Question of the Week # 50

A 50 year old woman with history of coronary artery disease and  hypertension presents to your office for regular health check up. The patient is compliant with her medications which include aspirin, atorvastatin and  enalapril. Her blood pressure is 110/70. Laboratory investigations including CBC and comprehensive metabolic panel are with in normal limits. A fasting lipid panel that was performed one week ago reveal an LDL cholesterol of 65, HDL of 50 and Triglycerides of 150. You discuss the results with her and you inform her that the goals of therapy are being adequately met. She seemed happy to know about the results but tells you that lately, her mood has been slightly low. There are good days but she tends to have frequent  bad days as well. She enjoys surfing as she used to before. She has no weightloss and her appetite is good. She denies any suicidal ideations. She asks you if there is any medication that would benefit her heart and also, help her mood. The next best step in managing this patient is :

A. Start escitalopram

B. Start clozapine

C. Refer to psychiatrist

D. Start Omega 3 Fatty Acids

E. Start St.John’s Wort


12 Responses

  1. Answer.D

    Omega 3 fatty acids are useful in improving the risk of coronary artery disease. Omega 3 fatty acids are also effective in reducin serum triglycerides and improves mood in mild to moderate depression. This is the medication that will help address ” her heart issues as well as her mood.”
    Choice. A is incorrect because the patient does not have significant depression that warrants pharmacotherapy at this time. Escitalopram also does not have any beneficial effect on cardiovascular risk.
    Choice. B is incorrect because the patient does not have pychotic depression that warrants clozapine at this time. Clozapine also increases cardiovascular risk by causing obesity, metabolic syndrome and worsening hyperlipidemia.
    Choice. C is incorrect because the patient does not have significant depression that warrants psychiatry referral at this time.
    Choice E is incorrect. St.John’s wort is useful in treating mild to moderate depression. However, St.John’s wort has no effect in improving the patient’s cardiovascular risk.

    • this lady does not need any medication,inspite of feeling good at her reports,her mood is fluctuating,definitely she needs to be dent to a psychiatrist

  2. a

  3. D

  4. good ques

  5. Give it a break
    Its well documented that this works well.The Omega 3 is ok to give but for antidepresion——-I would say thats a long shot

  6. in the previous question # 49 the aspirin with omega 3 combination increased the risk of bleeding and the correct advice was to discontinue omega 3, then why to start it in this patient who is already on aspirin?

  7. in fact, there is no Level 1 evidence that omega3s significantly reduce CV disease risk or mortality. the only evidence is from reduced stroke rate. they also improve cognitive function. bottomline-eat walnuts, people!

  8. American Heart Association recommends 1 g EPA (Ecosapentanenoic acid, i.e omega 3 fatty acid) per day in patients with Coronary artery disease. This translates into 1 oily fish or omega 3 fatty acid capsules.

    Research suggest the following benefits:
    Decrease risk of arrythmias and thrombosis (i.e decrease risk of sudden death, heart attack and stroke)
    Improves endothelial function, decrease rate of growth of atheroschlerotic plaque, decrease inflammatory response,
    Decrease triglycerides and remnant lipoprotein levels and slightly lower blood pressure.

    Omega 3 fatty acid use for treatment of depression is recommended as an adjunct therapy. This patient does not have depression. She does not meet the diagnostic criteria of depression. American Psychiatry Association published in DSM of Mental Disorders the diagnostic criteria for depression as depressed mood or loss of interest or pleasure and four or more of the following enlisted symptoms for more than 2 weeks, most of the day, almost every day:
    i, significant WEIGHT loss or gain,
    ii, SLEEP disturbance – insomnia or increased desire to sleep,
    iii, PSYCHOMOTOR disturbance – restlessness (agitation) or slowed behavior (retardation),
    iv, loss of ENERGY and/or FATIGUE
    v, FEELINGS of worthlessness or guilt
    vi, trouble THINKING, loss of concentration, decision making trouble,
    v, RECURRENT SUICIDAL ideas or one suicide attempt
    ‘frequent bad days and low mood’ is not sufficient to call our patient depressed. She has non of the SEVEN MAJORS of depression and ‘low mood’ is not sufficient for diagnosis. But it is true that low omega 3 fatty acid is linked with depression and some studies have shown benefit of treatment of depression with omega 3 fatty acid and so the recommendation is use as adjunct therapy for depression.

    Chiu CC, Huang SY, Chen CC, Su KP. Omega-3 fatty acids are more beneficial in the depressive phase than in the manic phase in patients with bipolar I disorder. J Clin Psychiatry. 2005;66:1613-1614.
    Rees AM, Austin MP, Parker GB. Omega-3 fatty acids as a treatment for perinatal depression: randomized double-blind placebo-controlled trial. Aust N Z J Psychiatry. 2008;42:199-205.
    Ruxton CH, Reed SC, Simpson MJ, Millington KJ. The health benefits of omega-3 polyunsaturated fatty acids: a review of the evidence. J Hum Nutr Diet. 2004;17:449-459.

    Since our patient does not have depression, non of the options A, B, C, & E would be the best next step. However, she may benefit from Option D (Omega 3 fatty acid). The ‘best next step’ (from the list of given options) in managing this patient is Omega 3 fatty acid (Option D)

    My answer is Option D – Thank u for staying awake while perusing through my comment.

    • Omega 3 fatty acid may be therapeutic for ‘depressed mood’ that does not meet the diagnostic criteria for clinical depression. Several mechanisms of this antidepressant property have been proposed but large scale studies to confirm this benefit in the index population are lacking; Logically speaking however, if randomized control trials have shown the benefit of use of Omega 3 fatty acid in clinical depression, it is likely that ‘low mood’ may also benefit from Omega 3 fatty acid therapy.
      Some physicians (including myself) will not hesitate to start Omega 3 fatty acid trial (for depressed mood as well). There are no serious side effects of short term low dose Omega 3 fatty acid (less than or equal to 3g per day). Agreed that greater than 3 grams has to be taken under medical supervision but one fish a day contains less than 2g Omega 3 fatty acid and one Omega 3 capsule contains 3g each; both of these options are acceptably safe especially for short term use. The major concern is risk of bleeding in susceptible patients using greater than 3 grams Omega 3 Fatty acid daily but this patient may actually report improvement in depressed mood symptoms with low dose Omega 3 fatty acid trial.

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