Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Need to improve detection rates of depression in medically ill
- Vivek Khosla (24 July 2002)
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Depression in medical patients and Need to Improve Rates
- Catherine W. Striley (25 July 2002)
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Detection is not enough and further initiatives are needed
- Sean P J Lynch (25 July 2002)
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depressive symptoms in cancer patients
- Ulrich S Schuler (1 August 2002)
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Re: depressive symptoms in cancer patients
- alan j carson (6 August 2002)
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Tryptophan deficiency and depression in medical patients
- Dietmar Fuchs, Gabriele Neurauter, Barbara Wirleitner (8 August 2002)
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Depression in medical patients
- Sanju George (9 August 2002)
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Vivek Khosla, Staff grade Psychiatric Intensive care and Community Psychiatry, 63, Headlands, Kettering, NN15 7EU
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EDITOR- A few points in the clinical review are worth discussing further. 1 As the authors mention, Depression is often undetected in medically ill. Detection rates need to be improved to ensure adequate treatment. The reasons for poor detection may be lack of training of necessary skills among the medical staff, required to identify and treat depression. Stigma associated with mental illness may prevent such discussions. Time constraints and the clinical setting may themselves contribute to poor detection of depression.2 Education is of paramount importance, especially targeted towards junior medical and nursing staff. They are well placed to identify depressive symptoms and illness. Liaison psychiatry services are scarce and such a role will fall on to generic psychiatric services. Ideally, there should be a Consultant psychiatrist with a specific interest in liaison work. Awareness about diagnosis and treatment of depression should be complemented by clear guidelines regarding possible pathways for support, advice and management once depression is detected. Integrated care pathways developed in close collaboration with other specialities with regular audit can have a useful role to play. Such education programme can be integral part of induction programme. On a wider level, departments of psychiatry with intake of medical students can play an important role in increasing the interest and awareness at an undergraduate level. Declaration of interest: none Author: Dr Vivek Khosla Staff Grade Psychiatric Intensive Care Unit & Community Psychiatry 63, Headlands Kettering NN15 7EU Tel: 01536 410365 Fax: 01536 412736 E-mail: khoslav@doctors.org.uk 1. Peveler R, Carson A, Rodin G. Depression in Medically ill BMJ 2002;325:149-152( 20 July) 2. Creed FH. Liaison Psychiatry or 21st Century: a review Journal of Royal Society of Medicine 84:414-417 |
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Catherine W. Striley, NIMH Postodctoral Fellow Washington University Medical School
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Depression in medical patients is an excellent, concise summary of the need for identification of depression as a part of medical care, and how-tos. Dr. Khosla's letter expands the article by noting constraints of doctor's detection of depression. Both the how-tos and the information in the letter, though, fail to mention that education alone is not enough, and that the literature has found that doctor's attitudes towards mental health and their assumptions about their patients attitudes effect their detection of mental health problems (1,2,3). Physicians need to receive training that will challenge not just their knowledge, but also their assumptions. In addition, reliance on continuing medical education to solve the problems with detection is misplaced. CME has not been found to be effective alone. Instead, work with a consultant,as suggested, is important. So too are opportunities to practice new interviewing skills, and the use of screeners, and reinforcement for that practice and use (4). Reminders, the use of opinion leaders, outreach visits and other components of multifaceted interventions are important in order to change behavior and thus increase the detection of depression(5). Catherine Woodstock Striley, MSW, Ph.D. NIMH Postdoctoral Fellow Department of Psychiatry Washington University School of Medicine 40 N. Kingshighway, Suite 4 St. Louis, Missouri 63108 strileyc@epi.wustl.edu 1. Rost, K, Smith, R, Matthews, DB & Guise, B. Arch Fam Med 1994;3:333-337 (April 4). 2. Susman, JL, Crabtree, BF, & Essink, G. Arch Fam Med 1995;4:427-431 (May 5). 3. Williams, JW, Rost, K, Dietrich, AJ, Ciotti, MC, Zyzanski, SJ & Cornell, J. Arch Fam Med 1999; 8;58-67. 4. Katon, W, Von Korff, M, Lin, E, Walker, E, Simon, GE, Bush, T, Robibnson, P & Russo, J. JAMA 1995:273:1026-1031 (13). 5. Davis, P, O'Brien,M, Freemantle, N, Wolf,FM, Maxmanian, P, Taylor- Vaisey, A. JAMA 1999;282:867-874 (9). |
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Sean P J Lynch, Honorary Senior Lecturer in Psychiatry Department Of Mental Health, University of Exeter, EX2 5AF
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Having had a long-standing interest in liaison psychiatry, I have read with great interest the excellent article by Peveler et al (1) and the rapid response letters by Khosla and Striley. Although it is vital that detection rates for depression are improved in non-psychiatric care settings (both in primary and secondary care), it is also crucial that this improved detection will lead to demonstrable improvements in management and outcome. As illustrated in one recent systematic review (2), routine administration of screening questionnaires to improve the rate of detection of depression does not consistently lead to improved outcomes.It is possible that developing brief management protocols based on the results of such screening questionnaires might represent a cost- effective method to help influence changes in management (in the desired direction) and improve outcomes (3). Finally to add to the debate (and from a purely personal perspective), I have always felt that a comparable multi-specialty, multi- agency initiative to the Defeat Depression Campaign is needed in this country to address these issues - for example contrast the number of currently available clinical management guidelines and protocols available for the management of depression in primary care settings to that in general hospital settings. Declaration of interest:- None References 1. Peveler R, Carson A, Rodin G Depression in the Medically Ill BMJ 2002: 325: 149-152 2. Gilbody SM, House AO, Sheldon TA Routinely administered questionnaires for depression and anxiety: Systematic review. BMJ 2001: 322:406-9 3. Lynch S, Clarkson P, Blenkiron P, Fraser J (in press) Discussion paper- Scale based protocols for the detection and management of depression. Primary Care Psychiatry |
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Ulrich S Schuler University Hospital Dresden, Fetscherstrasse 74, D-01307 Dresden
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Sir, thank you very much for this helpful series "ABC of psychological medicine". However I would like to comment on a few aspects in the article on depression in medical patients by Peveler et al. 1. As a haematologist I frequently have to respond to depressive reactions in patients with malignant disease, who are confronted with difficult treatment decisions and poor prognosis. One has to acknowledge the normality of some degree of this reactive demoralisation. Conceptually, this has been described as psychological in nature and opposed to major depression as a “disease of the brain” (2). Sometimes the problem is the distinction between depressed patients with tumours and patients depressed because of tumours. In this context some aspects of the quoted meta-analysis of drug treatment taken from the Cochrane review by Gill and Hatcher (3) deserve comment. Most of the studies included in this meta-analysis had to struggle with this distinction. This analysis did not compare tricyclic antidepressants with elective serotonin reuptake inhibitors (SSRIs), as stated in the caption of the table, rather it displays a comparison of drug treatment (tricyclic, tetracyclic antidepressants and SSRIs) with placebo. The reflected benefit is therefore neither the benefit of anti- depressive therapy in major depression (with medical comorbidity) nor the benefit in patients with reactive symptoms. The first two lines of the table should not be taken as evidence, that every symptom of depression in a cancer patient warrants medication. Meta-analyses of SSRIs versus other antidepressants are also available in the Cochrane library and show no major difference in efficacy (4;5) and only a modest advantage for SSRIs in terms of fewer dropouts. Fortunately, the majority of patients with cancer and depressive adjustment disorders respond to a supportive environment and counselling and do not need drug treatment. The observed depressive reaction e.g. after the disclosure of malignancy should neither be taken as an excuse to withhold the truth from patients nor should it be medicalized to much. After breaking bad news, I sometimes wonder whether those patients who seem to show no emotional reaction at all are in fact the more abnormal. References 1. Peveler R, Carson A, Rodin G. Depression in medical patients. BMJ 2002;325:149-52. 2. Angelino AF,.Treisman GJ. Major depression and demoralization in cancer patients: diagnostic and treatment considerations. Support.Care Cancer 2001;9:344-9. 3. Gill D,.Hatcher S. Antidepressants for depression in medical illness. Cochrane.Database.Syst.Rev. 2000;CD001312. 4. Geddes JR, Freemantle N, Mason J, Eccles MP, Boynton J. SSRIs versus other antidepressants for depressive disorder. Cochrane.Database.Syst.Rev. 2000;CD001851. 5. Barbui C, Hotopf M, Freemantle N, Boynton J, Churchill R, Eccles MP et al. Selective serotonin reuptake inhibitors versus tricyclic and heterocyclic antidepressants: comparison of drug adherence. Cochrane.Database.Syst.Rev. 2000;CD002791. |
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alan j carson, consultant neuropsychiatrist department of clinical neurosciences, western general hospital, edinburgh Eh4
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Thank you for your comments on our paper. You, correctly point out confusion with the caption for the meta-analyses. In the original version both the Gill and the Geddes reviews which you cite were mentioned, unfortunately due to space one had to be dropped and the captions have become confused. I should have noted this during proof reading. We will ask the BMJ to publish an eratum message. |
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Dietmar Fuchs, Professor University of A-6020 Innsbruck, Austria, Gabriele Neurauter, Barbara Wirleitner
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Robert Peveler and colleagues provide an excellent summary on depression in medical patients (1). Especially patients with various forms of chronic diseases have an increased susceptibility to develop mood disorders and depression, and very often it turns out to be complicated to distinguish between a coincidental association or development of depression in response of a physical illness. Interestingly, situations associated with an increased risk for developing depression include malignancy, myocardial infarction and neurodegeneration, but also ageing (1), and all these conditions are as well associated with signs of immune activation and/or inflammation (2). Recently, a link between development of depression and immune activation was suggested as the pro-inflammatory cytokine interferon-gamma potently stimulates indoleamine (2,3)- dioxygenase, an enzyme cleaving tryptophan to form kynurenine derivatives (3). Increased tryptophan degradation and consequently decreased serum/plasma tryptophan concentrations were found in conditions of prolonged or chronic immune activation such as HIV infection, autoimmune diseases, neurodegenerative disorders like Alzheimer's and Parkinsons's disease, and also in patients with cancer or in people with older aged (2). Diminished tryptophan availability, in turn, may affect biosynthesis of serotonin. From this background one is prone to conclude that immune activation and accelerated tryptophan degradation may underlie the increased risk for developing mood disorders and depression in older age and in patients suffering from diseases which go along with prolonged immune activation. An association between immune activation, decreased blood tryptophan and impaired quality of life has already been demonstrated in patients with colorectal cancer (4). Thus, immunobiological changes indeed could be of relevance in the pathogenesis of some forms of depression. We think, it would be very important to determine immune activation status and/or tryptophan concentrations in patients with depression. This strategy might assist to better distinguish different background of the disease and to better adapt treatment concepts. Gabriele Neurauter Barbara Wirleitner Dietmar Fuchs Institute of Medical Chemistry and Biochemistry,
University of Innsbruck, Innsbruck, Austria
References 1. Peveler R, Carson A, Rodin G. Depression in medical patients. BMJ 2002;325:149-52. 2. Widner B, Ledochowski M, Fuchs D. Interferon-gamma-induced tryptophan degradation: neuropsychiatry and immunological consequences. Curr Drug Metabol 2000; 1: 193-204. 3. Murr C, Widner B, Sperner-Unterweger B, Ledochowski M, Schubert C, Fuchs D. Immune reaction links disease progression in cancer patients with depression. Medical Hypotheses 2000; 55; 137-40. 4. Huang A, Fuchs D, Widner B, Glover C, Henderson DC, Allen-Mersh TG. Tryptophan decrease in advanced colorectal cancer correlates with immune activation and impaired quality of life. Brit J Cancer 2002; 86: 1691-6. |
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Sanju George, SHO in Psychiatry Queen Elizabeth Psychiatric Hospital, Birmingham, B15 2QZ
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EDITOR – I read with interest the above noted article by Robert Peveler et al. I would like to highlight some nosological and treatment aspects, which need further clarification. Firstly, in the introductory paragraph, the authors have defined adjustment disorders as milder or short- lived episodes of depression, which is not entirely in keeping with the current understanding of the concept. As defined in ICD- 10, for a diagnosis of adjustment disorders to be made, "none of the symptoms should be of sufficient severity or prominence in its own right to justify a more specific diagnosis."Furthermore, adjustment disorders are subdivided into six categories (ICD-10), not all categories having predominantly depressive features.This emphasizes the subtle, but important difference between adjustment disorder and depression. Also note that contrary to the authors’ statement that adjustment disorders are short- lived episodes, they need not necessarily be so. Adjustment disorder may or may not have co- existing depressive symptoms and can even last upto 2 years. From a treatment perspective, there are two points worth mentioning in the context of this article. Authors argue that clinicians should stick to prescribing and familiarizing one antidepressant from each class. This, though reasonable, simplifies the difficult task of choosing an appropriate antidepressant. In my view, the antidepressant choice in treating depressed patients with physical illnesses, will depend on the underlying medical condition(eg:avoiding Venlafaxine in severe hypertension and the concomitant medication being prescribed for the medical disorder. (eg: potential interaction of SSRIs with Warfarin). Also, because of the complexity of correctly choosing an antidepressant in this subgroup of depressed patients, doctors (surgeons and physicians) should if in doubt seek the advice of liaison psychiatrists, as this is their area of expertise. Dr.Sanju George
References: Gill D, Hatcher S. Antidepressants for depression in medical illness.Cochrane Database Syst Rev 2000;(4) CD001312 P Robert, C.Alan, R.Gary. Depression in medical patients. British Medical journal 2002;325:149-2(20 July) The ICD-10 classification of mental and behavioural disorders. WHO- 1992. |
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