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UPDATE IN PSYCHIATRY

UPDATE IN PSYCHIATRY. Robert K. Schneider, MD James L. Levenson, MD Departments of Psychiatry and Medicine The Medical College of Virginia at the Virginia Commonwealth University Richmond, Virginia. Previous Updates. Annals: October 1999. Annals: March 2001. Annals: February 2002.

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UPDATE IN PSYCHIATRY

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  1. UPDATE IN PSYCHIATRY Robert K. Schneider, MD James L. Levenson, MD Departments of Psychiatry and Medicine The Medical College of Virginia at the Virginia Commonwealth University Richmond, Virginia

  2. Previous Updates Annals: October 1999 Annals: March 2001 Annals: February 2002

  3. TOPICS COVERED – • Mood Disorders • Anxiety Disorders • Medical-Psychiatric Interface • Cognitive Disorders

  4. MOOD DISORDERS

  5. Which SSRI is works best? Zoloft citalopram fluoxetine Paxil paroxetine sertraline Celexa Prozac

  6. SSRIs Compared in Primary CareKroenke, JAMA 2001;286:2947 • Many claims of differences in efficacy • ARTIST: • ARandomized Trial Investigating SSRI Treatment • Aim: • Compare the effectiveness of 3 SSRIs in depressed primary care patients.

  7. SSRIs in Primary Care • Methods • RCT of paroxetine, fluoxetine and sertraline • 573 patients, in 2 primary care consortiums • Main Findings • No statistical differences between the 3 SSRIs in any of the outcomes.

  8. SSRIs in Primary Care • Limitations • Therapy based on MD perception • 74% met diagnostic criteria for major depression at baseline • Low power for small differences • No placebo control • Mostly female (80%) and white (80%) • No citalopram

  9. Impact on clinical practice • Efficacy not a basis for choosing SSRI • Consider instead: • Comorbidities • Half-life • Side effects

  10. Which came first, the depression or the erectile dysfuction?

  11. Erectile Dysfunction and DepressionSeidman, Am J Psych 2001;158:1623 • Depression and erectile dysfunction occur often together in men, but the causal relationship is unclear. • Aim: • Evaluate sildenafil in men with erectile dysfunction and mild depression

  12. Erectile Dysfunction and Depression • Methods • RCT, double bind, placebo controlled • Mild depression only • Main Findings • All measures of sexual function improved significantly more in the sildenafil group (p<.001). • Treatment-responders (48/66 given sildenafil, 10/70 given placebo) had significant improvements in depression symptoms and quality of life compared to nonresponders

  13. Erectile Dysfunction and Depression • Limitations • ? generalizable to patients with major depression or taking psychotropic medications • 12 week trial

  14. Impact on clinical practice • Treating physical symptoms in patients with minor depression relieves depressive symptoms. • Erectile dysfunction • Insomnia • Pain

  15. Is St. John’s wort an effective antidepresant?

  16. St. John’s WortShelton, JAMA 2001; 285:1978 • Background: • Many controlled trials of St. John’s wort claim efficacy for the treatment of depression, but they are methodologically flawed. • Aim: • To compare the efficacy and safety of St. John’s wort vs. placebo in major depression

  17. St. John’s Wort • Methods • RCT, double-blind, placebo-controlled • 200 patients received either St. John’s wort or placebo for 8 weeks. • Main Findings • No significant differences in any outcome measures between the two groups • St. John’s wort: 1% discontinued due to adverse effects

  18. St. John’s Wort • Limitations • Subjects had chronic depression (average over 2 years) • Subjects from tertiary care clinics

  19. Impact on clinical practice • St. Johns wort probably safe in minor depression • Caution with interactions with other drugs • warfarin, cyclosporine, theophylline, digoxin, protease inhibitors, anticonvulsants, oral contraceptives, triptans, SSRIs • Not a good choice for severe depression

  20. Is estrogen an antidepressant in menopausal women?

  21. Estradiol for depression Novaes Soares, Arch Gen Psych 2001;58:529 • Depressive and somatic symptoms are common in women entering menopause. • Studies of ERT for mood symptoms are complex and have shown mixed results. • Estrogen preparation: oral vs. transdermal • Longitudinal measurements of estradial • Endocrine confirmation of perimenopause: FSH • Measurement of mood symptoms • Placebo control difficult

  22. Estradiol for depression • Aim • Assess efficacy of transdermal ERT for treating depression in perimenopausal women. • Methods • RCT, double-blind, placebo-controlled • FSH > 25 IU/L • Depressive disorder (i.e. major depression, dysthymia or minor depression) • 17β-estradiol (100μg)transdermal patches or placebo for 12 weeks and 4 week washout.

  23. Estradiol for depression Main Findings • Remission of depressive symptoms in 68% vs. 20% (P=0.001) • no significant differences in response per type of depressive disorder • 50% reduction in menopausal symptoms was seen in 68% vs. 28% (P=0.005). Limitations • Small, short study in specialty clinic • No progesterone

  24. MADRS Depression BKMI Perimenopausal Symptoms

  25. Impact on clinical practice • Treatment with transdermal estrogen patches is effective for depressive symptoms in some perimenopausal women. • This represents a good first step in treatment of the depressed perimenopausal women • If symptoms persist or worsen, then consider the addition of an antidepressant

  26. How often do depressed patients turn out to be bipolar?

  27. Conversion from unipolar to bipolar depressionGoldberg, Am J Psychiatry 2001;158:1265 • Background • Underdiagnosis of bipolar disorder • 20% of Major Depression may be bipolar • Prescription of antidepressants without mood stabilizers may precipitate a switch to mania

  28. Unipolar to bipolar depression • Aim • In patients presenting with depression, what are the odds they will turn out to really be bipolar? • Methods • Young (mean 23 years), hospitalized patients with depression • Followed prospectively for 15 years

  29. Unipolar to bipolar depression • Main Findings • 41% developed either hypomania or mania (26% hypomania, 15% mania). • 80% of the 10 patients who were initially psychotic developed hypomania (4/10) or mania (4/10). • 34% of the non-psychotically depressed eventually became either manic or hypomanic

  30. What’s the differnece between mania and hypomania? • Mania (Bipolar I): • At least 7 days of racing thoughts, sleeplessness, grandiosity and sometimes psychosis • Hypomania (Bipolar II) • At least 4 days of racing thoughts, irritability, and sleeplessness

  31. MANIA MIXED EPISODE HYPOMANIA NORMAL MOOD DEPRESSION Stahl S M, Essential Psychopharmacology (2000) 5-5

  32. Unipolar to bipolar depression • Limitations • Started in the early 1980s • psychiatric hospitalization differs • treatments differ • Psychiatric inpatients • Naturalistic study and not a treatment intervention

  33. Impact on clinical practice • Younger patients with depression especially with psychotic features may be at a particularly high risk for conversion to bipolar depression. • Remember that antidepressants may precipitate switch to mania. • “Side Effects” to antidepressants may represent hypomania or mania • Screen for mania/hypomania BEFORE starting an antidepressant

  34. How good is the care given for depression and anxiety disorders?

  35. Quality of Care for Depression and Anxiety DisordersYoung, Arch Gen Psych 2001;58:55 • Depressive and anxiety disorders are common, and cause substantial disability. • Medications and psychotherapies have empirically demonstrated efficacy • BUT many patients do not receive adequate treatment

  36. Quality of Care • Aim • To estimate the rate of appropriate treatment of anxiety and depressive disorders • Measure effects of insurance, provider type, and demographics • Methods • One year of data, from the National Comorbidity Survey (1997-98)

  37. Quality of Care One year, adults, major anxiety or depression • Main Findings: • 83% saw a health care provider • 30% received some appropriate treatment • Most only saw PCP’s; 19% received appropriate care. • 90% visiting MH professionals received appropriate care. • Insurance status affected whether the individual saw a provider, but had no effect on whether appropriate care was received.

  38. Quality of CareOne year, adults, major anxiety or depression • Main Findings: • Appropriate treatment was less likely for • men • blacks • the less educated • those <30 or >59 years old • When a psychiatric medication was used, it was at an appropriate dose and duration in about 75% of the individuals.

  39. Quality of Care • Main Findings: • For patients seeing PCPs, those who received poor quality care were less likely to report that… • their mental health problems were evaluated • psychiatric drugs were recommended • referral to a mental health specialist was made • Patients who received poor quality care were less likely to view themselves as needing mental health care (31.4% vs. 70%)

  40. Impact on clinical practice • Limitations • Self report data, response rates • Conclusions • Most adults with depression or anxiety disorders did not receive appropriate treatment, though they saw health care providers • When given, psychiatric medications were usually given at appropriate dosage and duration. • The current barriers to appropriate treatment lie in recognition, diagnosis, referral, and acceptance by patients.

  41. ANXIETY DISORDERS

  42. What are the psychiatric consequences of a terrorist disaster? “The most severe incident of terrorism ever experienced on American soil.”

  43. Psychiatric Disorders Among Survivors of the Oklahoma City Bombing North, JAMA 1999; 282:755 • Sometimes difficult to distinguish normal from pathological reactions • Aim • Assess the psychiatric impact on adult survivors directly exposed to the bomb blast.

  44. Oklahoma City Bombing • Methods • Single diagnostic interview • Main Findings • 87% reported injuries • Predisaster (lifetime) prevalence vs postdisaster prevalence: • PTSD [15% vs. 34%] • Major Depression [12.6% vs. 22.5%]

  45. Oklahoma City Bombing • Main Findings: • Postdisaster, 74% of PTSD and 56% of major depression was new. • Conversely, 71% of those with no predisaster psychiatric diagnosis remained without a postdisaster diagnosis

  46. Oklahoma City Bombing • Main Findings: • Over 80% of the survivors had intrusive reexperiences or hyperarousal symptoms. • Only 34% of survivors had all three criteria (including avoidance) for PTSD. • Avoidance/numbing criterion was 100% sensitive for detecting PTSD.

  47. Oklahoma City Bombing • Limitations • Retrospective; direct exposure only • Conclusions • PTSD and Major Depression were the major psychiatric disorders • Hyperarousal and reexperiences common • Avoidance/numbing screens for full PTSD

  48. Impact on clinical practice • Health predicts health • Terror trauma uncommon, sudden death of a loved one is not • PTSD is very treatable • Medications • Psychotherapy

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