risk of relapse (i.e., past history of recurrent depression), the treatment should be continued for at least 2 years.
Risk factor for suicide:
- Old age
- Living Alone
- Associated co-morbid condition
- Previous attempts of suicides
Multiple Somatic Symptoms in a patient with anxiety disorder.
Stress anxiety Depression are major manifestation in clinical practice and may present with multiple bodily symptoms and are variedly called multiple somatic disorder, medically unexplained symptoms or functional disorder. This may present with various forms of symptoms involving different systems
Respiratory: Hyperventilation syndrome
Cardiac : Non-cardiac chest pain (De Costas syndrome)
Rheumatological : Fibromyalgia
Gastrointestinal: Irritable Bowel Syndrome
CNS: Tension headache
ENT: Globus hystericus
Maxillofacial : Atypical facial pain these symptoms should be differentiated from malingering which is deliberately and consciously done for some gainful purpose. In my clinical practice, I found multiple somatic symptoms are very common clinical presentation in outpatient practice and clinician should take a thorough history to make a diagnosis. A sympathetic and empathetic approach is essential for the treatment. They frequently need to refer to psychiatry colleague. The condition is treated with prolonged conversation and rational explanation, understanding the symptoms rather than ignoring them and reassurance should be given affirmatively. They frequently require SSRIs to treat the underlying anxiety. Cognitive behaviour therapy has been found to be helpful in similar conditions in the category of medically unexplained symptoms.
These symptoms should be differentiated from malingering which is deliberately and consciously done for some gainful purpose.
In my clinical practice, I found multiple somatic symptoms are very common clinical presentation in outpatient practice and clinician should take a thorough history to make a diagnosis. A sympathetic and empathetic approach is essential for the treatment. They frequently need to refer to psychiatry colleague.
The condition is treated with prolonged conversation and rational explanation, understanding the symptoms rather than ignoring them and reassurance should be given affirmatively.
They frequently require SSRIs to treat the underlying anxiety. Cognitive behaviour therapy has been found to be helpful in similar conditions in the category of medically unexplained symptoms.
Simple somatoform disorders
Somatisation disorder (Briquet’s syndrome)
Conversion reaction (loss of function of any part of the body)
While matching a diagnosis of somatoform disorder no stone should be unturned to rule out organic diseases, as many organic disorders may be initially present with non-specific symptoms and early investigation may be elusive. In my experience, I have come across some
Mitotic lesions like — Cholangiocarcinoma, pancreatic cancer, brain tumor,
Infections like — Tuberculosis, infective endocarditis,
Autoimmune disorders like — SLE, vasculitis,
Miscellaneous disorders like — Pheochromocytoma, cardiac arrhythmias and porphyria presenting like symptoms apparently suggestive of somatic disorder.