Criteria for persistent depressive disorder

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DEPRESSION IN SOMATIC DISEASES (DIAGNOSIS AND TREATMENT)

Dr. A. B. Smulevich - Dr. med. sciences, professor, director of Department borderline mental pathology and Psychomatic Disorders Research Institute Clinical Psychiatry NCPZ RAMS

Dr. M. Yu. Drobizhev - Ph.D. Honey. Sciences, leading researcher of the same branches

C among mental disorders seen in patients with topical somatic disease (SZ), most common depressive states. According to some authors [11, 17], according to the frequency manifestations, varying from 14 to 46% (Table 1), affective (depressive) syndromes in patients SZ can only be compared with dyssomnic disorders. However, how about evidence from a number of publications related to recent decades, there is also the danger of overdiagnosis depression in patients with SZ [8,14,15]. Traditionally, the composition clinical manifestations of depression includes disorders characteristic and for somatic disease (asthenia, weight loss, sleep disturbances, dizziness, tremor, tachycardia, chest pain cell, dyspnea, dyspeptic disorders - bitterness, dryness in mouth, constipation, flatulence, etc.). Differences in diagnostic approaches to such "common" for affective and somatic pathology symptom complexes in primarily reflected in prevalence rates depression in patients SZ (see diagram).
Presented data allow us to state that diagnosis validation depression in patients with current SZ requires clear differential diagnostic criteria ¹ . In our opinion, must be taken into account at least at least three circumstances: features of psychopathological disorders, history and hereditary burden, nature of psychosomatic correlations (ratio between expression, dynamics mental disorders and relevant indicators somatic disease - tab. 2).

Necessary emphasize that the nature of depression, comorbid with topical SZ, heterogeneous. Respectively nosology of depression not limited to somatogenic depression (affective disorder, directly associated with the course of SZ, for example, with atherosclerosis of the cerebral vessels brain). Along with them, there are also nosogenic depressions [4] (depressive reactions to constellation psychogenic and situational factors related to semantic significance of di- agnosia, awareness of danger diseases, physical suffering, quality change life), dysthymia (protracted neurotic depression) endogenous depression. At the same time, as seen from the table. 3, among affective (depressive) disorders predominate nosogenic depressions (depression, hopelessness, anxiety, pessimistic assessment

table 1. Prevalence of depressive conditions (DS) in patients somatic hospital

Authors, year	Volume sample (number of patients)	Frequency DC, %
Maguire, et al., 1974	230	23
Moffic and Paykel, 1975	100	19
Knights and Folstein, 1977	57	46
Cavanaugh, 1983	335	32
et al., 1985	453	14. 6
Levenson et al., 1987	253	23
Kathol et al., 1990	151	44

own somatic condition and prospects for improvement in future). The prevalence of the latter over depressions of other genesis confirmed in several studies [15,19].
Turning to basic principles therapy for depression, comorbid current SZ, it is necessary emphasize the expediency use of a wide range therapeutic interventions, including as different methods of psychotherapy, and psychotropic drugs. The use of psychotherapy most appropriate for nosogenic depressions psychogenic/situational conditional disorders (group and individual classes in technology self-regulation" - autogenous exercise, breathing and relaxation therapeutic gymnastics, various techniques neurolinguistic programming) [11].

Among antidepressants, traditionally used in the treatment of depression in somatic patients, point to tricyclic drugs (TCAs): melipramine (imipramine), anafranil, amitriptyline, nortriptyline. Recommending TCAs, many authors [9, 12] indicate not only a high thymoleptic activity, covering the entire spectrum depressive states, observed in the considered patient population (somatogenic, nosogenic depression, dysthymia, endogenous depressive disorders), but also the potential to provide positive therapeutic effect on some symptoms SZ. Thus, it has been shown that imipramine and nortriptyline is effective in ventricular extrasystoles [12]. S. Conolly et al. [9] found that taking imipramine in average therapeutic dose makes it difficult to induce ventricular paroxysm tachycardia with electrophysiological research. Showcased reduction in the frequency of episodes ventricular fibrillation in experimental infarction myocardium against the background of the introduction of TCA and tendency to spontaneous relief of emerging episodes arrhythmias [16]. shown also beneficial effect of TCAs with symptoms of bronchospasm patients with bronchial asthma [13].

Table 2. Diagnostic criteria depression, comorbid SD

(1) Mental status

Features hypothymia (sadness, anxiety, apathy, anhedonia, intellectual and motor inhibition) whose intensity obeys the circadian rhythm

Phenomena alienation in the form depressive anesthesia (feeling sore insensibility) and depression devitalization (weakening or disappearance of vital attraction - attraction to life, self-preservation instinct, somatosensory drives sleep deprivation, appetite)

Availability depressive meaningful complex (denotata)

1. Ideas worthlessness, guilt, damage reflecting self-consciousness disorder form of discontinuity "I" (persistent thinking with negative evaluation of the past, present and prospects for future)

2. Suicidal thoughts

3. Hypochondriacal ideas: dominant ideas about danger (usually exaggerated) somatic illness, unfavorable outcome and futility treatment, negative social consequences; anxiety and fears (up to phobias), not related to the current SZ and relating to functioning of various internal organs and body overall

(2) History, premorbid, heredity

Depressive and hypomanic states in history

Cycloid, hyperthymic, anxious suspicious, hysterical and schizoid constitutional warehouse with reactive lability (tendency to affective disorders)

Depressive conditions and suicides in the nearest relatives

(3) Violation of psychosomatic correlations

Mismatch manifestations of somatovegetative severity disorders and the nature of the SZ (for example, a sharp weight loss and menstrual disorder cycle in hyperthyroidism, despite the slight increase in hormone levels thyroid gland in the blood prolonged algia in the chest cage, uncharacteristic for angina voltage, persistent asthenia unexpressed iron deficiency anemia or prolonged agrypnia in the absence of night asthma attacks, angina).

Mismatch dynamics of somatovegetative disorders of the nature of the course CV (for example, persistent nausea, pain in the upper half of the abdomen, no appetite and others gastrointestinal complaints with a healed ulcer stomach or duodenum, asthenia, sleep disorders, decreased libido, anhedonia, persisting in clinical picture, despite the successful treatment of hypothyroidism)

Table 3. Nosology of depression in patients somatic hospital
Diagnosis	Frequency, %
	M. E. Stewart et al. [19]	by N. E. Koenig and et al. (15]	own data
Somatogenic depression (organic affective disorder)	-	1	1.4
Depressive reactions: nosogenic other	17 10	14 0.6	10 2
Dysthymia	-	2	4
Endogenous depression (major) depressive episode, cyclothymia)	3	9	2

Table 4. Comparison of fluoxetine and TCA clinical relevance effects on cardiovascular system
Symptoms	Fluoxetine	TCA
Bradycardia	Moderate	Moderate
Decreased blood pressure	Moderate	Moderate
Tachycardia	Not specific	Typical
Orthostatic hypotension	Not specific	Typical
Rhythm disturbances heart and conduction	Not specific	Characteristic

Table 5. Comparison of fluoxetine and TCA clinical relevance drug interactions, used for the treatment of SZ
Preparations, used in therapy	Fluoxetine	TCA.
Thyroid hormones	Not interacts	Violations heart rate
Methyltestosterone	No data	Disorder consciousness
Sympathomimetics	Not interacts	Hypertension
Antiarrhythmic class 1 drugs (quinidine, novocainamide, etc.)	Also	Toxic effect
Hypotensive preparations	" "	Orthostatic hypotension
Cardiac glycosides	" "	Bradycardia
Anticholinergics funds	" "	Gain tachycardia, accommodation spasm etc.

However, the use of TCAs in somatic patients is associated with a number of restrictions associated with pronounced anticholinergic action (Table 4). Introduction of drugs this group is accompanied by side effects: drowsiness during the day, disruption sensorimotor functions (coordination movements, attention, etc.), as well as bradycardia, decreased blood pressure (BP), orthostatic hypotension, dry mucous membranes, urinary retention, constipation. In addition, TCAs are quite often enter into unwanted interactions with somatotropic drugs (Table 5) - thyroid and steroid hormones, antiarrhythmic drugs first class, cordial glycosides, etc. ² .
In connection with the specified properties TCA is an obvious need introduction to the arsenal of psychotropic drugs used in patients with SD, drugs with minimal behavioral toxicity ³ , whose clinical effect is not accompanied by complications and negative impact on the course of SZ, and interaction with somatotropic drugs is limited character.
Among antidepressants, satisfying the specified requirements, in recent decades are widely distribution inhibitors serotonin reuptake (fluoxetine, sertalin, etc.), polycyclic drugs structures (ludiomil, lerivon, pyrazidol), reversible inhibitors monoamine oxidase (MAO) type A short action [18].
Positive qualities selective inhibitors of the reverse serotonin uptake - no side effects characteristic of TCAs, therapeutically significant interactions with a wide range drugs used in therapy (see Tables 4 and 5). Border guard staff mental illness and Psychosomatic Disorders Research Institute Clinical Psychiatry NTSPZ RAMS tested fluoxetine (Prozac, Eli Lilly) for psychogenic (nosogenic) depressive states of severity not less than 11 on the depression scale Hospital Anxiety Questionnaire and depression [20]. In the study patients participated in aged 21-65 years, who were on inpatient treatment for coronary artery disease (patients predominated with II - III functional class angina, have also been observed patients with acute myocardial infarction myocardium, with unstable and progressive angina) base of the Moscow Medical academy. I. M. Sechenova (Department of Coronary Heart Disease, I.M. Sechenov - Head Corresponding Member. RANS prof. A.L. Syrkin). Trial showed high safety and good tolerance of the drug, no adverse interactions with cardiotropic medicines ⁴ . Not deterioration in somatic state that could be due to the influence of fluoxetine. No significant adverse impact drug on ECG parameters, blood test scores. Not unfavorable interactions with nitrates prolonged action beta blockers, calcium channel blockers, cardiac glycosides, antiarrhythmic drugs.
A number of general properties of preparations polycyclic structure (ludiomil, larivon, pyrazidol) - insignificant effect on blood pressure [10], intraocular pressure, prostate and etc. - allows to consider such antidepressants as drug of choice for treatment depression in patients with somatic pathology. Especially domestic is preferred the drug pyrazidol, which virtually no effect on blood pressure conduction system of the heart completely devoid of anticholinergic properties (does not cause dryness mucous membranes, spasm accommodation, constipation, etc. ).
About prospects use of reversible MAO inhibitors in SD, including glaucoma, prostate adenoma, and also in the physically handicapped patients, the elderly, testify to a short withdrawal period, almost complete lack of clinically significant side effects (noted only mild hypotension) [6]. In a row drugs of the considered group should be called moclobemide (Aurorix, Roche). Orthostatic hypotension while using such a drug is observed even less than placebo (correspondingly 2 - 3% against 5%).
For the treatment of depression, comorbid ST, along with antidepressants within combination therapy widely also use tranquilizers and nootropic drugs - Valium, lexotan, lorazepam, alprazolam, phenazepam, nootropil. Finally, in last decade wide widespread drugs, spectrum of clinical whose actions include affective (depressive) disorders, and manifestations of SD. To such drugs may be assigned derivative adenosylmethionine - Heptral (Knoll), sulpiride (Eglonil, Synthelabo, calcium channel blocker nifedipine [5], verapamil [3].
Heptral not only has thymoleptic properties, but also effective in the syndrome intrahepatic cholestasis, due to cirrhosis of the liver chronic active hepatitis [1], cystic fibrosis 12]. His appointment especially justified in patients with depressive states, comorbid liver diseases. In a study conducted in department of borderline mental pathology and psychosomatic disorders Research Institute of Clinical psychiatry NTsPZ RAMS, drug demonstrated high safety indicators, consistent with literature data [7].
Application of this antidepressant also not accompanied by any hematological and biochemical changes.
Sulpiride along with stimulant and thymoleptic effect improves blood supply to the stomach, intestines, accelerating recovery processes in tissues, suppresses gastric secretion, antiemetic action.
Use of sulpiride indicated for depression comorbid peptic ulcer with localization of the process in the stomach or duodenum (both in acute and in chronic ulcerative process) ulcerative colitis, Crohn's disease and "operated stomach". It should be noted that when taking drug possible violations menstrual cycle, galactorrhea.
Nifedipine and verapamil, which used for prevention angina attacks, treatment hypertension, as well as as part of combination therapy chronic cardiac deficiencies, have normothymic properties, and, therefore, are drug of choice for secondary prevention of phasic affective (depressive) disorders that develop patients with ST ⁵ .

Abstract

Depressive disorders are the most common among mental disorders observing in patients with an urgent somatic disease (SD). The nosological entities of these depressions are not confined to somatogenic depressions (affective disorders directly related to the course of SD, such as with cerebral vascular atherosclerosis). Along with them there are also nosogenic depressions (depressive responses to a constelation of psychogenic and situational factors associated with the symptomatic value of a diagnosis, with the awareness of a risk for the disease, physical sufferings, with changes in the quality of life), dysthymias (chronic neurotic depressions), endogenous depressions. The differentially diagnostic criteria which validate the diagnosis of depression in SD patients have been proposed. These include the specific features of pathophysiological disorders, history and family data, the nature of somatomental correlations (relationships between the severity, dynamics of mental disorders and the relative characteristics of SD). The paper discusses the basic principles of the therapy for depression related to an urgent SD and emphasizes it necessary to use antidepressants of different chemical groups with regard to the profile of their therapeutic effects, the nature of adverse reactions, the interactions with the drugs used in the treatment of SD.

¹ Hereinafter provides data on depression conditions, comorbid current SZ. Wherein affective (depressive) disorders (main diagnosis), flowing "under the mask" somatic disease, called "somatized" depression, the study of which an extensive literature is devoted to this article is not are considered.

² Equity for the sake of it should be said that there were new TCAs, distinctive whose features are safety and good portability. One of these drugs-tianeptine (Coaxil, server).

³ I mean overwhelming effect of the drug on daily activity, associated with daytime sleepiness deterioration in memory, attention, slowing down sensorimotor reactions.

⁴ Preparation also has moderate neuroleptic activity.

⁵ Lithium salts, widely used for prevention of affective disorders, contraindicated patients with disorder concentration function of the kidneys, thyroid disease, with cardiovascular disease, associated with violation water and electrolyte balance, in individuals with hypertension, on a salt-free diet patients taking cardiac glycosides, beta-blockers, thiazide derivatives.

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2. Orlov V. A., Nikitina M. I. The use of heptral (ademetionine) with cystic fibrosis in children // Abstracts reports of the III Russian national congress "Man and medicine" - RC. "Farmedinfo" M., 1996. - S. 177.
3. Panteleeva G. P., Rayushkin V. A., Snedkova L. V. Use as calcium antagonists thymostabilizers// Abstracts reports of the III Russian national congress "Man and medicine" - RC."Pharmedinfo" M., 1996. P.183.
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