Psychiatry
10/31/01
Dr. Lewis
Chris T. for Aaron P.
So what do we really know about our unmet needs? Despite advances in out treatment,
the actually pathophysiology of major depression continues to elude us. Only about 1/3 of
patients achieve full remission. The pharmaceutical companies tell you a lot of ½ truths. You
have to be very skeptical about what drug reps tell you. They will try to up play the efficacy of
their drug. They will tell you 70% of your depressed patients will respond to their product. Only
25-35% of patients actually have true remission.
Remission is very different from response. Remission is defined as a Hamilton
depression score of 7 or less. Many patients are only partial responders. A patient who has a 50%
reduction of their Hamilton score is considered a responder in clinical trials. These patients will
come back to you and say they are still not feeling good. This leads to a tremendous amount of
frustration on the part of phycisians out there working with psychotropic drugs.
In 1990 mood disorders were the 4th leading cause disability, and in 2020 it will be 2nd
only to ischemic heart disease. Antidepressant nonresponders are the biggest problem for us.
As far as clinical trials go, patients with a response are count in the group that does well.
These patients really are not going to be satisfied. They're still suffering in subsyndromic kind of
way from their depression. We really want patients to acheive remission. Remission rates are
really not so good. The highest rates of remission are seen with the oldest drugs, tricyclics and
MAOIs. They are close to 45%. There is a 35% remission with SNRIs, which is Effexor. All the
SSRIs, Prozac and Paxil and Zoloft, the most widely used and frequently prescribed agents, have
a remission rate of 25%. The least effective agents are used the most frequently and the most
effective agents are used the least frequently. Tolerability gets worse as you go to drugs that are
more effective.
We should be very suspicious of patients who relapse very quickly when they are
compliant with antidepressant treatment. They are at high risk for possibly having bipolar
disorder. They probably need chronic maintenence management. Relapse and recurrance are
predictive of whether patients need chronic maintanence. Patients who have had 1 episode of
depression are 50% likely to have a second, patients who have had 2 episodes are 70% likely to
have a 3rd, patients who have 3, it's a foregone conclusion that they are going to have a 4th.
We did a survey in the area on primary care prescribing practices and got some
interesting results. Doctors were asked to rank disease states that are commonly treated occording
to which ones they enjoy seeing and which ones they don't enjoy seeing. Patients with depression
or anxiety were generally at the bottom of the list. These patients are resistant to treatment and
refractory to treatment. They don't get better and the keep coming back. Doctors don't like
patients like this, they like patients who get better.
Part of the problem of resistance and refractoriness is in diagnosis and detection. If the
diagnosis is cleaned up a bit, we can reduce the rate of resistance and refractoriness to about 8%
or so. And 8% is about the amount of depressed patients who end up getting ECT, maybe slightly
more.
1
Case 1
Forty seven year old latin-american male with no previous psychiatric history. Presents to
PCP (primary care physician) with complaints of depressed mood, fatigue, difficulty with
concentration, impaired sleep, early morning awakening, and loss of libido.
Upon examination the PCP noted poor eye contact, marked latency of response, and
marked hand-wringing. He denies suicidal ideation and admits the illness has impaired his ability
to work.
Diagnosis of major depression, single episode was made by PCP and patient was referred
to a social worker for psychotherapy once weekly. He was also given 3 antidepressant trials with
good therapeutic doses for 4 weeks (6 weeks would be better) each of Paxil, Zoloft and
Wellbutrin. This is reasonable, but going from one SSRI to another may not be the best idea,
trying another group would maybe have been better.
Despite treatment during the 12 week period, the patient deteriorates, becomes frustrated,
and becomes hopeless to the prospect of ever being well again. The PCP now refers him to a
psychiatrist for help. On psychiatric evaluation, the same things are noted, poor eye contact,
hand-wringing, and latency of response. He was very depressed, he spoke in a faint voice,
complained that food was tasting bland. He described guilt over failures at work. He complained
of loss of interest in his future and reports taking a leave of absence from his job.
At this point would you change the diagnosis? Maybe try some different medication,
TCAs or MAOIs. We changed his diagnosis. He does have major depression, single episode,
severe, without any psychotic features, but he fits into the melancholic subtype. This is the least
frequently seen subtype in the primary care setting. They generally go to some mental health
treatment more directly.
Dual-acting antidepressants or combination treatment is far more effective in melancholic
depression than SSRIs. We treated him with venlafaxine and he had a remission of his illness by
week 6, with a Hamilton score of 7. What we really had was an incomplete diagnosis for this
patient.
In regard to the psychotherapy, with depression there is a cut off with a Hamilton score of
20. This guy had a Hamilton score over 20 and did not do well with the psychotherapy. With
Hamilton scores below 20, patients generally do pretty well with therapy.
Case 2
Twenty three year old single white male presents to his PCP complaining of increasingly
depressed mood, accompanied by severe insomnia, marked agitation, anxiety, as well as difficulty
organizing and controlling his thought processes. His girlfriend claims that he is not himself. He
is very angry, irritable and sleepless. He is spending a great deal of time on office work but not
being very productive, he is staying up late but not getting things accomplished. No prior
psychiatric history. Mother was hospitalized 3x in the past for "nervous breakdowns". This is an
important clue.
The diagnosis by his PCP was agitated depression, which is not a true diagnosis, but we
do see patients with depression of an agitated type. His treatment plan was to use Prozac. After 5
days of therapy, the patient's girlfriend phoned the physician reporting the patient had increasing
2
insomnia, hostility and threatening behavior. The patient agrees to undergo psychiatric
hospitalization.
The average age of onset of major depression is 28, so it is suspicious whenever someone
this young comes in with depression. Anyone under the age of 25, you should be very suspicious
of other things, like drug abuse and bipolar. The average age of onset of bipolar disorder is late
teens-early twenties, and it is autosomal dominant inheritance.
SSRIs make bipolar patients worse. They can make them highly suicidal and homicidal.
You have to be very suspicious that a patient who becomes increasingly agitated on an SSRI, that
maybe you've missed the diagnosis.
On admission to the hospital he is found to be depressed, but is very irritable. He is very
hostile, exhibits marked psychomotor agitation, complains of racing thoughts and now we get the
suicidal ideation. We now have a patient that was started on Prozac and became suicidal. If you
are not careful who you give Prozac to, you may accelerate someone's bipolar illness and they
may become quite suicidal or homicidal.
His real diagnosis was bipolar disorder type 1 with mixed state. Mixed because he is
manic and depressed at the same time. The Prozac was discontinued and he was started on a
mood stabilizer, olanzapine. He was discharged after 6 days and returned to work and was doing
very well on the mood stabilizer.
The family history of nervous breakdowns was initially missed, which should have been
a tip-off for bipolar disorder. The early age of onset was missed which also points to bipolar
disorder. Global insomnia and agitation are also common in bipolar disorder.
Case 3
Thirty four year old married white female complains to her PCP of depressed mood,
fatigue, worry, insomnia, loss of appetite and weight loss. Symptoms emerging over the last 4
months. Reports that this is her third time since age 28 that she has felt this poorly. She reports
that despite multiple antidepressant trials she has never achieved more than a partial
improvement.
Diagnosis made by PCP is major depression recurrent, with poor interepisode recovery.
This is a very reasonable diagnosis. Patient reports that Prozac had helped the most in the past, so
she was started on Prozac 20mg a day and escalated to 60mg a day over the course of 5 weeks.
She experienced a marginal benefit from this.
She was sent for psychiatric evaluation and presents unchanged, and her Hamilton score
was 20. We see this patient as being treatment resistant. She was continued on Prozac and
olanzapine was added. The patient had reduced anxiety and increased sleep by day 2. Remission
is achieved and maintained after day 18 and she goes down to a Hamilton score of 6.
This case was really a treatment problem. Any SSRI and olanzapine are effective in the
treatment resistant patient. These are patients who have failed 2 antidepressant trials from 2
different classes. Polypharmacy is not such a bad word in psychiatry.
Proper diagnosis and medication selection are critical to good patient care.
3
Exam Review
-Know classes of medicines, there are a few little cases on the exam, the diagnosis is not given
away. Symptoms are given and you have to put together the diagnosis and what medication
would be a good choice.
-Know what categories drugs belong to.
-Know what are mood stabilizers, what are atypical antipsychotics, conventional antipsychotics,
potencies of conventionals.
-Know what's an SSRI, common side effects (sexual dysfunction).
-What drugs are TCAs, MAOIs, and other atypical antidepressants.
-Dr. Kass did not write any questions.
-Dr. Shaw will have some questions on psychotherapy.
-There's no matching, just T-F and MC.
-Make sure you read the pearls in the book.
-Look at the old exams.
-Read the questions very carefully, even if they look like old questions, they may not be.
4