With adjustment disorder and so-called minor depression, symptoms are fewer or less persistent (Table 2).
This distinction is important, as antidepressants are effective for major depression, but they have not yet been shown effective for adjustment disorders or minor depression. Major depression is the “hypertension of mental illness in primary care”—common, often undiagnosed, and associated with poor outcomes. Therefore, accurate diagnosis and appropriate treatment for major depression are essential.
Given the possibility of a depressive syndrome, gather further information to determine the duration of ongoing symptoms, and obtain answers to a short questionnaire (eg, the Beck Depression Inventory [BDI]3 or the PHQ-94). Elicit a family history of mood disorder, or personal history suggestive of thyroid dysfunction, a sleep disorder, or alcohol or drug abuse. Order a complete blood count (CBC) to evaluate for anemia, a thyroid-stimulating hormone (TSH) to evaluate for hypothyroidism, and, if indicated by history, a sleep study.
Beta-blockers and depression. The patient’s symptoms developed in the context of beta-blocker therapy. From the 1970s through the 1990s, the lore was that beta-blockers caused depression and should be avoided in patients with a history of depression. Because of this, many patients with myocardial infarction (MI) and congestive heart failure (CHF) have been denied treatment with beta-blockers when otherwise indicated.
Fortunately, a recent rigorous academic study of this issue was conducted by Ko and colleagues5 to rationally guide treatment. This study involved a meta-analysis of 15 randomized controlled trials of beta-blocker therapy in patients with MI, CHF, or hypertension; the authors found that beta-blockers were associated with a slight (though statistically significant) increase in fatigue and sexual dysfunction, and that their use was not associated with depressive symptoms. This is the best review to date of beta-blockers and depression, and it debunks the myth that beta-blockers cause depression—a myth that has prevented many post-MI patients from receiving much-needed beta-blocker therapy. In short, although idiosyncratic reactions are possible, it is unlikely the patient’s use of atenolol caused his apparent depressive symptoms.
TABLE 2
Major depression, minor depression, and adjustment disorder
| Major depressive disorder |
| Requires depressed mood or loss of interest/pleasure (anhedonia) most of the day, nearly every day for 2 weeks, with a total of 5 (out of 9) depressive symptoms, and resulting in functional impairment. |
| Minor depression (research criteria) |
| Requires depressed mood or loss of interest/pleasure (anhedonia) most of the day, nearly every day for 2 weeks, with a total of 2 to 4 depressive symptoms, and without history of major depressive disorder. |
| Adjustment disorder |
| Mood or anxiety symptoms occur within 3 months of a stressful life event. Such symptoms are in excess of the symptoms that would normally be expected as a result of the event or impair function. The symptoms do not meet criteria for major depressive disorder, bereavement, or another major psychiatric disorder. |
| Source: Adapted from DSM-IV.14 |
Further primary care evaluation
The patient has no cold intolerance or other symptoms of thyroid dysfunction. He does report a long history of snoring, confirmed by his wife. However, he did not notice feeling more fatigued after starting atenolol.Nonetheless, you switch his antihypertensive medication from atenolol to hydrochlorothiazide. In addition, you order a CBC, serum chemistries, a thyroid panel, and a sleep study. The patient is told to return for a follow-up appointment in 2 weeks and to call before that if symptoms worsen.
Q: Is this recommended course of treatment reasonable? What other options are available for the patient?
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In this situation, the evidence (depressive symptoms in the context of good blood-pressure control) was insufficient to justify a switch from a beta-blocker to hydrochlorothiazide. One could argue that the switch was reasonable regardless of his depressive symptoms; the most recent guidelines from JNC 71 indicate that thiazide diuretics are first-line therapy for hypertension in patients without CAD, and that beta-blockers are not the first-line agent in the patient’s clinical situation.
But discontinuing atenolol because of ongoing depressive symptoms is not supported. The patient may well need a beta-blocker in the future (eg, if he were to develop CAD). By prematurely concluding that the beta-blocker caused adverse effects, we may be denying him an important treatment down the road.
Option 1: 2-week drug holiday
If there was concern that the patient was having an idiosyncratic reaction to atenolol, or if he developed substantial fatigue or sexual dysfunction, a 2-week drug holiday could be conducted while carefully monitoring blood pressure and depressive symptoms. Atenolol could then be restarted to identify a temporal relationship between the symptoms and the medication.
Option 2: Treat for depression