When depression is diagnosed and treatment initiated by the consulation service, very often there will not be sufficient time to see response (50% reduction in symptoms), let alone remission (absence of depressive symptoms). This may be frustrating, but it stresses the need to arrange for proper outpatient followup. If the depressive symptoms are mild, then an antidepressant may be prescribed by the primary care MD, perhaps with concomitant psychotherapy. For more severe symptoms, or when suicidality is/was present, a psychiatrist would be more appropriate for followup.
Pharmacological
As with major depression in the absence of medical complications, antidepressants are a mainstay of treatment. SSRI's, which are covered individually elsewhere in Psycheteria and compared in this, are generally very well tolerated. It is important to be mindful of P450 interactions especially with potent 2D6 inhibitors such as fluoxetine or 3A4 inhibitors such as fluvoxamine.
In older or frail patients, dosages should be started low and titrated upward as the length of hospitalization permits.
In severe cases of treatment-resistant depression, electroshock therapy is a highly effective option.
General pharmacological issues
Though covering an entire psychopharmacology course really isn't practical in this context, here are some highlights to keep in mind with medically ill patients.
SSRIs
Of course, SSRIs are the initial choice in the management of depression. Simply choose the one whose interactions are lowest and whose side effect profile is slightly more in line with the patient. To be honest, differences in side effects among SSRIs are relatively minimal and the actual choice is more or less reliant on the academic nuance of the attending du jour.
The only particular differences among SSRIs relate to half-lives. Fluoxetine (or more properly, its active metabolite, norfluoxetine) has a fairly long half-life.
The usual statement is that it can take 6-8 weeks to feel effects, but many patients feel effects earlier. This could be from placebo effects, but it doesn't matter as long as someone feels better.
The most common side effect of SSRIs are nausea, constipation, and diarrhea. Sexual dysfunction is nontrivial and is manifest as decreased libido and/or delayed orgasm.
Importantly, SSRIs also have significant P450 interactions. Also about 7% of caucasians are slow metabolizers with respect to 2D6.
SSRIs are pretty much nontoxic. Death by overdose is very uncommon.
Tricyclic antidepressants
Tricylic antidepressants are effective, but it is not uncommon to find some psychiatrists who haven't prescribed one in years. In addition to depression, tricyclics help with headaches, chronic pain, insomnia, and anxiety. Most tricyclics are metabolized through 2D6, so you have to lower doses if patients are taking a 2D6 inhibitor.
There are a variety of side effects associated with tricyclics, including orthostatic hypotension, lowering the seizure threshold, and anticholinergic effects. With higher doses, tricyclics are associated with QT prolongation. Indeed there are a variety of cardiac effects associated with tricyclics. For example, they prolong ventricular depolarization and in patients with pre-existing bundle-branch blocks the risk of heart block is increased.
The major issue with tricyclics? Death. If a patient overdoses on tricyclics, death is not unusual, in stark contrast to SSRIs.
MAOI
MAOIs work well for depression and anxiety, but because of the restrictions associated with them, they are not used as much. There are three MAOIs used in the US, phenelzine (45-90 mg/day), tranylcypromine (30-50mg/d), and selegeline (9-12 mg/d). Note that phenelzine and tranycypromine are MAOI-A inhibitors and selegeline is an MAOI-B inhibitor. All are irreversible inhibitors and have much the same restrictions. Selegeline is available as a transdermal patch.
On the plus side, MAOIs have few side effects, though there is some significant orthostatic hypotension. However, patients must maintain a low-tyramine diet to avoid hypertensive crisis. In addition, SSRIs, sympathomimetics, and meperidine can precipitate hypertensive crises or serotonin syndrome and must be strictly avoided.
OTHER ANTIDEPRESSANTS
Venlafaxine, mirtazapine, and buproprion are all agents that can be used in the treatment of depression in the context of medical illness. One should be aware of side effects and P450 interactions.
Psychotherapy
Most of the year, the C&L service at UCLA has the ability to provide psychotherapy during hospitalization. Effective approaches in such settings include cognitive-behavioral interventions to help correct distorted expectations regarding medical illness or intervention and supportive psychotherapy. Depending on the nature of the patient, psychotherapeutic approaches are often combined with pharmacological interventions.