Optimizing Outcomes for Patients with Depression and Chronic Medical Illnesses

https://doi.org/10.1016/j.amjmed.2008.09.012Get rights and content

Abstract

Depression and comorbid chronic medical conditions such as coronary heart disease, diabetes mellitus, and osteoarthritis are frequently seen in the primary care setting, and the interaction of these illnesses can complicate diagnostic and treatment efforts. Although the etiologies of these bidirectional associations are not well understood, a number of negative outcomes are apparent, and challenges exist at patient, provider, and healthcare system levels to better recognize and treat depression in patients with chronic medical comorbidity. Such patients are more likely to present with somatic complaints, engage in unhealthy behaviors, harbor unhealthy thoughts or cognitions, and are less likely to comply with therapeutic recommendations. Primary care encounters often represent the only opportunities for these patients to address these issues and obtain the professional attention their depression requires. For clinicians, forging empathetic partnerships with patients, prescribing appropriate treatments, and closely monitoring symptoms and therapeutic progress are invaluable for optimal management of both affective and medical disorders. Further opportunities to improve care also exist at the healthcare system level, such as developing, funding, and implementing multimodal collaborative care models in the primary care setting.

Section snippets

Patient-level treatment issues

Although the risk of depression is higher for patients with all types of chronic medical conditions, the reasons for this association are not clear. The chronic nature of both depression and medical conditions strains the patient's sense of self, self-confidence, and social relationships. Depressed mood makes it difficult to be optimistic about the future and adherence to treatments for medical and affective conditions may be difficult and burdensome. A quantitative review demonstrated that

Empathy

Patients with depression and chronic medical conditions usually come to the office with an understandable sense of low self-worth and loneliness. In this situation, primary care physicians can provide an invaluable service by considering not only the technical aspects of diagnosis and treatment planning but also by attending to the affective component of the visit. Physicians characterized as empathic, interested in psychiatry, and curious about family and problems at home are more likely to

Depression and medical comorbidities at the healthcare system level

The question of how primary care physicians will be able to optimize medical care for patients with depression and chronic medical conditions remains. Competing demands and time constraints during visits make it difficult to address complex problems.69 Limitations on third-party coverage for mental illness, formulary restrictions, limited referral networks, lack of access to providers, and poor coordination of services between providers are additional system-level barriers that exist and may

Summary

Patients with depression and chronic medical illnesses are challenging to treat, but they are exactly the type of patient that can benefit from the expert care of a primary care provider. There is a growing body of evidence that chronic medical conditions and depression are interrelated and that treatment of one condition can affect the outcomes for the other.76, 77, 78, 79, 80 Primary care providers have the long-term perspective to understand how each condition is interrelated and affects the

Author disclosures

The author of this article has disclosed the following industry relationships:

Daniel E. Ford, MD, MPH, served as a consultant for Pfizer Inc.; and has received an honorarium from Forest Laboratories, Inc.

Acknowledgment

I thank Laurance Macke, MS, of Prescott Medical Communications Group for manuscript preparation assistance.

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    Statement of author disclosure: Please see the Author Disclosures section at the end of this article.

    Dr. Ford has received grants from the National Institute of Mental Health (NIMH) and the Robert Wood Johnson Foundation on management of depression in primary care.

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