The Vital Link Between Chronic Disease and Depressive Disorders

The Vital Link Between Chronic Disease and Depressive Disorders Daniel P. Chapman Psychiatric Epidemiologist Emerging Investigations and Analytic Methods Branch Division of Adult and Community Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Mission of the NCCDPHP • To prevent death and disability from chronic diseases • To promote maternal, infant, and adolescent health • To promote healthy personal behaviors • To accomplish these goals in partnership with health and education agencies, major voluntary associations, the private sector, and other federal agencies Chronic diseases are becoming increasingly prevalent causes of morbidity and mortality in the world Change in the rank order of disease burden for 15 leading causes, World, 1990–2020 Source: Murray CJL, Lopez AD. Summary: The Global Burden of Disease, 1996. And, remember, in the absence of diagnosis and treatment, depressive disorders often assume a persistent course — becoming chronic diseases in their own right… Chronicity of Depression Probability of Recurrence 1 0.9 0.7 0.5 0.5 0 1 2 3 Number of Prior Episodes Source: National Institutes of Health Consensus Conference, 1992 Depressive Disorders Chronic Diseases HOW DO THEY INTERACT? Yet, a MEDLINE search for literature reviews of *chronic disease/ x *depression/ yielded only two articles… METHODS Conducted MEDLINE search of *mental disorders/ or *depression/ x the following diseases or conditions: *asthma/ *arthritis/ *cardiovascular disease/ *cancer/ *diabetes/ *obesity/ Selection Criterion for Chronic Diseases and Conditions • highly prevalent • major sources of morbidity and/or mortality • costly • of programmatic relevance to the work of the Centers for Disease Control and Prevention Selection Criteria for Studies Reviewed • empirical investigations • provided definitional or diagnostic criteria for depression, depressive symptoms, and relevant chronic disease or condition • specified interval of observation or time course ASTHMA Depressive Symptoms and Asthma 45% meeting screening criteria for depression Source: Mancuso et al., J Gen Intern Med, 2000 Disruptive Symptoms Increase Risk for Depression in Persons with Asthma • dyspnea • nighttime awaking Source: Goldney et al., Med J Australia, 2003 Rates of Psychopathology and Frequency of Asthma Attacks Psychopathology No Psychopathology Less Frequent Attacks More Frequent Attacks 87.5% 25% Source: Erharbor et al., J Natl Med Assoc, 2002 Asthma in Children and Adolescents • Associated with the presence of anxiety disorder in clinical samples • “Anxious depressive” symptoms reported among youth with moderate or severe asthma Asthma in Children and Adolescents … and mothers of children with asthma may be at risk for increased depressive symptomatology Sources: Ortega et al., J Nerv Ment Dis, 2002 ; Janson et al., Am J Respir Crit Care Med, 1994; Bartlett et al., Arch Pediatr Adolesc Med, 2001 Treatments for Depression Investigated Among Persons with Asthma • Cognitive-behavioral therapy • Physical activity Sources: Grover et al., J Assoc Physicians India, 2002; Hurwitz, Ann Epidemiol, 2003 Cognitive Behavioral Therapy (CBT) Among Persons with Asthma • Patient monitors automatic thoughts, identifies cognitive traps, and furnishes rational rebuttal • Example: “I forgot my inhaler! I’m so stupid – now I’m bound to have an attack!” CBT Among Persons with Asthma • Cognitive traps: all-or-none thinking, labeling, fortune telling. • Rational rebuttal: “I forgot my inhaler, so next time I’ll post a note to remind myself inside the front door. And I’ve gone several days without any problems…” • CBT has yielded significant reductions in both depressive and asthma symptoms ARTHRITIS Correlates with Depression Among Persons with Arthritis activity restriction • • • • disability functional status recurrence of arthritic symptoms severity of arthritic symptoms (doseresponse relationship with depression) Sources: Sotosky et al, Arthritis Care Res, 1992; Vali et al. Med Care, 1998 ; Husaini et al., Health Soc Work, 1990; Musil et al. Soc Sci Med, 2001; Taal et al., J Rheumatol 1997 Effects of Arthritis SelfManagement Program • positive effect on perceived self-efficacy • improved communication with physicians • lessened self-reported fatigue and pain • decreased depressive and anxiety symptoms Effects of Antidepressants and/or Psychotherapy in Persons with Arthritis Antidepressants and/or Psychotherapy Usual care * p<0.05 Self-Ratings after 12 Months 7 6.2* 6 5.6 5.0* 4.4 3.2* 5 4 3 2 1 0 Pain Sensitivity 2.9 ADL Interference from Arthritis ADL Interference from Pain Dimension Source: Lin et al., JAMA, 2003 Rheumatoid Arthritis and Depression • CBT reduces depressive symptoms, especially when initiated early in the course of RA • CBT most effective when tailored to particular concerns of patient with RA (pain, disability) • Antidepressant medication associated with significant improvements in both psychological and health status in persons with RA Source: Parker et al., Arthritis Rheum, 2003 Osteoarthritis (OA) and Depression • Tailored program of aerobic and/or resistance exercise is important in the treatment of OA • In particular, aerobic exercise can ameliorate depressive symptoms and reduce disability and pain • “What’s the worst thing you can do for arthritis? Nothing.” Sources: Clyman, Curr Rheumatol Rep, 2001; Penninx et al., J Gerontol B Psychol Sci Soc Sci, 2002 CARDIOVASCULAR DISEASE Depressive Disorders Associated with Factors for Cardiovascular Disease (CVD): • smoking • physical inactivity Source: Hayward, Epidem Rev, 1995 Increased Risk for Development of CVD in Persons with Depression 2 1.6 Relative Risk of 1 Developing CVD 1.0 0 Nondepressed (referent) Sources: Rugulies, Am J Prev Med, 2002; Wulsin et al., Psychosom Med, 2003 Depressed Depression and Cerebrovascular Accident (CVA): 2 1.9 Probability of CVA 1 within 10 yrs 1.0 0 No hx depression (referent) Source: Ohira et al., Stroke, 2001 Prior hx of depression Post-CVA Depression is Common— Especially When CVA Affects Left Hemisphere of the Brain Source: Narushima et al., J Neuropsychiatry Clin Neurosci, 2003 Percentage of Patients Experiencing CVA Reporting Significant Depressive Symptoms 54% Source: Berg et al., Stroke, 2003 Outcomes Associated with Post-CVA Depression • impaired response to rehabilitation • increased mortality Source: House et al., Stroke, 2001 Clinical Pearl: CVA and Depression • Antidepressant treatment of post-CVA depression is clearly warranted and has also been associated with recovery of cognitive function and significantly increased survival. The merits of “prophylactic” antidepressant use post-CVA may merit consideration. Source (first line): Jorge et al., Am J Psychiatry, 2003 Depression and Myocardial Infarction (MI) 5 4 Odds of MI 3 2 1 0 No history of major depression History of major depression Source: Pratt et al., Circulation, 1996 Consequences of Post-MI Depression • less likely to adhere to lifestyle and behavioral changes • may foster a “vicious cycle” Post-MI Rehabilitation Depression • cardiac rehabilitation improves depressive symptoms Sources: Ziegelstein et al., Arch Int Med, 2003; Milani et al., Am J Cardiol, 1998 CANCER Estimates of the prevalence of psychiatric disorders among persons with cancer vary widely – depending on the type and stage of cancer Source: Minagawa et al., Cancer, 1996 Prevalence of Psychiatric Disorders in Patients Newly Admitted to a Cancer Center Other psychiatric disorders 12% No psychiatric disorder 52% Adjustment disorder 33% Source: Derogatis et al., JAMA, 1983 Depression in Persons with Cancer • Approximately 20% of patients with ovarian cancer reported to be depressed • Depression in cancer patients crucial – Associated with desire for hastened death in terminally ill – Increased depressive symptoms inversely related to length of survival Sources: Bodurka-Bevers et al., Gynecol Oncol, 2000 ; Breitbart et al., JAMA, 2000 ; Meyer et al., Palliative Med, 2003 Cancer Treatment May Foster Symptoms Resembling Depression • Improved hemoglobin levels among patients with cancer undergoing chemotherapy associated with “lifting” of depressive symptoms • As nausea and fatigue are not uncommon among patients being treated for cancer, reliance on “somatic” symptoms may not accurately gauge depression Source (first line): Kallich et al., Oncology, 2002 Use of Antidepressants in Patients with Cancer is Growing 1979: 1% of all psychotropic prescriptions written for cancer patients were antidepressants 2003: Survey of prevalence of antidepressant use in community cancer care: breast cancer: 19.2% colon cancer: 11.0% lung cancer: 13.7% Sources: Derogatis et al., Cancer, 1979; Ashbury et al., Support Care Cancer, 2003 Depression Screening Program and Antidepressant Algorithm Adopted by Oncologists • significantly improved patient’s mood • enhanced self-reported quality of life Source: Passik et al., J Pain Symptom Manage, 2002 CBT in Patients with Cancer • Decreased depressive symptoms • Decreased pain • Significantly reduced patient distress about symptoms • Significantly associated with subsequent improvement in cellular immune function Sources: Greer et al., BMJ, 1992; Dalton et al., Pain Manag Nurse, 2004; McGregor et al., J Psychosom Res, 2004 An ounce of prevention… In addition to ameliorating depressive symptoms, physical activity may decrease the risk of CVD and colon, breast, and lung cancer… Source: Varo Cenarruzabeita, Med Clin (Barc) , 2003 SUMMARY • The presence of depressive symptoms may be an important risk factor in the etiology of chronic diseases, as well as adversely affecting their course and treatment • The assessment, management, and appropriate referral of patients with depression and other psychiatric disorders is an important aspect of the provision of primary medical care A FINAL THOUGHT …and please always remember (and don’t ever forget!), in the absence of effective diagnosis and treatment, depression can become a chronic disease in its own right!