Depression treatment for women with breast cancer

Prachi Agarwala, MD, Psychiatry Resident, PGY-V, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Michelle B. Riba, MD, MS, Clinical Professor, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Psychological distress among patients with breast cancer is common and is linked to worse clinical outcomes. Depressive and anxiety symptoms affect up to 40% of breast cancer patients, and depression is associated with a higher relative risk of mortality in individuals with breast cancer. Psychotropic medications and psychotherapy used to treat depression in patients without carcinoma also are appropriate and effective for breast cancer patients. However, some patients present distinct challenges to standard treatment. For example, growing evidence suggests that some selective serotonin reuptake inhibitors (SSRIs) may reduce the effectiveness of tamoxifen, a chemotherapeutic agent. This article discusses challenges in diagnosing and treating depression in breast cancer patients and reviews evidence supporting appropriate psychiatric care.

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Cholesterol, mood, and vascular health

Jess G. Fiedorowicz, MD, MS, Assistant professor, Departments of psychiatry and epidemiology, Roy A. and Lucille J. Carver College of Medicine, College of Public Health, University of Iowa, Iowa City, IA

William G. Haynes, MD, Professor, Department of internal medicine, Institute for Clinical and Translational Science, Roy A. and Lucille J. Carver College of Medicine, University of Iowa, Iowa City, IA

Does low cholesterol predispose to depression and suicide, or vice versa? A growing body of literature examining the putative links among cholesterol, mood disorders, and suicide has produced inconsistent findings and unclear clinical implications that may leave psychiatrists unsure of how to interpret the data. Understanding cholesterol’s role in mood disorders may be relevant to the 2 primary causes of excess deaths in patients with mood disorders: suicide and vascular disease health.

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Women's response to antidepressants

Wendy K. Marsh, MD, Assistant professor, Department of psychiatry, University of Massachusetts Medical School, Worcester, MA

Kristina M. Deligiannidis, MD, Assistant professor of psychiatry, Director, Depression Specialty Clinic, Center for Psychopharmacologic Research and Treatment, University of Massachusetts Medical School, Worcester, MA

Both men and women respond well to antidepressants, yet there are notable differences between the 2. Understanding why men and women may differ in response to antidepressants helps clinicians better tailor their treatment choice and dosing.

This article outlines some of differences—and lack thereof—in response rates to antidepressants. Our discussion of why these differences may occur is framed in the context of pharmacokinetics, pharmacodynamics, and the influence of gonadal hormones on antidepressant-related neurotransmitter systems. The second section focuses on major reproductive phases of adult women (the menstrual cycle, pregnancy, postpartum, and menopause) and how antidepressant response rates can influence clinical decision making, such as antidepressant timing, dose, and choice of potential adjunct treatments.

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Late-life depression: Managing mood in patients with vascular disease

Helen Lavretsky, MD, MS, Associate professor of psychiatry, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA

Thomas Meeks, MD, Assistant professor of psychiatry, Division of geriatric psychiatry, VA San Diego Healthcare System, Sam and Rose Stein Institute for Research on Aging, University of California, San Diego

Newly diagnosed major depressive disorder (MDD) in patients age ≥65 often has a vascular component. Concomitant cerebrovascular disease (CVD) does not substantially alter the management of late-life depression, but it may affect presenting symptoms, complicate the diagnosis, and influence treatment outcomes.

The relationship between depression and CVD progression remains to be fully explained, and no disease-specific interventions exist to address vascular depression’s pathophysiology. When planning treatment, however, one can draw inferences from existing studies. This article reviews the evidence on late-life depression accompanied by CVD and vascular risk factors, the “vascular depression” concept, and approaches to primary and secondary prevention and treatment.

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Mindfulness interventions for depression and anxiety

Mark A. Lau, PhD, RPsych, Clinical associate professor, Department of psychiatry, University of British Columbia, Vancouver, BC, Canada

Andrea D. Grabovac, MD, FRCPC, Clinical assistant professor, Department of psychiatry, University of British Columbia, Vancouver, BC, Canada

Mindfulness-based cognitive therapy (MBCT) was originally developed to help prevent depressive relapse. MBCT also can reduce depression and anxiety symptoms. More recently, MBCT was shown to help individuals discontinue antidepressants after recovering from depression. Regular mindfulness meditation has been shown to result in structural brain changes that may help explain how the practice effectively addresses psychiatric symptoms. With appropriate training, psychiatrists can help patients reap the benefits of this cognitive treatment.

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CAM for patients with depression

Sy Atezaz Saeed, MD, Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Richard M. Bloch, PhD, Professor and director of research, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Diana J. Antonacci, MD, Associate professor and director of residency training, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

C. Ervin Davis, III, PhD, Assistant professor, department of psychology, Adjunct assistant professor of psychiatry, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Crystal Manuel, MD, Assistant professor, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Americans with depression turn to complementary and alternative medicine (CAM) more often than conventional psychotherapy or FDA-approved medication. In a nationally representative sample, 54% of respondents with self-reported “severe depression”—including two-thirds of those receiving conventional therapies—reported using CAM during the previous 12 months.

Unfortunately, popular acceptance of CAM for depression is disproportionate to the evidence base, which—although growing—remains limited. As a result, your patients may be self-medicating with poorly supported treatments that are unlikely to help them recover from depression.

In reviewing CAM treatments for depression, we found some with enough evidence of positive effect that we feel comfortable recommending them as evidence-based options. These promising, short-term treatments are supported by level 1a or 1b evidence and at least 1 study that demonstrates an ability to induce remission.

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Listen to Dr. Manuel discuss how to negotiate CAM use with patients

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