Depression comorbidities

In the study by Newport and colleagues (2004), the authors attempted to determine whether cortisol hypersuppression was related to early abuse in PTSD and major depression. However, insofar as all the exposed subjects with current depression had PTSD (all except one), it was difficult to attribute the observed hypersuppression to PTSD or depression. Recently, however, Yehuda et al. observed cortisol hypersuppression following 0.50 mg DST in PTSD, and subjects with both PTSD and depression, but noted that hypersuppression was particularly prominent in persons with depression comorbidity if there had been a prior traumatic experience. Thus, cortisol hypersuppression in response to DEX appears to be associated with PTSD, but in subjects with depression, hypersuppression may be present as a result of early trauma, and possibly past PTSD (Yehuda et al. 2004b). 

Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (1995) Posttraumaticstress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52 1048-1060 Kessler RC, Stang PE, Wittchen HU, Ustun TB, Roy-Burne PP, Walters EE (1998) Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry 55 801-808... 

Muller D, Pfeil T, von den Driesch V. Treating depression comorbid with anxiety—results of an open, practice-oriented study with St John s wort WS 5572 and valerian extract in high doses. Phytomedicine 2003 10(suppl 4) 25-30. 

Several subtypes of depression require specific treatment strategies that go beyond a simple course of conventional antidepressant therapy (these subtypes include bipolar depression, major depression with psychotic features, seasonal depression, atypical depression, comorbid anxiety disorder, comorbid substance abuse, double depression [major depression... 

Comorbid major depression Comorbid panic disorder... 

Grant BF, Harford TC Comorbidity between DSM-IV alcohol use disorders and major depression results of a national survey. Drug Alcohol Depend 39 197-206, 1995 Grant BF, Dawson DA, Stinson FS, et al The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence United States, 1991-1992 and 2001-2002. Drug Alcohol Depend 74 223-234, 2004a... 

In summary, research on the use of antidepressants to treat cannabis dependence, particularly among individuals with comorbid major depressive disorder, although limited, offers a promising avenue for the development of pharmacological aids to assist in the treatment of cannabis withdrawal. There are clear parallels between this literature and the existing research on the use of antidepressants in the treatment of alcohol dependence comorbid with major depressive disorder (see Chapter 1, Medications to Treat Co-occurring Psychiatric Symptoms or Disorders in Alcoholic Patients). 

Chen CY, Wagner FA, Anthony JC Marijuana use and the risk of major depressive episode epidemiological evidence from the United States National Comorbidity Survey. Soc Psychiatry Psychiatr Epidemiol 37 199-206, 2002... 

Grant BF Comorbidity between DSM-IV drug use disorders and major depression results of a national survey of adults. J Subst Abuse 7 481 97, 1995 Hall W, Babor TF Cannabis use and public health assessing the burden. Addiction 95 485 90, 2000... 

The rates of comorbid psychiatric disorders such as depression, ADHD, and antisocial personality disorder are significantly higher in stimulant abusers... 

Tollefson GD, Souetre E, Thomander L, Potvin JH (1993). Comorbid anxious signs and symptoms in major depression impact on... 

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. 

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. 

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. 

Monitor for comorbid disease states at each clinic visit. Evaluate for depression at every clinic visit. 

Finally, a recent meta-analysis of antidepressants to treat alcohol dependence with or without comorbid depression concluded that any beneficial effects were modest at best.44... 

Interpersonal therapy and cognitive behavioral therapy are types of psychotherapy that have well-documented efficacy for the treatment of MDD. Psychotherapy alone is an initial treatment option for mild to moderate cases of depression, and it may be useful when combined with pharmacotherapy in the treatment of more severe cases of depression. In fact, the combination of psychotherapy and pharmacotherapy can be more effective than either treatment modality alone in cases of severe or recurrent MDD. Psychotherapy can be especially helpful for patients with significant psychosocial stressors, interpersonal difficulties, or comorbid personality disorders.16... 

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... 

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. 

Patients with bipolar disorder have a high risk of suicide. Factors that increase that risk are early age at disease onset, high number of depressive episodes, comorbid alcohol abuse, personal history of antidepressant-induced mania, and family history of suicidal behavior.15 In those with bipolar disorder, 1 of 5 suicide attempts are lethal, in contrast to 1 of 10 to 1 of 20 in the general population. 

Lifetime prevalence rates of psychiatric comorbidity co-existing with bipolar disorder are 42% to 50%.16 Comorbidities, especially substance abuse, make it difficult to establish a definitive diagnosis and complicate treatment. Comorbidities also place the patient at risk for a poorer outcome, high rates of suicidal-ity, and onset of depression.2 Psychiatric comorbidities include ... 

Assess for the safety of others and potential for violence. If accompanied by friends or family with whom the patient is living, ask them to remove from the home all guns, caustic chemicals, medications, and objects the person might use to harm self or others. Risk factors for suicide include severity of depression, feelings of hopelessness, comorbid personality disorder, and a history of a previous suicide attempt.19... 

O The goals of therapy for GAD are to acutely reduce the severity and duration of anxiety symptoms and restore overall functioning. The long-term goal in GAD is to achieve and maintain remission. With a positive response to treatment, patients with GAD and comorbid depression should have minimal depressive symptoms. 

The main objectives of treatment are to reduce the severity and frequency of panic attacks, reduce anticipatory anxiety and agoraphobic behavior, and minimize symptoms of depression or other comorbid disorders.48 The long-term goal is to achieve and sustain remission. 

The initial dose of SSRI is similar to that used in depression. Patients should be titrated as tolerated to response. Many patients will require maximum recommended daily doses. Patients with comorbid panic disorder should be started on lower doses (Table 37-4). When discontinuing SSRIs, the dose should be tapered slowly to avoid withdrawal symptoms, with the possible exception of fluoxetine. Relapse rates may be as high as 50%, and patients should be monitored closely for several weeks.58 Side effects of SSRIs in SAD patients are similar to those seen in depression and most commonly include nausea, sexual dysfunction, somnolence, and sweating. 

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. 

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