Review articleImpact of major depression on chronic medical illness
Introduction
Due to the aging of the U.S. population, healthcare providers will be called upon to diagnose and treat patients with chronic medical illness with increasing frequency. This paper will review the epidemiology of depression in patients with chronic illness and the impact of comorbid depression on increased use of medical resources and costs, amplification of physical symptoms, additive functional impairment, decreased ability to adhere to medications, important lifestyle changes (i.e., increasing exercise, changing dietary patterns, quitting smoking), and increased mortality.
Section snippets
Epidemiology of depression and chronic medical illness
The prevalence rates of major depression have been shown to increase from 2–5% in community settings [1] to 5–10% in primary care [2] to 6–14% in medical/surgical inpatients [3], [4], [5]. A large study of community respondents found that people suffering from one of eight medical disorders had a 41% increase in the relative risk of having any recent psychiatric disorder compared to people without chronic medical disorders [6]. Anxiety, affective, and substance abuse disorders were each more
Medical utilization of costs
Recent data from both elderly and mixed-age samples of primary care patients have found significantly higher medical costs in patients with either depressive symptoms or major depression compared to patients without depression [9], [10], [11]. This increase in costs is seen in every category that was measured, including primary care visits, medical specialty visits, lab tests, pharmacy costs, inpatient medical costs, and mental health visits.
Simon et al. [9] recently showed that 6256 mixed-age
Amplification of symptoms
Patients with both psychiatric disorders as well as subsyndromal psychological distress report significantly more physical symptoms on medical review of systems than nondistressed populations when controlling for severity of medical illness [20], [21]. Many patients with chronic medical illness must learn to live and adapt to chronic medical symptoms caused by their medical illness. For instance, patients with osteoarthritis often live with chronic pain symptoms, patients with COPD have to
Depression and functional disability
Wells et al. [30] have shown in the Medical Outcomes Study that patients with major depression perceive their social and vocational functioning and general health as more impaired than patients with one of seven other medical disorders. Moreover, when major depression was comorbid with one of these medical disorders, there was additive functional impairment [30]. Subsyndromal depressive symptoms have also been found to be associated with additive disability in patients with chronic medical
Poor self-care and adherence
Self-management of chronic illness includes working effectively with healthcare providers, self-monitoring (i.e., checking blood glucose), implementing medication regimens, following prescribed diet and exercise regimens, quitting smoking and minimizing drinking as well as minimizing impact of medical illness on social role functioning. Depression has been shown to adversely impact self-management of chronic illness by its adverse effect on memory, energy, sense of self-efficacy, and
Depression and chronic medical illness relationship to mortality
Several large epidemiologic studies in recent years have suggested that prior episodes of major depression may be an important risk factor for the development of coronary artery disease [45] and diabetes mellitus [46], [47], two illnesses that are associated with decreased longevity in our aging populations. Pratt et al. [45] have shown that the risk of development of myocardial infarction in 1551 community respondents followed up 13 years after initial assessment was significantly higher in
Conclusion
Major depression has been shown in multiple studies in patients with chronic medical illness to increase symptom burden, lead to additive function impairment, increase medical costs and to impair self-care and adherence. There is also provocative evidence, particularly in male patients with heart disease, that depression may be associated with increased mortality. There is a need for large treatment trials aimed at improving outcomes of depression in medical illness to study the effects on
Acknowledgements
This study was supported by the National Institute of Mental Health Services, Rockville, MD (Grant No. MH4-1739 and No. MH0-11643 to Dr. Katon).
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