Elsevier

Biological Psychiatry

Volume 54, Issue 3, 1 August 2003, Pages 216-226
Biological Psychiatry

Mood disorders and medical illness
Clinical and health services relationships between major depression, depressive symptoms, and general medical illness

https://doi.org/10.1016/S0006-3223(03)00273-7Get rights and content

Abstract

Patients with chronic medical illness have a high prevalence of major depressive illness. Major depression may decrease the ability to habituate to the aversive symptoms of chronic medical illness, such as pain. The progressive decrements in function associated with many chronic medical illnesses may cause depression, and depression is associated with additive functional impairment. Depression is also associated with an approximately 50% increase in medical costs of chronic medical illness, even after controlling for severity of physical illness. Increasing evidence suggests that both depressive symptoms and major depression may be associated with increased morbidity and mortality from such illnesses as diabetes and heart disease. The adverse effect of major depression on health habits, such as smoking, diet, over-eating, and sedentary lifestyle, its maladaptive effect on adherence to medical regimens, as well as direct adverse physiologic effects (i.e., decreased heart rate variability, increased adhesiveness of platelets) may explain this association with increased morbidity and mortality.

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)

  • J. Konsman et al.

    Cytokine-induced sickness behaviorMechanisms and implications

    Trends Neurosci

    (2002)
  • F. Lespérance et al.

    Negative emotions and coronary heart diseaseGetting to the heart of the matter

    Lancet

    (1996)
  • M.P. Luber et al.

    Depression and service utilization in elderly primary care patients

    Am J Geriatr Psychiatry

    (2001)
  • G.E. Miller et al.

    Clinical depression and inflammatory risk markers for coronary artery disease

    Am J Cardiol

    (2002)
  • S. Patten

    Long-term medical conditions and major depression in a Canadian population study at waves 1 and 2

    J Affect Disord

    (2001)
  • M.C. Rosal et al.

    Behavioral risk factors among members of a health maintenance organization

    Prev Med

    (2001)
  • R. Rugulies

    Depression as a predictor for coronary heart diseaseA review and meta-analysis

    Am J Prev Med

    (2002)
  • B. Spire et al.

    Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patientsFrom a predictive to a dynamic approach

    Soc Sci Med

    (2002)
  • M. Sullivan et al.

    Disabling tinnitusAssociation with affective disorder

    Gen Hosp Psychiatry

    (1988)
  • Agency for Health Care Research and Quality (2001): The Medical Expenditure Panel Survey: Household component full-year...
  • R.F. Anda et al.

    Depression and the dynamics of smoking

    JAMA

    (1990)
  • R.J. Anderson et al.

    The prevalence of comorbid depression in adults with diabetesA meta-analysis

    Diabetes Care

    (2001)
  • A. Aromaa et al.

    Depression and cardiovascular disease

    Acta Psychiatr Scand Suppl

    (1994)
  • A. Bifulco et al.

    Adult attachment style. IIts relationship to clinical depression

    Soc Psychiatry Psychiatr Epidemiol

    (2002)
  • A. Bifulco et al.

    Adult attachment style. IIIts relationship to psychosocial depressive vulnerability

    Soc Psychiatry Psychiatr Epidemiol

    (2002)
  • J.A. Blumenthal et al.

    Physiological and psychological variables predict compliance to prescribed exercise therapy in patient recovering from myocardial infarction

    Psychosom Med

    (1982)
  • W. Breitbart

    Identifying patients at risk for and treatment of major psychiatric complications of cancer

    Support Care Cancer

    (1995)
  • M.L. Bruce et al.

    Social and physical health risk factors for first onset major depressive disorder in a community sample

    Soc Psychiatry Psychiatr Epidemiol

    (1994)
  • M.L. Bruce et al.

    The impact of depressive symptomatology on physical disabilityMacArthur studies of successful aging

    Am J Public Health

    (1994)
  • C.M. Callahan et al.

    Longitudinal study of depression and health services use among elderly primary care patients

    Am Geriatr Soc

    (1994)
  • R. Carney et al.

    Major depression and medication adherence in elderly patients with coronary artery disease

    Health Psychol

    (1995)
  • P. Ciechanowski et al.

    Depression and diabetesImpact of depressive symptoms on adherence, function and costs

    Arch Intern Med

    (2000)
  • Ciechanowski P, Katon W, Russo J, Hirsch I: The relationship of depressive symptoms to symptom reporting, self-care and...
  • P. Ciechanowski et al.

    The patient-provider relationshipAttachment theory and adherence to treatment in diabetes

    Am J Psychiatry

    (2001)
  • J.A. Ciesla et al.

    Meta-analysis of the relationship between HIV infection and risk for depressive disorders

    Am J Psychiatry

    (2001)
  • J.A. Cook et al.

    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

    (2002)
  • J. Cooper et al.

    Sadness predicts death in older people

    J Aging Health

    (2002)
  • L. Derogatis et al.

    The Hopkins Symptom Checklist (HSCL)A self-report symptom inventory

    Behav Sci

    (1974)
  • L.C. Dierker et al.

    Smoking and depressionAn examination of mechanisms of comorbidity

    Am J Psychiatry

    (2002)
  • M.R. Dimatteo et al.

    Depression is a risk factor for noncompliance with medical treatmentMeta-analysis of the effects of anxiety and depression on patient adherence

    Arch Intern Med

    (2000)
  • B. Druss et al.

    Quality of preventative medical care for patients with mental disorders

    Med Care

    (2002)
  • W. Eaton et al.

    Depression and risk for onset of type II diabetes. A prospective population-based study

    Diabetes Care

    (1996)
  • L. Egede et al.

    Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes

    Diabetes Care

    (2002)
  • J.R. Fann et al.

    Psychiatric disorders and functional disability in outpatients with traumatic brain injuries

    Am J Psychiatry

    (1995)
  • E. Feldman et al.

    Psychiatric disorder in medical inpatients

    Q J Med

    (1987)
  • A. Ferketich et al.

    Depression as an antecedent to heart disease among women and men in the WHANES I study. National Health and Nutrition Survey

    Arch Intern Med

    (2000)
  • N. Frasure-Smith et al.

    Depression following myocardial infarctionImpact on 6-month survival

    JAMA

    (1993)
  • A. Glassman et al.

    Smoking, smoking cessation and major depression

    JAMA

    (1990)
  • M. Gonzalez et al.

    Depression in patients with coronary artery disease

    Depression

    (1996)
  • E. Goodman et al.

    A prospective study of the role of depression in the development and persistence of adult obesity

    Pediatrics

    (2002)
  • Cited by (906)

    View all citing articles on Scopus
    View full text