CURRENT Essentials of Critical Care.pdf

Chapter 1 Monitoring & Support 9■■■DepressionEssentials of Diagnosis• Complaints of unhappiness, worthlessness, hopelessness, lackof planning for future, guilt; but anticipate depressed mood inall ICU patients regardless of symptoms• Decreased interest in condition, treatment plans, physical andmental activities; may exhibit lack of cooperation, refusal toagree to treatment or discuss with family• Suicidal ideation, lack of self-esteem• 10–40% of seriously ill, hospitalized patients have depression;but only 25–33% are diagnosed• May be related to underlying major psychiatric illnessDifferential Diagnosis• Medications: beta-blockers, sedatives, antihypertensives• Endocrinopathies: hypothyroidism, hyperadrenalism• Hyponatremia, hypoxia• Major depression• Sleep deprivation• Alcohol or substance abuse or withdrawalTreatment• Maximize interactions with family, visitors, nursing and physicianstaff; include patients in decision-making, daily activities;provide realistic support and prognostic information• Improve sleep quantity and quality• Anxiolytic agents may be helpful• Consider psychiatric consultation, if severe, or pharmacologicantidepressant therapy planned• Antidepressant drugs limited by side effects in critically ill patients;selective serotonin reuptake inhibitors (SSRIs) less hazardousthan tricyclic antidepressants; start SSRIs at low dose,gradual titration upwards, such as paroxetine 5–10 mg, sertraline12.5–25 mg, fluoxetine 5 mg; effect may take days■ PearlA depressed mood in seriously ill hospitalized adults is independentlyassociated with increased mortality, after adjustment for diseaseseverity and functional status.ReferenceRoach MJ et al: Depressed mood and survival in seriously ill hospitalizedadults. The SUPPORT Investigators. Arch Intern Med 1998;158:397.[PMID: 9487237]