Depression comorbid conditions

Out-patient treatment is substantially cheaper than in-patient management and is generally as effective (Lowman, 1991). A French study on patients with generalized anxiety disorder estimated costs per patient over 3 months to he US 423 for hospitalization, 335 for out-patient services and 43 for medications (Souetre et al, 1994). Comorbid conditions (mostly alcoholism and depression) doubled these direct health-care costs. Over three-quarters of all patients were taking anxiolytic medication. 

Antidepressant medications appear to be useful for certain children and adolescents, particularly those who have severe or psychotic depression, fail psychotherapeutic measures, or experience chronic or recurrent depression. SSRIs generally are considered the initial antidepressants of choice, although comorbid conditions may favor alternative agents. Clinicians should be aware of the possibility of behavioral activation with the SSRIs, including such symptoms as impulsivity, silliness, daring conduct, and agitation.44 Desipramine should be used with caution in this population because of several reports of sudden death, and a baseline and follow-up electrocardiogram (ECG) may be warranted when this medication is used to treat pediatric patients.9... 

ADHD is rarely encountered without comorbid conditions and often is underdiagnosed. Between 40% and 75% of patients with ADHD will have one or more comorbidities (e.g., learning disabilities, oppositional defiant conduct, anxiety, or depressive disorders).10 It is important to identify other coexisting conditions in patients with ADHD to assist in initial and ongoing selection of treatment. 

Comorbid conditions can also provide a way to either narrow or extend the phenotype. An analysis of the COGA data showed a very strong signal for the broadened phenotype of alcoholism or major depression this was located in the same region of chromosome 1 in which the alcoholism phenotype gave a signal [55]. The data for the combined phenotype was much stronger than that for the alcoholism-only phenotype. 

Appropriate management of AN also requires the early detection and treatment of any comorbid psychiatric disorders. The most common comorbid conditions associated with AN are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and substance use disorders. At the time of presentation, over 50% of AN patients also fulfill criteria for MDD however, accurate diagnosis of depression in these patients is complicated by the fact that prolonged starvation often produces a mood disturbance and neurovegetative symptoms identical to MDD. If MDD appears to be comorbid with AN at the time of presentation, there is debate as to whether it is more prudent to withhold treatment of the depression until weight restoration has been initiated. If the depression persists despite refeeding, then treatment of the depression is likely warranted. 

The safety and efficacy of combined SSRI and stimulant pharmacotherapy have been addressed in two open studies. Gammon and Brown (1993) reported on the successful addition of fluoxetine to stimulants in the treatment of 32 patients with ADHD with comorbid depressive and anxiety disorders (Gammon and Brown 1993). These children with comorbid conditions had failed to respond to methylphenidate alone. Another report detailed the addition of methylphenidate to SSRI treatment (Findling, 1996). Depressed children and adults with comorbid ADHD were treated with either fluoxetine or sertraline. While depressive symptoms remitted, ADHD symptoms persisted. Methylphenidate was added and successfully treated the ADHD symptoms. In both investigations, the combined treatment was well tolerated. 

Comorbid disorders may influence the onset, maintenance, and recurrence of depression (Birmaher et al., 1996a,b). Therefore, in addition to the treatment of depressive symptoms, it is of prime importance to treat the comorbid conditions that frequently accompany the depressive disorder. 

Other comorbid conditions, such as obsessive-compulsive, conduct, eating, and post-traumatic stress disorders, have also been found to affect the treatment response and need to be addressed for the successful treatment of depressed youths (Birmaher et ah, 1996b Goodyer et ah, 1997 Brent et ah, 1998). 

Children with PTSD may be more likely to have comorbid conditions because traumatic insults occur in developmentally sensitive periods. Early life trauma is particularly toxic in its effects on development. Adults with severe sexual abuse histories exhibit high rates of debilitating disorders such as depression, anxiety disorders, alcoholism, substance abuse, and personality disorders (Herman and Van der Kolk, 1987 Putnam and Trickett, 1993). 

Tricyclic antidepressants have been used for decades to treat depression and anxiety in the general population, and clomipramine has been used to treat OCD. Clomipramine has been studied with respect to treating school phobia or school refusal (Berney et ah, 1981). Gittleman-Klein and Klein (1971) found imipramine to be superior to placebo in treating school refusal. As the TCAs may improve other disorders such as nocturnal enuresis, ADHD, and sleep disorders, they may be attractive for children with any of these comorbid conditions and anxiety disorder. 

Comorbidity is an important factor influencing the choice of drug treatment. Depression is the most frequent and significant comorbid condition in patients with panic disorder. 

Insomnia is a common comorbid condition with depression, and frequently is made worse by antidepressants, particularly the SSRIs. When insomnia persists despite adequate evaluation and attempts to reduce it by other approaches, it is often necessary to use a concomitant sedative-hypnotic, especially a short-acting nonbenzodiazepine with rapid onset such as zaleplon or zolpidem. At times a benzodiazepine sedative hypnotic such as triazolam or temazepam may be necessary. If anxiety persists during the day and cannot be otherwise managed, it may be necessary to add an anxiolytic benzodiazepine such as alprazolam or clonazepam. Use of sedative-hypnotics and anxiolytics should be short-term whenever possible. 

A therapeutic range should be established for each patient. This range should define concentrations that result in minimal side effects and optimal seizure control. This therapeutic plasma concentration range should be used to identify the appropriate patient-specific dose. Patients should be monitored chronically for seizure control, comorbid conditions, social adjustment (including quality-of-life assessments), drug interactions, compliance, and adverse effects. Periodic screening for comorbid neuropsychiatric disorders such as depression and anxiety is also important. Clinical response is more important than the serum drug concentration. 

It is critical to clarify the diagnosis of ADHD in individuals with these symptoms. Inattention and distractibility can be symptoms of an anxiety disorder, depression, or bipolar disorder. - In other cases, these anxiety or mood disorders can coexist with ADHD, just as learning deficiencies and conduct or oppositional disorders are common comorbid conditions. The presence of multiple comorbid conditions, particularly conduct or oppositional disorder, may increase the likelihood of ADHD chronicity. ... 

Pharmacotherapy is only one of several treatment options for PTSD, especially in view of the great success of cognitive-behavioral therapy (CBT). Medication may be a good choice when patient acceptability of such an approach is high, when comorbid conditions are present that are responsive to pharmacotherapy (e.g. depression, panic disorder, social phobia, and obsessive-compulsive disorder), or when CBT is not applicable. ... 

The anxiety disorders are a case in point. They comprise a range of conditions contiguous with the affective disorders and the stress responses (Table 4.1). Much overlap and comorbidity exist. Furthermore, definitions and diagnostic criteria have changed substantially over the years. For example, generalized anxiety disorder is a rare condition in its pure form, but a common condition if comorbid phobic and depressive disorders are accepted. 

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Primary care physicians are critical to the successful identification of GAD. Characterized by often-vague physical complaints, GAD must be distinguished from medical illnesses and other psychiatric disorders, though the high rate of comorbidity requires that a thorough evaluation for GAD be completed even when another disorder has been identified. GAD warrants particular consideration for those patients with nonspecific physical complaints who nevertheless have an urgent need for relief that has resulted in repeated office visits. The differential diagnosis for GAD includes other anxiety disorders, depression, and a variety of medical conditions and substance-induced syndromes. 

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