b'Psychopharmacologic Considerations Limitations in the State of EvidenceChronic medical illness has been consistentlyThe current literature robustly supports theassociated with depressive symptoms and disorders.negative mental health and psychosocial impactsComorbid depression and medical illness are furtherof lymphatic diseases. Unfortunately, there has been associated with increased disease-related morbiditylittle consistency in the literature in quantifying the and mortality 179 . Randomized controlled trials haveincidence and prevalence of mental illness and proven efficacy in both pharmacologic and psycho- associated symptoms in patients with lymphatic social treatments of mood symptoms and disorders indiseases. In addition, there is a significant lack of numerous chronic medical conditions such as ischemicevidence-based research into the application of heart disease, chronic obstructive pulmonary disease,psychotherapeutic and psychotropic interventionsand diabetes 180182 . Treatment of comorbid anxiety andfor this patient population.depression is integral in improving adaptability inThe National Institutes of Health (NIH) established patients with chronic disease symptoms 183 . A Cochranethe National Commission on Lymphatic Diseases in review has shown that antidepressants, specifically2022, subsequently establishing an NIH research selective serotonin reuptake inhibitors (SSRIs) andcategory for lymphedema. The Congressionally tricyclic antidepressants (TCAs), are more effective Directed Medical Research Program (CDMRP)in the treatment of depression in physical illnessalso recently included lymphedema within its topcompared to placebo 184 . Currently, there is a dearth 50 research areas requiring further funding forof high-quality efficacy and safety data on the use ofthe fiscal year of 2023. With these promising specific psychotropics in lymphatic disease. Therefore,developments, it is our recommendation and hope psychotropic decision-making should include patient- that targeted research may improve our ability to centered education on the benefits and potentialassess, recommend, and apply evidence-based adverse effects in the context of comorbid conditions.psychotherapeutic and psychiatric interventionsIn patients with lymphedema and lymphatic diseases,to patients with lymphatic diseases.certain psychiatric medications have the potential Other Consult Services to Considerto exacerbate lymphatic disease. Pregabalin and gabapentin are two anticonvulsant medications thatIn addition to services offered by genetics,are often prescribed off-label for the treatment ofpsychiatry, and psychology, as previously detailed, anxiety and neuropathic pain. Both medications areother consultative services may include but areprescribed with increasing frequency for chronic painnot limited to:and surgery-induced neuropathic pain. However,gynecology for problems with sexual pain andproviders should exercise caution with their use, dysfunction,given the potential for worsening lymphedema. oncology for cancer-related pain,The incidence of peripheral edema in adult patients 185 dermatology or wound care for skin-related changes using pregabalin is up to 16% , and 7% with gabapentin 186 . According to the FDA, 3% of patientsand infections,taking pregabalin experienced potentially clinicallyoccupational therapy when LD affects the ability significant thrombocytopenia 187 . to work, and other referrals deemed necessary for the Gabapentin has a 1.1% rate of adverse effects on the hematologic and lymphatic systems, which includeimprovement of QoL. anemia, thrombocytopenia, and lymphadenopathy 188 .Among the psychotropics targeting depressive symptoms, trazodone has been reported to causefluid retention with a frequency of less than 10% 51 .A review of ten case studies found that, in patients with a predisposition to edematous states, trazodone administration with gradual titration of dose may decrease further fluid retention 189 . Edema has also been reported in treatment with mirtazapine and phenelzine 190,191 . Several dopamine-blocking psychotropics, especially atypical antipsychotics,have been associated with peripheral edema.One case report specifically mentions that risperidone and olanzapine are likely to be associated with edema 192 . | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|41'