Major depression in physical illness: Diagnosis, prevalence, and antidepressant treatment (a ten year review: 1982–1992)

Depression and social functioning in preschool children with chronic medical conditions

OBJECTIVE

To investigate the relations among depressive symptoms, social behavior, and chronic medical illness in preschool children.

STUDY DESIGN

Caregivers of 273 preschool children (3.0-5.2 years of age) completed questionnaires about preschoolers' physical health, depressive symptoms, and social behavior. Interviewers determined ratings for preschoolers' impairment in social and behavioral functioning. Analyses examined the relationships among chronic medical conditions, depressive symptoms, peer acceptance/rejection, and social behavior.

RESULTS

Chronic illness was significantly associated with early-onset depressive symptoms and impairment in several social functioning domains, even after accounting for socioeconomic status. Regression analyses demonstrated that the number of health conditions predicted higher depression scores, frequency of asocial behaviors, and impairment in daycare role cooperation and behavior toward others. Preschoolers with at least 1 medical condition experienced a greater frequency of peer rejection and bullying compared with healthy peers. Depressive symptoms mediated the relationship between illness and asocial behavior.

CONCLUSIONS

There is a need for greater attention to depression and difficulties in social functioning in preschool children with chronic illness. Because of the potential impact on later developmental and mental health outcomes, primary care physicians should be attentive now to depressive symptoms in chronically ill preschoolers.

The Diagnosis of Major Depression in Patients With Cancer: A Comparative Approach

Depressive symptoms not only impair quality of life in cancer patients but constitute an independent risk factor for increased mortality. In order to accurately and efficiently identify depression in cancer patients, the authors developed a biostatistical strategy to identify items of the 21-item, observer-rated Hamilton Rating Scale for Depression (Ham-D) that would optimize the diagnosis of depression among cancer patients. Exhibiting a relatively high sensitivity and specificity, our most optimal diagnostic tool contained six Ham-D items (late insomnia, agitation, psychic anxiety, diurnal mood variation, depressed mood, and genital symptoms). This study may serve as a prototype to generate valid instruments accurate for the diagnosis of major depression in other populations of cancer patients.

Design and rationale for a randomized, controlled trial of interpersonal psychotherapy and citalopram for depression in coronary artery disease (CREATE)

OBJECTIVE

Recognition that depression is associated with increased morbidity and mortality in coronary artery disease (CAD) patients has augmented the need for evidence-based treatment guidelines. This article presents the design of a multisite, Canadian trial of the efficacy, safety, and tolerability of interpersonal psychotherapy (IPT), an empirically supported, depression-focused therapy, and the selective serotonin reuptake inhibitor citalopram, alone or in combination, in the treatment of major depression in CAD patients.

METHODS

Two hundred eighty stable CAD patients with a current major depressive episode of at least 4 weeks' duration, based on the Structured Clinical Interview for Depression (SCID), and who have a baseline score >19 on a centralized, telephone-administered, 24-item Hamilton Depression Rating Scale (HAM-D) will be randomly assigned to receive 12 weekly IPT sessions or 12 weekly sessions of standardized clinical management (CM). Patients are also randomly assigned to receive 20 to 40 mg per day of citalopram or pill-placebo. This results in a 2-by-2 factorial design with four groups: IPT plus pill-placebo, IPT plus citalopram, CM plus pill-placebo, and CM plus citalopram. This permits the evaluation of both IPT and citalopram. Blinded, centralized, 24-item, HAM-D telephone ratings constitute the primary outcome variable. The self-report Beck Depression Inventory-II is the secondary outcome. Analyses will involve the intent-to-treat principle with last observation carried forward for incomplete assessments.

RESULTS

Not applicable.

CONCLUSIONS

The results of this trial will contribute to the development of evidence-based clinical guidelines for managing depression in the context of CAD.

Depression and renal disease

Major depressive disorder (MDD) is a highly prevalent disease, frequently characterized by recurrent or chronic course, and by comorbidity with other medical illnesses. The lifetime prevalence of MDD ranges up to 17% in the general population, and it almost doubles in patients with diabetes (9-27%), stroke (22-50%), or cancer (18-39%). Moreover, MDD worsens the prognosis, quality of life, and treatment compliance of patients with comorbid medical illnesses. Similar to what is observed with other comorbid illnesses, MDD worsens the outcome of kidney disease patients by increasing both morbidity and mortality. Treatment of depressive symptoms in renal failure patients increases medication acceptability and therefore potentially improves the overall patient outcome. The issue of the safety of antidepressant treatment in subjects with renal failure is frequently counterbalanced by the risks associated with depression comorbidity, provided that antidepressants with a low volume of distribution and low protein binding are prescribed, and most important, at low initial doses. Screening for CYP isoenzyme interactions with current medications is also recommended before starting antidepressant treatment.

Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients

CONTEXT

A previous study, described in Part I of this report, found that 71% of a sample of 5,003 general outpatients in the Veterans Affairs healthcare system were receiving a unique drug regimen (i.e., total specific drug entities regardless of dose, formulation, or administration schedule). The simplest regimens contained only one drug, while the most complex regimens exceeded 20 different drugs. The purpose of the present study was to determine if patients receiving a specific therapeutic class of medications (e.g., antidepressants) have more homogeneous drug regimens.

OBJECTIVE

to examine the extent and complexity of multiple medication use in younger and older adult outpatients receiving antidepressants compared with those not receiving antidepressants. The study focused on drugs that act systemically or gastrointestinally and hence have the potential to interact.

DESIGN, SETTING, AND PARTICIPANTS

Two subsets of stratified random samples of outpatients selected from prescription databases of U.S. Veterans Integrated Service Network 15. The first group involved 1,991 patients deemed to be on antidepressants (AD patients): 891 aged < 60 years and 1,100 aged > or = 60 years. The second group involved 3,732 patients who had received no antidepressants within the previous 365 days but who had a supply of at least one other current prescription (NoAD patients): 1,195 aged < 60 years and 2,535 aged > or = 60 years; 2 missing age information.

MAIN OUTCOME MEASURES

number of drugs, frequency of drug regimens, level of multiple medication use including and excluding antidepressants.

RESULTS

Younger AD patients received 3 more drugs than younger NoAD patients. 23.6% of younger AD patients, versus 5.9% of younger NoAD patients, received > or = 8 drugs. Older AD patients received 2 more drugs than older NoAD patients. 37.6% of older AD patients, versus 12.8% of older NoAD patients, received > or = 8 drugs. In both the AD and NoAD groups, 62%-96% of patients of all ages were receiving unique drug regimens. Each drug regimen containing 2 or more drugs occurred in fewer than 1% of patients.

CONCLUSIONS

AD patients were receiving more complex drug regimens and had a higher frequency of unique drug regimens than NoAD patients, even when the results were adjusted for age group and number of prescribers. The high prevalence of unique drug combinations in all patient groups in this study indicates that clinicians in this system have only limited experience with the total effects of all of the medications their patients are receiving and thus cannot rely on experience to guard against adverse multi-drug interactions. This fact is a particular concern with psychiatric medications because adverse DDIs involving these medications can mimic psychiatric symptoms and may therefore be more difficult to detect.

Effects of death within 11 years on cognitive performance in old age

Six different cognitive tests and the Heck Depression Inventory (BDI) were given to 3,572 active community residents aged 49 to 93 years. Causes of death were ascertained for 443 who died between 36 and 3,903 days later. Subsequent survival predicted test scores during the 3,903 days and independently during Days 36 to 1,826 and Days 1,827 to 3,903. Scores on the BDI and cumulative verbal learning and vocabulary tests predicted mortality after demographics and performance on other cognitive tests had been considered. Predictors were similar for deaths from heart disease, malignancies, and other causes. A new finding that cognitive tests did not predict survival duration within the sample of deceased explains previous findings of greater terminal decline in performance for young than for elderly adults.

Treatment of depression in comorbid medical illness

The rate of comorbid depression and medical illness varies from 10 to 40%. Over the years, there has been a paucity of studies completed despite the importance of knowing which antidepressants are the most effective and safest to use in comorbid states. In this review, focus is placed on disorders in these important areas: cardiovascular disease, neurological disorders, diabetes mellitus and cancer. Cardiovascular disease complications can be related in many cases to platelet clumping produced by medications; reductions in morbidity can be achieved by reducing platelet adhesiveness. Specific results have shown sertraline administration to be safe in the post myocardial infarction (MI) state. This is a time of depression-induced increases of 200-300% in mortality. Evidence for safe administration of bupropion, as well as the selective serotonin re-uptake inhibitors (SSRIs) fluoxetine and paroxetine, is also available. The appearance of major depression and diabetes mellitus has been successfully treated with fluoxetine, sertraline and nortriptyline (NTI), however, NTI may lead to a worsening of glucose indices due to its noradrenergic specificity. Regarding neurologic disorders, there is controlled data showing the safety and efficacy of citalopram, sertraline and fluoxetine in post stroke depression. Parkinson's disease has been associated frequently with depression, as might be expected from its characteristic dopamine deficient state. For perhaps the same reason, the agents that can block re-uptake of dopamine i.e., tricyclic antidepressants (TCAs), have been effective in comorborbid depression with Parkinson's disease. In dementia, there is a paucity of information on new agents. However, double-blind data seems to show efficacy for sertraline, paroxetine and citalopram. There are few studies of cancer-related depression treated in a controlled fashion with antidepressants; imipramine, amitriptyline, fluoxetine, paroxetine, mirtazapine and mianserin (not available in the USA) all have support from some published studies.

Depression in patients with cardiac disease: a practical review

Some degree of depression affects at least 30% of hospitalized patients with coronary artery disease (CAD), and is associated with increased risks of mortality and continuing depression over at least the first year following hospital discharge. Despite its consequences for prognosis and quality of life, depression is underrecognized and undertreated in cardiac patients. The diagnosis of depression is complicated in patients with medical illness. Their symptoms can reflect physical as well as psychological complaints. Many CAD patients resist the idea of additional medications, and drug interactions can be problematic for those willing to accept antidepressant treatment. Finally, depression tends to recur. Its successful treatment requires a long-term commitment from both physician and patient. This article examines the special challenges involved in diagnosing depression in patients with CAD, outlines available psychotherapeutic and pharmacological treatments, and considers the issues involved in deciding which patients to treat, with what approach, and for how long.

Religious and other predictors of psychosocial adjustment in cancer patients

The authors tested the hypothesis that religious variables, such as a person's belief that his/her illness was God's will, would predict psychosocial adjustment in 50 patients who were predominantly Catholic Hispanic women attending a medical oncology clinic (42 women, 8 men). The patients were free of an Axis I mental disorder, cognitive impairment, and severe pain and were not undergoing intensive chemotherapy. By using the Psychosocial Adjustment to Illness Scale as the outcome measure, the authors found few associations with religious variables, but many to clinical variables.

Depression in pediatric chronic illness. A diathesis-stress model

Depression in pediatric chronic illness has been receiving increasing attention in recent years. Studies to date have typically focused on characteristics of illness as the major determinants of the development of depression, but characteristics of the child have received less attention. This review suggests that a diathesis-stress model can be a fruitful heuristic that would incorporate illness characteristics and attributes of the child and environmental effects in an overall framework to guide future research and treatment.

Depression and the long-term risk of pain, fatigue, and disability in patients with rheumatoid arthritis

OBJECTIVE

To determine whether a previous episode of major depression leaves a "scar" that places previously depressed patients with rheumatoid arthritis (RA) at risk for experiencing high levels of pain, fatigue, and disability.

METHODS

A cohort of 203 patients with RA was randomly selected from a national panel and interviewed by phone about pain, fatigue, depressive symptoms, disability, and history of major depression.

RESULTS

Excluding patients who met the criteria for current major depression, patients with both a history of depression and many depressive symptoms at the time of the interview (dysphoria) reported more pain than those without current dysphoria, irrespective of whether they had a history of depression. Dysphoria alone was not reliably related to pain reports.

CONCLUSION

An episode of major depression, even if it occurs prior to the onset of RA, leaves patients at risk for higher levels of pain when depressive symptoms persist, even years after the depressive episode.

Combined medical and psychological symptoms: impact on disability and health care utilization of patients with arthritis

OBJECTIVES

Many reports indicate that patients with combined chronic illness and depressive symptomatology have more disability than those with illness alone, which may influence physician visits. Studies suggest that these combined conditions are unevenly accommodated by the delivery system and nonpsychiatric physicians often fail to recognize or treat these symptoms. To address this need, this study aimed to provide further information on combined conditions and report on relations found among arthritis disease symptoms, depression, and disability.

METHODS

The data was derived from a series of statewide surveys assessing the influence of psychosocial factors on disease course and treatment in a community sample of 277 patients under the care of a rheumatologist. A multivariate model was developed to assess these interrelationships, using measures of symptom severity, depression (CESD), disability (activities of daily living, days of restrictive activities, days in bed), service utilizations, and a few personal and health variables.

RESULTS

Even after removing somatic items from the CESD to reduce the risk of inflation due to physical disease, evidence was found for additive impact of depression on one measure of disability, days of restrictive activities. Patients with comorbid conditions also were a high-service utilization group. Very few patients reported receiving help in dealing with emotional problems, suggesting presence of substantial unmet need.

CONCLUSIONS

Nonpsychiatric physicians need to be aware of the mental health status of chronically ill patients. Although the association between medication use and depression suggests some awareness of the need to treat depression, especially in physically compromised patients, there may be some need to dispense psychological and psychosocial support to those in need.

Making the diagnosis of depression in the primary care setting

Making the diagnosis of depression in the primary care setting represents a challenge and an opportunity. With the numerous cultural, administrative, social, and financial obstacles to the assessment and management of mental disorders in primary care, it is a small wonder that so much treatment of depression actually does occur. However, much depression is missed, and even when the diagnosis is not missed, many depressed patients do not receive adequate treatment. This article reviews the different depressive conditions of importance that present in primary care, discusses complexities of differential diagnosis, and underscores the importance of the medical interview itself for eliciting relevant data, developing rapport, and educating the patient about the key issues of importance relevant to the management of depression.

Major depression in the primary care setting

This article has provided a brief overview of the prevalence, differential diagnosis, and clinical manifestations of depression in the primary care setting. While the high prevalence of depression is well documented, another body of evidence is accruing that demonstrates that depression not only increases over utilization of medical resources, but may worsen the long-term prognosis of certain medical conditions such as MI. Evidence also suggests that the diagnostic and management skills of primary care physicians--who comprise the "front line" and may offer the only line of care for these patients--is in need of improvement. This series of articles focusing on the diagnosis and treatment of depression in primary care will hopefully contribute to that effort.

Cross-sectional and prospective relationships between physical morbidity and depression in older adolescents

OBJECTIVE

To examine cross-sectional and prospective associations between major depressive disorder (MDD), physical morbidity (disease and injury), health-related reductions in activities, and functional impairment in adolescents.

METHOD

Data on depression and health-related variables were available for a sample of 1,410 adolescents (aged 14 to 18 years) at point of entry into the study and approximately 1 year later.

RESULTS

Girls were more likely to have been treated for a disease and to have a health-related reduction in activities, whereas boys were more likely to have been treated for an injury. The expected cross-sectional associations were found between disease, reductions in activities, functional impairment, and depression, but the association between injury and depression was not significant. Prospective analyses suggest that functional impairment and disease are risk factors for future MDD and that MDD is a risk factor for future functional impairment and disease.

CONCLUSIONS

The robust prospective associations between MDD and functional impairment suggest that the impact of disease on depression is particularly strong when it disrupts important behavior patterns. Clinically, the results emphasize the importance of assessing health-related variables in depressed adolescents and of assessing depression in those with functional impairment or disease.