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Depression and Chronic Medical Illness

Depression and Chronic Medical Illness. Jurgen Unutzer, MD, MPH, MA Professor and Vice Chair of Psychiatry University of Washington CHP Behavioral Health Conference May 16, 2008. Disclosure. No conflicts of interest Grant funding for the research presented from

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Depression and Chronic Medical Illness

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  1. Depression and Chronic Medical Illness Jurgen Unutzer, MD, MPH, MA Professor and Vice Chair of Psychiatry University of Washington CHP Behavioral Health Conference May 16, 2008

  2. Disclosure • No conflicts of interest • Grant funding for the research presented from • John A. Hartford Foundation • California HealthCare Foundation • Robert Wood Johnson Foundation • Hogg Foundation • American Federation for Aging Research • NIH • Consultant for National Council for Community Behavioral Health Care (NCCBH)

  3. Acknowledgements • Wayne Katon, MD – UW • Mark Sullivan, MD – UW • Paul Ciechanowski, MD - UW • Elizabeth Lin, MD - GHC

  4. Depression and Chronic Medical Illness • High rates of depression in the medically ill • Depression amplifies physical symptoms associated with medical illness • Depression worsens functional impairment • Depression decreases adherence toprescribed regimens • Depression is associated with adverse health behaviors (diet, exercise, smoking) • Depression increases health care costs & mortality

  5. Major Depression Common: 5-10 % in primary care Pervasive depressed mood / sadness Loss of interest/ pleasure …. plus lack of energy, fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), thoughts of guilt, irritability and thoughts of suicide If untreated, depression can last for years. Often complicated by chronic medical disorders, chronic pain, anxiety, cognitive impairment, grief/ bereavement, substance abuse

  6. Prevalence Of Major Depression Percent of Population Katon and Sullivan. J Clin Psychiatry. 1989;51(suppl 6):3.

  7. Major Depression Prevalence • Heart disease 15 to 23% • Diabetes 11 to 12% • Chronic obstructive pulmonary disease (COPD) 10 to 20% Katon W et al. Biol Psychiatry, 2003

  8. Depression Prevalence in Neurological Illnesses Lifetime prevalence • Parkinson’s disease: 40-50% • Huntington’s disease: 40%. Depression may antedate chorea by years • Multiple sclerosis: 10-50% • Alzheimer’s disease: 15-55% • CVAs: 30-50% Katon W et al. Biol Psychiatry, 2003

  9. Impact Of Depression In Chronic Medical Illness Morbidity And Mortality Economic Impact Treatment Implications Maladaptive Effects

  10. Depression is expensive:Annual Health Costs in 1995 $ $ Chronic disease score Unützer et al, JAMA, 1997

  11. Higher Health Care costs in Patients With Diabetes and Depression Health Care Costs ($) Mild depression Moderate depression Severe depression Ciechanowski et al. 2000 Arch Intern Med 2000 160(21):3278-3285.

  12. Impact Of Depression In Chronic Medical Illness Morbidity And Mortality Economic Impact Treatment Implications Maladaptive Effects

  13. Depression takes a large toll on quality of life QALYs Quality Adjusted Life Years (QALYs) ‘lost’ in population of 2,558 older adults over 4 years. Adjusted for age, gender, and comorbid medical conditions. Unützer et al, Intl Psychogeriatrics, 2000

  14. Maladaptive Effects of Depression on Chronic Medical Illness • Amplification of somatic symptoms (especially pain) • Increased adverse health behaviors (obesity, smoking, sedentary lifestyle) • Decreased self-care and adherence to medical regimens • Direct maladaptive physiologic effects • Modulated by autonomic nervous system, hypothalamus, and immunologic effects Katon W. Gen Hosp Psychiatry. 1996;18(4):215-219.

  15. Relationship of Major Depression to Diabetes Symptoms – Odds Ratios 1.93 Cold hands and feet 1.98 Numbness in hands and feet 2.23 Pain in hands and feet 2.24 Polyuria 2.66 Excessive hunger 3.30 Abnormal thirst 3.53 Shakiness 3.42 Blurred vision 4.00 Feeling faint 4.96 Daytime sleepiness 0 1 2 3 4 5 6 Ludman et al. Gen Hosp Psychiatry, 2004

  16. Pain DepressionBidirectional Relationship

  17. Treatment of Depression Improves Pain Outcomes in Patients With Arthritisand Depression Lin et al. JAMA, 2003

  18. Depression/Anxiety and Quality Of Life In Patients With CAD Baseline depression/anxiety is a better predictor of decreased quality of life over a 1-year period than the number of coronary vessels with >50% occlusion. Sullivan et al. Am J Med. 2007.

  19. Depression Decreases Adherenceto Medical Regimens by • Adversely influencing expectations and benefits about efficacy of treatment • Increasing withdrawal and social isolation • Reducing cognitive (executive) functioningand memory • Influencing dietary choices and reducing energy to exercise and follow self-management regimens (ie, checking blood glucose) DiMatteo MR, et al. Arch Intern Med. 2000;160(14):2101-2107.

  20. Depression Decreases Medication Adherence in Patients With Diabetes Nonadherent Days (%) Oral Hypoglycemic Lipid LoweringMeds ACE Inhibitors Lin E et al., Diabetes Care, 2004

  21. Depression Adversely Impacts Self-Management of Chronic Medical Illness • Depressed patients with MI are more likely to drop out of exercise programs1 • Smokers with history of depression are 40% less likely to succeed in quitting smoking over a 9-year period compared to nondepressed smokers2 • Patients with major depression and coronary artery disease are less likely to adhere to low-dose aspirin therapy than nondepressed controls3 • Patients with history of depression compared to nondepressed are more likely to develop depression with smoking cessation4 1. Blumenthal JA, et al. Psychosom Med. 1982;44(6):529-536. 2. Anda RF, et al. JAMA. 1990;264(12):1541-1545. 3. Carney RM, et al. Health Psychol. 1995;14(1):88-90.4. Dierker L, Am J. Psychaitry159:947-953, 2002

  22. Depression Is Associated With an Increased Percent of Smoking p<0.001; Major>None p<0.01; Minor>None N=4225 Adjusted for demographics, medical comorbidity, diabetes severity,diabetes type and duration, treatment type,HbA1c and clinic. Katon et al, Diabetes Care, 2004

  23. Depression is associated with increased smoking in CVD patients • Independently associated with a rapid relapse to smoking after discharge for CVD • Lower rates of smoking cessation at long-term follow-up • Thorndike AN, et al; Arch Intern Medicine 2008

  24. Depression is Associated with an increased BMI >30 kg/m2 by p<.001; Major>None p<.01; Minor>NoneN=4225 Depression Group Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment type,HbA1c and clinic Katon et al, Diabetes Care, 2004

  25. Depression Is Associated With Higher Percentage with HbA1c > 8% p<.001; Major>None p<.01; Minor>None N=4225 Adjusted for demographics, medical comorbidity, diabetes severity, diabetes type and duration, treatment typeand clinic. Katon et al, Diabetes Care, 2004

  26. Depression Is Associated With a Higher Number of Cardiac Risk Factors > 3 Cardiac Risk Factors (%) Diabetic Patients With CVD N=3010 Diabetic Patients Without CVD N=1215 Katon et al, J Gen Intern Med, 2004

  27. Impact Of Depression In Chronic Medical Illness Morbidity And Mortality Economic Impact Treatment Implications Maladaptive Effects

  28. Depression Is Associated With Increased Diabetes Complications • Meta-analysis of 27 studies showed a significant association between depression and a range of diabetes complications. DeGroot et al, Psychosom Med, 2001

  29. Depression: Effect on Risk of Diabetic Complications • Incidence of coronary artery disease was 3 times as common over a 10-year period in diabetics who were initially depressed vs nondepressed1 • In a prospective study of children with type 1 diabetes, the risk of development of retinopathy was associated with duration of diabetes, time spent in poor glucose control, and time spent in major depression2 1. Carney et al. 1994. Psychosom Med 2. Kovacs et al. 1997. Diabetes Care

  30. Depression is Deadly * * * * * * * RR 2,558 older adults from 4 primary care clinics. Mean age = 71. Odds ratios for mortality over 7-year followo-up. Adjusted for demographics and comorbid disorders. * P<0.05. Unutzer, et al; Am J Geriatric Psychiatry 2002.

  31. Depression Increases Mortality Rate in Patients With Diabetes by 2-Fold Katon et al. Diabetes Care, 2005

  32. Depression Associated With Increased Mortality Post-Myocardial Infarction Cox model hazard ratio for 6-month mortality associated with depression: 5.74 (95% CI: 4.61-6.87)p=.0006 % Mortality Time after MI (months) Frasure-Smith N, et al. JAMA. 1993;270:1819-1825.

  33. Depression kills …- Older men have the highest rate of suicide.- Depression & pain are among the most ‘modifiable’ risk factors.

  34. Impact Of Depression In Chronic Medical Illness Morbidity And Mortality Economic Impact Treatment Implications Maladaptive Effects

  35. Cancer Chronic tinnitus COPD Diabetes Inpatient rehabilitation needs Ischemic heart disease Parkinson’s disease Rheumatoid arthritis Stroke HIV+ Antidepressant Treatment Trials In Patients With Chronic Medical IllnessMajor depression is responsive to antidepressant treatment in patients with: Katon and Sullivan. J Clin Psychiatry. 1990;51(suppl 6):3.

  36. Improved Depression Care in Diabetes: More depression-free days over 2 years 412 359 331 216 +116 days +53 days Sources: Katon et al. Arch Gen Psych 2007; Katon et al., Diabetes Care 2006

  37. Better depression care lowers health care costs over 2 years. $22,258 $21,148 $18,932 $18,035 -$1,110 -$897 Sources: Simon et al., Arch Gen Psych 2007; Katon et al., Diabetes Care 2006

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