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.     

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.     

Anxiety disorders and comorbid depression in community dwelling older adults

Anxiety disorder is a common psychiatric problem during late‐life, and frequently co‐occurs with depression. High comorbidity between anxiety and depression may partly be explained by the definition of the disorders and the assessment of both disorders with one instrument at the same time. The current study investigates the relation of current and past depression with anxiety disorders in the Rotterdam Study, a large population‐based cohort study of older adults in the Netherlands (n study population = 5565). DSM‐IV anxiety disorder was ascertained with the Munich version of the Composite International Diagnostic Interview. DSM‐IV depression was diagnosed with the Schedules for Clinical Assessment of Neuropsychiatry (SCAN) on a different day. Past depression was assessed from general practitioners' records, self‐report, and a prior SCAN interview. Of the 457 persons with an anxiety disorder, 11.6% had a comorbid major depression, and another 6.3% had other depressive syndromes. However, 49.3% of persons with an anxiety disorder experienced or had in the past experienced a depressive episode. Our study suggests that comorbid depression in older adults with anxiety disorders may be less prevalent than previously suggested. However, the relation of current anxiety disorders with past depression is substantial. Copyright © 2011 John Wiley & Sons, Ltd.     

12-month outcome of patients with major depression and comorbid psychiatric or medical illness (compound depression)

OBJECTIVE: Inpatients with major depressive illness often have coexistent nonaffective psychiatric and/or medical conditions. The authors' objective is to address the following questions: 1) What is the effect of comorbid illness on the severity of major depression and associated psychosocial factors? 2) How does the course of depression differ for patients with and without concurrent illness? 3) Do patients with compound depression differ in rate of recovery and time to recovery from patients with pure depression? METHOD: The subjects were 78 patients with a DSM-III diagnosis of major depression who were consecutively admitted to an acute care university-affiliated psychiatric hospital; 37 of these patients had major depression only and 41 had major depression compounded by a coexisting axis I, II, or III condition. The patients were studied while hospitalized and for 12 months after hospital discharge. Instruments used included the Modified Hamilton Rating Scale for Depression, the Global Assessment Scale, and the Social Readjustment Rating Scale. RESULTS: Patients with compound depression reported significantly poorer functioning over the 12-month follow-up period and had lower recovery rates than the patients with pure depression. There were no differences in recovery rates between men and women with compound depression, but significantly more men than women with pure depression recovered. CONCLUSIONS: Compound depression is a common clinical occurrence, the course of illness is more difficult for patients with compound depression than for patients with pure depression, and the recovery rate of patients with compound depression is lower than that of patients with pure depression.     

Anxiety disorders and comorbid medical illness

OBJECTIVE: To provide an overview of the role of anxiety disorders in medical illness. METHOD: The Anxiety Disorders Association of America held a multidisciplinary conference from which conference leaders and speakers reviewed presentations and discussions, considered literature on prevalence, comorbidity, etiology and treatment, and made recommendations for research. Irritable bowel syndrome (IBS), asthma, cardiovascular disease (CVD), cancer and chronic pain were reviewed. RESULTS: A substantial literature supports clinically important associations between psychiatric illness and chronic medical conditions. Most research focuses on depression, finding that depression can adversely affect self-care and increase the risk of incident medical illness, complications and mortality. Anxiety disorders are less well studied, but robust epidemiological and clinical evidence shows that anxiety disorders play an equally important role. Biological theories of the interactions between anxiety and IBS, CVD and chronic pain are presented. Available data suggest that anxiety disorders in medically ill patients should not be ignored and could be considered conjointly with depression when developing strategies for screening and intervention, particularly in primary care. CONCLUSIONS: Emerging data offer a strong argument for the role of anxiety in medical illness and suggest that anxiety disorders rival depression in terms of risk, comorbidity and outcome. Research programs designed to advance our understanding of the impact of anxiety disorders on medical illness are needed to develop evidence-based approaches to improving patient care.     

Improving care for depression in patients with comorbid substance misuse

OBJECTIVE: The authors investigated whether quality improvement programs for depression would be effective among substance misusers and whether there would be a differential program-by-comorbidity effect. METHOD: A group-level randomized controlled trial (Partners in Care) compared two quality improvement programs for depression with usual care. Consecutive patients (N=27,332) from six managed care organizations in five states were screened, and 1,356 were enrolled: 443 received usual care while the rest entered a quality improvement program involving either medication (N=424) or therapy (N=489). Multiple logistic regression was used to test hypotheses and compute standardized predictions of the adjusted rates of depression and use of psychotherapy and antidepressants. RESULTS: Under usual care conditions, depressed patients with substance misuse had an increased probability of ongoing depression despite higher rates of overall appropriate treatment. Among clients with comorbid substance misuse, the quality improvement programs were associated with improved depression outcomes at 12 months and increased antidepressant use at 6 months. Among clients with no substance misuse, the quality improvement programs improved depression outcomes at 6 months and were associated with increased treatment utilization. CONCLUSIONS: Co-occurring substance misuse is associated with depression and with increased risk for poorer depression treatment outcomes under usual care conditions. Quality improvement programs can significantly reduce the likelihood of probable depressive disorders in depressed patients with and without comorbid substance misuse. No consistent evidence was found for a differential program-by-comorbidity effect except for a suggestion of greater increase in psychotherapy among individuals with no substance misuse.     

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.     

Pretreatment cortisol levels predict posttreatment outcomes among older adults with depression in cognitive behavioral therapy

Previous studies suggest that individuals with elevated levels of cortisol (the “stress hormone”) could be particularly resistant to treatment for depression. However, most of these studies have been conducted in the context of antidepressant medications, and no study has examined pretreatment cortisol levels as a predictor of treatment outcomes among older adults with depression in cognitive-behavioral therapy (CBT), despite the relevance of this population for such a research question. The current study includes 54 older adults with depression who provided salivary cortisol samples at baseline and completed measures of depression at pretreatment and posttreatment, following a 12-week course of CBT. Structural equation modeling results suggest that those with higher daily outputs of cortisol and flatter diurnal slopes were less likely to benefit from CBT—a finding which if replicated could have important implications for clinical practice and future research.     

Apathy and cognitive performance in older adults with depression

OBJECTIVES: Recent studies have linked apathy to frontal lobe dysfunction in persons with dementia, but few studies have explored this relationship in older, depressed persons without dementia. We examined the association between apathy and cognitive function in a group of older persons with major depression using standardized neuropsychological tests. We hypothesized that presence of apathy in depression is associated with poorer frontal executive performance. METHODS: We analyzed data from 89 older adults with major depression. We defined apathy using four items from the Hamilton Psychiatric Rating Scale for Depression which reflect the clinical state of apathy, including 'diminished work/interest,' 'psychomotor retardation,' 'anergy' and 'lack of insight.' RESULTS: Apathy most strongly correlated with two verbal executive measures (Stroop C and FAS), a nonverbal executive measure (Wisconsin Card Sorting Test-Other Responses), and a measure of information processing speed (Stroop B). Apathy was not associated with age, sex, education, medical illness burden, Mini-Mental State Examination score and Full Scale IQ score. Stepwise regression analyses of significant cognitive tests showed that apathy alone or apathy plus depression severity, age, or education accounted for a significant amount of the variance. CONCLUSIONS: The results of this study provide support for an apathy syndrome associated with poorer executive function in older adults with major depression.     

The Treatment Initiation Program: an intervention to improve depression outcomes in older adults

OBJECTIVE: This pilot study tests the usefulness of the Treatment Initiation Program (TIP) to improve depression in older adults. The TIP is an individualized, early intervention to address older adults' attitudes (e.g., perceived need for care and stigma) about depression and treatment. METHOD: Older adults with major depression seeking mental health treatment were randomly assigned to either pharmacotherapy alone or with the TIP. Severity was assessed with the Hamilton Depression Rating Scale at admission and at 6, 12, and 24 weeks. Mixed-effects models were calculated to evaluate the effects of the TIP. RESULTS: In mixed-effects models, TIP patients had a greater decrease in depression severity and reported less hopelessness than the patients receiving usual care. TIP patients were more likely to remain in treatment 12 and 24 weeks after seeking care. CONCLUSIONS: These data support the usefulness of the TIP to improve depression outcomes and treatment participation among older adults.     

Cost implications of depression in older adults

The economic effects of mental disorder on individuals and their families and on society have received little scientific attention. Late life depression imposes substantial disability and it affects all spheres of function. Therefore, the development of rational health policy regarding this disorder requires prospective evaluation of related costs and the determination of the value of proposed interventions. A vigorous review and analysis of the existing literature provides a framework for synthesis of an aggressive research agenda which emphasizes four major areas: (1) Improved diagnostic rigour; (2) Integration of economic and epidemiologic methods; (3) Microscopic studies of individual and family costs; (4) Interventional benefit/cost analysis.     

Psychiatric comorbidity and depression in older adults

Late-life depression rarely occurs in isolation. Thus, screening for and assessment of late-life depression should always involve screening for other psychiatric disorders, including anxiety, personality disorders, and alcohol misuse. Comorbidity often makes treatment to relieve depressive symptoms more complicated, more comprehensive, and longer. Current late-life depression research indicates the strongest support for antidepressant medication and/or cognitive-behavioral therapy for comorbid anxiety, antidepressants and dialectical behavior therapy for comorbid personality disorders, and antidepressants and counseling for alcohol abuse that incorporates specific coping skills training for mood management, based on cognitive-behavioral principles. The clinician should provide sufficient psychoeducation for the older client and involve the client in treatment planning and progress evaluation. Very little research has specifically focused on treating depression and psychiatric comorbidity simultaneously, so additional research in this area is needed.