From the literature and from anecdotal reports, depression is said to be common in patients with Cushing’s syndrome (CS). Certainly, patients with CS know this well. Depression may be seen in over 50% of patients in active Cushing’s. In this column we will address the following:
- What is depression?
- Is depression in CS different from other kinds of depression?
- Why is depression different in CS? and
- What can be done about it?
What is depression?
Depression is not just one disease or one syndrome. There are several types of depression. First, someone can have either “depressive symptoms” or a diagnosis of depression. Depressive symptoms include depressed mood, loss of interest or pleasure, change in weight, change in sleep, fatigue, as well as other symptoms. Second, a diagnosis of depression (Major Depressive Disorder, MDD) is usually made by those in the mental health profession, based on criteria outlined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). A diagnosis of MDD is made when a specific number of these symptoms occur for at least two weeks or more. In the most strict sense, one could not be diagnosed with MDD if a disease (like CS or hypothyroidism) is “causing” the disorder. Certainly, that doesn’t mean that patients with CS are not depressed. We know otherwise from clinical experience and research.
Is depression different in CS?
There are several subtypes of MDD, but we will focus on two that are more relevant to CS. One is melancholic depression, characterized by depressed mood as a feature and loss of pleasure in most activities. There also is weight loss and a decrease in the time one sleeps. The other type is atypical depression, also characterized by depressed mood, but with the ability to react to pleasurable events with a favorable response. Patients with atypical depression show increased fatigue, weight gain, and excessive sleeping; symptoms opposite of those patients with melancholic features. In the general population, melancholic depression is the most prevelent. We conducted a research study on 33 patients consecutively admitted to NIH for treatment of CS, evaluated each of these patients for depression while their CS was active, and at various time points following corrective treatment. Several important points emerged from this research.
As shown in Table 1, the majority (66.7%) of Cushing’s patients clearly demonstrated psychiatric symptoms at some time during their illness, while the number of patients with no diagnosis of psychiatric symtoms was much lower (30.3 %). Our research also showed that the most common type of psychiatric disorder in patients with CS is atypical depression. In the 33 patients with active CS in our study, 17 or 51.5% had atypical depression.
n | % | |
---|---|---|
Diagnosis before Cushing’s syndrome | 6 | 18.2 |
Diagnosis during Cushing’s syndrome but prior to admission at NIH | 15 | 45.5 |
Current diagnosis when admitted at NIH | 18 | 54.6 |
Total: during Cushing’s or at NIH admission | 22 | 66.7 |
No history of diagnosis | 10 | 30.3 |
Table 1. Row n’s and percentages represent the number of patients out of 33 at the specified time points. Therefore, the percentage column does not add up to 100. This table was reproduced with permission from Blackwell Science Ltd. |
Appoximately 17% of these patients also exhibited symptoms of both atypical and melancholic depression, while one patient with CS exhibited only melancholic depression. Another 29.4% of these patients had other diagnoses, such as panic attacks, anxiety, and drug and alcohol abuse.
Why is depression different in CS?
From our research and the synthesis of others, we have surmised that depression represents either over- or under-arousal of the stress system. In a simplistic sense, the stress system includes many neurotransmitters and hormones from the brain, pituitary gland, and adrenal gland that work together to help people respond to physically or psychologically stressful situations. Some of the changes that occur during arousal or activation of the stress system, include changes in CRH (corticotropin releasing hormone). A part of the brain releases CRH, which then acts on the pituitary gland to stimulate ACTH release. In turn, ACTH acts on the adrenal glands to increase cortisol production.
In melancholic depression, the stress system is overactive and CRH is increased. This increase may well bring about some of the symptoms of melancholia. In atypical depression, like in CS, there is under-arousal of the stress system and lower CRH. Due to increased ACTH and cortisol, patients with CS do have lower CRH (measured in spinal fluid). However, there has not been a study that has simultaneously measured CRH and depression in patients with CS. It is also important to remember that while CRH plays a role, depression most likely is not “caused” by just one factor.
What can be done about depression in CS?
No matter what kind of depression a patient with CS has, it should be treated. It is important that the patient be evaluated and followed, from someone in the mental health profession. Helpful therapy may include individual or group therapy, but sometimes antidepressants may also be necessary and should be prescribed by a psychiatrist. The therapist should also maintain close contact with the endocrinologist so he/she understands the disease and treatment from an endocrine perspective. Treating depression in this instance, is a team effort involving the patient and family, the mental health therapist and the endocrinologist. Patients and families should ask questions about the therapy and be informed about what to expect with a medication, and when it should begin working. Sometimes a different anti-depressant will need to be prescribed because the same medication doesn’t always work in the same way for everyone. So, patients and families will need to keep the therapist informed of progress, as well.
Authors: Lorah Dorn PhD, RN, CPNP & George Chrousos, MD (Fall, 1997)
Editor’s note: Lorah D. Dorn, PhD, RN, CPNP is an Assistant Professor of Nursing and Psychiatry at the University of Pittsburgh. Dr. Dorn conducted research on Cushing’s syndrome and depression in conjuction with Dr. George Chrousos, MD, who is the Chief of Pediatric Endocrinology at NIH in Bethesda, MD. This research was published in Clinical Endocrinology, Volume 43, pp. 433-442, 1995.
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