"acute" depression?

Hurricane · Apr 4, 2006

I'm doing a rotation in the ICU and my attending said that "since I'm the psych person" he wants me to look up the treatment for "acute depression" since many unit patients seem to be depressed. (The issue came up becaue we have a lady now who is tearful about having to be on the trach.) But isn't depression by definition not acute?

Related question: I never rotation on psych consults. Is there an SSRI that's usually used to start people on while in the hospital?

Thanks

Doc Samson · Apr 4, 2006

Hurricane said:
I'm doing a rotation in the ICU and my attending said that "since I'm the psych person" he wants me to look up the treatment for "acute depression" since many unit patients seem to be depressed. (The issue came up becaue we have a lady now who is tearful about having to be on the trach.) But isn't depression by definition not acute?

Related question: I never rotation on psych consults. Is there an SSRI that's usually used to start people on while in the hospital?

Thanks

I'd recommend that the attending ask for a formal psychiatry consult. Crying in the hospital is most often not depression. Patients go through perfectly normal periods of sadness and grief when confronted with major illness, that no SSRI will help.
See:
Boland RJ, Diaz S, Lamdan RM, Ramchandani D, McCartney JR.
Overdiagnosis of depression in the general hospital.
Gen Hosp Psychiatry. 1996 Jan;18(1):28-35.

Green RL, McAllister TW, Bernat JL.
A study of crying in medically and surgically hospitalized patients.
Am J Psychiatry. 1987 Apr;144(4):442-7.

Non-psychiatrists often see SSRIs as benign, "so what's the harm in starting one." My standard answers:

1) Increased risk of delirium in the medically ill patient
2) Increased risk of bleeding due to decreased platelet aggregation 2ndary to increased serotonin saturation of platelet receptors.
3) Pathologizing or minimizing the pt's very real feelings by suggesting they're abnormal and that a pill will take them away.

Which, when weighed against no benefit in the absence of an actual neurovegetative depression, should be prohibitive.

That being said, if I do make a dx of major depression, I'll usually start out with citalopram since a) reduced risk of p450 interactions with other medications for the medically ill patient, and b) it's generic.

Solideliquid · Apr 4, 2006

Doc Samson said:
I'd recommend that the attending ask for a formal psychiatry consult. Crying in the hospital is most often not depression. Patients go through perfectly normal periods of sadness and grief when confronted with major illness, that no SSRI will help.
See:
Boland RJ, Diaz S, Lamdan RM, Ramchandani D, McCartney JR.
Overdiagnosis of depression in the general hospital.
Gen Hosp Psychiatry. 1996 Jan;18(1):28-35.

Green RL, McAllister TW, Bernat JL.
A study of crying in medically and surgically hospitalized patients.
Am J Psychiatry. 1987 Apr;144(4):442-7.

Non-psychiatrists often see SSRIs as benign, "so what's the harm in starting one." My standard answers:

1) Increased risk of delirium in the medically ill patient
2) Increased risk of bleeding due to decreased platelet aggregation 2ndary to increased serotonin saturation of platelet receptors.
3) Pathologizing or minimizing the pt's very real feelings by suggesting they're abnormal and that a pill will take them away.

Which, when weighed against no benefit in the absence of an actual neurovegetative depression, should be prohibitive.

That being said, if I do make a dx of major depression, I'll usually start out with citalopram since a) reduced risk of p450 interactions with other medications for the medically ill patient, and b) it's generic.

Awesome reply!

Doc Samson · Apr 4, 2006

Solideliquid said:
Awesome reply!

I live for this stuff. I love consultation psychiatry... protecting patients from the misdeeds of internists and surgeons.

OldPsychDoc · Apr 4, 2006

Doc Samson said:
I live for this stuff. I love consultation psychiatry... protecting patients from the misdeeds of internists and surgeons.

Reason for consult: "Patient crying." ARRRGH!

MBK2003 · Apr 4, 2006

OldPsychDoc said:
Reason for consult: "Patient crying." ARRRGH!

I have two favorites from recent moonlighting
1) Reason for consult: "Patient appears oversedated."

The actual story - someone ordered the patient's Seroquel for 8am instead of 8pm when she was transferred out of the ICU. Despite pt stating over and over again to the nurse, "that's my nighttime medication" she was threatened with restraints unless she took the medication as the doctor (internal medicine resident) ordered. Fortunately that was a 10 minute consult --> Recommendation: Daytime sedation should improve once Seroquel is changed to bedtime dosing schedule. Monitor for orthostasis.

2) Reason for consult: "Patient wants to sign out AMA in two days. Please assess for capacity."

The actual story - Coke user with cocaine-induced chest pain, SSI check would be in mailbox on Monday afternoon (two days) and he could score some more coke with the money.

Recommendation: Referral to outpt rehab. Double portions (okay so I didn't write that, but it's generally true).

I'm sure we could have a great thread of all the funniest/most pointless C/L requests.

MBK2003

OldPsychDoc · Apr 4, 2006

MBK2003 said:
...(Cocaine)
Recommendation: Referral to outpt rehab. Double portions (okay so I didn't write that, but it's generally true).

Love it--it's practically on my standard order set for cocaine-induced depression admissions (the males anyway).
Celexa 20 mg q day
Seroquel 50 mg qhs
Chem Dep referral
Double portions, please.

Hurricane · Apr 4, 2006

Thanks for the info! That was very helpful. I don't think I'm quite smug enough to whip out a copy of an article called "Overdiagnosis of depression in the general hospital" and wave it at my attending, but I will definitely bring up some of the points mentioned in the article (and your excellent post)

I bumped into one of the psych consult residents and asked him, and he said "well y'know the fastest tx for depression is ECT."

Anyway, back to being on call. I think my other patient is going to die tonight.

Anasazi23 · Apr 4, 2006

Hurricane said:
I'm doing a rotation in the ICU and my attending said that "since I'm the psych person" he wants me to look up the treatment for "acute depression" since many unit patients seem to be depressed. (The issue came up becaue we have a lady now who is tearful about having to be on the trach.) But isn't depression by definition not acute?

Related question: I never rotation on psych consults. Is there an SSRI that's usually used to start people on while in the hospital?

Thanks

Perhaps unit patients are depressed and anxious because they are unit patients.

I, too, got a lot of these calls from the medical floors. "Please come see patient X...she's been crying since I told her she needs bilateral BKAs. She must be depressed."

Benzos in the trach scenario are your friend.

Hurricane · Apr 4, 2006

Anasazi23 said:
Perhaps unit patients are depressed and anxious because they are unit patients.

I, too, got a lot of these calls from the medical floors. "Please come see patient X...she's been crying since I told her she needs bilateral BKAs. She must be depressed."

Benzos in the trach scenario are your friend.

That's what I said! Maybe the poor woman is just anxious, and rightfully so!

Oh well, I'm liking the ICU for the most part, even so. Learning lots of procedures.

"acute" depression?

Hurricane

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Doc Samson

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Solideliquid

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Doc Samson

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OldPsychDoc

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MBK2003

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OldPsychDoc

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Hurricane

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Anasazi23

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Hurricane

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