Depression is More Complex Than Many of Us Know

Contributing Author: Gentle Heron

When a mental health practitioner is diagnosing clinical depression, she may ask questions about your feelings (“Are you sad? Feeling hopeless?”), whether you have lost interest in activities you used to enjoy, your energy level. But how often would a mental health specialist ask about headaches, digestive problems, or pain in the joints or chest?

And how often does a gastroenterologist or cardiologist question you about symptoms of depression?

Many people do not realize that depression, anxiety and other mood disorders often have physical ailments that are associated with them. The medical term for this is “comorbid condition.” All that means is that the two (or more) conditions occur together in one person.

The existence of comorbid health problems does not indicate that one condition causes the other. In fact, both could be caused by other conditions in the person’s body or life situations. However, it is important to realize that a person might not get diagnosed with clinical depression, which is treatable, if their doctor first sees one of the comorbid conditions and focuses treatment on it.

Obviously, this is important for us and for doctors to recognize. Here are the facts.

A majority of persons diagnosed with clinical depression have also consulted with their primary care physician or other specialists about pain (see reference 1 below). This pain can take many forms, and may be the primary (or only) diagnosis given.

• People diagnosed with fibromyalgia, a chronic condition with painful responses to particular pressure points plus widespread pain, are more than 3 times as likely to have clinical depression than do people without fibromyalgia (reference 2).
• More than one in ten persons with migraines, a particularly disabling form of headache, have one or more comorbid mood disorders, including depression (3).
• Persons with HIV/AIDS who have pain are also more likely to have clinical depression (4).

Three times as many persons with heart disease have depression compared to those without heart disease (5). Persons with heart failure who also are moderately or severely depressed are four times as likely to die as those without depression, and twice as likely to be hospitalized (6). Depression has been identified as a risk factor for coronary artery disease in men (7).

Gluten-sensitivity and other digestive system disorders may be another category of conditions comorbid with depression (8-11). Children with celiac disease who adhered to a gluten-free diet decreased their level of depression (12).

Osteoporosis, a condition resulting in weakened bones and loss of bone mass, is associated with depression (13).

Persons with chronic fatigue syndrome are seven times as likely to have major depression than are persons in the general population (2).

Sleep disorders may occur together with depression (14).

Persons with anxiety disorders (including PTSD, panic disorders, social phobias and obsessive-compulsive disorder) often have comorbid depression (15, 16). More than 4 out of 10 persons with PTSD have depression as well, 4 months after the traumatic event (17).

Alcoholism and other types of substance abuse or dependence are often comorbid with depression (18).

Hepatitis C virus infections often occur with depression (19), independent of the severity of liver disease the virus has caused.

Increased age is a risk factor for depression. Vascular depression results from hardening of blood vessels in the brain (20). Depression is also associated with self-neglect in the elderly (21).

Being female seems to be a risk factor for depression as well. An estimated 10-15% of new mothers are diagnosed with postpartum depression following childbirth (22). The hormonal changes at the onset of menopause may also be associated with depression (23), as may the existence of hot flashes (24).

Why is this important?

Persons who have depression along with (comorbid with) another serious health condition have more severe symptoms of both depression and the other health condition. They also have more difficulty adapting to their medical condition, and are likely to incur higher healthcare costs than do persons who have the same medical conditions without accompanying depression (5).

Persons with significant depression symptoms have a higher risk of dying from a range of health issues, including respiratory illness, heart disease and stroke, and nervous system conditions (25).

Treating depression significantly improves a person’s quality of life. The good news is that treating the depression can also help improve the outcome of treating the co-occurring health condition (26). Additional good news: non-mental health doctors are starting to take notice of the possibility that their patients may have comorbid depression (27, 28)

Will more doctors screen patients for depression? Will research indicate a cause-and-effect relationship between depression and other health issues? This remains to be seen.

(“Help! Do I have to read all these references?” No, of course not. But if you want further information on a topic, this is where to find it.)

References:

1. Kapfhammner, H-P. (2006, June). Somatic symptoms in depression. Dialogues in Clinical Neuroscience, 8(2), 227-239.
2. Patten, S. B., Beck, C. A., Kassam, A., Williams, J. V., Barbui, C. & Metz, L. M. (2005, March). Long-term medical conditions and major depression: strength of association for specific conditions in the general population. Canadian Journal of Psychiatry, 50(4), 195-202.
3. Ratcliffe, G. E., Enns, M. W., Jacobi, E., Belik, S. L. & Sareen, J. (2009, Jan-Feb). The relationship between migraine and mental disorders in a population-based sample. General Hospital Psychiatry, 31(1), 14-19.
4. Mwesiga, E. K., Mugenyi, L., Nakasujja, N., Moore, S., Kaddumukasa, M. & Sajatovic, M. (2015, Dec 30). Depression with pain co morbidity effect on quality of life among HIV positive patients in Uganda: A cross sectional study. Health and Quality of Life Outcomes, 13(1), 206.
5. Cassano, P. & Fava, M. (2002). Depression and public health, an overview. Journal of Psychosomatic Research, 53, 849–857.
6. Chamberlain, A. M., McNallan, S. M., Dunlay, S. M., Spertus, J. A., Redfield, M. M., Moser, D. K., Kane, R. L., Weston, S. A. & Roger, V. L. (2013, July). Physical health status measures predict all-cause mortality in patients with heart failure. Circulation, Heart Failure, 6(4), 669-675.
7. Ford, D. E., Mead, L. A., Chang, P. P., Cooper-Patrick, L., Wang, N. Y. & Klag, M. J. (1998, July). Depression is a risk factor for coronary artery disease in men: the precursors study. Archives of Internal Medicine, 158(13), 1422-1426.
8. Casella, G., Bordo, B. M., Schalling, R., Villanacci, V., Salemme, M., Di Bella, C., Baldini, V. & Bassotti, G. (2015, Nov 30). Neurological disorders and celiac disease. Minerva gastroenterologica e dietologica. [Epub ahead of print]
9. Ludvigsson, J. F., Reutfors, J., Osby, U., Ekbom, A. & Montgomery, S. M. (2007, April). Coeliac disease and risk of mood disorders: A general population-based cohort study. Journal of Affective Disorders, 99(1-3), 117-126.
10. Porcelli, B., Verdino, V., Bossini, L., Terzuoli, L. & Fagiolini, A. (2014, Oct 16). Celiac and non-celiac gluten sensitivity: A review on the association with schizophrenia and mood disorders. Auto-Immunity Highlights, 5(2), 55-61.
11. Zingone, F., Swift, G. L., Card, T. R., Sanders, D. S., Ludvigsson, J. F. & Bai, J. C. (2015, April). Psychological morbidity of celiac disease: A review of the literature. United European Gastroenterology Journal, 3(2), 136-145.
12. Simsek, S., Baysoy, G., Gencoglan, S. & Uluca, U. (2015, Sept). Effects of gluten-free diet on quality of life and depression in children with celiac disease. Journal of pediatric gastroenterology and nutrition, 61(3), 303-306.
13. Eskandari, F., Martinez, P.E., Torvik, S., Phillips, T.M., Sternberg, E. M. & Mistry, S. et al. for the POWER Study Group. (2007, Nov 26). Low bone mass in premenopausal women with depression. Archives of Internal Medicine, 167(21), 2329–2336.
14. Roberts, M. B. & Drummond, P. D. (2015, Dec 24). Sleep Problems are Associated with Chronic Pain Over and Above Mutual Associations with Depression and Catastrophizing. The Clinical Journal of Pain. [Epub ahead of print]
15. Devane, C. L., Chiao, E., Franklin, M. & Kruep, E.J. (2005, Oct). Anxiety disorders in the 21st century: status, challenges, opportunities, and comorbidity with depression. American Journal of Managed Care, 11 (Suppl. 12), S344–353.
16. Regier, D.A., Rae, D.S., Narrow, W.E., Kaebler, C.T. & Schatzberg, A.F. (1998). Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry, 173 (Suppl. 34), 24–28.
17. Shalev, A.Y., Freedman, S., Perry, T., Brandes, D., Sahar, T., Orr, S.P. & Pitman, R.K. (1998). Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry, 155(5), 630–637.
18. Conway, K.P., Compton, W., Stinson, F.S. & Grant, B. F. (2006, Feb). Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 67(2), 247–257.
19. Monaco, S., Mariotto, S., Ferrari, S., Calabrese, M., Zanusso, G., Gajofatto, A., Sansonno, D. & Dammaccao, F. (2015, Nov 14). Hepatitis C virus-associated neurocognitive and neuropsychiatric disorders: Advances in 2015. World Journal of Gastroenterology, 21(42), 11974-11983.
20. Krishnan KRR, Taylor WD, et al. (2004). Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression. Biological Psychiatry, 55, 390–397.
21. Hansen, M. C., Flores, D. V., Coverdale, J. & Burnett, J. (2015, Dec 30). Correlates of depression in self-neglecting older adults: A cross-sectional study examining the role of alcohol abuse and pain in increasing vulnerability. Journal of elder abuse & neglect. [Epub ahead of print]
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23. De Kruif, M., Molendijk, M. L., Haffmans, P. M. & Spijker, A. T. (2015). Depression during the perimenopause. Tijdschrift voor psychiatrie, 57(11), 795-804.
24. Woods, N. F., Hohensee, C., Carpenter, J. S., Cohen, L., Ensrud, K., Freeman, E. W., Guthrie, K. A., Joffe, H., LaCroix, A. Z. & Otte, J. L. (2015, Oct 26). Symptom clusters among MsFLASH clinical trial participants. Menopause. [Epub ahead of print]
25. Mykletun , A., Bierkeset, O., Dewey, M., Prince, M., Overland, S. & Stewart, R. (2007, May). Anxiety, depression, and cause-specific mortality: The HUNT study. Psychosomatic Medicine, 69(4), 323-331.
26. Katon, W. & Ciechanowski, P. (2002). Impact of major depression on chronic medical illness. Journal of Psychosomatic Research, 53, 859–863.
27. Kukla, U., Labuzek, K., Chronowska, J., Krzystanek, M. & Okopien, B. (2015, May). Mental disorders in digestive system diseases: Internist's and psychiatrist's insight. Polski merkuriusz lekarski, 38(227), 245-249.
28. Oflazoglu, K., Mellema, J. J., Menendez, M. E., Mudgal, C. S., Ring, D. & Chen, N. C. (2015, Dec 24). Prevalence of and factors associated with major depression in patients with upper extremity conditions. The Journal of Hand Surgery. [Epub ahead of print]