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      Epidemiology and treatment of depression in patients with chronic medical illness Translated title: Epidemiología y tratamiento de la depresión en pacientes con una enfermedad médica crónica Translated title: Épidémiologie et traitement de la dépression chez les patients ayant une pathologie chronique

      , MD *

      Dialogues in Clinical Neuroscience

      Les Laboratoires Servier

      depression, chronic medical illness, diabetes, heart disease

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          Abstract

          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.

          Translated abstract

          Hay una relación bidireccional entre la depresión y los trastornos médicos crónicos. Las conductas de riesgo adversas para la salud y los cambios psicobiológicos asociados con la depresión aumentan el riesgo de trastornos médicos crónicos, y los cambios biológicos y las complicaciones asociadas con los trastornos médicos crónicos pueden precipitar episodios depresivos. La depresión comórbida está asociada con un aumento de las repercusiones de los síntomas médicos, del deterioro funcional, de los costos médicos, de una pobre adherencia a los regímenes de auto-cuidado, y un mayor riesgo de morbilidad y mortal idad en los pacientes con trastornos médicos crónicos. La depresión puede empeorar la evolución de los trastornos médicos debido a su efecto sobre los factores proinflamatorios, en el eje hipotálamo-hipofisiario, en el sistema nervioso autónomo y sobre los factores metabólicos, además de estar asociada con un mayor riesgo de obesidad, de un estilo de vida sedentario, de tabaquismo y de una pobre adherencia a los tratamientos médicos. Tanto las psicoterapias basadas en la evidencia como los fármacos antidepresivos son tratamientos eficaces para la depresión. Los modelos de atención en salud de tipo colaborativo aplicados a la depresión han demostrado ser una forma efectiva para entregar estos tratamientos a grandes poblaciones de pacientes en atención primaria con depresión y enfermedades médicas crónicas.

          Translated abstract

          La dépression et les pathologies chroniques sont liées à double titre. Les comportements à risque délétères pour la santé et les modifications psychobiologiques associés à la dépression augmentent le risque de pathologies chroniques, tandis que les complications et modifications biologiques associées aux pathologies chroniques peuvent précipiter des épisodes dépressifs. La dépression, chez les patients présentant des pathologies chroniques, est associée à une augmentation de la charge symptomatique, à une détérioration fonctionnelle, à des coûts médicaux, à une mauvaise observance de l'autosurveillance et à une augmentation du risque de morbidité et de mortalité.. Elle peut aggraver le cours des maladies à cause de ses effets sur les facteurs pro-inflammatoires, sur l'axe hypothalamohypophysaire, sur le système nerveux autonome et sur les facteurs métaboliques, avec en plus un risque majoré d'obésité, de vie sédentaire, de tabagisme et de mauvaise observance des traitements médicaux. Les psychothérapies validées et les antidépresseurs sont deux approches utiles pour traiter la dépression. La prise en charge de la dépression de manière collaborative est efficace pour soigner un grand nombre de patients traités en soins primaires atteints de dépression comorbide de pathologies chroniques.

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          Most cited references 128

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          The functioning and well-being of depressed patients. Results from the Medical Outcomes Study.

          We describe the functioning and well-being of patients with depression, relative to patients with chronic medical conditions or no chronic conditions. Data are from 11,242 outpatients in three health care provision systems in three US sites. Patients with either current depressive disorder or depressive symptoms in the absence of disorder tended to have worse physical, social, and role functioning, worse perceived current health, and greater bodily pain than did patients with no chronic conditions. The poor functioning uniquely associated with depressive symptoms, with or without depressive disorder, was comparable with or worse than that uniquely associated with eight major chronic medical conditions. For example, the unique association of days in bed with depressive symptoms was significantly greater than the comparable association with hypertension, diabetes, and arthritis. Depression and chronic medical conditions had unique and additive effects on patient functioning.
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            Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial.

            Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment. To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI. Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention. Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks. Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months. Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients). The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.
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              Relationship of depression and diabetes self-care, medication adherence, and preventive care.

              We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. This predominantly type 2 diabetic population had a mean HbA(1c) level of 7.8 +/- 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA(1c) tests was 2.2 +/- 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m(2), and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 +/- 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients. In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.
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                Author and article information

                Contributors
                Professor and Vice-Chair, Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
                Journal
                Dialogues Clin Neurosci
                Dialogues Clin Neurosci
                Dialogues in Clinical Neuroscience
                Les Laboratoires Servier (France )
                1294-8322
                1958-5969
                March 2011
                : 13
                : 1
                : 7-23
                Affiliations
                Professor and Vice-Chair, Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
                Author notes
                [* ] To whom correspondence should be addressed. E-mail: wkaton@ 123456u.wash ington.edu
                Article
                3181964
                21485743
                Copyright: © 2011 LLS

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Neurosciences

                depression, heart disease, chronic medical illness, diabetes

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