What influence do cardiac, social or neurological problems have on psychiatric diseases and vice versa? This question was addressed by the speakers at the symposium "Recognising and Treating Psychiatric Comorbidities".
During the "Mental Health Week", experts shed light on the different sides of psychiatry. This was also the case with physicians from the Max Planck Institute for Psychiatry in Munich and the Department of Psychiatry and Psychotherapy at the Ludwig Maximilians University (LMU) Hospital, Munich. At the symposium "Recognising and Treating Psychiatric Comorbidities", they reported on their experiences with the concomitant symptoms of psychiatric illnesses. In this article, you can find out what is recommended in case of depression and anxiety disorders in heart disease and what influence addictive disorders have, which Prof. Susanne Lucae and Prof. Oliver Pogarell talked about.
The fact that depression is an independent risk factor for a heart attack and the development of coronary heart disease (CHD) was confirmed by Prof. Susanne Lucae, Deputy Chief Physician at the Max Planck Institute for Psychiatry, in her lecture "Anxiety disorders and depression are frequent companions of cardiovascular diseases". After a cardiovascular event, depressive comorbidity is associated with an unfavourable course of the physical disease. The S3 guideline on cardiac rehabilitation therefore always recommends monitoring for depression and anxiety in the following events: chronic heart failure (here the prevalence for depression is 36%), after heart valve corrections, ICD implantations and VAD implantations.
There are 3 main and 7 additional symptoms by which depression can be recognised. The three main symptoms are loss of interest and pleasure, depressed mood, reduced drive. Furthermore, there are seven additional symptoms, which are also decisive indications: suicidal thoughts, reduced self-esteem and lack of self-confidence, reduced appetite, disturbances in concentration and attention, sleep disturbances, feelings of guilt and worthlessness, and negative and pessimistic worries about the future. As soon as even two of the symptoms apply, GPs should consider a depression or anxiety disorder. These symptoms can be easily identified with the WHO 5 well-being questionnaire. It contains 5 questions about well-being within the last two weeks, for which the patient has six possible answers, for which there are different numbers of points: Was I happy and in a good mood? Did I feel calm and relaxed? Did I feel energetic and active? Did I feel fresh and rested when I woke up? Was my daily life full of things that interest me? The critical limit is 14 points. If there is a lack of time or if the patient is not able to answer the questionnaire so extensively, there are two simple questions. Have they often felt down, sad, depressed and hopeless in the last month? Have they had significantly less pleasure and joy in doing things they usually like to do in the last month? If the answer to any question is "yes", further treatment should be given.
In psychology, a distinction is made between panic disorder and anxiety disorder.
Does the patient suffer from repeated and unexpected panic attacks (anxiety attacks) with physical and psychological symptoms such as rapid heartbeat, shortness of breath, sweating, sensations of discomfort, nausea, anxiety up to and including fear of death, fear of losing control or a feeling of strangeness? Possible questions to ask the patient would be: Do they have sudden conditions where they become fearful and anxious, suffering from symptoms such as racing heart, trembling, sweating, shortness of breath, fear of death? Do you have fear or anxiety feelings when you are in a crowd, confined spaces, public transport and avoid such situations out of fear?
Generalised anxiety disorder, on the other hand, is indicated by anxious apprehension, tension and fears about everyday events and problems. Possible questions for diagnosis are: Do they feel nervous or tense? Do they often worry about things more than other people? Do they feel like they are constantly worried and can't control it? Do you often fear that a disaster could happen?
What is the recommended therapy for depression or anxiety disorder? Psychotherapy is effective in treating depressive disorders through behavioural therapy, interpersonal therapy or mindfulness-based cognitive therapy. Behavioural therapy, on the other hand, has shown clear evidence of effectiveness for anxiety disorders and for mild and moderate depressive episodes. However, it should last for more than 12 weeks to be effective. Ultimately, a combination of behavioural therapy and psychopharmacotherapy is significant and superior to any one treatment modality.
The S3 guideline on depression recommends pharmacotherapy preferably with SSRIs for CHD. TCAs should not be prescribed. Psychotherapy should be offered instead. In post-stroke depression, it is recommended not to administer anticholinergic substances and no general prophylaxis with antidepressants after a stroke. However, the guideline recommends regular monitoring for depressive symptoms during the course of treatment.
When using psychopharmacotherapy, detailed information is necessary in every case. Those receiving treatment should receive close weekly monitoring during the first 4 weeks, which should be continued during the following four months. After that, however, they only need to be seen every two to three weeks. Electrolyte, transaminase, creatinine, CRP and TSH levels should be checked during therapy. An ECG is recommended before therapy with SSRIs and TCAs.
When using depressant medications, the following medications are used: Antihypertensives such as reserpine, beta-blockers (propranolol), ACE inhibitors (enalapril) and CA2+ channel blockers (verapamil); digitalis preparations and other cardiac drugs; salbutamol; corticosteroids; anabolic steroids; baclofen; antibiotics (gyrase inhibitors) and viral drugs (aciclovir); oral contraceptives; antihistamines such as cimetidine; immunosuppressants such as interferon; and antiepileptic drugs such as carbamazepine.
The following agents are recommended for psychotropic drug therapy. The first choice is always the selective serotonin reuptake inhibitors (SSRIs). According to Lucae, two medications have proven themselves in therapy because they are particularly low-interacting. One is sertraline. Here, an initial dose of 25 mg is recommended in the morning, which can later be increased to 50 to 100 grams. The second drug is citalopram. Here Lucae recommends a starting dose of 5 mg in the morning. In case of administration in drop form, even 1 mg is sufficient.
Cardiac side effects are rare with this type of therapy, but when taking escitalopram, the QTc time should be kept in mind. It is always recommended to start with a low dose, especially if an anxiety disorder has been diagnosed. It is important to inform the patient about common side effects. For example, inner restlessness and GI discomfort may increase in the first few days.
If the therapy is successful, maintenance therapy is recommended for 4 to 9 months at the same dose that led to remission. Maintenance therapy can reduce the risk of relapse by 70%. Only then, a gradual reduction over four weeks is advised.
One possible course of action for depression is to increase the dose of therapy with TCA, venlafaxine and tranylcypromine. However, this is not useful with SSRIs. Another option is augmentation with quetiapine or lithium, a combination with another antidepressant (e.g. SSRI with mirtazapine) or switching to psychotherapy are possibilities for a successful therapy. In the case of an anxiety disorder, a change of therapy is recommended.
A psychiatrist should be consulted if the administration of a second antidepressant is not successful or if the patient shows delusional symptoms. Psychotherapy is always recommended when an anxiety disorder has been diagnosed. Otherwise, referral to a psychotherapist is also mentioned here as an option if drug therapy remains without effect. A special case that always requires referral to a psychiatrist or psychotherapist is the psychiatric emergency of suicidal tendencies. This is why physicians should always ask about suicidal thoughts. If the patient states that he/she is thinking about suicide, the following questions arise: How concrete are the thoughts? Are there any preparatory actions? How urgent are the thoughts? What is holding the patient back so far? Is the patient able to talk about it? Depending on how vulnerable the patient is, physicians should consider an inpatient psychiatric stay. In any case, the patient should be readmitted promptly.
Prof. Oliver Pogarell, Deputy Head of the Department of Psychiatry and Psychotherapy at the LMU Hospital, spoke about "Regular sick leave on Mondays - addictive disorders and other causes". Right at the beginning of his speech, he debunked the statement of his lecture title. Statistically, the most sick leaves are on Mondays, as a Barmer survey in Berlin and Brandenburg from 2016 shows, and this gives the impression of an alcohol-related "hangover". However, if the length of sick leave is included in the survey, Mondays actually have the lowest sick leave rate. This is because most people who are sick on Mondays were already sick at the weekend. Accordingly, sick leave on Mondays is not always caused by a "hangover". But it can be a reason.
According to the WHO, alcohol dependence is the second most common disease after depression and before dementia. According to a study by Wilcox (2004), the risk of suicide is ten times higher in alcohol dependence than in people who do not drink. In the case of opioid addiction, the suicide risk is 13 times higher, and even 17 times higher in the case of polytoxicomania. Addictive disorders are among the most frequent inpatient treatment diagnoses in Germany. Alcohol addiction in particular runs through the entire lifespan and is one of the leading risk factors for health burdens. These include physical illnesses such as cancer, the accident rate increases over the entire life span, and mental illnesses occur, such as anxiety disorders, depression, and suicidal tendencies are also increased. And the more one drinks, the higher the risk.
According to the S3 Guideline (2015) on screening, diagnosis and treatment of alcohol-related disorders, alcohol addiction is underdiagnosed because there is no follow-up, Pogarell explains. That is why the use of questionnaires such as the AUDIT (Alcohol Use Disorders Identification Test) is recommended for early detection. If this is too time-consuming in the hustle and bustle of everyday life, one can extract a partial aspect, the AUDIT C, which consists of three questions: How often do you drink, how much and how excessively. The risk of developing an alcohol-related disorder starts at 3 points for women. The risk does not only start when physical or psychological damage has occurred.
The goal of therapy is to ensure survival. The possibilities for this are the reduction of the amount of drugs taken up to abstinence. However, this is difficult to implement in this country, says Pogarell. To achieve the reduction of problematic alcohol consumption, brief interventions are recommended. This means reflecting the problem to the patient and encouraging motivation to work towards reducing drinking quantities. This can take a few minutes, but it is important to take the patient seriously. According to Pogarell, studies have shown that in the case of a lack of time, only the handing out of written information material was sufficient to make the patient aware of the problem and to achieve a reduction in drinking until the next visit to the practice.