Depression And Autonomic Dysfunction

[firewatcher]

Psychosom Med. 2009 Oct;71(8):852-60. Epub 2009 Sep 24.

Autonomy of autonomic dysfunction in major depression.

Koschke M, Boettger MK, Schulz S, Berger S, Terhaar J, Voss A, Yeragani VK, B?r KJ.

Department of Psychiatry and Psychotherapy, University Hospital Jena, 07743 Jena, Germany.

OBJECTIVE: To investigate cardiac autonomic dysfunction in patients with major depressive disorder (MDD). Research in this area has faced several limitations because of the heterogeneity of the disease, the influence of medication, and methodological shortcomings. METHODS: Participants were 75 patients suffering from an acute recurrent episode of MDD and 75 matched controls. All participants were assessed at baseline for linear and nonlinear parameters of heart rate variability, QT variability and baroreflex sensitivity. Participants with MDD were reassessed after 7 to 9 days of treatment with either a selective serotonin reuptake inhibitor (SSRI) or a serotonin and noradrenaline selective reuptake inhibitor (SNRI) antidepressant. RESULTS: In the initial examination, patients showed an overall shift of autonomic balance toward sympathetic predominance as compared with matched controls, with a decrease in parasympathetic parameters and baroreflex sensitivity, and an increase in sympathetically influenced QT variability. Overall, antidepressant treatment exacerbated this imbalance, with differential effects observed for SSRI and SNRI treatment. In contrast to autonomic dysfunction in other disorders, such as schizophrenia, autonomic dysfunction in MDD appeared to be independent of disease severity. CONCLUSIONS: Patients suffering from MDD show profound autonomic dysfunction, which is exacerbated by SNRI and to a lesser degree by SSRI treatment. This information could prove important when selecting antidepressant medication for patients at risk for cardiac arrhythmias.

PMID: 19779146

Sooooo, if an SSRI helps with the autonomic dysfunction, are we less likely to be depressed? And if we are both clinically depressed AND have autonomic dysfunction, we shouldn't use anti-depressants? Why is nothing simple?

[MamaTrain]

This is a little disheartening to read as I was seriously considering trying Zoloft! I think I will post and see how others have done on it! Thanks for the info!

[vemee]

I have had nothing but bad luck with antidepressants especially the norepinephrine ones. I was put on antidepressants initially because of fatigue and other pots complaints which the med doctors said was depression only years later did I learn about pots. The serotonin drugs did nothing for me but made me feel weird but I went into clinical depression and anxiety when taking the norepinephrine drugs at first. Later I could tolerate them because my norepinephrine levels were too high and I was kind of numbed. While on the norepinephrine I developed a first degree heart block and partial bundle branch blocks which cleared up after I got off of them. Withdrawing from the norepinephrine drugs was like getting off an illegal addictive drug. I had lots of complications especially since no one would listen that my problems were from withdrawal; they wanted to diagnose me as bipolar which I had never been manic before or since. I have been off all psych drugs for almost a year and feel a whole lot better mentally than on them. Pots wise I am still the same so I can't claim that they made my pots worse.

As far as recommending an antidepressant just take what I say with a grain of salt. I am not a balanced view since my experience was so bad. If you need it then take it, your experience might be better, not everyone reacts to drugs the same and there is always some one who is going to have a negative experience with any drug.

What I wish is that more studies would be done on how pots affects and/or can cause mood disorders. I have noticed on this board several people saying they have anxiety above what is normal when having a chronic disease. My daughter developed severe anxiety and had to be homebound educated for a year when she developed pots in eighth grade. We were so focused on the anxiety that we overlooked the pots. By the way she is on celexa and is doing fine now and no heart problems have been noted. I think that in some people pots causes the norepinephrine levels to go crazy (mine are over 2000 when standing, the upper ref. limit is 499) which causes mood problems but without valid research it is just my opinion and counts for nothing.

My question is are the patients with mdd depressed because of the autonomic dysfunction or is the dysfunction causing the depression

[erik]

Buspirone comes to mind (though there are many many other things) since it's characteristically anti-depressant & especially anxiolytic. Who knows, maybe it helps with autonomics stuff... I wouldn't know.

SSRI's and other things are characterized by initial exacerbation of problems, followed by eventual clinical benefit so be sure to consider that. Also, therapeutic benefit can be dose dependent, with too high or too low being problem zones (though "safety" dose issues are really minimal). Compounding that, many anti-depressents depend upon a "steady state" to be eventually reached but up to 10% of folks have variation in liver metabolism of those drugs... meaning their necessary target dose will be either higher or lower than a doc is expecting to see (and other meds, herbs, foods can exaggerate or mute these metabolisms too). Just a few generic complications to always keep in mind. Finding successful anti-depressant treatment can be easy for some, and take years of patience & bad effects for others... similar to dysautonomia I suppose. With both, it could get exponentially bad to find the right med regime.

In the "vierd" side of things, there is an antidepressant out there, used in but one country, which is an SNRE... the polar opposite of SSRI's but still a successful anti-depressant. I "have a friend" that might try it for their autonomic-disorder some day, to see if it happens to help adjust the autonomic system to good effect (like SSRI & SNRI can do for some folks). Just another twist... maybe autonomic specialists could investigate that as a potential option for those that have bad result from thorough SSRI & SNRI & DNRI attempts... or just as a "research topic". It is interesting to note that serotonin is probably kind of a negative thing when it spills over into hormonal (blood) effect... I think it is a potent inflammatory & leakage agent (perhaps a wee bit bad in context of POTS/CFS). Reuptake inhibition automatically means increased spillover to some extent (though hopefully nothing too significant)... but maybe reuptake enhancement can make sense for some (and it is still anti-depressant, statistically).

Also, playing with the thyroid can be anti-depressant without directly touching other stuff. Glucocorticoid manipulation can be similar. Low dose thyroid or adrenal augmentation is something some folks out there consider. Obviously that is a highly doctor supervised activity as is any personal application of any theories.

Additionally, I have read that in cases of people suffering depression specifically due to endocrine dysfunction, traditional anti-depressents most commonly backfire very very badly. In those rare cases, correcting the underlying cause is quite necessary... probably more so than in autonomic dysfunction. So be sure to screen for endocrine stuff... or if anti-depressants give bad result... re-consider such possibilities thoroughly. A shrink may not be inclined to think of this.

Lastly, in line with baroreflex stuff (which that study considered) here is another study. Baroreflex variations just happen to be suspicious in both POTS and even in hypertension too (in various ways), right?

Baroreflex Sensitivity Is Reduced in Depression

For some folks, baroreflex can be a part of their POTS... though by one view of it, it could actually be protective in a way (getting depressed could be a helpful adaptation just like "fatigue" can be a helpful protection from underlying problem & damage)... or if nothing else the old standard "causing different presentations" is always handy!

[ramakentesh]

Its paradoxical because SNRIs in normal situations reduce sympathetic outflow. But Ive got a feeling that it would do that for some and worsen sympathetic outflow in others maybe?

[vemee]

One thing they can do to help prevent the trouble I had is do blood tests to test the levels of norepinephrene before giving a norepinephrine reuptake inhibitor. This test was not available when I was started on antidepressants and if done it could have shown that I did not need anymore norepinephrine (ne). While on cymbalta, my ne levels were 580 resting which is well above the reference limit and almost qualifies me for Vanderbilt's pots study which requires a standing level of at least 600. The same can be said for serotonin, doctors no longer have to throw pills at patients blindly trying to guess which neurotransmitter they are low on or at least they can guard against raising the levels too much. I wonder if the study took blood neurotransmitter levels before and during the study?