Prevalence of Depression–PTSD Comorbidity: Implications for Clinical Practice Guidelines and Primary Care-based Interventions

BACKGROUND Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. OBJECTIVE To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). DESIGN Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. PARTICIPANTS Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. MEASUREMENTS The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen ≥ 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. RESULTS Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. CONCLUSIONS PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.     

Clinical Interventions for Late-Life Anxious Depression

Anxiety symptoms are frequently present in patients with late-life depression. The designation “anxious depression” has been used to describe major depressive disorder (MDD) accompanied by clinically significant but subsyndromal anxiety symptoms. MDD may also present comorbid with diagnosable anxiety disorders, although this presentation is less common in late life. Diagnosis of anxious depression in the elderly is complicated by several factors (eg, their tendency to experience and report psychiatric symptoms as somatic illness) and is associated with a more severe clinical presentation, increased risk for suicidal ideation, increased disability, and poorer prognosis. Standard pharmacotherapy for depression may be sufficient but for many patients must be modified or augmented. Psychosocial interventions may also be an important component in the treatment of these patients, although no specific psychosocial treatments have been developed for late-life anxious depression.     

Depression in nursing home residents.

Although their extent remains unclear, major and minor depressions are widespread in the nursing home population. This statement appears intuitively to be correct when consideration is given to the inactivity, decline in functional competence, loss of personal autonomy, and unavoidable confrontation with the process of death and dying that are associated with nursing home placement. In addition, some nursing home residents have had previous episodes of depression or are admitted to the facility already dysthymic or with other chronic forms of the illness. Such circumstances provide a favorable culture for the development and persistence of depressive illness. When the high frequency of other psychiatric disorders among nursing home residents is factored in, it is not surprising that long-term health care facilities have come to be regarded as de facto psychiatric hospitals. Nursing homes largely lack the treatment resources of psychiatric hospitals, however. Nursing home physicians are often unprepared to make psychiatric diagnoses, and a perfunctory annual psychiatric evaluation is insufficient to manage the complex depression syndromes of nursing home residents. Because nursing home psychiatrists typically work on a consultation basis, recommendations are not necessarily acted upon by the primary physicians. The consequences of undiagnosed and untreated depression are substantial. From the psychiatric perspective, the possibility that depression increases the risk for eventual development of permanent dementia highlights the importance of early identification for cases of reversible dementia. From the rehabilitation point of view, persistent depression among individuals with physical dependency following a catastrophic illness is associated with failure to improve in physical functioning. Depression can probably be linked to increased medical morbidity in nursing home residents, a relationship that also has been suggested for elderly medical inpatients. If so, the use of nursing time and other health-care facility services would be greater for depressed than nondepressed residents, and financial costs would be higher as well. Finally, recent data point to increased mortality in nursing home residents with major depressive disorder. It is apparent that depression in long-term care facilities is a condition with doubtful prognosis and negative medical, social, and financial consequences. The highest costs of all may be paid by nursing home residents who experience the unrelieved suffering of depressive illness. Only epidemiologic research using standard diagnostic criteria and direct resident assessment will adequately establish the magnitude of the need for intervention among depressed residents in long-term care.(ABSTRACT TRUNCATED AT 400 WORDS)     

Diagnosis and care of patients with anorexia nervosa in primary care settings

Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. In caring for patients with anorexia nervosa, the primary care physician has several critical roles. Because patients deny the severity of their illness, they delay seeking psychiatric treatment. The primary care physician must be skilled in recognizing this disorder, as well as in diagnosing and effectively treating the medical complications while educating the patient about them. The primary care physician is also involved with arranging and coordinating a comprehensive and multidisciplinary program, including dietary and mental health treatment. The multidisciplinary team is responsible for ensuring safe weight restoration and a judicious refeeding treatment plan. In addition to establishing the diagnosis and treating the multiple medical complications associated with anorexia nervosa, the primary care physician plays a central role in maintaining continuity of care despite the fact that successful care may require a variety of treatment settings. Factors that foster good prognoses for this increasingly common and often protracted eating disorder include early diagnosis and skilled medical intervention to prevent the inexorable physical decline that marked weight loss can cause.     

Efficacy of newer medications for treating depression in primary care patients

PURPOSE: Several medications have recently been introduced for the treatment of depression. We reviewed the literature to summarize their efficacy in the treatment of depression in adult patients in primary care settings. METHODS: We searched the literature published from 1980 to January 1998 using the Cochrane Collaboration Depression Anxiety and Neurosis Group's specialized registry of 8,451 clinical trials, references from trials and 46 pertinent meta-analyses, and consultation with experts. We included randomized controlled trials of at least 6 weeks' duration that measured clinical outcomes and compared one of 32 newer medications with another newer antidepressant, an older antidepressant, a placebo, or a psychosocial intervention for the treatment of depressed patients in primary care settings. The primary outcome was response rate, defined as the proportion of patients experiencing a 50% or greater improvement in depressive symptoms. RESULTS: There were 28 randomized controlled trials involving 5,940 adult primary care patients with major depression, depression requiring treatment, dysthymia, or mixed anxiety depression. Newer agents, including selective serotonin re-uptake inhibitors, serotonin norepinephrine inhibitors, reversible inhibitors of monoamine oxidase, and dopamine antagonists, were usually compared with tricyclic agents. Average response rates were 63% for newer agents, 35% for placebo, and 60% for tricyclic agents. Newer agents were significantly more effective than placebo [risk ratio = 1.6; 95% confidence interval (CI), 1.2 to 2.1), but similar to tricyclic agents (risk ratio = 1.0; 95% CI, 0.9 to 1.1). Response rates were similar in the different types of depressive disorders, except that two small trials in frail older patients showed no significant effects of newer agents compared with placebo. Dropout rates as a result of adverse effects were 8% with newer agents and 13% with tricyclic agents (P <0.05). CONCLUSIONS: In primary care settings, newer antidepressants are more effective than placebo and have similar efficacy compared with tricyclic agents in the acute treatment of depression. Dropout rates as a result of adverse effects are lower with newer compared with tricyclic agents. Future studies should compare the effectiveness of different therapies among primary care patients with less severe depression and greater medical and psychiatric comorbidity.     

Utilization of Primary Care by Veterans with Psychiatric Illness in the National Department of Veterans Affairs Health Care System

BACKGROUND

Psychiatric illness is associated with increased medical morbidity and mortality. Studies of primary care utilization by patients with psychiatric disorders have been limited by nonrepresentative samples and confounding by medical co-morbidity.

OBJECTIVE

To determine whether patients with psychiatric disorders use primary care services differently than patients without these disorders, after controlling for medical co-morbidity.

DESIGN

Data from the 1999 Large Health Survey of Veterans (LHS) ( = 559,985) were linked to VA administrative data in order to identify veterans who received primary care. After adjusting for sociodemographic and clinical characteristics, medical co-morbidity, and facility characteristics, multivariate logistic regression was used to evaluate whether seven psychiatric diagnoses were associated with an increased or decreased likelihood of any primary care visit over 12 months.

RESULTS

Veterans with either schizophrenia, bipolar disorder or a drug use disorder were less likely to have had any primary care visit during the study period: [OR 0.61, 95% CI 0.59 to 0.63], [OR 0.63, 95% CI 0.60 to 0.67] and [OR 0.88, 95% CI 0.83 to 0.92], respectively, than veterans without these diagnoses, even after controlling for medical co-morbidity. Among patients with any primary care utilization, those with six of the seven psychiatric diagnoses had fewer visits in the study period.

CONCLUSIONS

Patients with schizophrenia, bipolar disorder or drug use disorders use less primary care than patients without these disorders. Interventions are needed to increase engagement in primary care by these vulnerable groups.Key Words: primary care, psychiatric illness, Axis I psychiatric disorders, Veterans Affairs Health Care System     

Depression in elderly hospitalized patients with medical illness

Depressive symptoms and disorders were identified by structured psychiatric interview in 130 consecutively admitted male inpatients aged 70 years and over. Major depression was found in 11.5% and other depressive syndromes in 23%. While depressive symptoms and syndromes are common among the medically ill, this study demonstrated the need for careful diagnostic assessment of older patients with depressive symptoms before initiating treatment that may itself convey significant risk. Sociodemographic and health characteristics of older men at higher risk for depression were also identified. Patients more likely to be depressed were over age 75 years, had less formal education, experienced cognitive dysfunction, suffered from more severe medical illness (particularly recent myocardial infarction), and had a history of psychiatric illness. Depressive symptoms were also common among patients with renal or neurologic diseases, those having a family history of psychiatric illness, the unmarried, and the more severely disabled. Given the impact of depression on recovery from medical illness, compliance with medical therapy, and costs of extended hospital stays, detection and treatment of this disorder are imperative.     

Subsyndromal (“Mixed”) anxiety-depression in primary care

Objective: To determine in primary care settings the prevalence, clinical characteristics, and functional status of patients who have anxious and depressive symptoms who did not meet diagnostic criteria for major mood and anxiety diagnoses. Design: Patients were screened with the General Health Questionnaire and interviewed if they exceeded the cutoff score of 5. Also, one patient whose score was below the cutoff was interviewed for every two patients whose scores were above the cutoff. Setting: Five primary care sites in the United States, France, and Australia. Patient: Two hundred sixty-seven patients presenting to their primary care physicians for general medical care and follow-up. Methods: Structured diagnostic interviews were conducted and ratings of anxiety, depression, and functional impairment were obtained by trained interviewers. Results: After adjustments for sampling, 5% of the patients had symptoms of anxiety, depression, and functional impairment, without meeting formal criteria for a major DSM-III-R mood or anxiety disorder. This was comparable to the prevalence of diagnosable DSM-III-R mood disorders but only one-fourth the prevalence of diagnosable anxiety disorders. These patients who had subsyndromal symptoms had rates of lifetime psychiatric disorders and prior psychiatric treatment comparable to those of patients meeting criteria for major mood and anxiety disorders. Conclusion: The comparable rates of symptomatic distress, functional impairment, and prior psychiatric illness and treatment suggest that patients with subsyndromal anxiety and depressive symptoms warrant clinical recognition and possibly specific treatment. Supported in part by a grant from the American Psychiatric Association.     

Perfusion deficits,inflammation and aging precipitate depressive behaviour

Major depressive disorder (MDD) is a severe psychiatric illness that is associated with significant morbidity and mortality. Despite advances in the treatment of major depression, one-third of depressed patients fail to respond to conventional antidepressant medication. One pathophysiologic mechanism hypothesized to contribute to treatment resistance in depression is inflammation. Inflammation has been linked to depression by a number of putative mechanisms involving perfusion deficits that can trigger microglial activation and subsequent neuroinflammation in the elderly. However, the pathophysiological mechanisms remain to be further elucidated. This review focusses on recent studies addressing the complex relationships between depression, aging, inflammation and perfusion deficits in the elderly. We expect that a better understanding of neuroinflammatory mechanisms associated with age-related diseases may lead to the discovery of new biomarkers of MDD and development of new therapeutic interventions.     

Problems and strategies in the treatment of mental disorders in elderly patients with physical illness

There is a high prevalence of mental disorders in the community population of older adults, especially in medical treatment facilities. Therefore, clinicians who treat geriatric patients cannot neglect the psychiatric vulnerability of the elderly population. The fragility of psychological functioning of the elderly is caused not only by psychological contributors, such as various kinds of experiences of loss, but also by biological factors such as decreases in neurotransmitters and in the number of neurons. Another point geriatric clinicians should pay attention to is the powerful mind-body connection in the elderly. Recent psychoneuroimmunological research demonstrates that depression or other types of emotional stress damages the immune system, which can induce some physical diseases. This is especially true for the elderly, who have weakened cell-mediated immune function and are more susceptible to influence by the damaged immune function caused by such psychiatric dysfunction. Also, depression in the elderly can often lead to malnutrition or dehydration, which can induce various kinds of physical illness. On the other hand, physical illness in the elderly can induce depression, because of the psychological vulnerability of the elderly. Due to the strong mind-body connection in the elderly, the availability of psychiatric care is essential. When providing psychiatric care for the elderly, the clinician should attend to all symptoms, not minimizing the importance of biological treatment, while also trying to support the elderly patients psychologically through acceptance of their need for interdependency and respect for their narcissism.     

Psychiatric illness and the irritable bowel syndrome. Practical implications for the primary physician.

Twenty-nine consecutive outpatients with irritable bowel syndrome were given structured psychiatric interviews, as were 33 consecutive medical controls who did not have irritable bowel syndrome. All were from an internal medicine group practice. Seventy-two percent of irritable bowel syndrome subjects had psychiatric illness, with hysteria and depression the most prevalent syndromes. Only 18% of controls had psychiatric illness. The primary physician made an accurate psychiatric assessment in only 28% of the subjects. An awareness of his patient's psychiatric illness is necessary for the physician to provide effective treatment, as for depression, and to spare the patient needless medications, hospitalizations, and surgery, as with hysteria.     

Psychiatric management of the hepatitis C patient

Opinion statement Patients with hepatitis C virus (HCV) infection have a higher prevalence of psychiatric illness compared with the general US population, and the prevalence of HCV infection in patients with severe mental illness ranges between 8% and 19%, which is four to nine times that of the general US population (1.8%). Given the association between HCV infection and psychiatric illness, gastroenterologists are on the front line of identifying comorbid psychiatric and substance use disorders and conducting a psychosocial pretreatment risk-benefit assessment for HCV infection. The use of interferon-α (IFN)-based therapies in combination with ribavirin (RBV) to eradicate HCV has been associated with frequent neuropsychiatric adverse effects (eg, affective, anxiety, cognitive, and psychotic symptoms) that compromise the management of both HCV patients with and those without a preexisting history of psychiatric illness. Consequently, gastroenterologists have been reluctant to engage patients with HCV and comorbid psychiatric illness in antiviral treatment due to concerns about exacerbating or precipitating neuropsychiatric symptoms. Despite the clinical challenge that HCV treatment of patients with comorbid HCV and psychiatric illness presents, recent research indicates that HCV treatments can be safely administered to patients with psychiatric illness provided that there is a comprehensive pretreatment assessment, a risk-benefit analysis, and ongoing follow-up of neuropsychiatric symptoms during antiviral therapy. The process of pretreatment assessment involves screening patients for psychiatric and substance use disorders, educating patients about the treatment process, and addressing available psychosocial support. Most psychotropic medications (antidepressants, mood stabilizers, antipsychotics, and neuroleptics) are thought to be safe to use in the management of patients with HCV and psychiatric illness and for the management of IFN- and RBV-induced neuropsychiatric adverse effects. Nonetheless, the prophylactic use of psychotropic medications to prevent IFN- and RBV-induced neuropsychiatric adverse effects remains a controversial topic. The use of IFN and RBV in patients with HCV and severe mental illness can be done safely with expert psychiatric follow-up. In this review, we discuss the process of pretreatment assessment of patients with HCV and psychiatric illness and specifically address IFN- and RBV-induced depression in patients receiving HCV treatment.     

Comorbid psychiatric disorders in elderly medical patients: a 1-year prospective study

Cross-sectional studies have revealed a high prevalence of comorbid psychological problems among geriatric medical patients, a low rate of detection by primary care professionals, and greater psychosocial dysfunction and poorer physical health associated with comorbidity. Less is known about the course and impact of psychiatric comorbidity. Psychiatric status, physical health status, psychosocial functioning, and health care utilization for a sample of geriatric patients (n = 102) were assessed on admission to a medical hospital and again one year later. Results revealed a very stable and high prevalence of comorbid psychological problems, especially depression, a low rate of treatment by mental health professionals, greater physical impairment consistently associated with psychiatric comorbidity, but few health care utilization differences. A closer look at depression revealed that it typically began in late life and did not readily resolve.     

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

BACKGROUND: Depression and anxiety are common in medical patients and are associated with diminished health status and increased health care utilization. This article presents a quantitative review and synthesis of studies correlating medical patients' treatment noncompliance with their anxiety and depression. METHODS: Research on patient adherence catalogued on MEDLINE and PsychLit from January 1, 1968, through March 31, 1998, was examined, and studies were included in this review if they measured patient compliance and depression or anxiety (with n>10); involved a medical regimen recommended by a nonpsychiatrist physician to a patient not being treated for anxiety, depression, or a psychiatric illness; and measured the relationship between patient compliance and patient anxiety and/or depression (or provided data to calculate it). RESULTS: Twelve articles about depression and 13 about anxiety met the inclusion criteria. The associations between anxiety and noncompliance were variable, and their averages were small and nonsignificant. The relationship between depression and noncompliance, however, was substantial and significant, with an odds ratio of 3.03 (95% confidence interval, 1.96-4.89). CONCLUSIONS: Compared with nondepressed patients, the odds are 3 times greater that depressed patients will be noncompliant with medical treatment recommendations. Recommendations for future research include attention to causal inferences and exploration of mechanisms to explain the effects. Evidence of strong covariation of depression and medical noncompliance suggests the importance of recognizing depression as a risk factor for poor outcomes among patients who might not be adhering to medical advice.     

Neighborhood health center patients who use minor tranquilizers.

Thirty-four ambulatory medical patients who had used minor tranquilizers for varying lengths of time were interviewed to determine their medical and psychiatric statuses, and to learn their own perspective of their medical care. The population was elderly of lower socioeconomic status, and chronically ill (a significant minority with serious and disabling illness). Depressive equivalents, depression, and anxiety were prominent, but clinical states requiring psychiatric care were not. Slightly less than one-half were alcoholic. Forty-one percent took the medications for target symptoms other than anxiety, and 76% believed these agents were efficacious. Chronic users had significantly more chronic medical illness, and significantly more somatization, anxiety, and fatigue.     

Six-month outcomes for medical patients with major depressive disorders

The courses of depressive disorders and factors affecting recovery rates among patients treated in primary medical care facilities have rarely been studied. The authors investigated the clinical status of 274 patients initially and six months after they sought care at one of three primary care sites. Through use of the highly structured Diagnostic Interview Schedule, they found that physicians assigned a depressive diagnosis to only a fourth of the patients so assessed by the structured interview. Nevertheless, the rates of persisting major depressive disorders at follow-up were found to be very similar for patients whom both the structured interview and the physician initially considered depressed and those so diagnosed by structured interview but not by the physician (25% and 31%, respectively). An analysis of factors associated with course of illness suggests that psychiatric status at the initial assessment and the number of assigned medical diagnoses rather than the physician’s recognition and treatment of depression strongly predict continued affective disorder. Received from the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Supported by NIMH Grant MH35352.     

The prevalence and impact of alcohol problems in major depression: a systematic review

Major depression and alcohol problems are common in primary care, yet little is known about the prevalence of alcohol problems in patients with depression or alcohol's effect on depression outcomes. We strove to answer the following questions: How common are alcohol problems in patients with depression? Does alcohol affect the course of depression, response to antidepressant therapy, risk of suicide/death, social functioning and health care utilization? In which alcohol categories and treatment settings have patients with depression and alcohol problems been evaluated? English language studies from MEDLINE, PsychINFO, and Cochrane Controlled Trial Registry were reviewed. Studies were selected using predefined criteria if they reported on the prevalence or effects of alcohol problems in depression. Thirty-five studies met criteria and revealed a median prevalence of current or lifetime alcohol problems in depression of 16% (range 5-67%) and 30% (range 10-60%), respectively. This compares with 7% for current and 16-24% for lifetime alcohol problems in the general population. There is evidence that antidepressants improve depression outcomes in persons with alcohol dependence. Alcohol problems are associated with worse outcomes with respect to depression course, suicide/death risk, social functioning, and health care utilization. The majority of the studies, 34 of 35 (97%), evaluated alcohol abuse and dependence, and 25 of 35 (71%) were conducted in psychiatric inpatients. We conclude that alcohol problems are more common in depression than in the general population, are associated with adverse clinical and health care utilization outcomes, and that antidepressants can be effective in the presence of alcohol dependence. In addition, the literature focuses almost exclusively on patients with alcohol abuse or dependence in psychiatric inpatient settings, and excludes patients with less severe alcohol problems and primary care outpatient settings.     

Effectiveness of liaison psychiatric nursing in older medical inpatients with depression: a randomised controlled trial

OBJECTIVE: To compare liaison psychiatric nursing with usual medical care in the management of older medical inpatients who screen positive for depression. DESIGN: Pragmatic randomised controlled trial. SETTING: Medical wards of UK district general hospital in rural East Anglia. PARTICIPANTS: One hundred and thirty-eight medical inpatients aged 65+ screened positive on the 15-item geriatric depression scale (GDS). One hundred and twenty-one out of 138 screen positives entered the trial (58/121 fulfilled criteria for depressive disorder at baseline). INTERVENTIONS: (i) A liaison psychiatric nurse assessed participants, formulated a care plan for treatment of their depression, ensured its implementation through liaison with appropriate agencies, and monitored participants' mood and response to treatment for up to 12 weeks. (ii) Usual treatment by hospital and primary care staff. MAIN OUTCOME MEASURES: ICD-10 depressive disorder, change in GDS-15 score, quality-adjusted life weeks (QALWs) and patient satisfaction rating. RESULTS: Eighty-six out of 121 participants completed the 16-week trial. Participants in the intervention group were more satisfied with their care, but no significant differences in depressive disorder, depression rating or QALWs gained were found between groups. However, there was a trend towards improvement in the intervention group and effect sizes were higher in the subgroup with depressive disorder. CONCLUSIONS: This study is the first RCT to evaluate liaison psychiatric nursing specifically for depression in older medical inpatients; the findings suggest improvement in mental health and quality of life, but a larger trial is required to provide convincing evidence.     

Care for depression in HMO patients aged 65 and older

OBJECTIVE: To examine treatment for depression among older adults in a large staff model health maintenance organization (HMO). DESIGN: A 4-year prospective cohort study (1989-1993). SETTING: Four primary care clinics of a large staff model HMO in Seattle, Washington. PATIENTS: A total of 2558 Medicare enrollees aged 65 and older. MAIN OUTCOME MEASURES: Treatment of depression was defined as primary care visits resulting in depression diagnoses, use of antidepressant medications, or specialty mental health services. MAIN RESULTS: The older adults in our sample had low rates of treatment for depression, ranging from 4 to 7% in the entire sample and from 12 to 25% among those with probable depressive disorders. Predictors of treatment included female gender, severity, and persistence of depressive symptoms, and severity of comorbid medical illness. Even when patients were treated for depression, the intensity of treatment was very low. Overall likelihood of treatment for depression increased somewhat from 1989 to 1993, but among those treated, the rate of adequate antidepressant use remained below 30%. CONCLUSIONS: There is still considerable need to improve care for older adults with depression in primary care.