CANMAT Comorbidity Guidelines

Question 1

why do we care about the presence of depression in the medically ill

Answer 1

depression is associated with increased morbidity, mortality and chronic disease burden in patients with medical disorders

Question 2

what is the relationship between depression and medical illness

Answer 2

bidirectional

each has a negative impact on the onset, course, prognosis, and treatment of the other

Question 3

depression increases the risk for what 6 medical illnesses

Answer 3

coronary artery disease/ischemic heart disease

ischemic stroke

epilepsy

alzheimer’s disease

diabetes mellitus type II

cancer

Question 4

depression increases the risk of DM type II by how much

Answer 4

60%

Question 5

depression increases the risk of alzheimer’s by how much

Answer 5

2.1 fold

Question 6

depression increases the risk of epilepsy by how much

Answer 6

4-6fold

Question 7

depression increases the risk of CAD/ischemic heart disease/ischemic stroke by how much

Answer 7

1.5-2 fold

Question 8

how do we hypothesize depression increases risk for medical illness

Answer 8

increases in:

HPA axis activity

sympathetic stimulation

pro-inflammatory cytokine levels

behaviours such as non-adherence to medical treatment regimens, neglect of self care, physical inactivity, poor diet and substance use

Question 9

how do we think medical illness contributes to the risk of depression

Answer 9

direct physiological mechanisms –> ie brain injury and thyroid deficiency

stress related physiologic mechanisms (i.e increased HPA activation and immunologic system) associated with the physical condition or disability

psychosocial factors related to illness burden and disability

Question 10

how does early childhood adversity (ACEs) affect risk of depression and medical illness in later life? how do we think this happens?

Answer 10

these individuals may have ENDURING immune and HPA axis abnormalities that confer vulnerability to both depression and medical illness

those who experience ACEs have higher risk of both depression and medical illness in later life

Question 11

list three classes of medications used to treat medical illness that have been implicated in the pathogenesis of depression

Answer 11

corticossteroids

cancer chemotherapeutic agents (including vincristine)

antihypertensives (reserpine, methyldopa, beta blockers)

Question 12

are there differences in the clinical presentation and course of primary vs secondary depression

Answer 12

no not really

(thus wonder if secondary depression is really a distinct clinical entity)

Question 13

what symptoms of depression are more common in MDD rather than medical illness/sickness syndrome

Answer 13

guilt

worthlessness

SI

Question 14

what is considered the most appropriate approach to diagnosing MDD in the medically ill

Answer 14

the “inclusive” approach wherein all depressive symptoms are counted irrespective of whether they are related to medical illness

(vs. the exclusive or other approaches)

*there is risk of depression overdiagnosis but this risk appears small compared to risk of underdiagnosis in the medically ill

Question 15

how does the presence of both depression and medical illness affect immune markers comapred to those with medical illness and no depression

Answer 15

elevation in immune markers with both conditions, with higher immunological disturbance when both occur together

Question 16

name a screening scale that was found to be helpful in screening for depression in the medically unwell

Answer 16

beck depression inventory for primary care

also PHQ9

Question 17

name two ADs that are potent inhibitors of P-glycoprotein

why do we care?

Answer 17

sertraline and paroxetine are potent inhibitor of p-glycoprotein

p-glycoprotein is responsible for the efflux of several anticancer and cardiac meds like digoxin

Question 18

name an AD that should not be used in cardiac patients due to its antiarrhythmic effects

Answer 18

imipramine

Question 19

what type of psychotherapy was found to be effective in treatment of depression post-MI

Answer 19

CBT