15 Dec 2011
By: LEA WEE
1 Link between irritable bowel syndrome and depression
The brain may be nestled high in the head, but research over the last 15 years has shown it is in constant contact with the gut through signals sent by nerves in the brain to those in the gut.
This specific highway of information has been called the brain-gut axis, said Dr Ong Wai Choung, a consultant in the department of gastroenterology and hepatology at the Singapore General Hospital (SGH).
When a person is depressed or anxious, the brain-gut axis carries a message to the intestines, which react by contracting more strongly, forcing food through the intestines and causing symptoms of irritable bowel syndrome (IBS) such as pain, gas, bloating and diarrhoea.
The intestines can also react by contracting more slowly and causing constipation.
Conversely, when there is chronic abdominal pain or bowel changes, this information is transferred to the emotional centre of the brain, which then reacts by developing symptoms of distress.
SGH started screening patients newly diagnosed with IBS for depression or anxiety three years ago. Of the 700 patients screened, as many as four out of 10 had either depression or anxiety or both.
The patients were treated by the SGH gastroenterological depression team, made up of gastroenterologists, psychologists and psychiatrists.
After counselling or medication, most patients’ moods stabilised. With that, their bowel symptoms such as stomach pain also improved.
2 Link between HIV and depression
People infected with the human immunodeficiency virus (HIV), which causes Aids, are at high risk of anxiety and depression.
In addition to the burden of having a chronic disease, they have to deal with the stigma that still surrounds it, said Dr Jaspal Singh, an associate consultant in psychological medicine at Tan Tock Seng Hospital.
He added: “HIV medicine is also costly and many patients worry about their finances and if they will be able to continue paying for their medicine should their condition worsen.”
The cost of drugs is below $500 a month at subsidised rates. But it can grow to $700 to $800 a month when the symptoms worsen and patients need more medication.
The hospital’s Communicable Disease Centre, which treats the majority of HIV-positive patients in Singapore, started screening newly diagnosed patients for depression and anxiety last year. This was the effort of its pilot HIV-psychiatry team, which includes medical doctors, psychiatrists and medical social workers.
Since May last year, almost 400 patients have been screened. About 250 were newly diagnosed as being HIV positive. Of these, about 80 had significant symptoms of anxiety and depression.
Some were counselled by a medical social worker. But almost 15 per cent had symptoms severe enough to be referred to a psychiatrist.
The results of counselling and psychiatric treatment have been encouraging, said Dr Jaspal Singh.
He said: “Patients scored lower in their overall symptoms of anxiety and depression and higher in their quality of life.”
3 Link between traumatic injury and depression
It is logical to think that the more serious a traumatic injury is, the more likely the victim would be psychologically affected by it.
But research has shown this is not true.
What matters, instead, is the injured person’s perception of how severe the traumatic event was, said Dr Tang Hui Kheng, a consultant psychiatrist at the department of psychological medicine at Changi General Hospital (CGH).
She said a person is more likely to be psychologically affected if he feels a sense of helplessness and of not being able to prevent the accident from happening again.
The risk of being psychologically affected by a traumatic injury increases if the person has experienced it before or if he is distressed by the pain from his injuries and the treatment.
Hence, someone who is awake throughout the ordeal of having a fracture in his leg may be more traumatised than someone who loses his consciousness after having multiple fractures.
The latter may still feel distressed, but as he cannot recall how the accident happened, he is less likely to be traumatised by it.
In post-traumatic stress disorder, patients have flashbacks, nightmares and severe anxiety triggered by the traumatic event. The injury need not be serious to evoke distress.
Dr Tang cited an example of a mother who was so traumatised by a car accident that she refused to drive again, even though she was not seriously injured. “Her child was in the car with her and she felt she could have killed both of them,” she said.
In 2007, CGH started a trauma counselling service to identify patients who might be psychologically affected by traumatic injuries.
Those who were hospitalised for trauma-related events, such as assaults and road traffic and industrial-related accidents, were screened for depression and other psychological symptoms before discharge.
Since 2008, more than 2,000 patients have been screened. One in 10 was found to be at risk of post-traumatic stress disorder. Two in 10 were at risk of depression. Some patients had travel phobia after being in a road accident.
Dr Tang said the findings were similar to those in an Australian study.
Most patients who displayed acute post-traumatic stress symptoms were managed by a team of counsellors, occupational therapists and medical social workers.
Only one in 10 needed to be referred to a psychiatrist or a psychologist because their symptoms persisted beyond one to three months, said Ms Sheila Kaur, a trauma counselling coordinator.
Most eventually recover from their symptoms after six months to a year, she said. But some may take a longer time to get better, especially if they have a history of multiple trauma.
4 Link between stroke and depression
Any damage to the brain, for example, in a stroke, could result in physical, cognitive and psychological symptoms, said Dr Aaron Ang, head and consultant of psychological medicine department at Tan Tock Seng Hospital.
Psychological symptoms include depression, dementia and delirium.
The hospital started screening patients admitted to its stroke rehabilitation programme at Ang Mo Kio Community Hospital for depression in December 2008. They were managed by the hospital’s pilot Effective Mood Management After Stroke Team during their hospital stay and for a few months after their discharge.
The team is made up of rehabilitation doctors, nurses, therapists, psychologists and psychiatrists.
Of the 900 patients screened, about three out of every 10 had depressive symptoms such as moodiness or loss of interest or pleasure in the activities of daily life.
Of those with symptoms, one in 10 was diagnosed with a psychiatric disorder such as major depression. This figure is similar to that overseas, said Dr Ang.
Depression can happen any time after the stroke, he added. At the beginning, patients with left-sided strokes or strokes closer to the front of the brain are probably most vulnerable. But one to three years after the stroke, those who have psychosocial problems such as the lack of family or social support will be at higher risk of depression.
The hospital found that patients who were depressed upon admission scored lower on their ability to perform certain functions and their quality of life, compared to patients who were not depressed.
But after they were treated for depression, their score improved to the same level as that of the other patients upon discharge.
5 Link between diabetes and depression
Diabetics have to follow a strict diet and monitor their blood sugar levels regularly. Some end up with disabling complications such as limb amputations, kidney failure or blindness. These are major stressors for depression, reported a study here last year which looked at the impact of depression on the quality of life of diabetics.
An earlier 2008 study by the Diabetes Centre at the former Alexandra Hospital and the Institute of Mental Health found that nearly one in three diabetics had symptoms of depression. Nearly 10 per cent were diagnosed upon follow-up with clinical depression.
Following the study, when Alexandra Hospital staff moved to the new Khoo Teck Puat Hospital, a multidisciplinary team was formed in August 2009 to manage the chronic problem, said Dr Chan Keen Loong, a senior consultant from the hospital’s department of psychological medicine.
The MD3 (Management of Depression and Distress in Diabetes) team includes endocrinologists, psychiatrists, medical social workers and diabetes nurse educators.
Diabetics are screened for depressive symptoms as well as distress related to their illness when they return for their annual checks.
More than 90 per cent of patients – about 900 – have agreed to be screened. And more than 90 per cent of those referred for psychological treatment – about 230 – have been seen by a medical social worker or a psychiatrist.
The results have been encouraging. After six months to a year of treatment, the patients’ average score for depressive symptoms and distress fell by more than 60 per cent. They felt less depressed or distressed and faced less difficulties related to their diabetes.
The average levels of sugar in their blood also fell, indicating better diabetes control.
6 Link between gynaecological cancer and depression
Like other cancer patients, women with different types of cancer of the reproductive system have a higher risk of becoming depressed because they know they may have less time to live.
But such patients also have to grapple with problems concerning their sexual function and body image, said Dr Cornelia Chee, the director of Women’s Emotional Health Service at the National University Hospital (NUH).
As the tumour may block or adhere to the intestines, part of the intestines may need to be excised and a stoma bag attached to the remaining gut – temporarily or permanently – to collect faeces.
Patients who feel a loss of their “female identity” because they have to remove certain parts of their reproductive system may be at risk of depression.
Younger patients – especially those who had wanted to start a family and are no longer able to do so – may also be at risk of depression.
The NUH Women’s Emotional Health Service started to screen in-hospital patients with gynaecological cancers in September 2008.
It has also been checking up on women during their pregnancy and after, since March 2008.
About 300 – close to 100 per cent – women with various types of gynaecological cancer such as cancer of the ovary and uterus, have since been screened.
Of these, about 5 to 10 per cent had depression and were referred to a psychiatrist.
Some also received emotional support from the case managers – trained nurses or psychologists who call them once or twice a week.
Every week, the psychiatrist meets the medical team as well as the medical social worker to discuss the cases.
The results of the team approach have been positive.
Though patients did not necessarily live longer with the psychological treatment, they reported having a better quality of life or a sense of well-being after six months.
One 52-year-old cancer patient said in her early days of depression, her case manager, a trained nurse, would call her every week to find out how she was doing.
She said: “It felt good to have someone to talk to.”
At the encouragement of her case manager, the mother of two also picked up swimming.
She now swims every morning and is no longer on medication.
“My mood has improved and I feel much better now,” she said.
Click for jpeg format
« Back to previous
page
back to top