Activity restriction and depression in medical patients and their caregivers: A meta-analysis

https://doi.org/10.1016/j.cpr.2011.04.004Get rights and content

Abstract

Depression commonly occurs in conjunction with a variety of medical conditions. In addition, family members who care for patients with medical diagnoses often suffer from depression. Therefore, in addition to treating illnesses, physicians and other healthcare professionals are often faced with managing secondary mental health consequences. We conducted a systematic review and meta-analysis of the association between activity restriction and depression in medical patients and their caregivers. A total of 34 studies (N = 8053) documenting the relationship between activity restriction and depression were identified for the period between January 1980 and June 2010. Effect sizes were calculated as Pearson r correlations using random-effects models. The correlation between activity restriction and depression was positive and of large magnitude (r = 0.39; 95% CI, .34–0.44). Activity restriction was most strongly correlated with depression in medical patients (r = 0.45; 95% CI, 0.42–0.48), followed by caregivers (r = 0.34; 95% CI, 0.28–0.41) and community-dwelling adults (r = 0.28; 95% CI, 0.25–0.31). Activity restriction associated with medical conditions is a significant threat to well-being and quality of life, as well as to the lives of their caregivers. Assessment and treatment of activity restriction may be particularly helpful in preventing depression.

Highlights

► We model the correlation between restricted social activities and depressive symptoms. ► Medical patients and caregivers showed the strongest correlation. ► Higher quality assessment of restriction increases the correlation with depression. ► Assessment and treatment of activity restriction may help in preventing depression.

Introduction

Depression has been described as one of the most pressing public health problems in the United States (Hasin, Goodwin, Stinson, & Grant, 2005) and has been recognized as the third leading cause of disease burden in the world, accounting for 4.3% of disability associated life years (DALYs) (World Health Organization, 2008). While the lifetime estimate of Major Depressive Disorder (MDD) is estimated at 13.2% (Hasin et al., 2005), the prevalence of depression is significantly higher in those with various medical conditions (Egede, 2007, Moussavi et al., 2007) and their caregivers (Baumgarten et al., 1992, Beach et al., 2000, Bookwala et al., 2000). The presence of depressive symptoms nearly doubles healthcare costs including primary care, medical specialty, medical inpatient, pharmacy, and laboratory costs (Simon, VonKorff, & Barlow, 1995). Depression has been identified as a significant impediment to rehabilitation outcome in medical patients (Chemerinski et al., 2001, Pohjasvaara et al., 2001) and is a risk factor for morbidity and mortality in medical patients and their caregivers (Frasure-Smith et al., 2009).

A number of biological (Gillespie, Garlow, Binder, Schatzberg, & Nemeroff, 2009) and psychological (Beck & Alford, 2009) theories have been proposed as to the onset and maintenance of depression in older medical patients and caregivers. Among these, restriction of social and recreational activities is common to both medical patients and their caregivers, and is a theoretical contributor to the experience of depressive symptoms in these populations (Williamson & Shaffer, 2000). The Activity Restriction Model of Depressed Affect (Williamson & Shaffer, 2000) proposes that increases in depressive symptoms occur as a result of life stresses that interfere with normal social and recreational activities. In this model, among patients with medical conditions, depression is not directly attributable to symptoms of illnesses, but rather to the activity restriction these patients experience in their everyday activities. Similarly, patients with medical illnesses, particularly chronic illnesses, are often discharged to the care of family members, who assume the burden of providing care for the patient. This care often interferes with the caregiver's engagement in activities, thus resulting in increased depression.

To date, there has been no systematic quantification of the relationship between activity restriction and depression. We conducted the present meta-analysis 1) to identify the correlation between activity restriction and depression in a variety of patient samples, and 2) to identify for whom and under what circumstances activity restriction is more strongly related to depression.

Section snippets

Literature search strategy

We used 3 methods to identify studies for this meta-analysis. First, we used the reference lists of the most relevant reviews. Next, we searched MEDLINE, PsycINFO, and PsycARTICLES using the search terms activity restriction, activity loss, depression, and depressive symptoms. Finally, we used the “ancestry approach,” (Cooper, 1998) which involves consulting the reference lists of retrieved articles to find earlier relevant studies. We included all relevant and accessible journal articles that

Results

Of the initial 584 identified studies, most (n = 466) were excluded because they were not applicable to the present meta-analysis (e.g., articles on other topics, reviews or summaries) or were duplicate articles (n = 29). The remaining 89 articles were retrieved for full-text review, of which 57 were excluded because the study did not assess the relationship between activity restriction or depression, data presented in the article duplicated that of another study (i.e., participants and data

Discussion

This meta-analysis provides evidence for a strong relationship between restriction of social and recreational activities and increased severity of depressive symptoms, in support of the activity restriction model of depressed affect (Williamson, 2000, Williamson and Shaffer, 2000). Interestingly, although behavioral models of depression have been well-known over the past 4 decades, examination of the relationship between activity restriction and depression is relatively new. In fact, half of

Acknowledgements

All authors declare no competing interests. This manuscript was supported in part by the National Institute on Aging (NIA) via award R01 AG031090, and by the National Institute of Mental Health (NIMH) via award R01 MH084967.

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