Depression in medical patients
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7356.149 (Published 20 July 2002) Cite this as: BMJ 2002;325:149
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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
E-mail: dietmar.fuchs@uibk.ac.at
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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).
Competing interests: No competing interests
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
Competing interests: No competing interests
Depression in medical patients
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
S.H.O in psychiatry
Queen Elizabeth Psychiatric Hospital,
Mindelsohn Way,
Edgbaston,
Birmingham
B15 2QZ
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.
Competing interests: No competing interests