Given their relatively high prevalence in PWE, neurologists should be able to identify the depressive and bipolar disorders described above. They should know how to initiate pharmacotherapy for major, dysthymic and minor depressive episodes. Thus, in which type of depressive disorders can a neurologist start pharmacotherapy and when should patients be referred from the start to the care of a psychiatrist? The following are the mood disorders that deserve immediate referral to a psychiatrist.
Any Depressive Episode Associated with Suicidal Ideation
As mentioned above, PWE have a relatively higher suicidal risk than the general population. In the evaluation of any mood (or other psychiatric) disorder, it is essential to investigate the presence of suicidal ideation (active and passive), as well as of any prior history of suicidal attempts, as these patients are the ones at greatest risk.
Any Major Depressive Disorder with Psychotic Features
Approximately 25% of major depressive disorders can present with psychotic features. In such cases, pharmacotherapy has to include anti-psychotic and anti-depressant drugs and at times, the use of electroshock therapy has to be considered. Furthermore, the presence of psychotic symptomatology increases significantly the suicidal risk of these patients. Thus, these patients need to be placed immediately under the care of a psychiatrist.
Any Major Depressive or Dysthymic Episode that has Failed to Respond to Two Prior Trials with SSRI or SNRI at Optimal Doses
The therapeutic expectation of symptom remission with most anti-depressant drugs is of 50-60% of patients. The remaining patients may require a combination of anti-depressant drugs, or the addition of lithium, thyroid drugs or central nervous system stimulants to one or two anti-depressants or electroconvulsive therapy (ECT) to reach a euthymic state. Clearly, these patients require the care of psychiatrists with expertise in refractory mood disorders.
The management of bipolar disorders is fraught with a significantly lower therapeutic success and potential serious complications that go beyond the expected diagnostic and therapeutic skills of neurologists. Thus, patients with bipolar disorders should be referred for psychiatric evaluation and treatment from the start. In patients with 'apparent' stable bipolar disorders, neurologists should at least refer the patient for one psychiatric consultation to confirm that optimal treatment options are being considered, but above all to avert a potential worsening of the course of bipolar disease resulting from the inappropriate use of anti-depressant drugs. Indeed, clinicians must keep in mind that the use of anti-depressant medication in a bipolar disorder can facilitate the development of manic and hypomanic episodes and of a rapid cycling bipolar disorder (defined as the presence of four or more depressive, manic or hypomanic episodes in a 12-month period). The American Psychiatric Association guidelines for the treatment of acute depression in bipolar disease advise against an initial use of antidepressant drugs . Furthermore, a bipolar disorder can begin with recurrent major depressive episodes before the first manic or hypomanic episode occurs. Accordingly, before starting anti-depressant medication for a major depressive episode, or for a dysthymic or minor depressive disorder, neurologists must always inquire about any history of manic or hypomanic episodes as well as any family history of bipolar disease (which is a strong risk factor for the development of this disorder in the patient at hand). Furthermore, a suspicion of potential bipolar illness increases in patients with a first major depressive episode before the age of 20. Indeed, Strober and Carlson followed for a 3- to 4-year period 60 adolescents hospitalized for major depressive episodes. Twenty per cent of these patients went on to develop bipolar illness .
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