Depression and anxiety with physical illness

Depression alone is debilitating, and this effect is multiplied in people with physical illness

David M Clarke PhD, FRACGP, FRANZCP

Objective: To review the evidence for an association between depression and anxiety and the National Health Priority Area conditions — heart disease, stroke, diabetes mellitus, asthma, cancer, arthritis and osteoporosis — and for the effectiveness of treatments for depression and anxiety in these settings.Data sources: Systematic literature search of systematic reviews, meta-analyses and evidence-based clinical practice guidelines published between 1995 and 2007, inclusive.Data extraction: Each review was examined and summarised by two people before compilation.Data synthesis: Depression is more common in all disease groups than in the general population; anxiety is more common in people with heart disease, stroke and cancer than in the general population. Heterogeneity of studies makes determination of risk and the direction of causal relationships difficult to determine, but there is consistent evidence that depression is a risk factor for heart disease, stroke and diabetes mellitus. Antidepressants appear to be effective for treating depression and/or anxiety in patients with heart disease, stroke, cancer and arthritis, although the number of studies in this area is small. A range of psychological and behavioural treatments are also effective in improving mood in patients with cancer and arthritis but, again, the number of studies is small.Conclusion: The evidence for the association of physical illness and depression and anxiety, and their effects on outcome, is very strong. Further research to establish the effectiveness of interventions is required. Despite the limits of current research, policy and practice still lags significantly behind best evidence-based practice. Models of integrated care need to be developed and trialled.

David M Clarke PhD, FRACGP, FRANZCP · Kay C Currie GradDipAppPsych, BA, MPH

Objective: To compare the mental health and vitality of people caring for a family member with a disability with those of the general population. Second, to identify factors experienced by carers that put them at risk of poor mental health and vitality.Design: Cross-sectional design where logistic and multiple regression analyses were used to compare rates of mental health problems and vitality between carers and the general population while controlling for demographic characteristics. In addition, logistic and multiple regression using data from the survey of carers were used to identify risk factors for poor mental health and vitality that were particular to caregiving.Participants and setting: A randomly selected representative survey of 1002 carers from the Australian Centrelink administrative database (June 2006) who received government payments to care for a person with a disability or severe medical condition, or a person who was frail aged. A sample of 10 223 non-carers was drawn from the fourth wave of the Household, Income and Labour Dynamics in Australia Survey, a nationally representative household panel survey (August 2004 to February 2005).Main outcome measures: Mental health and vitality as measured by the Medical Outcomes Study 36-item Short-Form Health Survey.Results: Compared with the general population, carers were at significantly greater risk of having a mental health problem and lower levels of vitality, even after controlling for demographic characteristics. For carers, the risk factors for poor mental health and lower levels of vitality were caring for a person with a disability with higher care needs, experiencing greater levels of financial stress, lower levels of support and worse family functioning.Conclusion: Carers are at greater risk of mental health problems and lower energy levels than the general population.

Benjamin Edwards BA(Hons), PhD · Daryl J Higgins BA(Hons), PhD, MAPS

Objective: To determine the nature of depressive symptoms in a sample of patients with chronic pain, and to examine the relationship between depressive symptoms and physical disability due to pain.Design, participants and setting: Cross-sectional study of 812 patients with complete datasets from a total of 2419 patients with pain who were referred to the Pain Management Research Institute at Royal North Shore Hospital, Sydney, between January 2000 and December 2007.Main outcome measures: Pain severity and distress, physical disability, depressive symptoms, pain self-efficacy, catastrophising, fear of movement/(re)injury, use of unhelpful self-management strategies, sense of control over life, and perceived support from significant others, assessed by the West Haven–Yale Multidimensional Pain Inventory, modified version of the Roland Morris Disability Questionnaire, the depression subscale of the Depression Anxiety Stress Scales, Pain Self-Efficacy Questionnaire, Pain-Related Self-Statements Scale, Tampa Scale of Kinesiophobia, and Pain Self-Management Checklist.Results: After controlling for the effects of age, sex and duration of pain, depressive symptoms were most strongly correlated with a combination of catastrophising, sense of control over life, physical disability, pain self-efficacy beliefs, higher use of unhelpful self-management strategies and lower perceived social support. Depressive symptoms also correlated with physical disability, but to a lesser extent than other variables, including fear of re-injury, low self-efficacy for activity and pain severity. The depressive symptoms that were rated as most frequently experienced reflected sadness, lack of initiative and lack of ability to experience pleasure.Conclusions: In patients with chronic pain, depressive symptoms are correlated more strongly with cognitive variables than pain severity and pain distress, while physical disability is correlated more strongly with cognitive, behavioural and pain variables than depressive symptoms. Furthermore, depressive symptoms are characterised predominantly by mood-related symptoms, which suggests differences in the experience of depression in patients with chronic pain compared with those presenting with mental disorders.

Michael K Nicholas MPsychol(Clinical), PhD · Carissa M Coulston BSc(Hons), MPsychol(Clinical), PhD · Ali Asghari PhD · Gin Singh Malhi MD, FRANZCP, FRCPsych

Objectives: To examine the relationship between psychological response to injury at 1 week and 3 months, and disability at 12 months.Design: Multisite, longitudinal study.Participants and setting: 802 adult patients admitted to trauma services at four Australian hospitals from 13 March 2004 to 21 February 2006 were assessed before discharge and followed up at 3 and 12 months.Main outcome measure: Disability, measured with the 12-item version of the World Health Organization Disability Assessment Schedule II.Results: Logistic regression identified the degree to which high levels of depression and post-traumatic stress disorder (PTSD) at 1 week and at 3 months predicted disability at 12 months. After controlling for demographic variables and characteristics of the injury, patients with PTSD or subsyndromal PTSD at 1 week were 2.4 times more likely, and those with depression at 1 week were 1.9 times more likely to have high disability levels at 12 months. PTSD at 3 months was associated with 3.7 times, and depression at 3 months with 3.4 times the risk of high disability at 12 months.Conclusions: PTSD and depression at 1 week and at 3 months after injury significantly increased the risk of disability at 12 months. Routine assessment of symptoms of depression and PTSD in patients who have been physically injured may facilitate triage to evidence-based treatments, leading to improvement in both physical and psychological outcomes.

Meaghan L O’Donnell BSc (Hons), MA(Clin), PhD · Alexander C Holmes MMed(Psych), FRANZCP, PhD · Mark C Creamer BA(Hons), MA(Clin), PhD · Steven Ellen MB BS, MD, FRANZCP · Rodney Judson MB BS, FRCS, FRACS · Alexander C McFarlane MB BS(Hons), MD, FRANZCP · Derrick M Silove MD, FRANZCP · Richard A Bryant BA(Hons), MA(Clin), PhD

Objectives: To estimate the prevalence of depression among older Australians with common medical morbidities, and to determine the association between poor physical health and depression in this age group.Design: Cross-sectional, postal questionnaire survey.Setting and participants: 20 183 community-dwelling adults aged 60 years and over, under the care of 383 general practitioners participating in the Depression and Early Prevention of Suicide in General Practice (DEPS-GP) project (conducted between 2005 and 2008; the data in this article were collected during the baseline phase of the study in 2005).Main outcome measures: Depressive symptoms (measured by the nine-item depression scale of the Patient Health Questionnaire), health status (measured by the 12-item Short Form Health Survey and a medical morbidity inventory), social support (measured by the subjective support subscale from the Duke Social Support Index), and demographic and lifestyle information.Results: 18 190 participants (90.1%) reported having at least one chronic physical health condition, while 1493 (7.1%) experienced clinically significant depression (3.1% major depressive syndrome; 4.0% other depressive syndrome). Most chronic physical illnesses were associated with increased odds of depression, and participants with numerous medical morbidities and a high level of functional impairment were three to four times more likely to have a depressive illness.Conclusions: Depression is more the exception than the rule in later life, and among those who are medically unwell, the level of associated impairment may determine their risk of depression more than their acquired physical illness. Many of the factors associated with depression in medically ill patients are amenable to treatment, and GPs are in a unique position to address this important public health issue.

Jon J Pfaff PhD, MSc · Brian M Draper MD, FRANZCP · Jane E Pirkis PhD, MPsych · Nigel P Stocks MD, FRACGP · John A Snowdon MD, FRANZCP · Moira G Sim MB BS, FRACGP, FAChAM · Gerard J Byrne PhD, FRANZCP · Nicola T Lautenschlager MD, FRANZCP · Leon A Flicker PhD, FRACP · Ngaire M Kerse PhD, FRNZCGP · Robert D Goldney MD, FRANZCP · Osvaldo P Almeida PhD, FRANZCP

Objectives: To conduct initial analyses and examine ways in which depression and anxiety are associated with outcomes after participation in the Healthy Living Course (HLC), an early-intervention diabetes prevention program for adults with prediabetes.Design: Randomised controlled study using pre-intervention and postintervention measures to examine relationships between depression, anxiety and diabetes-related program outcomes.Participants and setting: 185 adults from urban and rural Victoria with prediabetes who had completed the HLC program and for whom postintervention measure data were available. Data were collected between 15 June 2006 and 15 June 2008.Main outcome measures: Baseline and postintervention scores on mood (anxiety, depression), biochemical (fasting plasma glucose, oral glucose tolerance), anthropometric (body mass index [BMI], waist circumference), cognitive (self-efficacy, diabetes knowledge) and behavioural (healthy eating, physical activity) measures; correlations between these measures.Results: The intervention alleviated depression, and improved eating patterns and scores on cognitive, anthropometric and biochemical measures. Cultural group and sex did not influence most results. Baseline mood was not associated with anthropometric or biochemical outcomes; however, more positive baseline mood factors were associated with activity changes, and with greater subsequent activity rates, self-efficacy and diabetes knowledge. In turn, baseline self-efficacy was associated with postintervention healthy eating. Changes towards healthier eating correlated with anthropometric and biochemical changes, while baseline cognitive measures were also associated with physiological outcomes. As expected, reductions in BMI and waist circumference were related to biochemical changes.Conclusion: Our findings highlight the importance of assessing mood factors in prediabetes, and the need to develop theoretical models of change mechanisms for mood in health outcomes.

Michael Kyrios BA, MPsych, PhD · Susan M Moore BSc(Hons), MEd, PhD · Naomi Hackworth BSc, BA(Hons), DPsych(HealthPsych) · Simone A Buzwell BA(Hons), PhD · Naomi Crafti BBSc(Hons), DPsych(Counselling) · Christine Critchley BA(Hons), PhD · Elizabeth Hardie BA(Hons), PhD

Objective: To assess the psychological impact of the different treatments for localised prostate cancer (PCA).Design, participants and setting: Observational, prospective study of consecutive patients with PCA attending clinics in public hospitals and private practices in metropolitan Melbourne between 1 April 2001 and 30 December 2005. Data were collected at initial diagnosis of histologically confirmed localised PCA, and close to the commencement of definitive treatment (Time 1), and 12 months later (Time 2). Patients were stratified according to treatment type (radical prostatectomy [RP], hormone therapy [HT] or other early treatment including radiation therapies [OET]). Patients who elected to undergo active surveillance/watchful waiting (WW) rather than active treatment were treated as a naturalistic control group.Main outcome measures: Levels of depression and anxiety were assessed by the Brief Symptom Inventory, and physical and psychosocial aspects of health-related quality of life (HRQOL) were assessed by the 36-item Short-Form Health Survey.Results: 211 patients with PCA were recruited; 193 completed the Time 1 questionnaires (38 RP, 56 HT, 38 OET and 61 WW); and 172 completed the Time 2 questionnaires (33 RP, 51 HT, 33 OET and 55 WW). At Time 1, the three active treatment groups all reported greater dysfunction in work role and daily activities compared with the WW group. The RP group also reported worse social and emotional role functioning, while the HT and OET groups reported poorer vitality levels. The HT group reported significantly higher depression scores. At Time 2, the RP and OET groups did not differ from the WW group on either HRQOL or psychological status. By contrast, the HT group reported significantly worse HRQOL (physical functioning, role-physical and vitality domains) and greater psychological distress compared with the WW group.Conclusions: Compared with the other active treatments for localised PCA, HT appears to be associated with poorer HRQOL and greater psychological distress 12 months after commencing treatment.

Jeremy W Couper MB BS, MMed(Psych), MD · Anthony W Love MA(Clin Psych), PhD · Judith V Dunai MPsych(Clin), PhD · Gillian M Duchesne BSc(Hons), MB ChB, MD · Sidney Bloch MB ChB, PhD · Anthony J Costello MB BS, MD · David W Kissane MB BS, MPM, MD

Assessing and managing depression and other forms of psychological distress in patients with advanced physical illness (such as advanced cancer) can be complex clinical tasks. Assessment of distress is complicated by the contribution of the physical disease and side effects of its treatment to symptoms. Clinical evidence has indentified factors that increase vulnerability to experiencing distress and interventions that can improve wellbeing in patients with serious physical illness, yet there are significant gaps in current practice and challenges for health professionals in addressing the core emotional concerns of patients with advanced physical illness. The 2003 publication Clinical practice guidelines for the psychosocial care of adults with cancer provides evidence-based recommendations for providing psychosocial care. Implementing existing guidelines, including systematic assessment of risk and adapting interventions to reflect the precise needs of patients, requires strategies to help clinicians in the emotional dimensions of this caring role.

Brian J Kelly BMed, FRANZCP, PhD · Jane Turner MB BS, FRANZCP

Objective: To assess the prevalence and predictors of anxiety and depression among a heterogeneous sample of long-term adult cancer survivors.Design and participants: Cross-sectional survey of 863 adults diagnosed with a new histologically confirmed cancer (local or metastatic) between 1 April and 30 November 1997 and still alive in 2002, living in NSW, able to read and understand English adequately, physically and mentally capable of participating, and aware of their cancer diagnosis, who were randomly selected from the New South Wales Central Cancer Registry.Main outcome measures: Prevalence of anxiety and depression assessed by the Hospital Anxiety and Depression Scale; and factors (patient, disease, and treatment characteristics; coping style; social support) predicting clinical or borderline levels of anxiety and depression.Results: Levels of anxiety and depression were low; only 9% of participants reported clinically important levels of anxiety and 4% reported depression. The strongest predictive factors of borderline or clinical anxiety were previous treatment for psychological illness, maladaptive coping styles (helplessness–hopelessness, anxious preoccupation) and poor social support. Borderline or clinical depression was most strongly predicted by previous treatment for psychological illness, being an invalid pensioner, maladaptive coping style (helplessness–hopelessness) and poor positive social interaction.Conclusions: By 5 years after diagnosis, most survivors had adjusted well to their cancer experience, with levels of anxiety and depression similar to those of the general population. Nevertheless, a small and important group of long-term survivors continue to experience adverse psychological effects and need assistance. Monitoring of psychological wellbeing and referring patients when appropriate need to be integrated into routine care for cancer survivors.

Allison W Boyes BA(Psych), MPH · Afaf Girgis BSc(Hons), PhD · Alison C Zucca BA(Psych)(Hons) · Christophe Lecathelinais DESS de Mathématiques Appliquées

Objectives: To assess the prevalence, severity and distress from physical symptoms and the prevalence of anxiety and depression in patients about to undergo chemotherapy for potentially curable cancers; and to explore the presence of symptom clusters and investigate their relationships with anxiety and depression.Design, participants and setting: Cross-sectional survey of 192 patients with breast or gastrointestinal cancers or lymphoma before first ever chemotherapy treatment with curative intent.Main outcome measures: Hospital Anxiety and Depression Scale to assess anxiety and depression and the Chemotherapy Symptom Assessment Scale to measure physical symptom prevalence, severity and distress (“bother”).Results: Prevalence of anxiety was 45% and depression 25%. The most prevalent physical symptoms were pain (48%), feeling unusually tired (45%) and difficulty sleeping (45%). Physical symptoms rated as most severe were pain (28%), difficulty sleeping (26%) and feeling unusually tired (19%). Physical symptoms causing the most distress were pain (39%), constipation (18%) and nausea (16%). Factor analysis of symptom distress scores indicated that five factors explained 36.7% of the variance and included: gastrointestinal (nausea, vomiting, pain), general malaise (tiredness, feeling weak, headaches), emotional (feeling depressed, feeling anxious), nutritional (changes to appetite, weight loss or gain) and general physical (mouth/throat problems, shortness of breath). Regression analysis indicated that symptom distress for the malaise (β = 1.46; P < 0.001), nutritional (β = 0.70; P < 0.05) and gastrointestinal (β = 0.73; P < 0.05) factors were independent predictors of depression.Conclusions: Before commencing chemotherapy, patients are already experiencing distressing symptoms and have high scores for anxiety and depression, partially explained by physical symptom distress. Patients should be routinely screened for both emotional and physical needs and appropriate interventions should be developed.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN012606000178549.

Sibilah J Breen BSc(Hons), PhD · Carl M Baravelli BBSc(Hons) · Penelope E Schofield BSc(Hons), PhD · Michael Jefford MPH, PhD, FRACP · Patsy M Yates RN, MSocSci, PhD · Sanchia K Aranda BApplSci(AdvNurs), MN, PhD