인제대학교 서울백병원 김원 - anxiety · 2011-06-09 · change on somatic symptoms...

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인제대학교 서울백병원 김원

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  • 인제대학교

    서울백병원

    김 원

  • 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

    * total

    suicidal ideation

    * guilt

    * low energy

    depressed mood

    * anhedonia

    * psychomotor retardation

    * poor concentraion

    * psychomotor agitaion

    * decreased sleep

    * decreased appetite

    controls past MDD current MDD

    * < 0.05

    Psychiatry Res, 2002

  • Painless somatic symptoms in depression ◦

    vague and exaggerated multiple somatic complaints (usually ≥ 3)

    fatigue, weakness, non-specific and painless musculoskeletal problems, sensations of heaviness or lightness in at least one part of the body, gastrointestinal dysfunction, shortness of breath, palpitations, dizziness, double vision, changes in sleep patterns and appetite, and polyuria

    Painful somatic symptoms ◦

    joint pains, lumbar pain and headache

    Age, female gender, and unemployment◦

    associated with the presence of somatic symptoms.

    The severity of the depression is greater in patients with moderate to severe discomfort due to somatic symptoms.

  • DSM system◦

    emphasize psychological sx. as key fx. of MDD◦

    underestimate somatic depression

    Masked depression in primary care◦

    1st stage, 442 patients, 1.8% prevalent.◦

    2nd stage, 62 patients with high somatization score, 39 (63%) prevalent.◦

    Most were diagnosed with Musculoskeletal disease◦

    Underestimation is crucial in minority population.

    Posse and Hallstrom, 1998

  • Nakao and Yano (2006)◦

    1066 Japanese workers (mean age 35 years), ◦

    annual health examinations, in 2 successive years, ◦

    Prediction of depression in the following year◦

    3.4~3.7% MDD seen among the Japanese workers◦

    WHO reported that 77% of Japanese depressive subjects complained of somatic symptoms. ◦

    Fatigue was the most common and powerful predictor of core depressive symptoms

    Insomnia was closely related to depressive mood and diminished interest or pleasure. Headache was the second most common symptom, less predictive than fatigue and insomnia.

  • Depressed moodMontgomery–Asberg Depression Rating Scale (MADRS)Only 3 items : physical symptomsHamilton depression rating scale (HAM-D)8 items : physical symptoms18/56 point (32%)PHQ-9

    Somatic symptoms Patient Health Questionnaire-15 (PHQ-15)Somatic Symptom Inventory (SSI) Visual Analog Scale (VAS) for pain (DeLoach et al., 1998)≥ 20 (on a scale of 0–100)Symptom questionnaire

  • Patient Health Questionnaire-15 (PHQ-15)◦

    self-report, somatic symptom type and severity over, the prior 4 weeks

    Somatic Symptom Inventory (SSI) ◦

    26-item questionnaire, painless and painful ◦

    patients' degree of discomfort for each symptom is rated from 1 to 5 (1 = absent; 3 = moderate; 5 = a great deal)

    MADRS relies less than HAM-D does on somatic symptoms.

  • 157 MDD patients

    0

    5

    10

    15

    20

    25

    30

    HAMD-17 HAMD-S MADRS MADRS-S

    0wk 8wk Change on somatic symptoms correlated with global improvement in MDD.

    Improvement in somatic symptoms is highly correlated with a favorable outcome in depression.

    Nonremitting responders had a significant smaller baseline-to-end point decrease in somatic symptoms.

    Nonremitter vs Remitter based on MADRS

    -2.45

    -3.71-4

    -3

    -2

    -1

    0

    0-8w

    k of

    HA

    MD

    -S

    nonremitting responder remitter

    p=0.011

    J Psychosom Res. 2006

  • Adapted from: Greco T, et al. J Gen Intern Med. 2004;19(8):813-818.

    Nonsomatic depressive symptoms

    Positive well-being

    Nonpain somatic symptoms

    Pain somatic symptoms

    Impr

    ovem

    ent

    Trea

    tmen

    t Effe

    ct S

    ize

    Emotional Symptoms

    Physical Symptoms

    A Randomized Trial Investigating SSRI Treatment

    0

    0.2

    0.4

    0.6

    0.8

    1.0

    1.2

    1.4

    Baseline 1 Month 3 Months 6 Months 9 Months

    N=573

  • Gender differences in prevalence of MDD◦

    may be due to the high prevalence of anxious depression, atypical depression and somatic depression in women.

    These three subtypes of depression ◦

    are also very prevalent during pregnancy, the post partum period, perimenstrually and during the menopause transition (perimenopause) period◦

    vulnerability and hormone instability in their pathobiology.

  • Atypical depression▪

    Mood reactivity1

    Increased appetite1

    Increased weight1

    Hypersomnia1

    Leaden paralysis1

    Sensitivity to interpersonal rejection1

    Intensified mood reactivity2

    Mood Lability2

    Anxiety, Irritability2

    Anxious depression phenotype3

    Depressed mood

    Negative self-evaluation▪

    Discouragement▪

    Diurnal variation▪

    Depersonalization or derealization

    Somatic overconcern▪

    Difficulty concentrating▪

    Insomnia▪

    Lack of energy▪

    Psychomotor agitation▪

    Subjectively experienced anger

    Distrustfulness▪

    Nonreactivity of mood to changes in circumstances

    1 APA, 1994. 2.West and Dally, 1959. 3 Clayton PJ et al, 1991. 4

    Silverstein, 1999, 2002.

    “Somatic Depression”4

    Depression▪

    Sleep disturbances▪

    Fatigue▪

    Anxiety▪

    Diversified pain and aches

  • Lifetime prevalence of somatic depression◦

    (F: 15.2%, M: 7.5%)

    but a prevalence of pure depression ◦

    (F: 6.9% , M: 6%)

    Somatic depression have a tendency with coexisting anxiety disorder

    Silverstein, 1999

  • Serotonin (5-HT) and norepinephrine (NE) pathways mediate various functions in the brain1-3

    Descending spinal projections modulate nociception2,3

    Disturbance in these pathways are thought to be associated with the emotional and physical symptoms of depression3

    Dorsal raphe nuclei

    Caudal raphenuclei

    Lateral tegmental NA cell system

    Locus ceruleus

    NE

    Depressed mood

    Suicidal ideation

    Sleep disturbances

    Changes in appetite/Lack of pleasure

    Vague pain in joints, limbs, back,

    abdomen, etc

    Headaches

    GI complaints

    Modulatory effects on nociception

    5-HT

    –Adapted from: 1Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Lippincott Williams & Wilkins; 1998:114-115.

    2Fields HL, et al. Annu Rev Neurosci. 1991;14:219-245.3Stahl SM. J Clin Psychiatry. 2002;63:382-383.

  • Atypical depression ◦

    MAOI > TCA , still in debate ◦

    SSRI + benzodiazepine

    Somatic depression◦

    Very few studies◦

    Secondary analysis

    Chronic pain◦

    TCA = SNRI ? > SSRI◦

    TCA + anticonvulsant => gabapentin ?

    Antonijevic, 2006; Matza et al., 2003

  • SNRI◦

    Venlafaxine, Milnacipran, Duloxetine◦

    Analgesic effect via descending pain pathway

  • 3

    4

    5

    6

    7

    8

    0 1 2 3 4 5 6 7 8Week

    Mea

    n H

    AM

    -D S

    core

    on

    6 A

    nxie

    ty-

    Som

    atiz

    atio

    n Fa

    ctor

    Item

    s*Venlafaxine XR (N=1136)Placebo (N=691)

    ‡‡

    Venlafaxine XR in the Reduction of Anxiety- Somatization Symptoms Associated with MDD*

    †P

  • In Depressed PatientsEffective in reducing pain associated with depression1

    1 Detke et al, 2003

    -45-40-35-30-25-20-15-10-50

    Overall Head Back Shoulder

    PlaceboDuloxetine

    *p

  • Effectiveness of mirtazapine in the treatment of depression with associatedsomatic symptoms.

    García Campayo. Actas Esp Psiquiatr. 2008 Jan-Feb;36(1):25-32.

    Somatic section on HAM-D, SPPI

  • Quetiapine◦

    Antipsychotics for anxious depression ?◦

    perphenazine

  • Omega-3 fatty acid (DHA & EPA)◦

    The deficit of omega-3 PUFAs is associated with depression. ◦

    Societies that consume a small amount of omega-3 PUFAs appear to have a higher prevalence of MDD. ◦

    depressive pt. showed a lower level of omega-3 PUFAs◦

    the antidepressant effect of PUFAs had been reported in a number of clinical trials.◦

    EPA and DHA are not synthesized in human body and can only be obtained directly from fish.

    the role of n-3 fatty acids in psychoneuroimmunology,somatic presentation, and medical illness comorbidity of depression. Su KP, Asia Pac J Clin Nutr.2008

  • Education◦

    Caffeine, alcohol

    Psychotherapy◦

    Supportive◦

    Cognitive-behavioral◦

    Mindfulness

    Biofeedback, relaxationExerciseMeditation, Yoga

  • New dimension of diagnosis

    Detailed and precise measurement of somatic symptoms

    New pharmacotherapy tailored to…

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