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Treating Depression

October 5, 2013 By

My patient is a 25-year-old female with a first episode of depression. She presents with a depressed mood, unable to sleep at night, increased appetite with a 10-pound weight gain over the past two months, and she has no energy or interest in life anymore. She does not want to kill herself, but she wants to stop feeling so bad. How do I go about choosing an antidepressant for her?

SSRI’s are considered first line of treatment for most depressions. Generally, I choose an SSRI based on the side effects of each SSRI. Prozac is the only SSRI that is stimulating and decreases the need for sleep and can be associated with weight loss as it decreases appetite. Therefore it should be taken in the morning. It has the longest half-life of any SSRI and requires five weeks for complete elimination.

Zoloft and Celexa are considered sleep and weight neutral as they do not generally increase or decrease appetite or sleep. Though all SSRI’s can cause some initial gastrointestinal distress for the first 48 hours, Zoloft is probably the worst in this area. I therefore do not use it in someone with Irritable Bowel Syndrome, or other GI issues. Celexa is the most benign in terms of side effects, as long as the dose is 40mg or below. There is a black box warning against higher doses of Celexa due to QT prolongation risks at doses higher than 40mg. This is important in the event that my patient will need higher doses of SSRI’s. If their depression is severe, I would probably not start with Celexa for this reason.

Lexapro is the S-enantiomer of Celexa. It causes more sedation and weight gain than the other SSRI’s mentioned so far. It is helpful when my patients are having trouble sleeping or are losing weight due to a decrease in appetite from depression.

Luvox is an SSRI that is seldom used for depression, mainly due to its sedative properties. It is used more for OCD, though could be used for depression in patients with extreme difficulties with sleep.

Now, back to the patient… Given that she has symptoms of decreased sleep and increased appetite, we may not be able to target all her symptoms with one medication. Lexapro is sedating, which might make it a good choice with her decreased sleep, however it also increases appetite and since she has already gained 10 pounds we may not want to add to that weight gain. Celexa and Zoloft are both reasonable choices, and though they will not help her sleep immediately, as they begin to help her depression, her sleep should improve as well. Prozac is also a reasonable choice given her symptoms of increased appetite and decreased energy. However, her sleep may take more time to improve with Prozac. The way to get around this is to supplement the Prozac or Celexa or Zoloft with a sleep aid like Trazodone.

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Managing the Stigma of Mental Illness in the Office

August 5, 2013 By

Stigma is an attribute, behavior or reputation which is socially discrediting in a particular way. It is a potent, insidious, and negative force which grows like a weed. It strangles the forward movement of psychiatric treatment unless identified, “outted”, extracted by the roots on a daily basis. Those of us working in primary care and psychiatry need to become the “weed-eaters” of stigma.

The power of stigma surrounds us. The 50-year-old businessman with depression who admits to taking 20 years to come for treatment.  The ADHD child whose parents simultaneously point the finger at one another when asked about family psychiatric history. The psychiatrist who recalls a “complement” by an esteemed professor in training: “Why are you wasting your talents in the halls of Freud?” The psychiatrist who’s internist friend states: “We know you guys that go into psychiatry are a little crazy yourselves”.  Many patients are willing to endure considerable psychic pain to avoid treatment. A high achieving high-school graduate (GPA above 4.0) about to enter university with severe anxiety heaped on more difficult to identify, ADHD-inattentive subtype has compensated for her short attention span, distractibility, and procrastination by being driven by fear.  Why has she avoided treatment? “Because if I need treatment I am flawed. Because if I need treatment I am weak. Because my family taught me that these are secrets not to be shared.”

Patients are often ambivalent about treatment. They start treatment, feel better, stop treatment, feel worse, and then wonder why treatment is ineffective. Ambivalent patients and families usually assume they will be the recipient of the “dreaded” prescription. Prescription pad aside! Giving voice to the patient’s ambivalence demands that the patient commit himself to, or against, treatment. “Why not continue as you are? What is so bad about the life you are leading now? You won’t have to explain treatment to others, or keep it a secret. Yet you want to decrease your pain and improve your functioning! Saying “no” to treatment gives you a better chance of saying “yes” when the time is right!”  Supporting a patient’s ambivalence often makes it easier for the patient to move forward with treatment. Minimize pharmacologic expectations and maximize patient ownership of the treatment process.  Patients worry they will “become a zombie, become dependent on the medicine, not do the work myself, be weaker.    If medicine is like a shovel, it does not dig the hole itself…you have to do the digging.  If you have severe social anxiety and do not expose yourself to anxiety-provoking situations, medicine alone will not do the job for you.”

A 9-year-old boy diagnosed with ADHD refused to take his stimulant medication “because I did not want it to make me do my homework”.  Medicine, he thought, would force him to grip the pencil against his will and complete all of his homework which he desperately did not want to do.  Medication refusal often comes up in families where stigma remains the elephant in the room. A child may be asked to take a medication that a parent would not be willing to take. A parent may not show himself in the office because he does not “believe in mental health treatment”. It is often what is unsaid and unseen that is most powerful. Empathizing with the child helps parents see the child’s impossible bind.  By identifying stigma in the office, we help patients confront one of the largest obstacles to successful treatment and empower them to work towards physical and mental health.

(Joshua Lowinsky, MD Adolescent and Adult Psychiatrist is a partner at Children’s Resource Group in Indianapolis, a consultant to the Indianapolis Public Schools, and Co-founder of the Primary Care Psychiatry Foundation)

Filed Under: ADHD, Agoraphobia, Anxiety Disorder Due to Another Medical Condition, Anxiety Disorders, Bipolar and Related Disorder Due to Another Medical Condition, Bipolar and Related Disorders, Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, Depression, Disruptive, Impulse-Control and Conduct Disorders, Generalized Anxiety Disorder, insomnia, Panic Disorder, Selective Mutism, Separation Anxiety Disorder, Social Anxiety Disorder, Specific Phobia, Stigma of Mental Illness, Substance-Medication-Induced Anxiety Disorder, Substance-Medication-Induced Bipolar and Related Disorder

Depression – An Overview

July 21, 2013 By

Depression is very common. Women are twice as likely as men to get depressed and have approximately a 20% lifetime prevalence of depression while men have a lifetime prevalence of 10%. Most likely the percentage is higher in a PCC due to the fact that those who are depressed are also more likely to have medical problems, pain, and will request medical treatment.

Risk factors for depression include: a family history of depression, early parental death or loss, early trauma, history of childhood sexual abuse, history of disruptive childhood environments, recent negative stressful events, being female, lower socioeconomic status, separation or divorce, and the absence of a confidant.

Depression, known in the DSM IV as Major Depressive Disorder, is diagnosed through interviewing the patient. Certain symptoms, such as chronic pain, vague complaints such as muscle pain, fatigue, low energy, and head aches might be symptoms that would start to appear in a PCC. In our culture, it is much more acceptable for patients to present with physical pain rather than emotional pain. Emotional pain, or depression, is more ambiguous and difficult to describe. Other tools for diagnosis include how you feel when you see the patient: you might feel an emotional heaviness or you might get a “blah” feeling as you walk in to the exam room. This feeling should not be ignored as it is information about how the patient feels.  In Psychiatry, we call this feeling that we get from our patients countertransference.  However, some patients will do a very good job of covering up their depressed feelings and may appear fine, unless asked specifically if they have any symptoms of depression. Unfortunately, in the general population, depression is sometimes considered a moral weakness rather than a biological illness that requires treatment. It can be very reassuring to the patient to hear that depression is a real medical illness with biological factors that are beyond their control.

Diagnosis of depression requires only 2 things: an understanding of the symptoms and some time to interview the patient. The symptoms to look for include:

  1. Depressed mood
  2. Diminished pleasure in activities (also called anhedonia)
  3. Change in appetite (could be increased or decreased)
  4. Change in sleep (could be increased or decreased)
  5. Psychomotor agitation or retardation
  6. Fatigue or decreased energy
  7. Feelings of worthlessness
  8. Decreased memory or concentration
  9. Recurrent thoughts of death or suicide

In order to meet criteria for depression, one must have five of the above nine criteria for two weeks or longer.

The first line of treatment for depression is usually an SSRI.  There are many to choose from and are more or less equally efficacious.  We usually choose an SSRI based on it’s side effect profile in order to make the patient more comfortable.  If an SSRI does not work, we might either augment with another agent, such as buproprion, or switch to an SNRI, such as venlafaxine or duloxetine.  Some of the atypical neuroleptics have also shown efficacy as augmenting agents for depression.  Generally speaking, if a medication helped the patient some but not completely, the next step is to augment.  If the first agent did not help the patient at all, the next step is to change the medication to a different class.

Psychotherapy can also be very helpful for depression.  Cognitive behavioral therapy (CBT) has been shown to be very effective for the treatment of major depression.  The combination of pharmacological treatment together with psychotherapy has repeatedly been shown to be superior to either medication or therapy alone.  Therefore, the best form of treatment for a depressed patient is both medication and therapy.

If a patient does not improve after trying one or two antidepressants, it is probably a good idea to involve a psychiatrist in the treatment. Treatment-resistant depression is complicated and usually indicates a  medical or psychiatric comorbidity. Though the patient may initially be hesitant to see a psychiatrist, if the patient is severely depressed, they usually welcome the idea of seeing an ‘expert’ to help them feel better.

Joanna Chambers, M.D. is the Residency Training Director and Vice Chair for Education in the Department of Psychiatry at the Indiana University School of Medicine.  The statements in this post reflects her own opinions and do not reflect the opinions of the Department of Psychiatry or the School of Medicine.

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