Treatment of depression in the medically Ill
Depression and ischemic heart disease (IHD) are the two most prevalent health problems afflicting patients not only in the United States but worldwide (1). The lifetime prevalence of major depressive disorder in the general population of the United States has been found to be 16.2% (2). The prevalence of depression in medically ill patients is much higher, ranging 20-50%. Depression is a major contributor to work place absenteeism, diminished or lost productivity, and increased use of health services (3). It is also known to increase disability, morbidity, and mortality among the medically ill. Because of the high prevalence of depression and its risk for the wellbeing and prognosis of the medically ill, treating depression becomes an extremely important issue (1-3). Even though depression with medical comorbidity is the norm, rather than the exception, most studies on treatment methods in depressive patients have included primarily individuals in good physical health and have excluded those with comorbid medical illness. Recognizing the medical and socioeconomic significance of late-life depression, a multicenter randomized trial (the Improving Mood-Promoting Access to Collaborative Treatment study) began examining the benefits of integrating depression intervention into the primary care for elderly patients (4). In the study, patients were randomly assigned to the Improving Mood-Promoting Access to Collaborative Treatment intervention (n = 906) or to usual care (n = 895). Improving Mood-Promoting Access to Collaborative Treatment patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert. The care manager offered education, care management, and support of antidepressant management by the patients primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care. At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants. This suggests that effective treatment of depression is possible in the context of a primary care setting, i.e., probably those with comorbid medical conditions. Kurzthaler et al. have suggested that selective serotonin reuptake inhibitors (SSRIs) are effective and reasonably safe in elderly depressive patients with comorbid physical illness, based on a small open-label study using multiple SSRIs (5). He noted, however, that adverse effects were more common than what has been observed in younger and physically healthy patients. We evaluated the effect of the SSRI sertraline with respect to treatment response in patients with major depression and comorbid vascular disease (6). Patients were retrospectively categorized into 1 of 3 clinical groups: (1) individuals with a current diagnosis of hypertension but no cardiovascular illness (HTN), (2) individuals with a current or past history of cardiovascular illness other than hypertension (VASC), and (3) individuals with no hypertension or comorbid vascular illness (NoVASC). Response was defined as much or very much improved on the Clinical Global Improvement scale. At study end point, sertraline treatment yielded similar levels of response in all three groups on a complete analysis (HTN, 86%; VASC, 89%; NoVASC, 77%), although the level of response at 12 weeks was higher in those VASC patients than in the other two groups. Sertraline treatment was well tolerated, with no between-group differences in rates of adverse events or in discontinuation caused by adverse events. This study essentially reaffirmed the opinion of Kurzthaler et al., that antidepressants are effective for depression in primary care setting (5). However, it is of critical importance to understand the impact of treating depression in patients who present with specific medical illness. This article briefly reviews depression treatments with reference to diabetes, stroke, cardiovascular disease, and neurological disorders. © 2011 Springer Science+Business Media, LLC.
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