In the primary care setting, depression is the most commonly seen psychiatric diagnosis, with a symptom rate of 12% to 36% in association with another, nonpsychiatric, general medical condition.1 It is easy to see that this is several times the rate reported for the overall community sample of 4%* or the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-P/) gender breakdown of 2.3% to 3.2% for men and 4.5% to 9.3% for women.2 In terms of added health costs, an HMO study contrasted mean annual costs for primary care patients with and without depression.3 For those with depression, it was $4246, and for those without depression, it was $2371 (P<.0001). Presence of depression has been found, when untreated, to lead to overutilization of medical visits, unnecessary tests, use of unneeded pharmacotherapy, and increased hospital stays.
For these reasons, it is crucial to look at the unique etiologic and treatment factors for treatment of patients with combined medical illness and depression. The topics selected for this review recently formed part of the symposia on "Medical Illness and Depression" at the 1996 meetings of the American Psychiatric Association in New York and of the World Psychiatric Association in Madrid, Spain. These include neurologic illnesses, cardiovascular conditions, diabetes mellitus, cancer, chronic fatigue syndrome, and HF/.
In the first article, Dr. Maldonado and colleagues4 review the rates of depression and the special considerations involved in treating the patient with depression in the background of biochemical disorders, eg, Parkinson's disease, or structural problems, eg, following a cerebrovascular accident. Depending on the etiology of the disorder, one might choose an agent to treat both disorders, eg, bupropion or deprenyl with dopamine activity in Parkinson's disease. In contrast, a selective serotonin reuptake inhibitor (SSRI) might be more appropriate for depression after a stroke because of ease of administration.
Dr. Shapiro and colleagues5 from the Columbia Group review the current status of the use of antidepressants. This is an area of change in philosophy of approach with much current activity. Perhaps 5 to 10 years ago, Imipramine as a IC antiarrhythmic was thought to be a possibly ideal treatment for a patient with both depression and arrhythmias. Ever since the CAST study found that IC anti-arrhythmics worsened morbidity and mortality after a myocardial infarction, Imipramine has fallen into disfavor. More focus has now been placed on medications such as bupropion, sertraline, and paroxetine.
Although all classes of antidepressants will show some overall efficacy, a situation can occasionally arise in which the medical illness may dictate a particular choice. This situation may be seen in the treatment of diabetes mellitus with depression, which I review.6 It appears that an increase in norepinephrine function increases insulin resistance. Thus, results appear to indicate that noradrenergic tricyclic antidepressants, eg, nortriptyline, are successful in ameliorating depression but worsen measures of glucose utilization. In contrast, improved serotonergic function has been shown to reduce insulin resistance. The SSRIs, particularly sertraline, may be indicated for the treatment of patients with both diabetes mellitus and depression.
Cancer, in all its various forms, has been frequently associated with depression. Although there may be a tendency to view this depression as a psychological consequence of life-threatening disease, studies have shown that, biologically, major depression findings are similar in depression with cancer versus depression without cancer. Dr. McDaniel and associates7 review findings on making a diagnosis of depression in a patient with cancer and discuss the most recent information on pharmacotherapy and psychosocial therapy for these patients. The relative need for higher doses of antidepressants combined with reduced tolerability is considered.
A controversial area is whether chronic fatigue syndrome truly exists or is simply a form of depression. In our discussion of this disorder, Dr. Jorge and I8 differentiate this disorder from major depression in terms of epidemiology, pathophysiology, clinical findings, and biology, showing major similarities and differences. Directions for laboratory testing that may separate these two conditions as a future standard is indicated. A review of currently considered medications is provided, with a look to future possibilities.
The last of the presentations, from Dr. McDaniel's group,9 looks at the complicated matter of treatment of depression in the human immunodeficiency virus (HlV)-infected patient. Prevalence rates, the problem of overlap of symptoms of HIV infection with those of depression, and research problems in study design that influence reported results in this field are discussed. Drug interactions and general health considerations are also reviewed, as are psychotherapy suggestions to maximize benefits.
Effective and safe treatment in these days of managed care requires optimization of both diagnosis and therapy at the earliest possible moment. We hope that this series of articles will enable the clinician to increase the accuracy of diagnosis in these often-confusing scenarios and to improve the efficacy of the first choice of treatment.
1. Depression in Primary Care. Rockville, Md: Public Health Service, USDHHS; 1993.
2. Diagnostic and Statistical Manual. 4th ed. Washington, DC: American Psychiatric Press Ine; 1994.
3. Simon GE, VonKorff M, Barlow W. Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry. 1995; 52:850-856.
4. Maldonado JL, Fernandez F, Garza-lrevino ES, Levy JK. Depression and its treatment in neurological disease. Psychiatric Annals. 1997; 27:341-346.
5. Shapiro PA, Lidagoster L, Glassman AH. Depression and heart disease. Psychiatric Annals. 1997; 27:347-352.
6. Goodnick PJ. Diabetes mellitus and depression. Psychiatric Annals. 1997; 27:353-359.
7. McDaniel JS, Musselman DL, Nemeroff CB. Cancer and depression: theory and treatment. Psychiatric Annals. 1997; 27:360-364.
8. Jorge CM, Goodnick PJ. Chronic fatigue syndrome and depression: biological differentiation and treatment. Psychiatric Annals. 1997; 27:365-371.
9. Stober DR, Schwartz JA, McDaniel S, Abrams RF. Depression and HIV disease: prevalence, correlates, and treatment. Psychiatric Annals, 1997; 27:372-377.