Pharmacotherapy of Depression in Patients with Chronic Medical Illness

Major depressive disorder (MDD) is a psychiatric disorder which affects to public health system and lead to disability. MDD is prevalent in several medical illnesses including cardiovascular disease, stroke, cancer, Parkinson’s disease and Alzheimer disease. Evidence from clinical studies suggest that the relationship between MDD and chronic medical illness is a bidirectional relationship, moreover, depression is associated with poor prognosis of chronic medical illnesses. Therefore, appropriate treatment of depression is an important issue in depression with comorbid medical illnesses. Pharmacotherapy is the mainstay for treatment of depression. Selection of antidepressant must consider both efficacy and safety of medications in a various medical conditions in individual patient. This article will cover some of antidepressant therapy in depression with comorbid medical illnesses: treatment of depressive patients with coronary artery disease recommended selective serotonin reuptake inhibitors (SSRIs) such as sertraline and escitalopram as a first-line therapy because SSRIs showed efficacious outcomes and low risk for adverse cardiovascular events. Tricyclic antidepressants (TCAs) were associated with a significant risk for cardiovascular events. Therefore, TCAs should not use as first-line agents in depressive patients with coronary artery disease. Pharmacotherapy of depression in patients with heart failure still has limited data and conflicted results especially in large trial (SADHART-CHF and MOOD-HF study), which showed inefficacy for both depressive and cardiovascular outcomes. Pharmacotherapy of post-stroke depression (PSD) is an important strategy to improve patient outcome because appropriate use of antidepressant can reduce both depressive symptom and mortality risk. SSRIs are first-line therapy in PSD because the study showed beneficial effect and well tolerated. Treatment of depression in patients with Parkinson’s disease focused on antidepressants that increased various monoamines, therefore, TCAs (e.g. nortriptyline) that increase serotonin, norepinephrine in numerous brain areas and dopamine in prefrontal cortex may be more effective than SSRIs in these patients. However, weighed risk against benefit of TCAs in depressive patients with Parkinson’s disease especially in elderly should be consider. Pharmacotherapy of depression in patients with Alzheimer’s disease recommended SSRIs as first-line therapy and avoided antidepressants causing cognitive impairment such as TCAs and paroxetine because these drugs have anticholinergic effect. Selection of antidepressants in patients with chronic pain should use drugs that increase both norepinephrine and serotonin such as TCAs and serotonin and norepinephrine reuptake inhibitors (SNRIs) because these drugs provide benefit both depressive and pain symptoms improvement.