Treating depression in patients with chronic disease: recognition and treatment are crucial; depression worsens the course of a chronic illness.

摘要: see also p 332 Recognition and treatment are crucial; depression worsens the course of a chronic illness Chronic medical illness is consistently associated with an increased prevalence depressive symptoms disorders.1,2 In some cases, appears to result from specific biologic effects illness. Examples this relationship include central nervous system disorders—such as Parkinson's disease, cerebrovascular or multiple sclerosis—as well endocrine hypothyroidism. other association between be mediated by behavioral mechanisms; limitations on activity imposed lead gradual withdrawal rewarding activities.3 Why should primary care physicians alert possibility in their patients disease? do they sometimes miss it? And what can manage distressing mental health problem? Depression significantly increases overall burden conditions. Compared those without depression, outpatients disorders experienced decrements quality life4 had almost twice many days restricted missed work because illness.5 Similarly, 50% 100% increase services use costs.6 Depression has been linked disease-related morbidity mortality. Results population-based studies have shown modest all-cause mortality stronger resulting cardiovascular disease.7 Depression clearly poorer prognosis more rapid progression illnesses, including ischemic heart disease8 diabetes.9 Here well, interaction may either mechanisms. For example, affect disease through platelet activation diabetes decreased glucose tolerance. It these diseases decreasing adherence physical increasing tobacco alcohol use.10 The presence reduce likelihood that providers recognize treat depression. The demands management crowd concerns out visit agenda. Providers not look beyond explain nonspecific symptoms, such fatigue poor concentration. Even when defer treatment, believing “anyone would depressed” situation. Yet, somatic often reflect combination psychological factors, clear explanation for does rule contributing factor.11 Patients receive appropriate regardless whether there obvious precipitant depression. Because depression—such changes appetite—may overlap manifestations illness, using standard screening tools diagnostic criteria overdiagnosis This concern led development measures, Geriatric Scale,12 fewer symptoms. However, it seems underdiagnosis important problem than overdiagnosis. Concern about accuracy measures interfere efforts improve access treatment. So treatment? First, consider medication causing symptoms; treating changing alleviate Chronic illnesses known mimic sleep apnea, thyroid disorders, Cushing's syndrome. Among outpatients, however, major (6%-10%) greater “medical mimics” Exhaustive delay needed reinforce stigmatization something less “real” illness. Second, randomized trials efficacy both pharmacologic13,14,15 psychosocial16 treatments across range Effective reduces improves daily functioning. Treating positive effect indicators severity progression, level glycosylated hemoglobin diabetes15 disease.17 Given benefits recognizing all who people identification clinical priority.