Here I’ve annotated only the most pertinent section of a long online “book” you can find at the link above.
Treatment and Management
A fifth of people with a chronic physical health problem (such as cancer, diabetes, heart disease and stroke) have depression – a rate that is two to three times higher than in those who are in good physical health.
A combination of depression and a chronic physical health problem can significantly worsen the negative outcomes for people with both conditions.
The guideline reviews the evidence for the identification of depression in people with a chronic physical health problem and the associated service-level interventions (such as stepped care and collaborative care) and psychosocial, psychological and pharmacological interventions.
It has a useful introduction to depression in adults with a chronic physical health problem and a chapter on service user, carer and staff experience of care.
In this guideline, particular attention is paid to the following as chronic physical health problems: cancer, heart disease, musculoskeletal disorders, respiratory disorders, neurological disorders and diabetes.
However, it must be appreciated that people with any chronic physical health problem have higher rates of depression and anxiety than physically healthy controls – depression is approximately two to three times more common in people with a chronic physical health problem than in people who are in good physical health.
But it must also be emphasised that the majority of those with a chronic physical health problem do not have depressive or anxiety disorders (depression occurs in about 20% of those with a chronic physical health problem).
2.2. DEPRESSION IN ADULTS WITH A CHRONIC PHYSICAL HEALTH PROBLEM
2.2.1. Depressive disorders
The identification of major depression is based not only on its severity but also on persistence, the presence of other symptoms and the degree of functional and social impairment. However there appears no hard-and-fast ‘cut-off’ between ‘clinically significant’ and ‘normal’ degrees of depression; the greater the severity of depression the greater the morbidity and adverse consequences
Behavioural and physical symptoms often include tearfulness, irritability, social withdrawal, reduced sleep, an exacerbation of pre-existing pains, pains secondary to increased muscle tension and other pains (Gerber et al., 1992), lowered appetite (sometimes leading to significant weight loss), a lack of libido, fatigue and diminished activity, although agitation is common and marked anxiety frequent.
Along with a loss of interest and enjoyment in everyday life, feelings of guilt, worthlessness and deserved punishment are common, as are lowered self-esteem, loss of confidence, feelings of helplessness, suicidal ideation and attempts at self-harm or suicide. Cognitive changes include poor concentration and reduced attention, pessimistic and recurrently negative thoughts about oneself, one’s past and the future, mental slowing and rumination
2.2.2. Presentations of depression in adults with a chronic physical health problem
People with depression and a chronic physical health problem are especially common in primary and general hospital care. But only a minority of patients attending primary care mention psychological problems as their presenting complaint.
2.2.3. Impairment and disability
Mental disorders account for as much of the total disability in the general population as physical disorders (Ormel et al., 1995), and there is a clear dose–response relationship between illness severity and the extent of disability (Ormel et al., 1995).
Depression and disability show synchrony of change (Ormel et al., 1993) and onsets of depression are associated with onsets of disability, with an approximate doubling of both social and occupational disability (Ormel et al., 1999).
When both depression and physical health problems are present, disability is likely to be correspondingly greater.
An important distinction is that between social disability, which has a linear relationship with the number of depressive symptoms, and any functional disability due to physical health problems (for example, impaired mobility because of arthritis, or limitation of movements because of stroke). It is likely that such functional impairments or disabilities greatly increase the risk of depression among those with a chronic physical health problem.
2.2.4. Suicide risk in people with a chronic physical health problem
Large population-based epidemiological studies have reported higher suicide risk linked with various major physical health problems including cancer (Allebeck et al., 1989), diabetes (Tsang, 2004), end-stage renal disease (Kurella et al., 2005), epilepsy (Christensen et al., 2007), multiple sclerosis (Brønnum-Hansen et al., 2005), stroke (Teasdale & Engberg, 2001a) and traumatic brain injury (Teasdale & Engberg, 2001b).
These findings indicate the importance of detecting and treating depression in people with a chronic physical health problem.
2.2.5. Diagnosis of depression in people with a chronic physical health problem
Although the advent of operational diagnostic criteria has improved the reliability of diagnosis, this does not circumvent the fundamental problem of attempting to classify a disorder that is heterogeneous and best considered on a number of dimensions.
This is further complicated in patients with a chronic physical health problem because somatic criteria such as fatigue, appetite disturbance and sleep disturbance may be sequelae of physical health problems rather than depression. Zimmerman and colleagues (2006) have suggested a simplified method of diagnosis using five non-somatic criteria as a response to the problems of overlapping symptoms.
The GDG considered it important to acknowledge the uncertainty inherent in our current understanding of depression and its classification, and that assuming a false categorical certainty is likely to be unhelpful and, even worst, damaging.
An important motivation has been to provide a strong steer away from only using symptom counting to make the diagnosis of depression and, by extension, to emphasise that symptom severity rating scales should not be used by themselves to make the diagnosis, although they can be an aid in assessing severity and response to treatment.
It is important to emphasise that making a diagnosis of depression does not automatically imply a specific treatment. A diagnosis is a starting point in considering the most appropriate way of helping that individual in their particular circumstances.
To make a diagnosis of a depression requires assessment of three linked but separate factors, (a) severity, (b) duration and (c) course, with four severity groupings:
- subthreshold depressive symptoms: fewer than five symptoms of depression
- mild depression: few, if any, symptoms in excess of the five required to make the diagnosis, and symptoms result in only minor functional impairment
- moderate depression: symptoms or functional impairment are between ‘mild’ and ‘severe’
- severe depression: most symptoms, and the symptoms markedly interfere with functioning; can occur with or without psychotic symptoms.
However, diagnosis using the three factors listed above (severity, duration, course) only provides a partial description of the individual experience of depression. People with depression vary in the pattern of symptoms they experience, their family history, personalities, premorbid difficulties (for example, sexual abuse), psychological mind-edness and current relational and social problems – all of which may significantly affect outcomes
It is also common for depressed people to have a comorbid psychiatric diagnosis, such as anxiety, social phobia, panic and various personality disorders (Brown et al., 2001), and physical comorbidity (the specific concern of this guideline). Gender and socioeconomic factors account for large variations in the population rates of depression
2.2.6. Incidence and prevalence
Egede (2007) studied the 1-year prevalence of depression in 10,500 patients with chronic disease with 19,460 age-matched healthy controls in the US and found that as a group they were almost three times more likely to be depressed
Patients with comorbid depression and anxiety disorders – who by definition have a greater number of symptoms than either depression or anxiety disorders on their own – have a stronger relationship with chronic physical health problems than people with either depression or anxiety (Scott et al., 2007).
2.3. THE RECIPROCAL RELATIONSHIP BETWEEN DEPRESSION AND CHRONIC PHYSICAL HEALTH PROBLEMS
Not only can chronic physical health problems both cause and exacerbate depression, but the reverse also occurs with depression antedating the onset of physical health problems that go on to become chronic. In a model of the relationship between major depression and chronic physical health problems, Katon (2003) points out a number of ways that major depression and physical health problems interact with one another.
Moreover, the functional impairment associated with physical illness, as well as indirect pathophysiological factors (for example, increased cytokine levels or other inflammatory factors) may increase the risk of developing and worsening depression. These interactions between mental and physical health disorders will be discussed in further detail below.
2.3.1. Chronic physical health problems causing depression
Two population-based prospective cohort studies found that physical illness was a risk factor for the later development of depression.
The risk was similar for a wide range of physical health problems, namely hypertension, asthma, arthritis and rheumatism, back pain, diabetes, heart disease and chronic bronchitis. In a Dutch cohort study of 4,664 participants who had never had depressive disorder, the presence of two out of three illnesses (migraine, respiratory problems or abdominal problems) predicted the later development of depressive disorder
There are at least three distinct ways in which a chronic physical health problem causes depression.
First, the number of different pains a person experiences is directly proportional to the prevalence of depression: Dworkin and colleagues (1990) showed that primary care patients with a single pain had no increased risk of depression, those with two pains had double the risk, but those with three or more had five times the risk. Pain, in turn, causes emotional distress and poor sleep irrespective of whether pain has a known cause (Von Korff & Simon, 1996).
Second, chronic physical health problems carry the risk of disability and this can be very depressing for a person who has previously been healthy
Third, there are physical changes in some diseases that may underlie the development of depression, such as changes in the allostatic load. Allostasis refers to the ability of the body to adapt to stressful conditions. It is a dynamic, adaptive process.
Tissue damage, degenerative disease (like arthritis) and life stress all increase allostatic load and can induce inflammatory changes which produce substances such as bradykinin, prostaglandins, cytokines and chemokines. These substances mediate tissue repair and healing, but also act as irritants that result in peripheral sensitisation of sensory neurons, which in turn activate central pain pathways (Rittner et al., 2003).
2.3.2. Depression causing chronic physical health problems
A depressive illness can also precede a new episode of a physical health problem. Systematic reviews of 11 prospective cohort studies in healthy populations show that depression predicts later development of coronary heart disease in all of them
It has been hypothesised that increases in proinflammatory cytokines in depression and increased adrenocortical reactivity may also lead to atherosclerosis, and with it increased risk for both stroke and coronary artery disease (Wichers & Maes, 2002). In the latter, autonomic changes in depression may also cause electrocardiogram (ECG) changes, which favour the development of coronary disease
Another suggested way in which depression may increase the likelihood of a person developing a physical disease is by the immune changes that occur during depression:
- changes in immune cell classes with an increase in white cell counts and a relative increase in neutrophils,
- increases in measures of immune activation, and
- a suppression of mitogen-induced lymphocyte proliferation with a reduction in natural killer cells (Irwin, 1999)
2.4. CONSEQUENCES OF DEPRESSION IN ADULTS WITH A CHRONIC PHYSICAL HEALTH PROBLEM
Prince and colleagues (2007) argue that there is consistent evidence for depression affecting the outcome of coronary heart disease, stroke and diabetes.
2.4.1. Effects on length of survival
Depression may lead to a shorter life expectancy (Evans et al., 2005), and therefore treatment might be expected to prolong life
DiMatteo and colleagues (2000), in a metaanalysis of factors related to non-compliance, found that depressed patients were three times more likely to be non-compliant with treatment recommendations than non-depressed patients, suggesting that there may be real advantages to treating depression among the physically ill.
(See also: Severe Chronic Pain is a Killer, Literally)
2.4.2. Effects on quality of life
s the severity of depression increases, the subjective quality of life decreases. One of the reasons for persevering with active treatment for depression is that even if the outlook for survival is not improved, the quality of survival may be greatly enhanced
2.4.3. Advantages of treating depression in adults with a chronic physical health problem
Effects on disease management of the chronic physical health problem
While randomised trials on the treatment of depression often report beneficial effects on outcome measures of depression, they often fail to show much effect on heart disease (Berkmann et al., 2003; Glassman et al., 2002) or diabetes (Katon et al., 2006; Williams et al., 2004).
More recently, trials of collaborative care for depression (which has its origins in the management of chronic disease) have focused on people with depression and a chronic physical health problem (for example, Katon et al., 2004). However, Gilbody and colleagues (2008a) conclude on the basis of a meta-analysis that depression can be treated effectively by collaborative care, but there does not appear to be consistent evidence that such treatment improves physical outcomes.
Effects on quality of life and related measures
Treatment for depression does have other beneficial effects on outcomes other than measures of depression. Simon and colleagues (2005) showed improvements in social and emotional functioning, and disability,
Based on studies in this area, von Korff and colleagues (2009) argue that the weight of the evidence suggests that, in addition to reducing depressive symptoms, the treatment of depression is effective in reducing functional disability.
Treatment for depression, as one might expect, is associated with a smaller beneficial effect for severe pain (Kroenke et al., 2008; Mavandadi et al., 2007; Thielke et al., 2007).
This last statement essentially admits that severe pain isn’t helped much by treatment for the associated depression that’s likely to occur.