Mood disorders and medical illnessClinical and health services relationships between major depression, depressive symptoms, and general medical illness
Introduction
The United States population is aging substantially. It is estimated that today, 12.5% of the U.S. population is 65 years and older, but by 2050, 20%–25% will be older than 65 years (Olshansky et al 1993). The decline in mortality rate is, in part, a tribute to the improved medical treatment of chronic medical illness, substantially lengthening the lives of patients who suffer from these medical illnesses. One end result of this, however, is that with the aging of our population, physicians will be called upon to treat a higher percentage of patients with chronic medical illness. Eighty-eight percent of people aged 65 and older have one or more chronic medical illness, and one quarter of them will have four or more conditions (Hoffman et al 1996).
This article will review the incidence and prevalence of major depression in patients with chronic medical illness and the association of this affective disorder with symptom burden, functional impairment, adverse health behaviors and adherence to self-care regimens (diet, exercise), satisfaction with care, medical utilization and costs, morbidity and mortality, and possible pathophysiologic mechanisms that may worsen the course of medical illness. This review of the adverse impact of depression will focus on diabetes and heart disease because of their high prevalence and the depth of research describing the impact of depression comorbidity in patients with these illnesses. The literature review for this manuscript included screening English-language articles identified through MEDLINE (1992 to the present) by pairing the word “depression” with the following key words: medical illness, heart disease, myocardial infarction, diabetes, HIV, cancer, stroke, Parkinson’s disease, multiple sclerosis, somatization, function, pain, health risk behaviors, smoking, obesity, adherence, costs, and mortality.
Section snippets
Epidemiology of depression and chronic medical illness
As one moves from community settings to primary-care settings to inpatient medical settings, the prevalence of major depression increases from 3%–5% to 5%–10% to 10%–14% Feldman et al 1987, Katon and Schulberg 1992, Kessler et al 1994, Myers et al 1984, Rapp et al 1988. Patten (2001) recently described in a longitudinal community-based study in Canada the incidence of new-onset episodes of major depression in subjects with and without long-term medical conditions. Patten (2001) found that there
Conceptual model
Figure 1 describes a conceptual model for the complex interactions between risk factors for major depression, major depression, and chronic medical illness. This model describes three known risk factors for the development of major depression: genetic vulnerability, childhood adversity, and stressful life events (Kendler et al 2002). This model also shows that an underlying vulnerability to major depression from childhood adversity (neglect and abuse experiences) may also lead to maladaptive
Relationship of depression to adverse health behaviors and lack of adherence to self-care regimens
Several studies have reported that patients with major depression have higher rates of adverse health-risk behaviors, such as sedentary lifestyle, smoking, and over-eating, which may lead to a higher incidence of diabetes and heart disease Goodman and Whitaker 2002, Rosal et al 2001. Several large longitudinal studies have shown that adolescents with depression were found to have increased risk of developing obesity in their early twenties compared with adolescents without depression Goodman
Relationship of depression to physical symptom perception
Patients with both DSM-IV depressive and anxiety disorders have been found to have significantly more medically unexplained symptoms compared with patients without these disorders when controlling for severity of medical illness (Katon et al 2001). In the Epidemiologic Catchment Area Study, 50% of community respondents with five or more medically unexplained symptoms over a 6-month period met the criteria for a DSM-III psychiatric disorder compared with 5% of respondents without these symptoms
Functional impairment
Data from the Medical Outcomes Study revealed that patients with major depression perceived their vocational and social functioning and general health as more impaired than patients with one of seven other medical conditions (Wells et al 1989). Moreover, when major depression was comorbid with chronic medical illness, there was additive functional impairment (Wells et al 1989). The MacArthur Foundation Midlife Development in the United States Study recently showed that having three or more
Depression and the doctor–patient relationship
Satisfaction with the quality of care of a patient’s physician has been linked with enhanced adherence to medical regimens (Sherbourne et al 1992). Depressive disorders have been shown to be associated with decreased ratings of satisfaction with care (Webster et al 2001). Moreover, primary care effectiveness studies that tested interventions that were shown to improve major depressive outcomes showed that enhanced depressive outcomes were associated with increased satisfaction with care Katon
Medical utilization and costs
Recent data from both mixed-aged (Simon et al 1995) and elderly samples of primary-care patients have found significantly higher medical costs in patients with either depressive symptoms or major depression compared with patients without depression Callahan et al 1994, Unützer et al 1997, Katon et al). This increase in costs is seen in every component of medical costs, including primary care visits, specialty visits, mental health visits, emergency room visits, pharmacy costs, laboratory and
Relationship of depression to mortality
Multiple large, epidemiologic studies have examined whether depressive symptoms or major depression increased the risk of mortality. A systematic survey of 57 studies (1966–1996) from the world’s literature examining the risk of increased mortality in patients with depression found that 29 (51%) were positive, 13 (23%) were negative, and 15 (26%) were mixed (Wulsin et al 1999). The summary of this analysis suggested that depression seemed to increase the risk of death from cardiovascular
Mechanisms for increased cardiac risk
Recent research studies have suggested several possible biologic mechanisms that may explain why major depression increases risk after myocardial infarction. These studies have described that depressed patients had decreased heart rate variability (Gorman and Sloan 2000), increased platelet aggregation Langhrissi-Thode et al 1997, Musselman et al 1996, Pollack et al 2000, Whyte et al 2001, higher levels of inflammatory risk markers (C-reactive protein and interleukin-6) (Miller et al 2002), and
Conclusion and future research directions
The data suggest that there is a higher incidence and prevalence of major depression in patients with chronic medical illness. Major depression is associated with more health-risk behaviors such as smoking, sedentary lifestyle, and over-eating, which may increase risk of incidence of medical illness. The aversive symptoms, functional decrements, or physiologic changes associated with chronic medical illness may also increase the incidence and prevalence of major depression. Depression has been
Acknowledgements
This work was supported by grants no. MH4-1739 and no. MH0-16473 from the National Institute of Mental Health Services Division, Bethesda, Maryland (WJK).
Aspects of this work were presented at the conference, “The Diagnosis and Treatment of Mood Disorders in the Medically Ill,” November 12–13, 2002 in Washington, DC. The conference was sponsored by the Depression and Bipolar Support Alliance through unrestricted educational grants provided by Abbott Laboratories, Bristol-Myers Squibb Company,
References (115)
- et al.
Medical and economic costs of psychologic distress inpatients with coronary artery disease
Mayo Clinic Proc
(1995) - et al.
Improvement in mood, physical symptoms, and function with nortriptyline for depression in patients with chronic obstructive pulmonary disease
Psychosomatics
(1992) - et al.
Major depressive disorder in coronary artery disease
Am J Cardiol
(1987) - et al.
Depression, fatigue and functional disability in patients with hepatitis C
J Psychosom Res
(2000) - et al.
The effect of changes in depression on health-related quality of life (HRQOL) in HIV infections
Gen Hosp Psychiatry
(2002) - et al.
The association between depressive symptoms and health status in patients with chronic pulmonary disease
Gen Hosp Psychiatry
(2001) - et al.
A cross-national study of the course of persistent pain in primary care
Pain
(2001) - et al.
Epidemiology of depression in primary care
Gen Hosp Psychiatry
(1992) - et al.
Distressed high utilizers of medical careDSM-III diagnoses and treatment needs
Gen Hosp Psychiatry
(1990) On the inseparability of mental and physical health in aged personsLessons from depression and medical comorbidity
Am J Geriatr Psychiatry
(1996)
Cytokine-induced sickness behaviorMechanisms and implications
Trends Neurosci
Negative emotions and coronary heart diseaseGetting to the heart of the matter
Lancet
Depression and service utilization in elderly primary care patients
Am J Geriatr Psychiatry
Clinical depression and inflammatory risk markers for coronary artery disease
Am J Cardiol
Long-term medical conditions and major depression in a Canadian population study at waves 1 and 2
J Affect Disord
Behavioral risk factors among members of a health maintenance organization
Prev Med
Depression as a predictor for coronary heart diseaseA review and meta-analysis
Am J Prev Med
Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patientsFrom a predictive to a dynamic approach
Soc Sci Med
Disabling tinnitusAssociation with affective disorder
Gen Hosp Psychiatry
Depression and the dynamics of smoking
JAMA
The prevalence of comorbid depression in adults with diabetesA meta-analysis
Diabetes Care
Depression and cardiovascular disease
Acta Psychiatr Scand Suppl
Adult attachment style. IIts relationship to clinical depression
Soc Psychiatry Psychiatr Epidemiol
Adult attachment style. IIIts relationship to psychosocial depressive vulnerability
Soc Psychiatry Psychiatr Epidemiol
Physiological and psychological variables predict compliance to prescribed exercise therapy in patient recovering from myocardial infarction
Psychosom Med
Identifying patients at risk for and treatment of major psychiatric complications of cancer
Support Care Cancer
Social and physical health risk factors for first onset major depressive disorder in a community sample
Soc Psychiatry Psychiatr Epidemiol
The impact of depressive symptomatology on physical disabilityMacArthur studies of successful aging
Am J Public Health
Longitudinal study of depression and health services use among elderly primary care patients
Am Geriatr Soc
Major depression and medication adherence in elderly patients with coronary artery disease
Health Psychol
Depression and diabetesImpact of depressive symptoms on adherence, function and costs
Arch Intern Med
The patient-provider relationshipAttachment theory and adherence to treatment in diabetes
Am J Psychiatry
Meta-analysis of the relationship between HIV infection and risk for depressive disorders
Am J Psychiatry
Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women
J Acquir Immune Defic Syndr
Sadness predicts death in older people
J Aging Health
The Hopkins Symptom Checklist (HSCL)A self-report symptom inventory
Behav Sci
Smoking and depressionAn examination of mechanisms of comorbidity
Am J Psychiatry
Depression is a risk factor for noncompliance with medical treatmentMeta-analysis of the effects of anxiety and depression on patient adherence
Arch Intern Med
Quality of preventative medical care for patients with mental disorders
Med Care
Depression and risk for onset of type II diabetes. A prospective population-based study
Diabetes Care
Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes
Diabetes Care
Psychiatric disorders and functional disability in outpatients with traumatic brain injuries
Am J Psychiatry
Psychiatric disorder in medical inpatients
Q J Med
Depression as an antecedent to heart disease among women and men in the WHANES I study. National Health and Nutrition Survey
Arch Intern Med
Depression following myocardial infarctionImpact on 6-month survival
JAMA
Smoking, smoking cessation and major depression
JAMA
Depression in patients with coronary artery disease
Depression
A prospective study of the role of depression in the development and persistence of adult obesity
Pediatrics
Cited by (906)
The prevalence of depression, anxiety, and sleep disturbances in patients with neuromyelitis optica spectrum disorders (NMOSD): A systematic review and meta-analysis
2023, Multiple Sclerosis and Related DisordersBody mass index modifies the relationship between dietary iron intake and depressive symptoms among adults: A national population-based cohort
2023, Journal of Affective DisordersUsing machine learning to forecast symptom changes among subclinical depression patients receiving stepped care or usual care
2023, Journal of Affective Disorders