The Impact of Comorbidity of Depression and Anxiety on Outcomes of Illness

Sylvia E, B.S,MPH

Depression and Common Co-morbidites: Depression: – A mood (affective) disorder that’s a widespread issue, ranking high among causes of disability, Associated with a potential risk for suicide

Common co-morbidites of depression:

1) Anxiety disorders :Comorbid in approximately 70% of the patients. This combination makes a patient’s prognosis poorer, with a higher risk for suicide and disability

2) Psychotic disorders: Such as schizophrenia

3) Substance use disorders: Patients often use substances in an attempt to relieve manifestations of depression or self-treat mental health disorders

4) Eating disorders

5) Personality disorders

Comorbidity . Comorbidity refers to one or more diseases or conditions that occur along with another condition in the same person at the same time

. Conditions considered comorbidities are often long-term or chronic conditions.

. It is common for health care professionals to miss or ignore a diagnosis of depression or anxiety because they feel the symptoms are fully explained by the situation.

. A missed diagnosis can have detrimental effects on outcomes, transition back home and return functioning.

Depressive disorders recognized by the DSM-5

Major depressive disorder(MDD)à single or recurrent episodes of unipolar depression accompanied by at least 5 clinicals findings

o Psychotic features- presence of auditory hallucinations o Postpartum onset- begins within 4 wks of childbirth and can include delusions

Seasonal affective disorder(SAD)usually during winter o Light therapy is the first-line treatment for SAD

Dysthymic disorder- milder form of depression usually with early onset (childhood/adolescence) and lasts at least 2 yrs for adults Premenstrual dysphoric disorder(PMDD)- associated with the luteal phase of the menstrual cycle incluing emotional lability and persistenor sever anger and irritability Substance-induced depressive disorder- associated with the use of or withdrawal from drugs and alcohol

Client care

Acute phase (severe clinical findings of depression) o Treatment is generally 6-12 wks in duration o Assess suicide risk, and implement safety precautions or one-to-one observation PRN

Continuation phase (increased ability to function) o Treatment is generally 4-9 months in duration o Relapse prevention through education, medication, psychotherapy is goal

Maintenance phase (remission of manifestations) o Phase can last for years o Prevention of future depressive episodes is goal

Risk factors

Family history Females between the ages of 15-40 Pts over 65+ (can be similar to dementia) Neurotransmitter deficiencies (serotonin or norepinephrine deficiency) Stressful life events Medical illness, postpartum, comorbid substance use Poor social support network Being unmarried Trauma occurring early in life

Expected Findings Anergia Anhedonia Sluggishness or inability to relax/sit still Vegetative findings, change in bowel habits (constipation), sleep disturbances, decreased interest in sexual activity Somatic reports (fatigue, GI change, pain) Physical: looks sad, poor grooming, psychomotor retardation, becomes socially isolated, slowed speech

Standard Screening Tools Hamilton Depression scale Beck depression Inventory Geriatric Depression Scale Zung Self rating depression scale Pt Health Questionnaire-9

Patient Centered Care Nursing care

Milieu therapy o Suicide risk o Self-care o Communication o Maintenance of a safe environment o Counseling

Medications SSRI’s-> Citalopram, Fluoxetine, Sertraline TCA’s -> Amitriptyline MAOI’s -> Phenelzine Atypical antidepressants -> Bupropiion SNRI -> Venlafaxine, Duloxetine

Patient centered care cont’d Alternative or complementary therapies

St. John’s Wort -> plan product not regulated by FDA o Potentially fatal when taken with SSRI’s or other antidepressants o Avoid foods with tyramine

Light therapy o First line treatment of SAD o Inhibits nocturnal secretion of melatonin

Therapeutic procedures

ECT ->depressive disorders and unresponsiveness to other tx Transcranial magnetic stimulation -> depressive disorders Vagus nere stimulation -> implanted device that stimulates vagus nerve

Meet Eugene Shaw:

Students will meet Eugene Shaw, he is an 82 year old former marine who served in the Korean War. We would focus on Eugene’s hospitalization for vascular problems related to his diabetes. There are also hints that he may have an underlying depression or anxiety.

Learning objectives

Identify behaviors that may indicate a mood disorder

Identify behaviors that may indicate anxiety

Develop an understanding of the difference between depression and difficulty coping

Identify tools that could be useful in assessing cognition and mood

Demonstrate an understanding of the impact of depression and anxiety on outcomes of physical illness

Diagnosis of Eugene Shaw

“My name’s Eugene Shaw but everybody calls me Gene. I was born on May 21 in Cleveland, Ohio. I am 82-years old and live with my wife Nancy. We have a son, Robert Shaw who is 57. He lives about 500 miles away with his wife and they come to visit us fairly often. He went to college and got some fancy job selling chemicals. We have no family living close by except for my cousin Arthur and his family. We see them sometimes but Nancy doesn’t seem to be too social these days so I don’t push her too much. I try to get out with my buddy Jim. We served together in the Korean War but Nancy yells that we drink too much when we are together and it gets my sugar high. Who cares at my age?I’m not going to be around forever. I like my beer and a little nip of whiskey at night to help me sleep.

I am a Veteran. I proudly enlisted and served for 2 years in the Marines. I was a private in the Medina County Marine Corps League Detachment 569, Medina VFW Post 5137. A great group of guys and we lost quite a few. I didn’t know what I was getting myself into when I signed up. It was so cold that first winter. Korea was a land of weather extremes–all bad. It went from 30 below zero in the winter to over 100 degrees in the summer. During the cold winter months, we wore long- johns, utility trousers, waterproof cold weather trousers, utility jacket, sweater, a parka and thermo boots. The enemy wore heavy quilted coats and pants and, for the most part, sneaker-like shoes. From what I understand, they weren’t very warm. In between summer and winter was the monsoon season that turned the country into a flooded swamp. Aside from the war, the bad weather was a morale factor more than anything. The cold and heat were unbearable and during monsoon season, no one was ever dry. That’s where my troubles started with my feet. Wow wee, my darn feet were always wet, stinking wet in the summer and cold and frozen in the winter. Those boots didn’t protect at all; in fact I think that they made things worse because they leaked so much. Probably can’t blame anyone but the soggy wet soil. You ever hear of trench-foot? I had it and still got some of it. That’swhat I got to take home with me from Korea but it’s better than the alternative. Yeah that is war or a least it was in my time. I bet they have made some progress in getting those troops better equipment than in my day.

Diagnosis of Enugen Shaw cont.

I came home from the Marines and I had a hard time walkin. I went to the VA and they told me – “Boy, it’s off with those toes,” and off they went. You didn’t ask questions in those times. They took three off my right foot and left the others. Sometime after one just got black and fell off. My poor Nancy she washed my feet and tried to keep them circulating but it was too late.

I go to the doctor sporadically, never can remember those dates. I’ve had several visits the last year or so. I keep getting sores on my right lower leg that don’t go away. My heel had a big ulcer not too long ago and I needed a lot of antibiotics to get that one to go away. Now look, it’s back again and it looks so blue. My foot is always so cold.

I came here today because my leg is really bothering me for about a week. I was getting into my car and I hit my foot on the car door. Since then I started to have these pains and my heel is getting bad again. My right calf has some awful pains and burning down the sides. I couldn’t hardly sleep at all last night cause of the pain and it got worse during the day. Nancy has been nagging me to have my leg checked out all week. She really got worried today when she saw how bad the pain was and the color of my leg and foot. She insisted that I come here to see what’s up, so here I am.”

Learning objective for Eugene Shaw:

We would be evaluating, and trying to better understand the diagnoses compounded with his medical problems.

In addition the student will explore the general impact of stress, depression and anxiety on outcomes when seen in concert with chronic illness.

Assignment: Due Thursday, 06/11/2020 7:00PM EST

What evidence do you read that may be indicative of depression? How can you assess Eugene’s baseline functional status? What coping strategies does Eugene use? Who are Eugene’s support system and how can they help him? What evidence of anxiety do you hear as Eugene talks? What are Eugene’s strengths and weaknesses?

Assignment: Due Friday, 06/12/2020 7:00PM EST

Consider assessment tools that would be appropriate for continuing to evaluate Eugene?

Utilize these tools to better understand:

The behaviors associated with Major Depression

Evidence of any cognitive impairment that may be complicating Eugene’s recovery

The overlap of depressive, cognitive and anxiety behaviors and what they mean

How alcohol may be a factor in compromising outcomes

What is Eugene’s baseline level of functioning and has he deviated from that point?

How can you evaluate Mrs. Shaw’s ability to manage the caregiving role?

Assignment: Due Sunday, 06/14/2020 11:59pm EST

In the third scenario of the simulation, Eugene is recovering from surgery: Answer these questions based on the scenario given

What is depression?

What are the causes for depression?

What are the symptoms of depression?

What are the pharmacological treatments for depression?

Will these treatments impact any other treatments the patient may be getting?

What are the non-pharmacological treatments for depression?