Quality of depression treatment in Black Americans with major depression and comorbid medical illness

Objective

The objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans.

Methods

Data came from the National Survey of American Life (N= 3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N= 402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care.

Results

Only 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07–10.31).

Conclusions

Although individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.     

Treating depression complicated by comorbid medical illness or anxiety

In this online activity, Trivedi discusses pharmacotherapy treatments for depression in the presence of comorbid medical illness or physical symptoms. The focus is on key aspects of treatment such as remission as the treatment goal, effects of different classes of antidepressants, and benefits of using treatment algorithms. Clayton addresses issues related to comorbid depression and anxiety including prevalence and recognition, risk factors and outcomes, and treatment considerations. Frank highlights the importance of psychotherapy in the treatment of complicated depression, citing empirically validated psychotherapies for acute depressive episodes as well as describing how to apply psychotherapy to medical patients with depression.     

Improving the care for depression in patients with comorbid medical illness

OBJECTIVE: The authors compared treatment and outcomes for depressed primary care patients with and without comorbid medical conditions and assessed the impact of quality improvement programs for these patients. METHOD: The study group included 1,356 patients with major depression, dysthymia, or subthreshold depression from 46 managed primary care clinics. Clinics were randomly assigned depression treatment programs consisting of usual care for depression or one of two quality improvement programs for depression. The quality improvement programs included training experts and nurse specialists to provide education and assessment, plus access to nurse specialists for medication follow-up or access to psychotherapists. Outcomes were assessed at 6 and 12 months. RESULTS: At 6- and 12-month follow-up, the likelihood of having a probable depressive disorder was higher, but the rates of use of antidepressant medication and specialty counseling were similar, for depressed patients with comorbid medical disorders than for depressed patients who did not have comorbid medical disorders. Among the depressed patients with comorbid medical disorders, the combined quality improvement programs resulted in greater use of antidepressant medications and psychotherapy and lower rates of probable depressive disorders at both 6- and 12-month follow-up than did the usual care depression treatment program. CONCLUSIONS: Depressed patients with comorbid medical disorders tend to have similar rates of treatment but worse depression outcomes than depressed patients without comorbid medical illness. Quality improvement programs for depression can improve treatment rates and outcomes for depressed primary care patients with comorbid medical illness. The authors discuss the implications of these findings for clinical practice.     

Improving depression outcomes in older adults with comorbid medical illness

BACKGROUND: Depression is common in older adults and often coexists with multiple chronic diseases, which may complicate its diagnosis and treatment. OBJECTIVE: To determine whether or not the presence of multiple comorbid medical illnesses affects patient response to a multidisciplinary depression treatment program. DESIGN, SETTING AND PARTICIPANTS: Preplanned analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from eight health care organizations in five states across the United States from July 1999 to August 2001. INTERVENTION: Intervention patients had access for up to 12 months to a depression care manager, supervised by a psychiatrist and a primary care expert, who offered education, care management and support of antidepressant management by the patient's primary care physician, or provided brief psychotherapy (Problem-Solving Treatment in Primary Care). MEASUREMENTS: Depression, quality of life (QOL; scale of 0-10) and mental health component score (MCS) of the Short-Form 12 assessed at baseline, 3, 6 and 12 months. RESULTS: Patients suffered from an average of 3.8 chronic medical conditions. Although patients with more chronic medical conditions had higher depression severity at baseline, the number of chronic diseases did not affect the likelihood of response to the IMPACT intervention when compared to care as usual. Intervention patients experienced significantly lower depression during all follow-up time points as compared with patients in usual care independent of other comorbid illnesses (P<.001). Intervention patients were also more likely to experience substantial response (at least a 50% reduction in depressive symptoms) regardless of the number of comorbidities, to experience improved MCS-12 scores at 3 and 12 months, and to experience improved QOL. CONCLUSIONS: The presence of multiple comorbid medical illnesses did not affect patient response to a multidisciplinary depression treatment program. The IMPACT collaborative care model was equally effective for depressed older adults with or without comorbid medical illnesses.     

Clinical outcome of ECT in patients with major depression and comorbid borderline personality disorder

OBJECTIVE: Previous research suggests that the comorbidity of major depression with a personality disorder, especially borderline personality disorder, is associated with a poorer response to ECT. The authors compared the acute outcome of ECT in depressed patients with borderline personality disorder, with personality disorders other than borderline personality disorder, and with no personality disorder. METHOD: The study subjects were 139 patients with a primary diagnosis of unipolar major depression and scores of at least 20 on the 24-item Hamilton Depression Rating Scale. Patients were treated with suprathreshold right unilateral or bilateral ECT in a standardized manner and were assessed with the Hamilton depression scale within 3 days and 4-8 days after completing ECT. RESULTS: Compared to patients with personality disorders other than borderline personality disorder (N=42) and those with no personality disorder (N=77), patients with borderline personality disorder (N=20) had less symptomatic improvement assessed up to 8 days after ECT. Patients with personality disorders other than borderline personality disorder responded as well to ECT as those with no personality disorder. Borderline personality disorder patients were more likely to be female and to have medication-resistant depression than the patients in the two comparison groups; they were also younger. However, none of these differences accounted for the borderline personality disorder patients' poorer response to ECT. CONCLUSIONS: Patients with borderline personality disorder have a poorer acute response to ECT, but explanations for this finding remain elusive.     

Somatization, depression and medical illness in psychiatric inpatients

In a study to determine the relationship between somatic symptoms and psychiatric diagnosis, 206 consecutively admitted inpatients at the University of Iowa Psychiatric hospital were given a structured medical history (MH) and physical examination (PE). Depressed patients were significantly older, had an increase in number of medical diagnoses (NDX), and were found to have a significant increase in somatic symptoms in which there was no confirmatory evidence on the PE and in which there was confirmation on the PE. When age, sex, and NDX were controlled for, depressed patients did not have an increase in either of the types of somatic symptoms noted above but did have a slight increase in the vague somatic symptoms in which PE findings would be unlikely. Our results suggest that the majority of the increases in somatic symptoms in depressed patients may not be due to depressive psychopathology but rather to their increased number of medical problems and increased age.     

Facilitating treatment of anxiety disorders in patients with comorbid medical illness

Anxiety is a universal human response that usually is adaptive, allowing one to prepare for a perceived threat. This can be a normal coping mechanism when dealing with a medical illness that may require hospitalization, surgery, or painful procedures. It becomes maladaptive when it is persistent and leads to panic attacks, severe physical symptoms, and impairment in functioning. Most of these patients are treated by primary care providers who frequently fail to adequately recognize and treat anxiety disorders in their patients. This leads to increased health care costs and chronic disability. To reach this under-served group of patients, mental health practitioners need to collaborate with their primary care colleagues to provide screening tools and education on diagnosis and effective treatment of these disorders.     

Factors associated with outcome in major depression: a 6-month prospective study

A number of authors have indicated in recent years that the course of depression is not as favourable as previously expected. Research conducted in order to identify predictors of recovery has shown widely different results. In this paper a sample of 90 consecutive patients with non-chronic major depressive disorders (index episode <6 months) attending four mental health centres in Madrid were followed up prospectively for 6 months, and clinical social and cognitive variables were studied. The patients were treated pharmacologically and controlled. The rate of recovery was measured according to the Hamilton Rating Scale for Depression (HAM-D). Other tools used were: Life Events and Chronic Difficulties, Global Assessment Functioning in the 6 months prior to the onset of episode, Brown Rating Scale for Self-Esteem and Mannheim Interview of Social Support. The results showed that 41 cases recovered (HAM-D score <8), 29 cases achieved a partial remission, and major depressive disorder persisted in 17 cases (HAM-D score ≥18). The presence of personality disorders, having suffered a previous episode, GAF score and some aspects of social support were the variables most associated with non full remission in the logistic regression analysis. Personality disorders and the initial HAM-D score were related to non-improvement. Some clinical and cognitive variables maintain a weak relation to outcome and are rejected in logistic regression. This study emphasizes the relationship of personality, and social variables such as social support and previous global functioning, with incomplete recovery in major depression. Accepted: 11 May 1998     

Neuroendocrine responses in psychiatric and pain patients with major depression

Basal and postdexamethasone concentrations of cortisol and prolactin were studied in three groups of male patients: chronic pain patients with no psychiatric diagnosis (n = 12), chronic pain patients with coexisting major depression by Research Diagnostic Criteria (RDC) (n = 24), and pain-free psychiatric patients meeting RDC criteria for major depression (n = 28). Basal cortisol concentrations were significantly higher in pain-major depression and psychiatric-major depression patients compared to pain patients without psychiatric illness. The frequency of cortisol nonsuppression after dexamethasone was significantly greater in pain patients with major depression (41.7%) compared to pain patients without psychiatric disorder (8.3%), and was comparable to that of psychiatric patients (21.4%). Prolactin concentrations, but not cortisol levels, were significantly correlated with observer-rated severity of depression in pain patients. These findings suggest that cortisol and prolactin abnormalities in chronic pain may be related to psychiatric disorder rather than to pain per se, at least in male patients, and may indicate a role for cholinergic mechanisms in the interface of pain and depression.     

Epidemiology and treatment of depression in patients with chronic medical illness

There is a bidirectional relationship between depression and chronic medical disorders. The adverse health risk behaviors and psychobiological changes associated with depression increase the risk for chronic medical disorders, and biological changes and complications associated with chronic medical disorders may precipitate depressive episodes. Comorbid depression is associated with increased medical symptom burden, functional impairment, medical costs, poor adherence to self-care regimens, and increased risk of morbidity and mortality in patients with chronic medical disorders. Depression may worsen the course of medical disorders because of its effect on proinflammatory factors, hypothalamic-pituitary axis, autonomic nervous system, and metabolic factors, in addition to being associated with a higher risk of obesity, sedentary lifestyle, smoking, and poor adherence to medical regimens. Both evidence-based psychotherapies and antidepressant medication are efficacious treatments for depression. Collaborative depression care has been shown to be an effective way to deliver these treatments to large primary care populations with depression and chronic medical illness.     

Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder

Zimmerman M, Martinez JH, Young D, Chelminski I, Dalrymple K. Sustained unemployment in psychiatric outpatients with bipolar depression compared to major depressive disorder with comorbid borderline personality disorder. Bipolar Disord 2012: 14: 856–862. © 2012 John Wiley & Sons A/S.Published by Blackwell Publishing Ltd. Objectives: The morbidity associated with bipolar disorder is, in part, responsible for repeated calls for improved detection and recognition. No such clinical commentary exists for improved detection of borderline personality disorder in depressed patients. Clinical experience suggests that borderline personality disorder is as disabling as bipolar disorder; however, no studies have directly compared the two disorders. For this reason we undertook the current analysis from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project comparing unemployment and disability rates in patients with bipolar disorder and borderline personality disorder. Methods: Patients were interviewed with semi‐structured interviews. We compared three non‐overlapping groups of depressed patients: (i) 181 patients with DSM–IV major depressive disorder and borderline personality disorder, (ii) 1068 patients with major depressive disorder without borderline personality disorder, and (iii) 84 patients with bipolar depression without borderline personality disorder. Results: Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder were significantly more likely to have been persistently unemployed. A similar difference was found between patients with bipolar depression and major depressive disorder without borderline personality disorder. No differences were found between patients with bipolar depression and depression with borderline personality disorder. Conclusions: Both bipolar disorder and borderline personality disorder were associated with impaired occupational functioning and thus carry a significant public health burden. Efforts to improve detection of borderline personality disorder in depressed patients might be as important as the recognition of bipolar disorder.     

The association of depression and anxiety with medical symptom burden in patients with chronic medical illness

BACKGROUND: Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses. METHODS: MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes. RESULTS: Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures. CONCLUSIONS: Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.     

Prevalence of depression in a 12-month consecutive sample of patients with ALS

There is an impression both in clinical practice and in research literature that patients with amyotrophic lateral sclerosis (ALS) possess 'heroic stoicism with a low frequency of depression'. Reliance on specific interview methods may have contributed to differing estimates of mood disorder in people with ALS. The objective of the current study was to compare prevalence rates of depression and anxiety in ALS using different assessment tools. The Beck Depression Inventory (BDI), The Hospital Anxiety and Depression Scale (HADS) and the Spielberger State-Trait Anxiety Inventory (STAI) were sent to a 12-month consecutive sample of 190 patients with ALS attending a tertiary referral clinic in the UK. Data were collected from 104 patients with ALS. Using BDI scores, 44% were categorized as not depressed, 37% were mild-moderately depressed, 13% were moderately-severely depressed, and 6% were severely depressed. In contrast, the HADS depression subscale identified 75% as not depressed, 13% were in the borderline range, and 13% were categorized as meeting 'caseness' for depression. Twenty-five percent of the patients were using antidepressant medication. The estimated prevalence of mood disorder amongst patients with ALS may vary significantly depending on the measure used.     

Citalopram treatment of social anxiety disorder with comorbid major depression

Treatment of patients with both social anxiety disorder and major depression has been little studied although social anxiety disorder and depression frequently co-occur. Each disorder has been shown to respond to serotonin reuptake inhibitor treatment. Objectives of this study were to characterize a sample of these comorbid patients and to assess response to treatment with citalopram. Patients with primary DSM-IV generalized subtype of social anxiety disorder and comorbid major depression (N = 21) were assessed for symptoms of each disorder, including atypical depressive features, and functional impairment. Patients were treated with a flexible dose of open label citalopram for 12 weeks. Response rates for the intention-to-treat sample at week 12 were 14/21 (66.7%) for social anxiety disorder and 16/21 (76.2%) for depression. All continuous measures of social anxiety, depression, and functional impairment improved significantly with treatment, but depression symptoms responded more rapidly and more completely than social anxiety symptoms. Mean dose of citalopram at study endpoint was 37.6 mg/day. Only three patients (14.3%) fulfilled DSM-IV criteria for atypical features of depression, although 18 (85.7%) fulfilled the criterion for interpersonal rejection sensitivity. Citalopram treatment may benefit patients with primary social anxiety disorder and comorbid major depression, and it should be further studied in controlled trials. Improvement in social anxiety disorder symptoms lagged behind improvement in depression, and greater than 12 weeks of treatment may be required to assess full social anxiety response in patients with comorbid depression. The overlap of social anxiety disorder with atypical features of depression may primarily be due to the shared feature of rejection sensitivity.     

Awareness of illness in patients with bipolar I disorder with or without comorbid anxiety disorders

BACKGROUND: The present study examined whether specific types of comorbid anxiety disorders, namely panic disorder (PD), social phobia (SP) and obsessive-compulsive disorder (OCD) are differentially associated with course variables and insight into bipolar illness. METHOD: The sample consisted of 151 consecutively hospitalized patients with bipolar I disorder. They were assessed in the week prior to discharge using the Structured Clinical Interview for DSM-III-R (SCID-P), the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning Scale (GAF) and the Hopkins Symptom Checklist (HSCL-90). Level of insight was assessed with the Scale to assess Unawareness of Mental Disorders (SUMD). RESULTS: Of the 151 bipolar subjects, 92 had no PD, SP and OCD comorbidity, 35 had PD and 24 had SP and/or OCD. The three groups differed significantly on the current awareness of illness and treatment response scores and the retrospective awareness of illness and treatment response scores. Post-hoc analyses revealed that, compared with bipolar patients without PD/SD/OCD and those with comorbid PD, patients with comorbid SP and/or OCD had better insight on current awareness of illness, current awareness of treatment response, retrospective awareness of illness and retrospective awareness of treatment response. The regression analysis showed that the presence of no panic type anxiety comorbidity was a predictor of good insight. CONCLUSIONS: These data indicate the value of identifying comorbid anxiety disorders in patients with bipolar illness. The results could be interpreted as evidence of discrete disorders within the bipolar spectrum, one that is characterized by, among other things, SP and/or OCD with good insight, another characterized by PD with poor insight.     

The association of suicide attempts and comorbid depression and substance abuse in psychiatric consultation patients

Substance abuse has been associated with attempted suicide and suicide. Few studies have examined the prevalence and associations of combined depression and substance abuse in suicide attempters. A chart review study of 1136 adult general hospital patients referred for psychiatric consultation between 1995 and 1998 was conducted to assess this further. Among 371 cases with self-harm, 311 (84%) attempted suicide. Suicide attempters were younger and diagnosed more often with comorbid substance abuse than patients without self-harm. Depressive disorders were found in 59% and substance abuse disorders in 46%. Comorbid depression and substance abuse was the most frequent category in suicide attempters, i.e., in 37%. Self-reported suicide intent was associated with increasing age, male gender, and comorbid depression and substance abuse. The suicide rate in suicide attempters was 322 per 100,000 patient-years, and 131 per 100,000 in consultation patients without self-harm. It is concluded that comorbid depression and substance abuse is associated with attempted suicide in psychiatric consultation patients. Suicide attempters should be thoroughly assessed for substance abuse. The increased suicide rate in psychiatric consultation patients with and without suicide attempts warrants further research.     

Psychotherapy of patients with serious intercurrent medical illness (cancer)

Exploratory psychotherapy of patients with chronic intercurrent illness has received little attention by psychoanalysts. A young woman with life-long characterologic problems presented herself for analytic psychotherapy shortly after surgery and radiotherapy for a malignancy. The debility of her illness facilitated a slowdown in an action-prone patient and permitted the necessary introspection and regression. willing One finds in these patients a readiness to reorder priorities and a willingness to examine and make the most of their lives, and psychotherapy can therefore become an opportunity for positive change rather than just support for a medical catastrophe. The therapy must address itself to childhood losses and betrayals symbolically repeated in the current medical state.