Elsevier

General Hospital Psychiatry

Volume 26, Issue 6, November–December 2004, Pages 421-429
General Hospital Psychiatry

Psychiatry and Primary Care
Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Wayne J. Katon, M.D., will publish informative research articles that address primary care-psychiatric issues.
Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR*D

https://doi.org/10.1016/j.genhosppsych.2004.06.008Get rights and content

Abstract

Background

A significant percentage of patients with major depressive disorder (MDD) suffer from concurrent general medical conditions (GMCs).

Objective

The objective of this preliminary report was to describe the rates of co-occurring significant GMCs and the clinical correlates and symptom features associated with the presence of GMCs.

Design

Baseline cross-sectional case–control study of patients enrolling in a prospective randomized multistage treatment study of MDD.

Setting

Fourteen regional U.S. centers representing 19 primary care and 22 psychiatric practices.

Patients

One thousand five hundred outpatients with DSM-IV nonpsychotic MDD.

Measurements

Sociodemographic status, medical illness ratings, psychiatric status, quality of life and DSM-IV depression symptom ratings.

Results

The prevalence of significant medical comorbidity in this population was 52.8% (95% CI 50.3–55.3%). Concurrent significant medical comorbidity was associated with older age, lower income, unemployment, limited education, longer duration of index depressive episode and absence of self-reported family history of depression. Somatic symptoms common in MDD were endorsed at a higher rate in those with GMCs. Those without a GMC had higher rates of endorsement of impaired mood reactivity, distinct mood quality and interpersonal sensitivity.

Conclusions

Concurrent GMCs are common among outpatients with MDD in both primary care and specialty settings. Concurrent GMCs appear to influence the severity and symptom patterns in MDD and describe a vulnerable population with sociodemographic challenges to effective assessment and treatment.

Introduction

Major depressive disorder (MDD) is a common disorder with significant role impairment, but most cases in the United States do not receive adequate treatment [1]. General medical conditions (GMCs) and MDD commonly co-occur and present for treatment in both primary care and psychiatric practices. Multiple studies have demonstrated the high (20–50%) rates of major depression in a number of specific medical conditions [2], [3], [4], [5], [6], [7], [8]. However, there are fewer systematic studies of co-occurring GMCs in populations with major depression [9], [10], despite the potential impact of the GMCs on the presentation, diagnosis and treatment of MDD.

Co-occurring GMCs may complicate the presentation and diagnosis of depression. Clinicians may have difficulty distinguishing the normal adjustment to significant medical illness and the presentation of MDD [11]. Many physical symptoms attributed to the GMC (e.g., fatigue) may also be symptoms of MDD. Significant debate continues on the best method of diagnosing major depression in the medically ill [12], [13], [14]. This debate stems in part from few studies examining the symptom patterns of MDD in those with and without one or more concurrent GMCs.

Studies that have focused on medical conditions co-occurring with MDD have demonstrated important clinical findings. Those with both conditions tend to have a more chronic depression [15], require greater time to achieve recovery [16], be less responsive to standard depression treatments [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. Additionally, MDD in medically hospitalized patients increases risk for in-hospital mortality [27]. Patients with both GMCs and MDD are more likely to be taking more different kinds of medications with the resultant risk for drug–drug interactions.

We explored the relationship between GMCs and MDD in a large consecutive series of patients from primary care and psychiatric practices entering the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study's depression treatment protocol (http://www.star-d.org) [28]. This preliminary report estimated the prevalence of significant GMCs and examined the clinical correlates and symptom patterns associated with this comorbidity.

Section snippets

Population and methods

The population and methods of STAR*D are described in detail elsewhere [28]. The key elements of the methods are described below.

Results

Table 1 summarizes the sociodemographic characteristics of the sample. Similar to most clinical trial samples in MDD, most subjects were female (63%). The racial composition approaches U.S. Census estimates of 76% White, 18% Black and 6% other [48]. Hispanic ethnicity was endorsed by 9% of the subjects. Most subjects were employed with private medical insurance. The average age for the sample was 40.4 years with 13.6 years of education and a monthly household income of $2423 (yearly income

Conclusions

Although preliminary, this is one of the largest samples analyzed to identify subjects with concurrent GMCs and clinical and depressive symptom features. Co-occurring GMCs were common in both psychiatric and primary care settings, with an estimated prevalence of 53% when a score of ≥2 on impairment is required to declare the presence of a GMC. The figure rises to 87.8% (95% CI, 86.2–89.5%, if the threshold is set at 1 for declaring the presence. Our estimate approximates the prevalence estimate

Acknowledgment

This project has been supported with federal funds from the National Institute of Mental Health, National Institutes of Health, under Contract N01MH90003 to UT Southwestern Medical Center at Dallas (P.I.: A.J. Rush).

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