1. Date: 7/4/2016
By: Mahmoud Mostafa

2. Contents : Why Physicians should be conscious ? Somatisation Pain
Psycho Somatic

3. Contents : Psycho Somatic IBS Post Stroke Depression Diabetes Migraine
Why Physicians should be conscious ?

4. Recognition of general practice patients
Up to 50% of general practice patients may have some depressive symptoms.
Approximately 5% of these will have major depression defined by DSM-III-R criteria.
Freeling and Tylee (1992); Regier et al (1988); Vazquez-Barquero et al (1987)

5. How the Mood disorder patients present in the clinic
Somatisation
How the Mood disorder patients present in the clinic

6. 90% of Mood disorder patients reported primarily somatic symptoms

7. General practice patients and recognised major depression
How do patients with major depression usually present in primary care?
Patients with major depression often present with predominantly physical (somatic) symptoms such as:
significant weight loss, or gain
insomnia or hypersomnia
agitation or retardation
fatigue or loss of energy
The presence of physical symptoms reduces the likelihood of diagnosis by the GP.
Many patients with major depression also have a physical illness.
Blacker and Clare (1987); Bridges et al (1991); Freeling et al (1985)

8. Psycho Somatic disorder

9. Definition
The co morbidity between chronic medical illness and depression or anxiety
The first complain is the medical disease then symptoms of depression and anxiety appear
As far as depression is there , the prognosis and treatment of medical illness will delay

10. The association between depression and medical illness
Depression is associated with disability caused by a variety of diseases.
Stroke
Alzheimer’s disease
Parkinson’s disease
CNS
Pulmonary
Chronic obstructive pulmonary disease
Cardiac
Myocardial infarction
Rheumatic
Arthritis
Gurland et al (1988)

11. IBS

12. World Wide IBS Prevalence`
9-23% of worldwide patients suffering from IBS
12% of total visits of primary care providers due to IBS
Women are 2.5 times more common to suffer than men
20-75% of individuals with IBS symptoms seek medical care for their symptoms
Ref: International foundation for functional Gastrointestinal disorders IBS article by LIN Chang 2008 (1)
Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi: /gast PMID  (2)

13. World Wide IBS Prevalence`
9-23% of worldwide patients suffering from IBS
12% of total visits of primary care providers due to IBS
Women are 2.5 times more common to suffer than men
Ref: International foundation for functional Gastrointestinal disorders IBS article by LIN Chang 2008 (1)
Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi: /gast PMID  (2)

14. IBS Co Morbid with Psychiatric Disorders
psychiatric disorders were found to occur in 50-94% of IBS patients
Rates of IBS in 60% of outpatients with dysthymia and in 27% with major depressive disorder
Prevalence of co morbid IBS with Anxiety 39.2% & with Depression 42%
Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi: /gast PMID  (2)
J Clin Psychiatry. 1995;56(8): (3)

15. IBS Co Morbid with Psychiatric Disorders
psychiatric disorders were found to occur in 50-94% of IBS patients
Prevalence of co morbid IBS with Anxiety 39.2% & with Depression 42%
Whitehead WE, Palsson O, Jones KR (2002). "Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?". Gastroenterology 122 (4): 1140–56. doi: /gast PMID  (2)
J Clin Psychiatry. 1995;56(8): (3)

16. Co morbid IBS with Anxiety & Depression
Abdominal Pain or discomfort
Headache
Pain
Sharp dull gas-like
Fatigue
Backache
Bloating
Sleep problems
Gut movement
Palpitation
Anxiety
Depressed mood
Ref: International foundation for functional Gastrointestinal disorders IBS article by LIN Chang 2008

17. Reason For Co Morbidity

18. `

19. Choosing an Anti-depressant
Considering drug profile.
Considering patient profile.

20. Considering drug profile
Efficacy of drug in treating the condition both acute & long term.
Efficacy in treating any co-morbid conditions eg: anxiety ,panic….etc.
Tolerability of the drug.
Safety in overdose.

21. Cipriani Et Al
Independently funded meta-analysis that compared the efficacy and patient acceptability of 12 antidepressants
117 randomised clinical trials ( participants) from th Nov. 2007
Included bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, mirtazapine, paroxetine, reboxetine, sertraline and venlafaxine
Cipriani et al. Lancet 2009; 373 (9665): 746–758

22. Cipriani Et al Cont.
Only assessed the acute treatment phase (first 8 weeks of treatment) in adults with unipolar major depressive disorder
Side-effects, toxic effects, discontinuation symptoms, social functioning and cost-effectiveness were not considered
Fluoxetine was used as the reference drug
Cipriani et al. Lancet 2009; 373 (9665): 746–758

23. Primary outcome measures
Response (proportion of patients who had a reduction of at least 50% from baseline on
Hamilton depression rating scale or
Montgomery-Åsberg depression rating scale or
Who scored much improved or very much improved on the clinical global impression at 8 weeks)
Acceptability (number of patients who terminated the study early for any reason during the first 8 weeks)
Cipriani et al. Lancet 2009; 373 (9665): 746–758

25. Acceptability also differs between antidepressants
Adapted from Cipriani et al. Lancet 2009; 373 (9665): 746–758 (Source: Patrick et al. J Fam Pract 2009; 58 (7): 365–369)
OR=odds ratio, using fluoxetine as the reference medication

26. Post Stroke Depression

27. Depression increased mortality rate when associated with post stroke

28. Cipralex Enhances positive recovery from stroke

29. Diabetes

30. Depression as a Co morbidity to Diabetes: Implications for Management
Diabetes and depression are debilitating conditions that are associated with significant morbidity, mortality, and healthcare costs.
Coexisting depression in people with diabetes is associated with :
Decreased adherence to treatment.
Poor metabolic control.
Higher complication rates.
Decreased quality of life.
Increased healthcare use and cost.
Increased disability and lost productivity.
Increased risk of death.
diabetes research and clinical practice 87 (2010) 302–312 30

31. Depression affects negatively the glycemic control
diabetes research and clinical practice 87 (2010) 302–312

32. Depression as a Co morbidity to Diabetes: Implications for Management
overall people with type 2 diabetes have a 24% increased risk of incident depression compared with people without diabetes.
Only 25% to 50% of diabetic patients with depression are identified in primary care.
Diabetologia (2010) 53:2480–
diabetes research and clinical practice 87 (2010) 302–312

33. Depression as a Co morbidity to Diabetes: Implications for Management
diabetes research and clinical practice 87 (2010) 302–312

34. ADA Recommendations.
The American Diabetes Association (2008)
Advises regular screening for Depression throughout the course of diabetes management: at diagnosis, routine management visits, hospitalizations, when complications develop, or when problems with glucose control, quality of life, or adherence to self-care are identified.

35. Controlling depression improve all the diabetes related symptoms

36. Cipralex shows unsurpassed efficacy in treating comorbid depression and anxiety patients Vs Paroxetine.
Boulenger et al. Curr Med Res Opin 2010; 26 (3): 605–614

37. Reaching complete remission with high baseline anxiety levels10 20 30 40 50 60 70 80 90
100
Complete remission (MADRS ≤5) rate (%)
Baseline HAM-A total score * **
Escitalopram
Paroxetine
All (n=451)
>20 (n=280)
≥22 (n=254)
≥24 (n=201)
≥26 (n=166)
≥28 (n=120)
≥30 (n=84)
≥32 (n=67)
*p<0.05; **p<0.01 (Fisher’s Exact test); LOCF
Boulenger et al. Curr Med Res Opin 2010; 26 (3): 605–614

38. Cipralex® is better tolerated than Paroxetine
†Incidence based on male patients only ‡Incidence based on female patients only ‡ †
#p ≤0.05; ##p ≤0.01 # ##
More patients treated with Paroxetine withdrew from the study due to adverse events three times than did patients treated with Cipralex13
Bielski et al. Poster presented at ADAA, 2004 38

39. Migraine

40. Cipralex Enhances the relief from headache

42. Drug-drug interaction:
Interactions may arise when SSRIs are administrated with other drugs that share a common metabolic pathway via the Cytochrome P450 isoenzyme system.
Many psychotropics – including SSRIs - inhibit to varying degrees specific Cytochrom P450 isoenzymes involved in the elimination of drugs.
Escitalopram has a very low potential for drug-drug interactions, mainly because of the absent or very low inhibition of the Cytochrom P450 isoenzymes.
(Speaker note: Regarding CYP 2D6 – in vitro data did not reveal an inhibitory effect of escitalopram. However, there are limited in vivo data suggesting a modest CYP2D6 inhibitory effect for escitalopram 20 mg/day.)

44. Thank You