Depressive syndrome and ischemic cardiopathy

The prevalence of ischemic heart disease and depressive syndrome in the occidental population is high. Clinical depression appears to be an independent risk factor for coronary heart disease. Depression after an acute coronary event exerts a profoundly negative effect on quality of life and is related to poor prognosis (increased mortality rates and further cardiac events). Moreover, medical therapy in patients with ischemic heart disease and depressive symptoms is not free of problems. The purpose of this review is to present the relationships between depression and cardiovascular disease on the data collected from different studies and make recommendations for improving assessment and treatment of depressive symptoms in the family practice, internal medicine or cardiologist setting. Only an interdisciplinary integration among basic scientists and clinicians, will decrease the comorbidity.     

Depression in the elderly. Characteristics and clinical management

Major depression and clinically significant depressive symptoms occur commonly in the community-dwelling, medically ill, and institutionalized elderly. Both major depression and depressive symptoms need thorough evaluation and treatment because of the significant morbidity and mortality associated with these syndromes. Depression may be difficult to diagnose, especially in the medically ill elderly, because of the masking of depressive symptoms by somatic complaints or the presumption that symptoms are attributable to concurrent medical illness. Therefore, the clinician must be alert to the possibility of depression in the elderly patient. Although no specific diagnostic test is available, rating scales can be useful in screening for depression in the elderly patient. It is necessary to rule out medical illness or medications as contributing factors to depression. Psychotherapy and psychopharmacology, alone or in combination, are effective treatments for most elderly patients with depression. ECT is a safe and effective treatment for major depression in this population. Depression in the elderly is potentially a chronic and relapsing illness with significant associated medical and social morbidity. Because of their frequent contact with the elderly, nurses play a particularly important role in the diagnosis and treatment of depression. They need to recognize typical and atypical symptoms of depression and must be familiar with the potential side effects of antidepressant treatment. Close monitoring for these potential side effects can minimize disability. By working as a team with physicians, psychologists, and others, nurses have a necessary role in the care of the elderly depressed patient.     

Depressive disorders in older medical inpatients

Symptoms of depression that are temporary or caused by physical illness can be difficult to differentiate from those that represent a depressive disorder. A diagnosis of depressive disorder depends on the underlying cause, and on the nature, severity and duration of symptoms. Management involves accurate diagnosis and treatment of medical illness, practical interventions to resolve concurrent family, social and economic stressors, and emotional support. Cognitive, behavioral and brief psychodynamic therapies may be helpful in selected cases. Antidepressants and electroconvulsive therapy have a role in the treatment of severe or persistent depression associated with suicidal behavior, marked psychomotor retardation, starvation or other life-threatening symptoms. Suicidal thoughts are frequent in older patients with concurrent major depression and chronic illness, and measures to ensure patient safety are a priority.     

Assessing psychiatric illness in geriatric patients

Assessing psychiatric illness in geriatric patients can be difficult for a variety of reasons. First, medical comorbidity may obscure the diagnosis. For example, the patient with multiple chronic illnesses will often have many "vegetative" symptoms of either dementia or depression (e.g., fatigue, loss of energy, poor appetite) attributed to the primary medical condition rather than to an underlying psychiatric illness. Second, the phenomenology of psychiatric illness in the elderly is often different. For example, depression in the elderly is often characterized by prominent anhedonia--loss of interest in virtually everything--and physical complaints leading to an unnecessary medical workup. Third, physicians are often reluctant to diagnose new-onset mental illness in their elderly patients. The fear of stigmatizing the patient or physician discomfort with "psychologic language" often results in underdetection of straightforward psychiatric syndromes. This article will focus primarily on detection of 3 of the most common psychiatric syndromes: dementia, depression, and delirium. The field of geriatric psychiatry has done a good job of characterizing the prevalence (Table I) and clinical features of these syndromes. The problem--briefly addressed here--is how to incorporate some of these findings into a busy clinical practice where there is very little time for the assessment of psychiatric symptoms.     

Primary care for depression

Depressive patients often visit a primary care physician due to various physical symptoms. Though it is necessary to differentiate organic diseases, it is also important to approach from a viewpoint of psychosocial background and psychiatric disorders. Especially, as mild depression is seen widely in general practice, early diagnosis and early treatment is essential for its good prognosis and medical economics. So, primary care physician is expected to understand its symptomatology and treat depressive patients appropriately. Finally, I want to say that the cooperation between primary physician and psychiatrist is important, because typical bipolar disorders and severe depressive patients should be refer to psychiatry clinic.     

系统健康教育与心理干预对哮喘患者抑郁和躯体症状的影响

目的探讨健康教育与心理干预对哮喘患者抑郁和躯体症状的影响,为推行健康教育及心理干预提供参考依据。方法采用目的抽样法选取2007年3月至2008年3月某院确诊的48例支气管哮喘伴抑郁的患者,按随机数字表法将其分为干预组（n=24）和对照组（n=24）;对照组患者给予常规药物治疗、健康教育及心理干预;干预组患者在常规药物治疗的基础上进行系统地健康教育及心理干预,总疗程3个月。治疗前后两组患者均采用抑郁自评量表（self-rating depressivescale,SDS）、汉密顿抑郁量表（Hamilton depression rating scale,HRSD）进行评估,并对患者躯体症状改善情况进行分析。结果支气管哮喘患者中治疗前合并抑郁者占60%（48/80）。经过健康教育与心理支持治疗3个月后,两组患者的SDS、HRSD评分均低于治疗前（均P〈0.05）,且干预组与对照组比较,差异均有统计学意义（均P〈0.05）。干预组患者的躯体症状改善情况优于对照组,差异有统计学意义（P〈0.05）。结论支气管哮喘患者常合并抑郁,健康教育与心理干预不仅有助于支气管哮喘患者改善抑郁症状,而且有益于患者躯体症状的改善。     

Assessment and treatment strategies for depressive disorders commonly encountered in primary care settings.

Frequently overlooked, depression is a very common complex disorder that causes significant morbidity and mortality. This article provides a review of three commonly encountered depressive disorders in primary care settings: adjustment disorder with depressed mood, dysthymia and major depression. Since many individuals minimize the affective symptoms of depression, clinicians must maintain a high index of suspicion when clients present with vague somatic complaints, such as fatigue, headache, constipation and difficulty sleeping. To reach an accurate diagnosis, a thorough history, physical examination and appropriate laboratory studies should be performed. Numerous rating scales are presented to aid assessment. Common intervention strategies for the treatment of depressive disorders include education, drug therapy, and supportive individual and family counseling.     

Psychiatric Morbidity and Depressive Symptomatology in Patients with Permanent Pacemakers

Implantation of a permanent pacemaker requires a psychological effort on the patient's part for adaptation in the acute term, and chronically, it restricts activities of the patient and may cause some psychiatric disturbances. To investigate psychiatric morbidity and depressive symptomatology of the patients with permanent pacemakers, 84 pacemaker patients were diagnosed using the DSM-III-R criteria and depressive symptoms were determined by modified Hamilton Depression Rating Scale (mHDRS). Sixteen (19.1 %) patients had been given a psychiatric diagnosis. The most frequent diagnoses were adjustment disorder (5.9%) and major depressive episode (4.7%). Nine patients (10.7%) were diagnosed as having clinical depression (mHDRS ≥ 17). The mean score of mHDRS was 7.57 ± 7.46, and the severity of depression was significantly higher in females. The most frequent symptoms are difficulties in work and activities (53.6%), psychic anxiety (48.8%), loss of energy (42.9%), and hypochondriasis and insomnia (39.3%). Depressed mood, psychic anxiety, loss of energy, loss of interest, insomnia, and hypochondriasis were significantly more frequent in females. Uneducated patients had a more significant loss of energy than educated patients. Depressed mood, psychic anxiety, and somatic concerns and symptoms were more frequent in patients with permanent pacemakers than in the general population. These symptoms, resembling mixed anxiety-depression disorder, were related to fears of having a permanent pacemaker, since our series were composed of uneducated patients who did not have enough knowledge about the device.     

Depression in schizophrenia: nursing care as a generalized resistance resource

Although depression can be a feature of acute psychosis and an aftermath of a psychotic episode (postpsychotic depression), data indicate that depressive syndromes in schizophrenia can be found years after the immediate postacute phase. Researchers acknowledge the clinical importance of recognizing that depressive symptoms are frequently described in patients diagnosed with schizophrenia. Using the framework of Antonovsky's (1972, 1987, 1992) Sense of Coherence as a guide, this article explores what nurses can do to facilitate development of generalized resistance resources (GRRs) in the physical, psychological, and emotional armamentarium of those diagnosed with schizophrenia, mood disorder not otherwise specified (NOS).     

Considerations in the management of the patient with comorbid depression and anxiety

PURPOSE: To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting. DATA SOURCES: Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR. CONCLUSIONS: Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services. IMPLICATIONS FOR PRACTICE: This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.     

Depression and suicide assessment

Depressed patients and suicidal patients are common Emergency Department patrons with the potential for serious morbidity or death. Dysphoric mood, vegetative symptoms, and negative perceptions of oneself, the environment, and the future are characteristic of depression. Often, the patient is unaware of the depression and presents with a variety of somatic complaints, chronic fatigue, or pain syndromes. In these instances, the physician must consider the diagnosis of depression and ask the patient about any history of depressive symptoms. In all depressed patients, a careful history and physical examination are needed to identify any drugs or concurrent medical illnesses which might cause or exacerbate the depression. If depression is suspected or if the patient presents after a suicide attempt, then a thorough evaluation of suicide potential is mandatory. Several risk factors for completed suicide exist. Male sex, age under 19 or over 45, few social supports, and a history of previous suicide attempts are all factors associated with increased suicide rates. Concurrent chronic or severe medical illnesses and certain psychiatric illnesses, notably depression, schizophrenia, and substance abuse, also increase an individual's risk for suicide. The method of suicide attempt and the chance for rescue must also be considered when determining risk as well as the presence of an organized plan. Acute psychosis in the suicidal patient is an ominous finding and these patients should be admitted to the hospital. The physician must adopt an empathetic and nonjudgmental attitude when caring for potentially suicidal patients. Disposition can be determined after careful evaluation of risk factors, circumstances surrounding the attempt, and the patient's current feelings. Consultation with a psychiatrist or another mental health professional is desirable for any potentially suicidal patient. Many such patients can be safely treated as outpatients with proper referral; certain high-risk individuals will need to be admitted to the hospital. The decision to either hospitalize or discharge can be difficult and the emergency physician should admit the patient if doubt exists.     

Clinical aspects of depression in chronic pain patients.

It has been widely recognized that an appreciable proportion of chronic pain patients have depressive disorders. Although numerous studies and several literature reviews have examined the relationship between chronic pain and depression, disorders of mood come in many forms, and little attention has been paid to the different types of depressive disorders found among patients with chronic pain. In this article, the different ways in which a chronic pain patient may manifest depression are discussed. Diagnostic criteria for major depression, dysthymia, and atypical depression are described, and the relevance of these disorders and of masked depression to chronic pain is discussed. The medical illnesses and medications that can cause symptoms of depressive disorders are also briefly described. Depressive disorders and their concomitants are an integral part of the experience of chronic pain and are important in developing an optimal treatment plan. For these reasons, they should be carefully evaluated in all patients with chronic pain.     

Bipolar spectrum disorder: differential diagnosis and treatment

Bipolar disorder commonly presents as a recurrent mood disorder characterized by frequent depressive episodes. Although manic or hypomanic phases are required for the diagnosis to be made based on current diagnostic criteria, a wider expression of mood instability and other historical features or family history may suggest the presence of a bipolar spectrum illness. This article covers the diagnostic issues related to bipolar disorder and the spectrum concept of the illness. A new definition of bipolar spectrum disorder is suggested, and treatment principles and options are discussed. Primary care providers often encounter patients who have depression and mood problems, placing them in a key position for the diagnosis and treatment of this psychiatric illness.     

Treating persistent depressive symptoms in post-ACS patients: the project COPES phase-I randomized controlled trial

Depression and sub-syndromal depressive symptoms are important predictors of morbidity and mortality after acute coronary syndrome (ACS). Prior trials of depression treatment in post-ACS patients have demonstrated no improvement for event-free survival, and only modest improvement in depression symptoms. These trials have raised a number of important issues regarding timing of depression intervention, acceptability of depression treatment to ACS patients, and safety for subsets of the treated population. This article describes Project COPES (Coronary Psychosocial Evaluation Studies), a multi-center Phase-I randomized clinical trial. Project COPES uses a patient preference depression treatment that has previously been found acceptable to medical patients, and a 3-month pre-randomization observation period to insure depression status. The study sample will include 200 post-ACS patients. The primary outcome is patient satisfaction with depression care. Secondary, exploratory aims include the acceptability of depression treatment, reduction in depressive symptoms, and the effects of treatment on two key pathways--medication adherence and inflammation--hypothesized to link depression to post-ACS prognosis. These analyses will provide important data to inform subsequent clinical trials with this population.     

Chronische Schmerzen aus psychiatrischer Sicht

Epidemiological studies suggest a high comorbidity of pain disorders and major depression. This has been shown for somatoform disorder, fibromyalgia syndrome, migraine and neck pain. However, a dual diagnosis is still rare as patients predominantly report somatic symptoms during physical examination. Nevertheless, such a comorbidity is reflected on a brain systems level as chronic pain and depressive symptoms are mediated by similar brain structures. Over the past years modern imaging techniques have been able to underline the efficacy of psychotherapeutic and psychopharmacological treatment for chronic pain disorders by demonstrating a normalization of dysfunctional brain circuitries that accompanies a relief of clinical symptoms. Specifically, antidepressants increasing synaptic serotonin and noradrenalin levels as well as cognitive behavioral therapy are currently considered to be most efficient in the treatment of chronic pain from a psychiatric point of view.     

The effect of depressive symptoms on survival in peritoneal dialysis patients.

OBJECTIVE: There is little information on the relationship between depressive symptoms and survival in peritoneal dialysis (PD) patients. We examined whether a single measurement of depressive symptoms using a simple self-administered tool predicts survival. DESIGN: Screening test of depressive symptoms as a predictor of outcome. SETTING: Three dialysis centers in Southwestern Pennsylvania. PARTICIPANTS: 66 adult PD subjects were screened in 1997-1998 for depression using the Zung scale. MAIN OUTCOME MEASURES: Baseline data collection included assessments of comorbidity, residual renal function, total Kt/V, nPNA, previous renal transplant, and serum albumin. Outcomes were collected prospectively after completion of the depression survey to 12/01. Cox regression analysis of patient survival was performed using all cofactors with p < 0.05 on univariate analysis. RESULTS: One third of patients had depressive symptoms. Compared to nondepressed patients, depressive symptom patients were older (62.5 vs 52.5 years, p = 0.012), had borderline lower serum albumin levels (3.47 vs 3.70 g/dL, p = 0.058), and were more disabled (Karnofsky score 70 vs 90, p< 0.001), but had similar Kt/V, residual renal function, and previous time on PD at the point of the testing. Using multivariate analysis and controlling for comorbidity (using a measurement that includes diabetes mellitus and age) and serum albumin, the survival of patients with depressive symptoms was significantly reduced compared to nondepressed patients. CONCLUSION: A single measurement of depressive symptoms using a simple self-administered test was an independent predictor of death in a cohort of PD patients, which extends observations in hemodialysis patients. Screening for depressive symptoms should be routine for dialysis patients, and those depressed should have thorough assessment and treatment. Whether treating depression will have an impact on survival is unclear and needs to be studied.     

Sertraline effectiveness and safety in depressed oncological patients

Goals of work Cancer is often burdened by psychological comorbidity, mainly represented by depression, anxiety and adjustment disorders. Efficacy and tolerability of sertraline in the treatment of depressive disorders is well known; however, its efficacy and safety in patients with cancer has been poorly studied. This study was aimed to provide evidences of effectiveness, safety, tolerability and rapidity of action of sertraline in a population of oncological outpatients affected by mood disorders and its effects on quality of life. Materials and methods Thirty-five adult cancer outpatients with mood depression, during chemotherapy, were enrolled to a 12-week trial with a flexible dose regime of sertraline. The treatment response was assessed at baseline, week 4 and week 12, with hospital anxiety and depression scale (HADS) and Montgomery Asberg depression rating scale (MADRS), to rate depression and anxiety; mini mental adjustment to cancer scale (Mini-MAC), to assess the psychological response to the diagnosis of cancer; clinical global impression (CGI) to evaluate severity of illness; dosage record and treatment emergent symptom scale (DOTES), to assess the adverse effects of the clinical treatments and their possible relation with the drug used; and QL index to rate quality of life. Main results Both mean depression scores, analysed by HADS and MADRS scales, and HADS anxiety scores significantly decreased during the 12 weeks of study. Mean MINI-MAC scores show that hopelessness and anxious preoccupation decreased significantly at T2 compared with T0. No severe adverse effects were observed. Conclusion In this preliminary study, sertraline was found to be effective and well tolerated in the treatment of depressed outpatients with cancer.     

Case-finding for depression among medical outpatients in the Veterans Health Administration

OBJECTIVES: We sought to determine the rates and predictors of screening, screening positive, follow-up evaluation, and subsequent diagnosis of depression among medical outpatients. RESEARCH DESIGN: This was a cross-sectional study using chart-review data from the Department of Veterans Affairs (VA) 2002 External Peer Review Program merged with administrative data. SUBJECTS AND MEASURES: We studied a national sample of VA medical outpatients with no depression diagnosis or mental health visits in the past 6 months (n = 21,489) and used chart-review and administrative data to follow the chain of events from depression screening to diagnosis. RESULTS: Overall, 84.9% of eligible patients (n = 18,245) were screened for depression in the past year. Of the 8.8% who screened positive, only 54.0% received follow-up evaluation and, of these, 23.6% (n = 204) subsequently were diagnosed with a depressive disorder (representing 1.1% of the originally screened sample). Patients who were younger, unmarried, and had more medical comorbidities were less likely to be screened; however, if screened, they were more likely to screen positive. Male gender and greater medical comorbidity were associated with decreased odds of follow-up evaluation after a positive screen. At the facility level, likelihood of depression screening was inversely associated with spending on teaching and research but positively associated with spending on mental health care. CONCLUSIONS: VA's depression case-finding activities yielded relatively few positive cases, raising questions about cost-effectiveness. Targeted strategies may increase the value of case-finding among patients at greatest risk for depression and at more academically affiliated medical centers. Targeted efforts also are needed to ensure proper follow-up evaluation of suspected cases, particularly among male patients and those with increased medical comorbidity.     

Symptomatology and diagnosis of depression

It is characterized by mainly depressive mood and psychomotor retardation. Another symptoms are retardation of thought, diurnal change, anxiety, irritability, delusion of belittlement, etc. There are often somatic symptoms as loss of appetite, sleep disturbance, loss of body weight, constipation, etc. Depressive symptoms are often seen in schizophrenia, brain injury, endocrinosis illness and other somatic illness. Diagnosis of depression is carefully carried out by detailed interviews and symptoms. Recently diagnosis of depression is determined mechanically by DSM-IV or ICD-10. Neuro-endocrine tests as DST or Dex-CRH test, are useful strategies in examination of depression.