Cases That Test Your Skills

The painful truth about depression

Current Psychiatry. 2004 April;3(4):89-93

References

1. Sood N, Treglia M, Obenchain RL, et al. Determinants of antidepressant outcome. Am J Manag Care 2000;6:1327-36.

2. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000;157(suppl 4):1-45.

3. Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care 1996;33:67-74.

4. McBeth J, MacFarlane G, Silman A. Does chronic pain predict future psychological distress? Pain 2002;96:239-45.

5. Ohayon M, Schatzberg A. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry 2003;60:39-47.

6. Nakao M, Yamanaka G, Kuboki T. Major depression and somatic symptoms in a mind/body medicine clinic. Psychopathology 2001;34:230-5.

7. Posse M, Hallstrom T. Depressive disorders among somatizing patients in primary health care. Acta Psychiatr Scand 1998;98:187-92.

8. Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med 1995;25:1171-80.

9. Von Korff M, Simon G. The relationship between pain and depression. Br J Psychiatry 1996;168:101-8.

10. Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care setting. J Psychosom Res 1988;32:137-44.

11. Sartorius N. Physical symptoms of depression as a public health concern. J Clinical Psych 2003;64(suppl 7):3-4.

12. Keller MB. Long-term treatment strategies in affective disorders. Psychopharmacol Bull 2002;36(suppl 2):36-48.

13. Keller MB, Berndt ER. Depression treatment: a lifelong commitment? Psychopharmacol Bull 2002;36(suppl 2):133-41.

14. Segal Z, Vincent P, Levitt A. Efficacy of combined, sequential and crossover psychotherapy and pharmacotherapy in improving outcomes in depression. J Psychiatry Neurosci 2002;27:281-90.

15. Denninger JW, Henderson PO, Fallis K. The relationship between somatic symptoms and depression (presentation). Philadelphia, PA: American Psychiatric Association annual meeting, 2002.

16. Worthington J, Fava M, Davidson K, et al. Patterns of improvement in depressive symptoms with fluoxetine treatment. Psychopharmacol Bull 1995;31:223-6.

17. Fava M. Somatic symptoms, depression, and antidepressant treatment. J Clin Psychiatry 2002;63:4-305-7.

18. Fishbain DA, Cutler RB, Rosomoff HL, et al. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosom Med 1998;60:503-9.

19. O’Malley PG, Belden E, Tomkins G, et al. Treatment of fibromyalgia with antidepressants: a meta-analysis. J Gen Intern Med 2000;15:659-66.

20. Salerno SM, Browning R, Jackson JL. The effect of antidepressant treatment on chronic back pain: a meta-analysis. Arch Intern Med 2002;162:19-24.

21. Fishbain DA. Evidence-based data on pain relief with antidepressants. Ann Med 2000;32:305-16.

22. Fishbain DA, Cutler R, Rosomoff HL, et al. Evidence-based data from animal and human experimental studies on pain relief with antidepressants: a structured review. Pain Med 2000;1:310-16.

Be sure to include chronic pain or other somatic symptoms in the systems review. Screening tools such as the Visual Analogue Scale can measure pain intensity, while the Cornell Medical Index can uncover somatic symptoms. No all-inclusive tool exists to help detect depression-related somatic symptoms. however.

Should the psychiatrist continue to address Ms. F’s depressive symptoms, or should the focus shift to her somatic symptoms?

Dr. Fishbain’s observations

Patients who do not respond to depression treatment (ie, achieve >50% symptom reduction), or who respond without achieving remission, usually have residual physical symptoms—often fatigue, sleep disturbance, decreased appetite, anxiety, sexual dysfunction, and/or pain.^12-14 Severe pain and other somatic symptoms are likely prolonging Ms. F’s depression, despite increased paroxetine dosages.

Paykel et al⁸ have associated residual depression symptoms with early relapse of depression. In their study, 94% of depressed patients with lingering depressive symptoms had mild to moderate physical symptoms. By contrast, degree of physical symptom improvement has been shown to correlate with likelihood of depression remission.¹⁵

Although emotional symptoms improve with antidepressants,¹⁶ some evidence¹⁷ indicates that physical symptoms associated with depression may be less responsive.

Also, because many psychiatrists have been taught to track emotional symptoms and only some physical symptoms, somatic symptoms of depression often are not targeted for treatment.¹⁷ Lack of rating scales to track somatic symptoms compounds this problem.¹⁷

Psychiatrists need to target both the physical and emotional symptoms of depression. When pain prolongs depression, it should be the primary target of antidepressant drug therapy (Algorithm).

To date, several meta-analyses^18-20 have demonstrated that antidepressants have a separate analgesic effect on all forms of chronic pain. Evidence^21,22 also indicates that the dualaction antidepressants—such as amitriptyline, bupropion, venlafaxine, and (awaiting FDA approval) duloxetine—have a more-consistent analgesic effect than do the serotonin reuptake inhibitors.

The analgesic effects of bupropion, duloxetine, and venlafaxine have not been compared with those of tricyclics or other older antidepressants. If one of the newer dualaction antidepressants does not reduce somatic conditions or produce an adequate response, consider switching to a tricyclic.

Treatment: No pain, some gain

Another psychiatrist who specializes in pain medicine targeted some of Ms. F’s somatic symptoms with antidepressants. Paroxetine and zolpidem were discontinued and the patient was started on:

venlafaxine, 37.5 mg bid, titrated to 225 mg/d across 2 weeks. Because of its activating properties, venlafaxine was chosen to address Ms. F’s pain and daytime fatigue.
amitriptyline, 50 mg at bedtime nightly, to promote sleep
prochlorperazine, 10 mg as needed, and meclizine, 25 mg as needed, to treat her nausea and dizziness, respectively.

Algorithm Suggested drug treatment of depression with somatic symptoms

Ms. F also was advised to take an abortive migraine compound (Midrin, 2 tablets at headache onset and 1 additional tablet every half-hour as needed, maximum 5 tablets per day). Mr. F’s primary care physician also referred her to a physical therapist to treat her neck and low-back pain; workup revealed no surgically treatable problem.

Four weeks later, Ms. F reported that her somatic symptoms significantly improved and that she was sleeping nearly 8 hours per night. Her BDI score was 12, indicating normal mood. She was functioning much more effectively at work and could once again routinely perform her daily activities.

Ms. F continued her medication regimen for 8 months, after which she was lost to follow-up. At her most recent visit, her depression remained in remission. Her pain persisted, though at a lower intensity.

Related resources

Fishbain DA, Cutler R, Rosomoff HL, Rosomoff RS. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clin J Pain 1997;13:116-37.

Drug brand names

Amitriptyline • Elavil
Duloxetine • Cymbalta
Meclizine • Antivert
Modafinil • Provigil
Paroxetine • Paxil
Prochlorperazine • Compazine
Venlafaxine • Effexor
Zolpidem • Ambien

Disclosure

Dr. Fishbain is a consultant to Eli Lilly and Co. and a speaker for Purdue Pharmaceuticals.