Depression and Comorbid Illness in Elderly

Primary Care Patients: Impact on Multiple

Domains of Health Status and Well-Being
Polly Hitchcock Noël, PhD; John W. Williams, Jr, MD, MHS; Jürgen Unützer,
MD, MPH; Jason Worchel, MD; Shuko Lee, MS; John Cornell, PhD; Wayne
Katon, MD; Linda H. Harpole, MD, MPH; Enid Hunkeler, MA

| Disclosures

Ann Fam Med. 2004;2(6)






 References

Purpose: Our objective was to examine the relative association of depression

severity and chronicity, other comorbid psychiatric conditions, and coexisting
medical illnesses with multiple domains of health status among primary care
patients with clinical depression.
Methods: We collected cross-sectional data as part of a treatment effectiveness
trial that was conducted in 8 diverse health care organizations. Patients aged 60
years and older (N = 1,801) who met diagnostic criteria for major depression or
dysthymia participated in a baseline survey. A survey instrument included
questions on sociodemographic characteristics, depression severity and chronicity,
neuroticism, and the presence of 11 common chronic medical illnesses, as well as
questions screening for panic disorder and posttraumatic stress disorder. Measures
of 4 general health indicators (physical and mental component scales of the SF-12,
Sheehan Disability Index, and global quality of life) were included. We conducted
separate mixed-effect regression linear models predicting each of the 4 general
health indicators.
Results: Depression severity was significantly associated with all 4 indicators of
general health after controlling for sociodemographic differences, other
psychological dysfunction, and the presence of 11 chronic medical conditions.
Although study participants had an average of 3.8 chronic medical illnesses,
depression severity made larger independent contributions to 3 of the 4 general
health indicators (mental functional status, disability, and quality of life) than the
medical comorbidities.
Conclusions: Recognition and treatment of depression has the potential to improve
functioning and quality of life in spite of the presence of other medical
comorbidities.

Epidemiological and clinical studies consistently indicate that depression adversely

affects the lives of older adults. The relative contribution to adverse effects is not
entirely clear, because depression often occurs in conjunction with other
psychiatric illnesses, such as anxiety disorders; somatic symptoms, such as pain;
and chronic medical illnesses, such as diabetes. The latter is particularly of
concern, because it is often difficult to know whether a particular symptom, such
as lethargy, is caused by depression, a coexisting medical illness, or both. Patients
with chronic medical illness are known to have a high prevalence of comorbid
depression.[1] Furthermore, both major depressive disorder and subsyndromal
depression have been associated with increased somatic symptoms, morbidity,
mortality, health care utilization, and costs in the presence of comorbidities. [1-4]

Some studies have found that patients with depression have more functional
impairment and poorer quality of life than patients with other chronic illnesses.[5-
7]
Furthermore, severity of depressive symptoms is inversely related to patients'
health-related quality of life, even after controlling for age, sex, and medical
comorbidities.[8,9] Many older persons, however, have more than one chronic
illness that may differentially impair health status. Elders with multiple
comorbidities may be particularly vulnerable to the debilitating impact of
depression. Much of the previous research examining the interconnections between
depression, medical comorbidities, and health status has been conducted in
restricted settings. It is therefore difficult to compare the impact of depression with
that of other chronic medical disorders to inform policy decisions about health care
resource allocation.[8]

Although researchers have increasingly recognized the importance of including

patient-centered measures of health status in outcomes research, a wide variety of
concepts and measures have been used, including quality of life, functional status,
and disability. Because depression and other illnesses may affect multiple
dimensions of health status, simultaneous examination of these may provide a
richer understanding. Using baseline data from an intervention study of 1,801
depressed elders,[16] we examined the association of depression severity and
chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses
with multiple domains of general health status. Our goal was to answer the
following question: among older adults with clinical depression, what is the
relative association of depression severity and chronicity with functional status,
quality of life, and disability compared with comorbid psychiatric illnesses and
coexisting medical illnesses?

1 of 4
Next Page

Latest in Family Medicine/Primary Care

 Anaphylaxis: Early Epinephrine Tied to Fewer Overall Doses

 Maine Mandates e-Prescribing of Controlled Substances
 Release Raises False Alarm Over Hep B Meds and Cancer Risk
 Aspirin May Lower Risk for Bile Duct Cancer
 Healthy Weight, but Expanding Waist Boosts Fatty Liver Risk

Ann Fam Med. 2004;2(6) © 2004 Annals of Family Medicine, Inc.

[ CLOSE WINDOW ]
Table 1. Sample Characteristics (N = 1,801)
Sample Characteristics Mean SE %
Sociodemographic characteristics
Age
≤64 y 23.2
65-69 y 22.5
70-74 y 19.5
5-79 y 20.1
≥80 y 14.7
Sex, female 64.9
Race or ethnicity
White 77.0
African American 12.3
Hispanic 7.6
Other 3.1
Education
Less than high school graduate 19.2
High school graduate or general equivalency diploma 22.7
Some college 35.3
College graduate or graduate degree 22.8
Marital status
Married or living with partner 46.3
Divorced, separated, or never married 28.9
Widowed 24.8
Psychiatric illnesses
Depression severity (0-4), 1.68 0.014

scores indicate

depression
Chronic depression 83.0
Positive screening test for posttraumatic stress disorder 10.6
Positive screening test for panic disorder 21.7
Anxiety-neuroticism, 19.62 0.126

scores indicate

neuroticism
Positive screening test for mild cognitive impairment 35.4
Medical Illnesses
Chronic lung disease 23.3
Hypertension 57.9
Diabetes 23.2
Arthritis 55.6
Sensory deficit 55.2
Cancer (excluding skin cancer) 10.9
Neurological disease 8.4
Heart disease 27.6
Chronic pain 56.8
Gastrointestinal disease 20.9
Urinary/prostate disease 38.7
Sum of all chronic diseases (0-11) 3.79 0.046
General health indicators
PCS-12 (0-100), 40.26 0.150

scores indicate better functioning

MCS-12 (0-100), 36.68 0.235

scores indicate better functioning

QOL (0-10), 5.35 0.047

scores indicate better QOL

SDI (0-10), 4.63 0.061

scores indicate greater disability

[ CLOSE WINDOW ]
Table 2. Bivariate Correlations Between Outcomes (N = 1,801)
MCS-12 (P Value) QOL (P Value) SDI (P Value)
PCS-12 -0.18 (<.001) 0.17 (.397) -0.41 (<.001)
MCS-12 0.26 (<.001) -0.24 (<.001)
QOL -0.30 (<.001)
[ CLOSE WINDOW ]
Table 3. Final Models Predicting Physical Functioning (PCS-12), Mental Functioning
(MCS-12), Disability (SDI), and Quality of Life (QOL) (N = 1,801)
PCS-12 MCS-12 SDI QOL

Scores Indicate Scores Indicate Scores Scores

Characteristics Better Physical Better Mental Indicate More Indicate
 Functioning Health Disability Better
Functioning Quality of
Life
95% 95% 95%
Coeff CL Coeff 95% CL Coeff CL Coeff CL
Intercept 48.23* 45.29, 49.85* 46.80, 1.17† 0.15, 7.99* 7.18,
51.17 52.89 2.19 8.80
Demographics, P value <.001 <.001 <.001 <.001
Age‡ 0.28 1.04 0.07 0.26
Male 0.86† 0.10, -0.17 -0.98, 0.63 0.04 -0.23, -0.41* -0.62,
1.67 0.32 -0.20
Education‡ 3.04† 0.38 0.30 2.29
Ethnic group‡ 3.00† 2.59 0.38 1.52
Marital status‡ 0.46 1.09 0.64 3.54†
Organization‡ 3.79§ 8.02* 3.65§ 2.71§
Psychological, P value <.016¶ <.001¶ <.001¶ <.001¶
Depression severity, -0.26* -1.90, - -3.96* -4.62, -3.29 1.43* 1.21, -1.24* -1.44,
0.63 1.66 -1.05

scores indicate

severity
Chronic depression 0.14 -0.73, -0.40 -1.32, 0.51 -0.07 -0.37, -0.01 -0.24,
1.00 0.23 0.23
Positive screening test for 0.06 -0.95, -0.04 -1.02, 1.09 0.20 -0.16, -0.01 -0.29,
PTSD 1.07 0.56 0.26
Positive screening test for 0.05 -0.75, -0.23 -1.06, 0.60 0.05 -0.23, -0.03 -0.25,
panic 0.84 0.33 0.18
Neuroticism, -0.07† -0.14, - -0.01 -0.08, 0.06 0.003 -0.02, 0.01 -0.01,
0.001 0.03 0.03

scores indicate

neuroticism
Positive screening test for -1.13§ -1.82, - 0.14 -0.58, 0.87 0.44§ 0.20, 0.07 -0.12,
mild cognitive Impairment 0.44 0.68 0.25
Medical illness, P value <.001¶ .447¶ <.001¶ .071¶
Chronic lung disease -1.63* -2.37, - 0.11 -0.66, 0.89 0.42§ 0.16, -0.05 -0.26,
0.89 0.69 0.15
Hypertension -0.99§ -1.64, - -0.28 -0.96, 0.39 0.10 -0.13, -0.02 -0.20,
0.34 0.32 0.16
Diabetes -1.56* -2.33, - -0.27 -1.09, 0.54 0.38§ 0.11, -0.04 -0.25,
0.78 0.66 0.17
Arthritis -2.09* -2.77, - 0.73† 0.02,1.45 0.24 -0.003, -0.13 -0.32,
1.41 0.48 0.06
Sensory deficit -0.43 -1.09, 0.04 -0.65, 0.74 0.14 -0.10, -0.11 -0.29,
0.24 0.37 0.07
Cancer excluding skin -0.92 -1.91, -0.35 -1.39, 0.69 0.13 -0.23, -0.06 -0.33,
Cancer 0.08 0.48 0.22
Neurological disease -1.80§ -2.91, - 0.25 -0.93, 1.42 0.86* 0.47, -0.21 -0.52,
0.69 1.25 0.10
Heart disease -0.99§ -1.71, - -0.61 -1.36, 0.14 0.32† 0.06, -0.80§ -1.39,
0.27 0.57 -0.21
Chronic pain -3.08* -3.78, - -0.01 -0.72, 0.71 0.56* 0.32, -0.02 -0.20,
2.39 0.81 0.17
§
Gastrointestinal disease -1.08 -1.86, - -0.11 -0.92, 0.71 0.12 -0.16, -0.03 -0.24,
0.29 0.39 0.18
Urinary tract or prostate -0.48 -1.15, 0.38 -0.31, 1.08 0.0001 0.24, -0.14 -0.32,
disease 0.19 0.24 0.05
¶
Interactions, P value .021 <.041¶
Depression chronicity X 3.26†
ethnic group‡
Depression severity X 0.35† 0.01,
heart disease 0.68
[ CLOSE WINDOW ]

References