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SamiPirkola

Treatment of Depression in Association with other Psychiatric Disorders

In association with depression, the patient often has other mental disorders as well, most commonly anxiety disorders (in about 50%), substance abuse disorders (in 10-30%) and personality disorders (in about 50%).
The associated disorders have significance on the prognosis and functional ability so that concomitant occurrence of the disorders renders the treatment more challenging and increases the risk of a reduction in the functional ability.
Comorbidity is considered to be severe if the patient has
- severe personality disorder or substance abuse disorder or
- several concurrent mental disorders.

Depression is common in patients with substance abuse or dependence. Substance abuse may also cause depressive disorders.
- The term 'dual diagnosis' is often used in psychiatry to denote the combination of a substance abuse disorder and a mental disorder in the same patient Dual Diagnosis.
Co-morbid substance dependence or abuse (most often alcohol abuse), exists in 10-30% of patients with major depression. In women, the depression may precede substance disorder more often than in men. Generally speaking, substance disorder, however, more often precedes than follows the depression.
A co-morbid substance abuse disorder increases the risk of suicide.
Treatment choices: see table T1.
The treatment should be integrated, i.e. both the depression and the substance abuse disorder should be treated concomitantly with the available means. There are some promising preliminary research results on separate but concurrent pharmacological treatments for co-occurring depression and alcohol dependence.
See also Providing Care for an Alcohol or Drug Abuser and Drugs Used in Alcohol Dependence.

The coexisting of depression and anxiety disorder is a common clinical problem and the aim is to control the symptoms of both disorders.
Antidepressants are effective both for depression and for most anxiety disorders (except specific phobias). They are effective also for the symptoms of anxiety in depressive patients when depresion and anxiety disorders co-exist.
Selective serotonin reuptake inhibitors are effective in almost all anxiety disorders and are to be recommended (see table T1).
Panic disorder patients are sensitive to overstimulation and increased anxiety caused by SSRIs and the dosages of the SSRIs must be increased slowly in these patients.
Antipsychotic drugs may be effective for the symptoms of generalized anxiety disorder, post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) in a depressed patient, usually combined with other psychotropic medication.
When considering the need and form of psychotherapy it is important to assess the possible co-existing of anxiety disorders Anxiety Disorder.
In the treatment of co-existing disorders, the combination of different treatment modalities (e.g. drug therapy and psychotherapy) may be particularly beneficial.

Depression in patients with co-morbid borderline personality disorder usually requires specialist treatment Borderline Personality Disorder.
The use of SSRIs is recommended if the patient has a co-morbid borderline personality disorder (see table T1).
- Personality disorders seem not to have a negative effect on the outcome of pharmacological treatment.
Long term psychotherapy, lasting up to several years, may also be considered if available and if the patient is motivated and capable to benefit from psychotherapy. See also Antisocial Personality Disorder.
Self-destructive behaviour and other manifestations connected with borderline personality disorder have been effectively relieved with therapeutic programs that include either dialectical behaviour therapy (DBT) or psychodynamic psychotherapy based on mentalization.

Co-morbid conditions	SSRIs	Other antidepressants	Brief psychotherapy	Other treatments
Depression and substance abuse disorders	++ Antidepressants for Co-Occurring Depression and Alcohol Dependence	-	-	Substance withdrawal therapies
Depression and anxiety disorder (generalized anxiety, panic disorders, social phobia)	++	+	+
Depression and personality disorders (borderline personality)	++	-	-	Small dose of antipsychotic, mood-stabilizing medication, long term psychotherapy

In approximately 10-20% of patients with major depressive disorder, depression is preceded by a long-term, milder dysthymic disorder; the patient is said to suffer from double depression Chronic Depression (Dysthymia).
The preceding mild chronic depression means a poorer prognosis for complete recovery.
The treatment is similar to normal depression but special attention has to be paid to residual symptoms and to proper follow-up.

The patient has episodes of major depressive disorder especially during autumn and winter Planning the Treatment of Patients with Depression.
In addition to symptoms of depression, so-called atypical symptoms are often present, e.g. hypersomnia, daytime tiredness, increased appetite, weight gain and reactivity to environmental factors.
Bright light has been used for treatment (green/blue/yellow but not ultraviolet wavelengths). A dose-response relationship has been observed for the typical symptoms of SAD.

Pettinati HM, O'Brien CP, Dundon WD. Current status of co-occurring mood and substance use disorders: a new therapeutic target. Am J Psychiatry 2013;170(1):23-30. [PubMed]
Fergusson DM, Boden JM, Horwood LJ. Tests of causal links between alcohol abuse or dependence and major depression. Arch Gen Psychiatry 2009;66(3):260-6. [PubMed]