LITHUANIAN UNIVERSITY OF HEALTH SCIENCES MEDICAL ACADEMY
Jūrat÷ Pečeliūnien÷
MOOD, ANXIETY DISORDERS AND
SUICIDAL IDEATION IN PRIMARY CARE
PATIENTS
Doctoral Dissertation
Biomedical Sciences, Medicine (06 B)
The doctoral dissertation was prepared during 2006–2010 at the Institute of Psychophysiology and Rehabilitation, Academy of Medicine, Lithuanian University of Health Sciences.
.
Scientific Supervisor:
Dr. Habil. Robertas Bunevičius (Medical Academy, Lithuanian University of Health Sciences, Biomedical Sciences, Medicine – 06 B) Scientific consultant
Prof. Dr. Leonas Valius (Medical Academy, Lithuanian University of Health Sciences, Biomedical Sciences, Public Health – 09 B)
CONTENT
LIST OF ABBREVIATIONS... 5
INTRODUCTION ... 7
1. REVIEW OF LITERATURE ... 13
1.1. The prevalence of mental disorders in a primary care population ... 13
1.2. Mood, anxiety disorders and suicide ideation in primary care patients ... 16
1.3. Screening for depression and anxiety disorders in primary care ... 20
1.4. Mental disorders and general medical conditions in primary care... 24
1.4.1. The association of depression and anxiety disorders with general medical conditions ... 26
1.4.2. Suicide ideation, mental disorders and general medical conditions ... 37
1.4.3. Thyroid immunity, blood pressure and body mass index in primary care patients ... 42
1.4.4. Mental disorders and thyroid immunity in primary care ... 43
2. MATERIALS AND METHODS... 45
2.1. Subjects ... 45
2.2. Methods ... 47
3. RESULTS ... 53
3.1. Screening for depression and anxiety disorders in primary care patients ... 53
3.2. The prevalence of mental disorders in an adult primary care population... 55
3.3. Suicidality and mental disorders in primary care... 63
3.4. Mental disorders and general medical conditions in primary care... 66
3.4.1. The association of depression and anxiety symptoms, with general medical conditions in primary care patients... 66
3.4.2. The association of thyroid immunity with blood pressure and body mass index in primary care patients ... 75
3.4.3. Mood and thyroid immunity assessed by ultrasonographic imaging in primary care ... 79
4. DISCUSSION ... 82
4.1. Screening for depression and anxiety disorders in primary care patients ... 82
4.2. The prevalence of mood and anxiety disorders in primary care ... 84
4.3. The prevalence of suicidal ideation in primary care ... 88
4.4.1. The association of depression, anxiety symptoms and suicidal
ideation with general medical conditions in primary care patients ... 96
4.4.2. The association of thyroid immunity with blood pressure and body mass index in primary care patients ... 99
4.4.3. Mood and thyroid immunity assessed by ultrasonographic imaging in primary care ... 102
CONCLUSIONS... 104
PRACTICAL RECOMMENDATIONS ... 105
REFERENCE LIST ... 106
APPENDIXES ... 134
LIST OF ABBREVIATIONS
ACE – angiotensin-converting enzyme AITD - autoimmune thyroid disease
AUC- the area under the receiver operating characteristics curve BMI - body mass index
BP – blood pressure
CAD – coronary artery disease CHD – coronary heart disease CI(s) – confidence interval(s)
CREATE - Тhe Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy
CVD – cardiovascular disease
DALYs - disability-adjusted life years DM – diabetes mellitus
DSM–IV - the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
DSM-IV-TR - the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition text revision
ECA - the Epidemiologic Catchment Area Study
ECNP - European College of Neuropsychopharmacology Efficacy trial
ESEMeD – the European Study of the Epidemiology of Mental Disorders EU – European Union
EUGLOREH - Eropean Union Public Health Project Global Report on the Health Status in the European Union
FP – family physician
GAD – Generalized Anxiety Disorder
GAD-7 – the Generalized Anxiety Disorder -7 scale GP – general practitioner
HAD – Hospital Anxiety and Depression (Scale) HADS – Hospital Anxiety and Depression Scale
HADS-A – Hospital Anxiety and Depression Scale Anxiety subscale HADS-D – Hospital Anxiety and Depression Scale Depression subscale HIV – Human immunodeficiency virus
HR – heart rate
INSERM - the Institut National de la Santé et de la Recherche Médicale study
MD – Major Depression
MDD – Major depressive disorder MDE – major depressive episode MI – myocardial infarction
MINI – the Mini International Neuropsychiatric Interview MJA – Medical Journal of Australia
N (n) – number
NICE – the National Institute on Clinical Excellence OCD - obsessive-compulsive disorder
OMH – the Office of Mental Health OR(s) – odds ratio(s)
PC - primary care
post-ACS HRV – post acute coronary syndrome heart rate variability PRIME-MD – Primary Care Evaluation of Mental Disorders
PTSD - post-traumatic stress disorder ROC – the receiver operating characteristics RR - relative risk
SADHART - Sertaline AntiDepressant Heart Attack Randomized Trial SCAN - Structured Clinical Assessment for Neuropsychiatric disorders SCID - the Structured Clinical Interview for DSM screening questionnaire for depressive symptoms
SD – standard deviation SI – suicidal ideation
SPSS 12.0 - Statistical Package for the Social Sciences 12.0 version SSRI – selective seratonin reabsorbtion inhibitor
SUI – suicidal ideation
TSH - thyroid stimulating hormone UK – United Kingdom
USA – the United States of America WHO – the World Health Organization
INTRODUCTION
Mood and anxiety disorders as well as suicidal ideation are highly prevalent, unrecognized and untreated in general population as well as in primary care settings [4; 5; 7; 8; 23; 35; 51;112; 132, 134; 137; 138; 145; 158; 160; 161; 200; 202; 204; 208; 230; 245; 272]. Different studies consistently demonstrated that individuals with depression and anxiety disorders experience impaired physical and role functioning, more days in bed due to illness, more work days lost, increased impairment at work, and high use of health services [8; 159; 233; 261]. Disorders must be carefully monitored and treated because it is well known that depression as well as anxiety disorders has a negative but significant effect on the course, outcomes, longterm survival, and treatment efficacy of patients affected by physical disease [17; 78; 163; 271].
Common mental health disorders, such as depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and social anxiety disorder, may affect up to 15% of the population at any one time [(11i)]. Psychiatric comorbidity, or the concurrent clinical presentation of two or more diagnosable behavioural disorders, is the rule rather than the exception [29; 70]. The comorbidity of major depressive and anxiety disorders is associated with barriers to treatment and worse psychiatric outcomes, including treatment resistance, increased risk for suicide, greater chance for recurrence, and greater utilization of medical resources [1]. Epidemiological research has found that 45% of those who warrant at least one diagnosis also meet the criteria for one or more additional disorders [132].
Suicide, depression and addiction is recognised as a major public health issue [112; 124; 158; 159; 188; 202; 244; 266; 273; (7i); (11i)]. Nevertheless there is an evidence that the prevalence of common mental disorders and suicide varies across Europe and all over the world, the prevalence of mental illness continuing to increase internationally [112; 202; (7i); (8i)]. Suicide is a major public health problem and should be given high priority with regard to prevention and research.
Mood and substance use disorders, in particular, have been found to frequently co-occur. Authors address that significant number of completed suicides is associated with mental disorders, especially with mood disorders and substance misuse [176; 183; 242; 243] and conclude that the link between common psychiatric comorbidities, alcohol misuse and suicidal behaviour is robust and the very complex issue [29].
Primary care providers can perform a central role in bridging mental health and public health and have a unique opportunity to reduce the risk for onset of mental disorders [60] as primary care is usually the first point of contact for people with mental health and/or addiction issues. The vast majority (up to 90%) of depressive and anxiety disorders that are diagnosed are treated in primary care [(11i)].
In community samples, fewer than 25% of patients with psychiatric disorders see specialty mental health providers and the majority of patients are seen in primary care settings [5; 138; 139]. The literature clearly supports the view that primary care services have a key role in the provision of mental health services for those with mild to moderate mental health and/or addiction issues. Primary mental health care also has a role to play in supporting people with severe mental health issue. Luoma and colleagues found that over 50% of people who committed suicide had had health care contact within the month prior to their death [176], however most primary care clinicians do not routinely screen for suicide risk [111].
Anxiety and depression are the two most common mental health problems seen in primary care and are a major cause of distress and disability [7; 204; 208], but recognition of those mental conditions in primary care is poor [35; 230]. Effective recognition and treatment of anxiety and mood disorders in primary care may also positively impact on the economic burden of these disorders, may assist primary care physicians better understand the comorbidity issues and to prevent from severe mental health issues like suicide. Epidemiological surveys in primary care typically show that only 10% - 15% of primary care patients have well-defined anxiety or depressive disorders [63; 160; 298]. The disability caused by depression and anxiety is just as great as that caused by other common medical condition, such as hypertension, ischaemic heart disease, diabetes, and arthritis [159; 271; (7i)].
Primary care physicians need proper instruments for screening mental disorders. Several screening tools have been established to diagnose depressive and anxiety disorders in different populations [3; 28; 38; 47; 71; 79; 106; 120; 130; 153; 209; 255; 268; 282; (4i)], but not all of them are appropriate to use in a primary care setting. Useful instruments must be easily administered, inexpensive, and highly sensitive. Instruments used for screening emotional disorders in a busy primary care setting should avoid questions about somatic distress because this population is expected to have complaints concerning their physical health and these questions could bias the results of a screening [64; 152; 153; 232; 287]. Despite the prevalence, morbidity, and cost, psychiatric disorders continue to be underdiagnosed and treated incompletely in primary care settings, even though it was stated
that the prevalence of such disorders, including PTSD in primary care may indeed be higher than expected [157; 158; 298]. Routine mental health screening in primary care can detect possible symptoms of depression and other mental illness, much like a blood pressure test can identify possible cardiovascular risk factors. Making mental health checkups routine is key to early identification and critical to prognosis for those who suffer from mental illness [311; (6i)] Primary care clinicians who maintain a high index of suspicion for symptoms of depression or anxiety, or other signs of psychological distress, PTSD in their patients with positive histories of trauma plus suicidal thoughts or actions, alcohol or substance abuse, or excessive health care service utilization may increase the recognition rate of these disorders in their practices [157; 158; 160; (8i)].
There is still limited information that accounts for comorbidity on the impact of role disability associated with a wide range of mental and general medical conditions in primary care (PC) samples, as most research has been completed in the community and only rarely in PC samples [193]. Physical-mental comorbidity is very common in the general population and leads to a greater absenteeism from work than pure disorders that also cause personal and social problems [32; 290], further increases the disability experienced by sufferers, but there is a lack of research in primary health care [4; 159; (11i)].
As up to one third of patients presenting to primary care clinics with somatic complaints have a mood or anxiety disorder, they often remains hidden under the guise of somatic physical complaints so that the underlying mental condition is essentially untreated [230]. Many factors may conspire against the diagnosis of a mentalhealth condition, particularly when patients present with acomplicated somatic history [147; 159; 271; 289]. The early recognition of psychotic symptoms in patients with somatic illnesses, as well as somatic illness in patients primarily treated because of psychotic disorder concluded to be crucial by investigators [102; 143; 193].
The disability caused by depression and anxiety is just as great as that caused by other common medical condition, such as hypertension, ischaemic heart disease, diabetes, and arthritis [159; 271; (7i)].
Long-standing chronic medical conditions such as obesity, cardiovascular disease and diabetes mellitus, known to have major public health effects, are frequently found coexisting with mood and anxiety disorders [13; 20; 81; 118; 135; 159; 193; 236; 253; 271; 293]. On another hand, people with mental disorders have a higher prevalence of physical illnesses and reduced life expectancy [290], depression has long had a popular link to cardiovascular disease and death. However, only during the last 15 years scientific evidence supporting this common wisdom has been
available [89]. Obesity and common mental disorders, such as anxiety and depression, independently account for a substantial proportion of the global burden of disease and its associated economic costs, so it is important to determine the interaction between these conditions [12; 58; 199]. Depression occurs in up to one-quarter of patients with cardiovascular disease and diabetes. Depressed patients with heart disease have poorer medical outcomes including increased risk of reinfarction and all-cause mortality. Patients with diabetes and depression have poorer glycemic control, more diabetes symptoms, and greater all-cause mortality. Depression is associated with both biological (hypothalamic-pituitary-adrenal axis dysregulation) and psychosocial processes (adherence, poorer diet, and exercise) that may mediate adverse medical outcomes [68].
An association between mood disorders and thyroid immunity has been demonstrated in different studies [34; 40; 74; 100; 151; 216; 285], however, this has never been studied in an unselected medical population, such as in primary care patients. These studies suggest that an autoimmune thyroid disease (AITD), even without clinical or subclinical thyroid dysfunction, is related to mood and anxiety disorders. It has been demonstrated that thyroid autoimmunity is related to changes in general medical conditions such as body mass index (BMI) [256], to increased cardiovascular morbidity in general [180], or to specific cardiovascular dysfunction such as pulmonary arterial hypertension [46]. These findings indicate that autoimmune thyroid disease (AITD) may have significant impact on mental and physical health.
The high prevalence and clinical consequences of mental as well as physical disorders, attention to their comorbidity, demonstrates the enormous significance of mental conditions to overall illness-related disability and should remain a clinical and research priority, especially in a primary care [147; 193; 247].
The aim of the study was to evaluate the prevalence and management of
depressive disorders and anxiety disorders in primary care patients in association with suicidal ideation, thyroid autoimmunity and cardiovascular factors.
The objectives of the study
In detail, the objectives were:
1. To evaluate the Hospital Anxiety and Depression Scale (HADS) as screening instrument for depressive disorders and anxiety disorders in an adult primary care population.
2. To evaluate the prevalence and management of mental disorders in primary care population.
3. To evaluate factors affecting suicidal ideation (SI) in primary care patients.
4. To evaluate an association between mental disorders and general medical conditions in an adult primary care patients.
5. To evaluate an association of thyroid immunity with symptoms of depression, with symptoms of anxiety and with cardiovascular risk factors in primary care patients.
Defended statements:
1. Mental disorders are prevalent in primary care patients, unfortunately most of them are undiagnosed and untreated
2. There is no adequate management and attention for suicide ideation in primary care
3. Psychiatric disorders are associated with cardiovascular and endocrine disorders in primary care population
Scientific novelty and significance of the study
1. New information of scientific value is contained in this study. To our knowledge this is the first study to dissertate how prevalent are mood, anxiety disorders and suicidal ideation in primary care, evaluated by standard method, in Lithuania. The evaluation on how precise the HAD Scale is in screening for current MINI diagnoses of depressive disorders and anxiety disorders in an unselected population of primary care patients has the real purpose and significant issue of the present study.
2. Suicide is not only personal tragedy, it represents a serious public health problem in Lithuania. And it has been never studied in the primary care, using standard method. New information was collected in the present study, regarding the prevalence and the factors, affecting suicidal ideation, in primary care patients.
3. To-date there is limited information on the subject of co-morbidity of general medical conditions known to have major public health effects and general psychiatric disorders in primary care; and new studies on the evaluation of anxiety disorder and medical conditions are highly needed, since most research has been completed in the community, and only rarely in PC samples. To our knowledge this is the first study to evaluate the prevalence of mental disorders using standard method in association with general medical conditions in primary care in Lithuania.
4. Autoimmune thyroid disease has significant impact on mental and physical health, cardiovascular risk factors such as increased blood pressure
(BP) or increased BMI, however, this has never been studied in an unselected medical population, such as in primary care patients. The present study covered the autoimmune thyroid evaluation by ultrasonografic imaging in association with mental status and general medical conditions, and new data and evidences were given.
5. Based on the results new practical recommendations and new training issues could be comprised in general primary care level, from the perspective of the successful integrity of primary care and public mental health sector in the preventive and everyday practice.
1. REVIEW OF LITERATURE
1.1. The prevalence of mental disorders in a primary care population
Mood and anxiety disorders as well as suicidal ideation are highly prevalent, unrecognized and untreated in general population as well as in the primary care settings [5; 7; 8; 23; 35; 52; 112;132, 134, 137; 138; 145; 158; 160; 161; 200; 202; 204; 208; 230; 245; 272]. The World Health Organization (WHO) Global Burden of Disease Survey estimates that by the year 2020, major depression will be second only to ischemic heart disease in the amount of disability experienced by suffers. [159; 174; 293]. Different studies consistently demonstrated that individuals with depression and anxiety disorders experience impaired physical and role functioning, more days in bed due to illness, more work days lost, increased impairment at work, and high use of health services [8; 159; 261].
The prevalence of mental disorders in primary care in Europe has been estimated to range approximately between 20 and 55% [7; 8; 10; 14]. Recognition of anxiety and depression in primary care is poor, with only 23% of pure anxiety cases being recognized [230]. Common mental health disorders, such as depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder and social anxiety disorder, may affect up to 15% of the population at any one time.
The prevalence of major depression in people seen in primary care is between 5% and 10%, and two to three times as many people have depressive symptoms but do not meet the criteria for major depression. It is the third most common reason for a consultation in primary care. About two thirds of adults will at some time experience depressed mood of sufficient severity to influence their activities. Annually, 6% of adults have an episode of depression, and more than 15% of the population will experience an episode during their lifetime [(11i)]. Most depressive states are at the mild-to-moderate end of the spectrum and it is these that are mainly seen in primary care.
Chronic physical illness increases the risk of depression: 23% people with two or more chronic physical problems were rated as depressed versus 3.2% of healthy controls. [310] NICE recently issued specific guidance regarding depression in adults with a chronic physical health problem [(11i)].
Numerous studies have shown that only approximately 50% of depressed patients are recognized as such in primary care [126; 158]. Data from the World Health Organization Collaborative Study on Psychological Problems in General Health Care, which was conducted in 26,422 primary care attendees in 14 countries worldwide, and from the Institut National de la Santé et de la Recherche Médicale (INSERM) study, which was conducted in over 2400 consecutive primary care patients in France, demonstrate the high prevalence of major depression in general practice (13.7% and 14.0% in each study, respectively). These 2 studies are supported by the more recent European Study of the Epidemiology of Mental Disorders (ESEMeD), which was conducted in over 21,400 adults from the general populations of 6 European countries and which revealed lifetime prevalence for major depression of 13.4%. Despite this high prevalence, both the WHO and INSERM studies revealed that only 54% to 58% of depressed patients were recognized as "psychiatric cases" by their general practitioner and only 15% to 26% were given a specific diagnosis of depression [160]. Comorbidity is the rule with anxiety and depressive disorders with the high levels of it in primary care [5; 204]. Comorbidity of depression with anxiety or medical illness further increases the disability experienced by sufferers [4; 159; (11i)].
There is evidence that the prevalence of common mental disorders varies across Europe [138; 290]. Unselected attendees to general practices in the UK, Spain, Portugal, Slovenia, Estonia and The Netherlands were assessed for major depression, panic syndrome and other anxiety syndrome [138]. Prevalence of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) major depression, other anxiety syndrome and panic syndrome was compared between the UK and other countries after taking account of differences in demographic factors and practice consultation rates (Table 1.1.1).
Common mental health disorders, such as depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder and social anxiety disorder, may affect up to 15% of the population at any one time. Epidemiological research has found that 45% of those who warrant at least one diagnosis also meet the criteria for one or more additional disorders [91; 132].
The highest prevalence for all disorders occurred in the UK and Spain, and lowest in Slovenia and The Netherlands. Men aged 30–50 and women aged 18–30 had the highest prevalence of major depression; men aged 40– 60 had the highest prevalence of anxiety, and men and women aged 40–50 had the highest prevalence of panic syndrome. Demographic factors
accounted for the variance between the UK and Spain but otherwise had little impact on the significance of observed country differences [138].
Table 1.1.1. Prevalence of depression and other psychiatric syndromes across Europe [138]
UK Spain Slovenia Estonia
Nether-lands Portugal p
Major depression
Women 13.2 18.4 6.5 14.8 11.4 17.8 <0.001
Men 12.7 11.2 4.4 9.3 7.0 6.5 <0.001
Other anxiety syndromes
Women 11.3 20.1 3.0 10.2 4.8 8.2 <0.001
Men 8.4 9.9 2.2 5.5 2.0 2.4 <0.001
Panic syndrome
Women 10.3 11.6 7.6 8.0 3.4 13.3 <0.001
Men 8.8 5.9 4.7 5.5 3.1 5.8 <0.001
Epidemiological research has found that 45% of those who warrant at least one diagnosis also meet the criteria for one or more additional disorders [132]. The high prevalence and clinical consequences of the co-occurrence of mental and physical disorders, attention to their comorbidity should remain a clinical and research priority [247]. Still further research is needed on the evaluation of the prevalence and management of mental disorders in primary care patients in association with suicidal ideation and general medical conditions [55].
The institution of family physician practice is very vernal in Lithuania. When family health care reform was started in 1995, the physician workforce in Lithuania was dominated by specialists, the inherited soviet health system was grounded on the biomedical model, emphasizing technical facilities, underestimating the patient's role [121] and the specialty of family physician (FP) did not exist at all [260].
The very first data showed that the prevalence of mood disorders in outpatient clinic of internal medicine in Lithuania twenty years ago was 23% [35] and it remained in the same high level in the past decade with the very high numbers of suicide [83]. In 2004 Puras and colleagues discussed that the real prevalence of mental disorders in Lithuania was unknown [221].
The public mental health in Lithuania became a prioritized issue with the aim to develop new mental health Strategy for 2006-2010 in 2005. The then minister of Health of the Respublic of Lithuania emphasized the importance
of primary care practice from the perspective of the successful integrity of primary care and public mental health sector in the preventive and everyday practice [(10i); (16i)] The lack of the researches on mental health in primary care still meets the challenges. New studies could have plausible impact on the developmental teaching of primary care physicians, forward planning of practical recommendations for primary care givers and could have a significant influence to the primary mental health care policy in Lithuania.
1.2. Mood, anxiety disorders and suicide ideation in primary care patients
Anxiety and depression are the two most common mental health problems seen in the general medical setting [7; 160; 208]. Mood or anxiety disorders often remain hidden under the guise of somatic physical complaints so that the underlying mental condition is essentially untreated [230].
Although increasing attention has been paid to anxiety, it still lags far behind depression in terms of research as well as clinical and public health efforts in screening, diagnosis, and treating affected individuals. This is unfortunate given the prevalence of anxiety and its substantial impact on patient functioning, work productivity, and health care costs [5; 261]. Recognition of anxiety and depression in primary care is poor, with only 23% of pure anxiety cases being recognized compared with 56% of depression cases [230]. Studies confirm the high prevalence of generalized anxiety disorder (GAD) and major depression (MD) in primary care and the role of several socioeconomic and regional factors in the illnesses [8]. The comorbidity of major depressive and anxiety disorders is associated with barriers to treatment and worse psychiatric outcomes, including treatment resistance, increased risk for suicide, greater chance for recurrence, and greater utilization of medical resources. Paying careful attention to the development of anxiety and depression may also positively impact the economic burden of these disorders [1; 155].
Common mental health disorders, such as depression, generalised anxiety disorder, panic disorder, OCD, post-traumatic stress disorder and social anxiety disorder, may affect up to 15% of the population at any one time. Psychiatric comorbidity, or the concurrent clinical presentation of two or more diagnosable behavioural disorders, is the rule rather than the exception [29; 70]. The comorbidity of major depressive and anxiety disorders is associated with barriers to treatment and worse psychiatric outcomes,
including treatment resistance, increased risk for suicide, greater chance for recurrence, and greater utilization of medical resources [1]. Epidemiological research has found that 45% of those who warrant at least one diagnosis also meet the criteria for one or more additional disorders [132].
The 4 most common anxiety disorders (excluding simple phobias that seldom present clinically) are generalized anxiety disorder, panic disorder, social anxiety disorder, and posttraumatic stress disorder [84; 97; 115; 178; 229; 230; 299]. Generalized anxiety disorder is chronic, disabling, and associated with other health problems [52]. However, despite the substantial disability associated with each anxiety disorder and the availability of effective treatments, only a minority of patients (15% to 36%) with anxiety are recognized in primary care [131; 160; 175]. Anxiety disorders are the most common psychiatric disorders in the elderlies [225]. Despite the
prevalence, morbidity, and cost, psychiatric disorders continue to be underdiagnosed and treated incompletely in primary care settings, even though it was stated that the prevalence of such disorders, including PTSD in primary care may indeed be higher than expected [157; 158; 298].
Anxiety and major depressive disorders are commonly associated with other psychiatric disorders, e.g., psychiatric comorbidity, or the concurrent clinical presentation of two or more diagnosable behavioural disorders, is the rule rather than the exception [70]. Mood and substance use disorders, in particular, have been found to frequently co-occur. According to the Epidemiologic Catchment Area (ECA) Study, the lifetime prevalence for any mood disorder and any alcohol use disorder is 21.8%. For major depression and dysthymic disorder, the comparable comorbidity rates with any alcohol use disorders are 16.5% and 20.9%, respectively [224]. Among those with an existing alcohol-related disorder, as many as 30-48% of women and 9-24% of men will also meet the diagnostic criteria for major depressive disorder at some point during their lifetime [136; 224]. Depressive disorders and anxiety disorders often coexist in general population as well as primary care settings and are often secondary to other psychiatric disorders. The comorbidity between depression and anxiety is so high that debate continues as to whether they are categorically separate disorders or part of a continuum. For example, studies suggest that 30%– 40% of patients with panic disorder or obsessive compulsive disorders also have depression. Comorbidity between anxiety disorders is common (e.g., 30% of patients with OCD report simple or social phobias, and 15% report panic disorder).
Comorbidity with other psychiatric disorders is also common. Depression can be a feature of virtually any psychiatric disorder. Particularly high rates of depression are found in alcohol-related disorders, eating disorders,
schizophrenia and somatoform disorders [(12i)] and the disabilities caused by depression and anxiety are just as great as that caused by other common medical condition [159; 271; (1i)].
The literature clearly supports the view that primary care services have a key role in the provision of mental health services for those with mild to moderate mental health and/or addiction issues. Primary mental health care also has a role to play in supporting people with severe mental health issue as suicide.
Suicide, depression and addiction is recognised as a major public health issue [112; 124; 159, 158; 188; 202; 244; 266; 273; (7i); (11i)]. Most primary care clinicians do not routinely screen for suicide risk [111].Mood and substance use disorders, in particular, have been found to frequently co-occur. Authors address that significant number of completed suicides are associated with mental disorders, especially with mood disorders and substance misuse [176; 183; 242; 243] and conclude that the link between common psychiatric comorbidities, alcohol misuse and suicidal behaviour is robust and the very complex issue [29].
There is an evidence that the prevalence of common mental disorders and suicide varies across Europe and all over the world and the rates of mental illness continuing to increase internationally [112; 202; (7i) (8i), (9i)] (Fig 1.2.1; Fig 1.2.2.).
Fig 1.2.2. Numbers of suicide deaths in numerous nations, for the most recent year available. Data were obtained from the World Health
Organization [202].
The Projections of Global Mortality and Burden of Disease from 2002 to 2030 represented that self-inflicted injuries, rated as the 14th rank place on the rankings for 15 leading causes of death all over the world in 2002 would be on the position No.12 in the year 2030 [188]. Measured in terms of disability-adjusted life years (DALYs), mental and neurological disorders globally account for more than 15% of the total burden of all diseases and 17% in low and middle income countries [293]. For developing countries, the treatment gap for mental and neurological disorders has been estimated to be 3.6 times higher than in developed countries [99]. In 2004, more people died in Europe from suicide than from road accidents [158].
The very first data showed that the prevalence of mood disorders in outpatient clinic of internal medicine in Lithuania twenty years ago was 23% [35] and it remained in the same high level in the past decade with the very high numbers of suicide [83] in the period between 1990 and 1996 when suicide mortality in Lithuania rose 82.4%, with the rate peaking at more than 47 per 100,000 persons in 1996. After a slight decrease in 1997 (to 45.6) and in 1998 (to 43.8), suicide rates stabilized at a very high level (in 1998–2002 the average rate was 44.6) [83; 304]. In 2004 Puras and colleagues discussed that the real prevalence of mental disorders in Lithuania was unknown [221]. Throughout the last decade of the twentieth
century, Lithuania had the highest suicide rates in Europe among both men and women, aged 25-64 years [269]. The data from EU Public Health Project Global Report on the Health Status in the European Union [(11i)] conclude that Lithuania has the highest rate for males at 50-54 years of age (121.1) and at 15-19 (25.9). The suicidality among both men and women in Lithuania still remains standing as one of the highest suicide rates all over the World [112; 202; (8i)]. There is lack of research on primary care recognition and management of suicide in Lithuania [221]
Although there has been significant interest in whether anxiety disorders are risk factors for suicidal behaviour, this remains a controversial area as anxiety disorders are highly comorbid with other anxiety disorders and tend to cluster together, not only amplify the risk of suicide attempts in persons with mood disorders [133; 244; (11i)]. Authors address that significant number of completed suicides are associated with mental disorders, especially with mood disorders and substance misuse [176; 183; 242; 244] and conclude that the link between common psychiatric comorbidities, alcohol misuse and suicidal behaviour is robust and the very complex issue [29].
The primary care plays a critical role on recognition and management of suicide - Luoma and colleagues found that over 50% of people who committed suicide had had health care contact within the month prior to their death [176].
The high prevalence and clinical consequences of the co-occurrence of mental and physical disorders, attention to their comorbidity should remain a clinical and research priority [247]. Still further research is needed on the evaluation of the prevalence and management of mental disorders in primary care patients in association with suicidal ideation and general medical conditions [55].
1.3. Screening for depression and anxiety disorders in primary care
Recognition and treatment of anxiety and depression in primary care as well as in general population is poor [5; 7; 8; 23; 35; 112; 132; 134; 137; 138; 145; 158; 160; 161; 200; 202; 208; 230; 245; 272]. Many factors may conspire against the diagnosis of a mental health condition, particularly when patients present with a complicated somatic history [147; 159; 271; 289]. Improved recognition and diagnosis of psychiatric disorders is the first step toward an enhanced management of mental health disorders in the primary care setting [15]. The ability to diagnose mental disorders by primary care givers is found to be problematic all over the world. A number of diagnostic instruments have been proposed for use in primary care but the
final estimation on the best diagnostic instrument was not stated [45]. In 2001, the International Consensus Group on Depression and Anxiety Spectrum proposed an algorithm for improved recognition and treatment of the depression and anxiety spectrum in primary care. The International Consensus Group went on to discuss diagnostic scales and consider the most appropriate approach for the recognition and diagnosis of spectrum disorders in primary care, and ended by developing management guidelines that can be applied across the spectrum of depressive and anxiety disorders. The characteristics of the Primary Care Evaluation of Mental Disorders
(PRIME –MD) [257], the Symptom – Driven Diagnostic System for Primary Care (SDDS – PC) [207], the General Healthcare Questionaire (GHQ) [90;
92], the Center for Epidemiologic Studies Depressed Mood Scale (CES–D) [306] and Mini International Neuropsychiatric Interview (MINI) [156; 250; 251] were discussed [15].
Emotional disorders are common diagnoses among primary care patients [8; 245; 272] which must be carefully monitored and treated because it is well known that depression as well as anxiety disorders have a negative but significant effect on the course, outcomes, longterm survival, and treatment efficacy of patients affected by physical disease [17; 78; 163]. Primary care physicians need proper instruments for screening emotional disorders. Several screening tools have been established to diagnose depressive and anxiety disorders in different populations these include PRIME-MD [258], the General Health Questionnaire [90], the Beck Depression Inventory [21], the Zung Self-Rated Depression Scale [309], etc. but not all of them are appropriate to use in a primary care setting [3; 28; 38; 47; 71; 79; 92; 106; 120; 130; 153; 209; 255; 268; 282, (4i)]. Doctor-rated screening tests are a more structured way of interviewing and rating the severity of the illness. Patient-rated screening tests have the advantage of being completed in the patient’s own time, and hence allowing more widespread and time-efficient screening. [(12i)] Useful instruments must be easily administered, inexpensive, and highly sensitive. Instruments used for screening emotional disorders in a busy primary care setting should avoid questions about somatic distress because this population is expected to have complaints concerning their physical health and these questions could bias the results of a screening [64; 152; 153; 232; 287]. Instruments used for screening emotional disorders in a busy primary care setting should avoid questions about somatic distress because this population is expected to have complaints concerning their physical health and these questions could bias the results of a screening [64; 152; 153; 232; 287]. Identification of mood and anxiety disorders is of course key to treatment: the size of treatment gaps relates in part to how well these mental disorders are identified, the
availability of treatment resources, stigmatization of illnesses, and the policies and frameworks that are in place to deliver effective interventions for these disorders [273].
The PRIME-MD questionnaire consists of 2 parts: a screening question-naire that is completed by the patient and a categorical diagnostic checklist that is completed by the physician. Diagnostic categories are checked ac-cording to the orientation indicated by the patient's answers. PRIME-MD explores only a limited spectrum of disorders: major depression, anxiety, so-matoform disorders, eating disorders, and alcohol abuse. It is a self-assess-ment form, and symptoms need to have been present for 1 month. A degree of validation of this questionnaire has taken place by both primary care physicians and health care professionals who have shown it to be an acceptable instrument for the diagnosis of mood disorders but unacceptable for the diagnosis of other psychological disorders by a primary care physi-cian [15; 257]. The SDDS-PC is also a patient-administered questionnaire, which explores 16 symptoms covering 6 diagnostic areas; this instrument has been developed from a more extensive (62 symptom) version. If the patient has a positive response in 1 area, a specific physician-administered module is then used. The criteria in the SDDS-PC are more precise than those in the PRIME-MD and include symptom duration and impairments caused by the symptoms. The possible existence of physical illness must be ruled out. The SDDS-PC is a longitudinal tracking form that explores the diagnosis of a limited number of disorders-major depression, GAD, OCD, panic disorder, alcohol abuse, and suicidal behaviour. Validation of this instrument has again raised questions regarding its suitability for use in primary care due to the difficulties in collecting the correct information [15; 207].
The General Healthcare Questionnaire (GHQ) [90; 92] assesses symptoms and the general distress caused by depression and/or anxiety disorders. It is not a diagnostic tool but a list of either 12 (GHQ-12) or 28 (GHQ-28) questions. As part of the World Health Organization (WHO) Collaborative Study on Psychological Problems in General Health Care (PPGHC), the GHQ was administered to 5269 consecutive primary care patients [274]. The data showed a linear relationship between GHQ-12 score and percentage recognition by general practitioners; however, the GHQ appears to be most useful in identifying those patients most severely affected, and a disadvantage of the questionnaire is that it is not diagnosis-specific [15].
Many other diagnostic instruments have limitations that make them unsuitable for use in primary care; for example, either they are time consuming to complete and to score, not all disorders are covered,
sensitivity and validity have not been fully explored, or only limited language translations are available [15]. This was the background to the development of the MINI, which was developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-IO psychiatric disorders. In a validation study versus the Composite International Diagnostic Interview (CIDI) [295] which was considered the gold standard, the MINI had high specificity, sensitivity, and positive predictive values for all the depressive and anxiety disorders tested with the exception of GAD. However, following amendments to the questions asked, results equivalent to those seen with the other disorders can now be achieved for GAD [54;55] Similar results were observed against the Structured Clinical Interview for DSM-III-R in the United States [156]. The diagnoses made by primary care physicians using the MINI have been compared with the diagnoses made by a specialist. When the MINI was used, diagnostic concordance with the specialist was high for almost all disorders (positive predictive values of approximately 70%), a finding that was all the more notable given that in the absence of a structured interview an accurate diagnosis is achieved in only 15% of cases [274]. The results of this study suggest that with the use of this short structured diagnostic interview there is an increased rate of recognition of depressive and anxiety disorders in primary care [15]. A further investigation in primary care patients in France has examined the positive predictive value of using only the screening questions that are contained at the beginning of each diagnostic module in the MINI. Consecutive primary care patients com-pleted a questionnaire containing the 17 screening questions, and the "self-report" diagnosis was compared with that reached by a specialist following a telephone interview; the positive predictive value of the screening questions was found to be 68.5%. This shortened screening form of the MINI takes only 5 to 10 minutes to complete [15].
The Hospital Anxiety and Depression Scale [307] was developed as a screening instrument for anxiety disorders and depression in a nonpsychiatric medical population [311]. It is widely used all around the world in patients with both somatic and mental problems, including primary care patients [16; 287], and shows good psychometric properties [24]. But little is known about how well the HADS can identify depression and anxiety disorders diagnosed using standard structured diagnostic psychiatric interviews, such as the Mini International Neuropsychiatric Interview [251], in a population of primary care patients.
Some organizational activities were suggested to be included for a better chance of achieving good mental health outcomes when teams work within collaborative care models that include mental health specialists who perform
consultation/liaison activities and provide specialized care in primary care facilities [72; 293].
The new charts were developed by the Dartmouth Primary Care Cooperative Research Network (COOP) and the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA) recently and concluded to be valid and feasible option for screening for mental disorders by primary care teams trained community health workers and nurse assistants working in a collaborative mental health care model [189].
Despite the prevalence, morbidity, and cost, psychiatric disorders continue to be underdiagnosed and treated incompletely in primary care settings, even though it was stated that the prevalence of such disorders in primary care may indeed be higher than expected [157; 158; 298]. Studies of primary care screening programs have indicated that approximately 12%-14% of those receiving a mental health checkup receive a positive score, and require an interview with a physician or other health professional to determine whether there is evidence of a possible mental illness, and if necessary a referral to a mental health professional. Primary care settings are ideal for implementing mental health checkups, given the regularity with which patients see their PCPs and the existing screening practices already in place there for other health issues [311; (6i)]
Routine mental health screening in primary care can detect possible symptoms of depression and other mental illness, much like a blood pressure test can identify possible cardiovascular risk factors. Making mental health checkups routine is key to early identification and critical to prognosis for those who suffer from mental illness [113; 311; (6i)].
Primary care clinicians who maintain a high index of suspicion for symptoms of depression or anxiety, or other signs of psychological distress, PTSD in their patients with positive histories of trauma plus suicidal thoughts or actions, alcohol or substance abuse, or excessive health care service utilization may increase the recognition rate of these disorders in their practices [157; 158; 160; (11i)].
1.4. Mental disorders and general medical conditions in primary care
Primary care is usually the first point of contact for people with any health issues, included mental disorders and/or suicidal ideation [5, 138]. Effective recognition of anxiety and mood disorders in primary care may also positively impact on the economic burden of these disorders, may assist primary care physicians better understand the comorbidity issues and to prevent from severe mental health issues like suicide. The early recognition of psychotic symptoms in patients with somatic illnesses, as well as somatic
illness in patients primarily treated because of psychotic disorder concluded to be crucial [102; 143; 193]. Primary care settings are ideal for implementing mental health checkups, given the regularity with which patients see their PC practitioners and the existing screening practices already in place there for other health issues [311; (6i)], but only few studies were performed. There is still limited information that accounts for comorbidity on the impact of role disability associated with a wide range of mental and general medical conditions in primary care samples, as most research has been completed in the community and only rarely in PC samples [193]. Data regarding the prevalence of mental disorders in association of general medical conditions in primary care are scarce [26]. This presents treatment difficulty as primary care physicians are not trained to identify the clinical signs and symptoms of psychiatric illness. Researchers have found the association of depression only with severe, but not with the mild or moderate physical illness which is commonly found in PC, and unmet needs in this area of research have been discussed. Similarly, the association of anxiety disturbance and medical conditions needs more attention in primary care, since most research has been completed in the community, and only rarely in PC samples.
The first study - the ZARADEMP Project documented that there is a positive and statistically significant association between general somatic morbidity and general psychiatric morbidity in the (predominantly) elderly population in 2007. It has been concluded that cardiovascular accidents and thyroid disease may have more weight in this association [173].
The high prevalence and clinical consequences of the co-occurrence of mental and physical disorders, attention to their comorbidity should remain a clinical and research priority [247].
Physical-mental comorbidity is very common in the general population , people with mental disorders have a higher prevalence of physical illnesses and reduced life expectancy [290] and leads to a greater absenteeism from work than pure disorders that also cause personal and social problems [32; 122], further increases the disability experienced by sufferers [5; 159; (11i)]. It is important to recognize psychotic symptoms in patients with somatic illnesses, as well as somatic illness in patients primarily treated because of psychotic disorder [143; 193].
As up to one third of patients presenting to primary care clinics with somatic complaints have a mood or anxiety disorder, they often remains hidden under the guise of somatic physical complaints so that the underlying mental condition is essentially untreated [230]. Anxiety and depression are the two most common psychiatric disorders observed in patients with a general medical condition. In early, primary care studies estimated
psychiatric illnesses are commonly found in acute care settings, with estimations as high as 30 to 60% of general medical inpatients having experienced some type of comorbid psychiatric illness [18; 169]. The majority of patients with psychiatric illness are in fact most often treated by non psychiatrists: fewer than 25% of patients with psychiatric disorders see specialty mental health providers and the majority of patients are seen in primary care settings [5; 138; 139].
The literature clearly supports the view that primary care services have a key role in the provision of mental health services for those with mild to moderate mental health and/or addiction issues. Primary mental health care also has a role to play in supporting people with severe mental health issue [158; 176]. Many factors may conspire against the diagnosis of a mental health condition, particularly when patients present with a complicated somatic history [147; 159; 271; 289].
Long-standing chronic medical conditions such as obesity, cardiovascular disease and diabetes mellitus, known to have major public health effects, are frequently found coexisting with mood and anxiety disorders [13; 20; 81; 118; 135; 159; 193; 191; 236; 253 271; (1i); (14i)]. An association between mood disorders and thyroid immunity has been demonstrated in different studies [34; 40; 74; 100; 151; 216]. These studies suggest that an AITD, even without clinical or subclinical thyroid dysfunction, is related to mood and anxiety disorders.
The impact of thyroid immunity on cardiovascular risk factors such as increased blood pressure or increased BMI in primary care patients has never been studied.
There is limited information on the subject of co-morbidity of general medical conditions and general psychiatric disorder in primary care, the association of anxiety disorder and medical conditions needs new studies, since most research has been completed in the community, and only rarely in PC samples. Still further research is needed on the evaluation of the prevalence and management of mental disorders in primary care patients in association with suicidal ideation and general medical conditions [55].
1.4.1. The association of depression and anxiety disorders with general medical conditions
Psychiatric comorbidity with many chronic physical disorders has remained neglected. Long-standing chronic medical conditions such as obesity, cardiovascular disease and diabetes mellitus, known to have major public health effects, are frequently found coexisting with mood and anxiety
disorders [13; 20; 81; 118; 135; 159; 193; 236; 253; 271; 275; 293]. Persistent depression increases mortality and decreases medication adherence [88].
Evaluation of a person and their family psychiatric history, current psychiatric symptoms, temporary relationship of the psychiatric symptoms to the physical illness, and concurrent substance abuse is essential [158; 311; (6i)]. Medically ill depressed patients more commonly have an onset of depression over the age of 40, have no previous psychiatric history, lower family history of alcoholism, less suicidal ideation, and fewer suicide attempts when compared to nonmedically ill depressed patient. A negative personal or family history of anxiety disorders, substance abuse, or personality disorders increases the likelihood of the anxiety disorder resulting from a secondary source [113; 202; 224; 296].
It was estimated 53.4 % of USA adults have 1 or more of the mental or physical conditions and these respondents report an average 32.1 more role-disability days in the past year than demographically matched controls, equivalent to nearly 3.6 billion days of role disability in the population. Authors conclude that the staggering amount of health-related disability associated with mental and physical conditions should be considered in establishing priorities for the allocation of health care and research resources, bearing in mind frequent comorbidity between of psychotic and somatic disorders, early recognition of such comorbidity as very important issue, as well as the selection of antipsychotics.
With the exception of depression, there is considerable less information on the issue of psychiatric disturbances co-morbid with general medical conditions. Furthermore, some studies found the association of depression only with severe, but not with the mild or moderate physical illness which is commonly found in PC, and unmet needs in this area of research have been discussed. Similarly, the association of anxiety disturbance and medical conditions needs more studies, since most research has been completed in the community, and only rarely in PC samples. Anxiety, like depression, is a normal reaction to certain events that occur in everyday life; however, a true anxiety disorder has more serious implications. Anxiety related to medical illness is generally associated with one of the following: 1) acute anxiety secondary to acute medical illness; 2) acute anxiety secondary to a chronic medical illness; 3) chronic anxiety existing prior to the medical illness; and 4) chronic anxiety and medical illness [297]. In the DSM-IV, anxiety disorders are differentiated to include panic disorder with or without agoraphobia, agoraphobia without a history of panic disorder, specific phobia, social phobia, obsessive–compulsive disorder, posttraumatic stress disorder, acute stress disorder, generalized anxiety disorder,
substance-induced anxiety disorder, anxiety disorder not otherwise specified, and anxiety disorder due to a general medical condition. Early recognition and treatment is vital to improved patient outcome, quality of life, and cost of care [263; 311; (6i)].
The ZARADEMP Project documented that there is a positive and statistically significant association between general somatic morbidity and general psychiatric morbidity in the (predominantly) elderly population in 2007. It has been concluded that cardiovascular accidents and thyroid disease may have more weight in this association [173]. GAD is chronic, disabling, and associated with other health problems. Anxiety was found to be an independent risk factor for the incidenceof CHD and cardiac mortality in initially healthy individuals [228].
Patients with concomitant diagnoses of stable CAD and either major depressive disorder (MDD) or generalized anxiety disorder (GAD) had a greater-than-twofold increase in the risk of major adverse cardiac events in the two years following a baseline assessment, although comorbid MDD and GAD appeared not to be additive in their effects on cardiac risk [77].
Depression has long had a popular link to cardiovascular disease and death. However, only during the last 15 years scientific evidence supporting this common wisdom has been available [89]. Major depressive disorder is the most common psychiatric disorder in patients with CAD, with a prevalence of approximately 15% to 20% in those with stable or unstable coronary artery disease (CAD) (ie, myocardial infarction and unstable angina). Since the early 1990s studies have reported prevalence of major depression between 17% and 27% in hospitalized patients with coronary artery disease [239]. MDD may be even more common after coronary artery bypass graft surgery, approaching 30% in some studies [25].Depression is also very common in congestive heart failure, with a prevalence of up to 20%. Studies using depression symptom (ie, not diagnostic) measures report even higher rates in cardiac patients. Despite such extensive studies of depression in heart disease, the diagnosis is still often missed, and only a minority of depressed patients receives treatment; fewer, yet, receive adequate treatment [164]. Research has demonstrated an association between psychologicalfactors such as stress and both the development of coronaryheart disease (CHD) and CHD outcomes [30; 235]. Most studies have focused on the role of depression, with several meta-analyses indicating that depression is an independent risk factor forthe development of CHD in the general population [303] as wellas a prognostic risk factor in CHD patients [279].
It is becoming clear that the comorbidity of depression and cardiovascular disease does not occur by chance but the mechanisms
responsible for this relationship are poorly understood. Platelet abnormalities, autonomic tone, and health behaviours have all been implicated. There exists also the possibility that depression and vascular disease share certain vulnerability genes [190].
A new study confirms that patients with stable CAD and a diagnosis of depression or anxiety have a greater risk of cardiac events [77].
Moreover, it is now apparent that depression aggravates the course of multiple cardiovascular conditions [89] and has regularly been shown to lower adherence to prescribed medication and secondary prevention measures [87].
Several early studies have demonstrated that depression increases the risk of developing cardiac disease, in particular coronary artery disease, and to worsen prognosis after myocardial infarction [39; 75; 199; 248; 249; 263; 297]. Few randomized controlled trials have evaluated the efficacy of treatments for major depression in patients with coronary artery disease. The impact of depression was mostly related to the premorbid cardiac disease status with a two- to fourfold increased risk of mortality during the first 6 months following myocardial infarction, but it has been shown that depression increases the risk for cardiac mortality independently of baseline cardiac status. The mechanisms of increased cardiac risk attributable to depressive illness are at present uncertain, but activation of the sympathetic nervous system with increased levels of monoamines, exaggerated platelet activity, and/or enhanced inflammatory-mediated atherogenesis are likely to be of primary importance. New research helps us to understand which common biological changes are involved in the already known link between depression and life-threatening cardiovascular disease [(5i)]. The Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy, a randomized, controlled, 12-week, parallel-group trial (CREATE) [162], was the first trial specifically designed to evaluate the short-term efficacy and tolerability of 2 depression treatments in patients with CAD: citalopram, a first-line selective seratonin reabsorption inhibitor (SSRI) antidepressant and interpersonal psychotherapy (IPT), a short-term, manual-based psychotherapy focusing on the social context of depression. The trial documents the efficacy of citalopram administered in conjunction with weekly clinical management for major depression among patients with coronary artery disease and found no evidence of added value of IPT over clinical management. Similar to the results of SADHART, CREATE found the benefits of SSRIs for patients with CAD to be clearer for recurrent episodes of major depression than for first episodes [(5i)]
Depression is a painful state, and it should be treated aggressively when indicators of benefit are present; major depression following myocardial
infarction is consistently associated with about a 3-fold increase in cardiac mortality and evidence continues to accumulate [87].
There is burgeoning literature on the relationship between mood disorders and cardiovascular Table 1.2.1 summarizes results of large studies of the relationship between depression and prognosis of coronary artery disease, in people without preexisting CAD [144].
Table 1.4.1.1. Studies of the relationship between depression and prognosis of coronary artery disease), in people without preexisting CAD (144)
Study Age
(years)
Follow-up
(years) RR*
Hallstrom et al., 1986 38-54 12 Severity of depression, predicted angina only
Appels and Mulder, 1988 39-65 4.5 RR = 2.28 for nonfatal MI; no association with fatal MI Anda et al., 1993 45-77 12.4 RR = 1.5 for depressive affect Aromaa et al., 1994 40-64 6.6 RR = 3.36
Wassertheil-Smoller et al.,
1996 ≥ 60 4.5
Deaths: RR = 1.26 MI or stroke: RR = 1.18 MI: RR = 1.14, but not significant*
Barefoot and Schroll, 1996 50 24 Death: RR = 1.59 MI: RR= 1.71 Pratt et al., 1996 >18 13
MI: RR= 4.54 for major depressive episode
MI: RR = 12.07 for dysphoria Ford et al., 1998 26±2 37 MI or CAD: RR = 2.12 Mendes de Leon et al, 1998 65-99 9 Mortality: RR = 1.03
*Adjusted for multiple factors (varies between studies, in general age, conventional cardiovascular risk factors, such as smoking, cholesterol, weight, or body mass index, and physical conditions at entry of the study).
MI, myocardial infarction; RR, relative risk.
Major depression severely impairs heart rate variability recovery following an acute coronary event. It is now clear, that depression is also associated with biological changes involving increased heart rate, inflammatory response, plasma norepinephrine, platelet reactivity, absent post-ACS HRV recovery -- all of which is associated with life-threatening consequences. It also impairs compliance with doctor’s advice and health behaviours. From a clinician's point of view, patients with depression after myocardial infarction, especially those with prior episodes, should be both carefully watched and aggressively treated, because they are at an elevated cardiac risk and less likely to get better spontaneously [(5i)].
Several epidemiological studies have associated depressive symptoms with cardiovascular disease. The slogan “no health without mental health”
supports an insistence on the similarities between physical and mental health. A study by Prince et al. (2007) looked at the interaction between mental and physical health status [219].
Disease Factors
The symptoms of a mental illness can increase a person’s risk of developing some chronic diseases. For example, depression changes:
• Serotonin levels (i.e., a chemical found in the brain), impacting heart
function, red blood cell clotting, and the narrowing of blood vessels.
• Cortisol levels (i.e., a hormone involved in the stress process), increasing red blood cell clotting and causing swelling of the blood vessels. These changes may increase a person’s risk of developing coronary heart disease or having a stroke [219].
Treatment Factors
The medications used to treat a mental illness may have side effects that increase a person’s risk of developing some chronic diseases. For example, antipsychotic medication used to treat schizophrenia, bipolar disorder, and dementia may cause weight gain and increase the risk of developing type 2 diabetes and cardiovascular disease [227].
Additionally, the physical health of a person with a mental illness may be neglected during the treatment process, delaying early diagnosis of a physical condition and increasing the risk of chronic disease development [227].
Studies of psychological treatments for hypertension, primarily relaxation techniques and biofeedback, have sometimes found modest but clinically significant sustained reductions in blood pressure. However, drug therapy is much more effective than such techniques [164].
Neuropsychiatric side effects are common with many cardiovascular drugs. Common psychiatric side effects of selected cardiovascular drugs are shown in the Table 1.2.2.
While a number of clinical authorities have reported the safe use of modest doses of stimulants in patients with significant cardiac disease, including congestive heart failure, coronary artery disease, arrhythmias, and hypertension, recent concern has been raised regarding cardiac risk. Here, too, a careful weighing of potential risks versus benefits is warranted rather than total avoidance [164].
Table 1.4.1.2. Common psychiatric side effects of selected cardiovascular drugs [164]
