Medical conditions depression

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. 

Uncomplicated, with delirium, with delusions, and with depressed mood Dementia due to HIV disease Dementia due to head trauma Dementia due to Parkinson s disease Dementia due to Huntington s disease Dementia due to Pick s disease Dementia due to Creutzfeldt-Jakob disease Dementia due to a specific general medical condition (specify) Dementia that is substance-induced Dementia due to multiple etiologies Dementia not otherwise specified... 

Bipolar disorder can be conceptualized as a continuum or spectrum of mood disorders and is not comprised solely of bipolar I disorder.9 They include four subtypes bipolar I (periods of major depressive, manic, and/or mixed episodes) bipolar II (periods of major depression and hypomania) cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet all criteria for diagnosis of a major depressive episode) and bipolar disorder, NOS. The defining feature of bipolar disorders is one or more manic or hypomanic episodes in addition to depressive episodes that are not caused by any medical condition, substance abuse, or other psychiatric disorder.1... 

Myxedema coma is seen in advanced hypothyroidism. These patients develop CNS depression, respiratory depression, cardiovascular instability, and fluid and electrolyte disturbances. Myxedema coma often is triggered by an underlying acute medical condition such as infection, stroke, trauma, or administration of CNS depressant drugs. 

Bipolar disorder, previously known as manic-depressive illness, is a cyclical, lifelong disorder with recurrent extreme fluctuations in mood, energy, and behavior. Diagnosis requires the occurrence, during the course of the illness, of a manic, hypomanic, or mixed episode (not caused by any other medical condition, substance, or psychiatric disorder). 

See Chap. 70 for medical conditions, substance use disorders, and medications associated with depressive symptoms. 

Common Medical Conditions, Substance Use Disorders, and Medications Associated with Depressive Symptoms... 

The mood disorders were once called affective disorders and are grouped into two main categories unipolar and bipolar. The unipolar depressive disorders include major depressive disorder and dysthymic disorder the bipolar disorders include bipolar 1, bipolar II, bipolar not otherwise specified, and cyclothymic disorder. Other mood disorders are substance-induced mood disorders and mood disorders due to a general medical condition. In addition, mood disturbance commonly occurs as a symptom in other psychiatric disorders including dementia, post-traumatic stress disorder, substance abuse disorders, and schizophrenia. 

The unipolar mood disorders consist solely of episodes of depression. On the other hand, the bipolar mood disorders consist of episodes of both depressed and elevated mood. The periods of elevated mood are characterized by either euphoria or irritability and are called mania or hypomania depending on the level of severity. A schematic of the mood disorders is shown in Figure 3.1. Substance-induced mood disorders and mood disorders due to general medical conditions usually manifest depressed mood however, manic episodes are occasionally seen as well. 

The cause of most psychiatric disorders including depression remains unknown nevertheless, some diagnostic considerations are based on presumed causative factors. In these cases, the distinction from major depression is not based on the symptomatic presentation because there may be no symptomatic difference. The difference lies in the presence of an identifiable biological factor that is presumably causing the depressive syndrome. The causative differential of MDD includes a mood disorder due to a general medical condition in medically ill patients and a substance-induced mood disorder in patients using certain medications or substances of abuse. A comprehensive evaluation of depression must include consideration of potentially treatable causative factors. 

A number of medical conditions are associated with high rates of depression (see Table 3.4). In some instances, the distinction between MDD and depression due to a general medical condition is largely academic with little bearing on treatment selection. For example, pancreatic cancer may induce depression directly through the release of tumor-secreted substances however, depression in the pancreatic cancer patient is treated with conventional antidepressant medications. In other cases, the diagnostic distinction bears important treatment implications. One commonly cited example is depression occurring in association with hypothyroidism. Patients with depression and hypothyroidism do not respond to antidepressant treatment alone but require a thyroid hormone supplement. 

TABLE 3.4. Medical Conditions that May Cause Depression... 

Mood Disorder Due to a General Medical Condition. Commonly called secondary manias, certain medical and neurological illnesses produce symptoms that mimic mania. Often, secondary manias occur when injury or disease interferes with right-sided brain function. As one might anticipate, this is in contrast to the predilection for left-sided brain injury to be associated with depressive symptoms. 

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. 

In non-REM sleep patterns in depression, stage 1 sleep increases and SWS decreases (Benca et al. 1992 Gillin 1983a Kupfer and Foster 1978 W. B. Mendelson et al. 1977). These findings, in conjunction with the numerous shifts from one stage to another observed in depressed patients, indicate that sleep in depression usually is not only reduced in quantity but also quite unstable and shallow (Soldatos et al. 1987). The non-REM sleep characteristics of depression also have been seen in many other psychiatric and medical conditions (Benca et al. 1992 Soldatos et al. 1987). Thus, they do not distinguish depression from other disorders. 

Most patients with medical disorders who commit suicide, even those with terminal disorders, have concurrent treatable major depression. In addition, the type of medical condition may increase risk. Thus, patients with respiratory diseases are three times more likely to commit suicide than patients with other medical conditions. Those on hemodialysis or who suffer from cancer also constitute high-risk groups, in comparison with the general population. 

Herbal remedies are used for a wide range of psychiatric and nonpsychiatric medical conditions, but a number are specifically touted as being useful in treating depression. These agents include the following ... 

Depression as an emotion is common and usually short-lived. As a symptom it can occur in most psychiatric disorders as well as other medical conditions, e.g. hypothyroidism, Parkinson s disease. As an illness, major depressive disorder (MDD), it is less common but, nevertheless, moderate to severe forms affect 5-10% of people in their lifetime and milder forms 20-30%. After a first episode, prophylaxis is required for at least 6 months and ideally 12 months to prevent relapse. This should usually be with the dose of antidepressant to which the patient initially responded. Those with recurrent episodes require prophylaxis over many years. 

The diagnosis of depression still rests primarily on the clinical interview. Major depressive disorder (MDD) is characterized by depressed mood most of the time for at least 2 weeks and/or loss of interest or pleasure in most activities. In addition, depression is characterized by disturbances in sleep and appetite as well as deficits in cognition and energy. Thoughts of guilt, worthlessness, and suicide are common. Coronary artery disease, diabetes, and stroke appear to be more common in depressed patients, and depression may considerably worsen the prognosis for patients with a variety of comorbid medical conditions. 

The primary indication for antidepressant agents is the treatment of MDD. Major depression, with a lifetime prevalence of around 17% in the USA and a point prevalence of 5%, is associated with substantial morbidity and mortality. MDD represents one of the most common causes of disability in the developed world. In addition, major depression is commonly associated with a variety of medical conditions—from chronic pain to coronary artery disease. When depression coexists with other medical conditions, the patient s disease burden increases, and the quality of life—and often the prognosis for effective treatment—decreases significantly. 

Ritalin and related generic methylphenidate drugs are available by prescription for individuals six years and older. Ritalin is distributed in 5, 10, and 20 mg tablets. In addition to ADHD, methylphenidate is used for several other medical conditions. It continues to be used for narcolepsy. It has also been used in treating depression, especially in elderly populations. Methylphenidate has been suggested for use in the treatment of brain injury from stroke or brain trauma it has also been suggested to improve appetite and the mood of cancer and HIV patients. Another use is for pain control and/or sedation for patients using opiates. 

In previous chapters, we examined drugs specifically intended to keep you awake (such as caffeine) and drugs that are specifically intended to help you sleep (such as benzodiazepines). There are, however, many medications that are taken for the purpose of treating other medical conditions—allergies, high blood pressure, epilepsy, obesity, chronic pain, and psychiatric disorders such as schizophrenia and depression—that also can affect your sleep. In addition, addictive drugs such as alcohol, nicotine, and cocaine have strong effects on sleep. 

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. 

Those disorders that require the presence of psychosis (Table 10—1) as a defining feature of the diagnosis include schizophrenia, substance-induced (i.e., drug-induced) psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, and psychotic disorder due to a general medical condition. Disorders that may or may not have psychotic symptoms (Table 10—2) as an associated feature include mania and depression as well as several cognitive disorders such as Alzheimer s dementia. 

In California, mixer-loaders and spray applicators who work with toxicity category I and II organophosphates or N-methyl carbamates more than 30 hours per 30-day period are required to have medical supervision. Supervision consists of an interview and a medical examination to determine if a medical condition exists which would make the worker unusually susceptible to poisoning due to cholinesterase inhibition, and to caution the individual about the use of certain drugs such as the pheno-thiazine tranquilizers vdtich potentiate the effects of cholinesterase (ChE) inhibition. Two blood samples, taken several days apart, are analyzed to determine the individual s preexposure plasma and red blood cell (RBC) ChE activity (baseline value). The physician arranges a routine ChE testing program and provides for extra ChE tests should the worker be accidently exposed to OP s. If ChE activity is depressed to 50 percent of the baseline value, the physician may ask the employer to place the worker on... 

Although they have been used for over 30 years, benzodiazepines are still widely prescribed in the treatment of anxiety disorders and other medical conditions. These drugs are classified as sedative-hypnotic agents, which depress or slow down the body. In the past 15 years, the development of the newer selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression and anxiety have pushed benzodiazepines aside as the first treatment choice because the SSRIs as a class of drugs have not yet been found to be addictive. 

Methylphenidate also has been used to treat other medical conditions. For example, it has been used as a short-term treatment for depression in the medically ill, as an adjunct to conventional antidepressants for patients with major depressive disorder, and in combination with opiates for pain control. Methylphenidate has been prescribed to reduce apathy in patients with dementia or other brain diseases (28,34,35). 

Progressive inactivity, dissatisfaction with social life, and presence of medical and psychiatric illness can be most predictive of insomnia in old age [6, 7], In modern societies higher rates of insomnia are present in women, people who are less educated or unemployed, separated or divorced, the medically ill, and those with depression, anxiety, or substance abuse [8], In a number of studies, insomnia has been found to be correlated with frequent use of medical facilities [9-13], chronic health problems [13-18], perceived poor health [17], increased use of drugs [10,14], and specific medical conditions including respiratory diseases [19-21], hypertension [21], musculoskeletal and other painful disorders [19-24], heart diseases [19, 23], and prostate problems [19], On the other hand, chronic insomnia predisposes to the development of psychiatric disorders [25-27], Therefore, it is important to clearly establish whether co-morbidities are causative for, or simply co-exist with insomnia, in order to recommend the most appropriate treatment. This is why it is better to categorize insomnia as a disease rather than as a symptom [28],... 

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