Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being

The article by Noel et al. reinforces our current literature that depression is under-diagnosed and under-treated particularly in our older patients. I commend the group on their objective research and like other reviewers I agree that the 15-20 minute appointment for many of our patients does not allow the adequate time to address multiple illnesses and counsel regarding depression. We have to find a way in our busy practices to address and treat a patient’s medical illness and the psychological pathology that affects the patient and their potential for recovery. Without fair reimbursement for the time necessary to address these multiple issues we are limited in what we can do for our patients. Although counseling of patients can be billed for - I find that in many cases referral to a qualified therapist or psychiatrist in addition to medication (in some cases) for depression has worked best.

Competing interests:   None declared

Great data set! I can't wait to see the results of the RCT.

I'm concerned in the present analysis that you are comparing the effects of untreated depression with those of treated, primarily stable chronic medical problems, on health status and QOL. Is that fair? I would think that newly diagnosed diabetes might have a similar or greater impact on these outcome measures and that severity of diabetes symptoms would also correlate with worse health status and QOL.

I'm also a little concerned about the number of comparisons that you have made and wonder whether the p-value should have been adjusted to reduce the opportunity for type 1 errors.

Competing interests:   None declared

The finding by Noel and colleagues concerning the impact of depression severity on quality of life, functioning and disability underscores two important issues facing the organization and delivery of primary care services today. First, depression is often under-recognized in primary care settings, not because primary care clinicians lack the knowledge or feel that it is unimportant, but because multiple competing demands during the primary care encounter often overwhelm the clinician. The effect of competing demands on recognition and adequate treatment of depression in the primary care setting was well-documented by Rost, Nutting and colleagues.(1,2 ) Moreover, Redelmeier and colleagues found that in patients 65 years of age and older with one or more chronic illnesses, unrelated medical disorders often go untreated.(3) In our own recent research on the content of visits by patient with type 2 diabetes to primary care clinicians, we found that during the average visit, 15.5 topics were discussed in 17.5 minutes.(unpublished)

Second, providing adequate treatment of depression in the primary care office setting is often complicated by organizational and system issues. Many third-party payers now have mental health ‘carve-outs’ that result in denials of payment to primary care clinicians for treating depression.(4) Patients with multiple chronic illnesses may already have consultations with various specialists for their other illnesses. To require another referral and consultation for treatment of their depression may further complicate their lives and add an additional “competing demand.” Furthermore, follow-up visits for depression care in patients with multiple other chronic illnesses are again complicated by the same multiple competing demands that interfere with recognition of the depression in the first place.

Improvements in the quality of life experienced by patients with multiple chronic illnesses may require a restructuring of the manner in which primary care is delivered to these patients.(5) Unfortunately, there are little or no financial incentives for most primary care practices to engage in efforts that require additional resources such as use of a nurse case manager. In their commentary on “A Primary Care Home for Americans” Grumbach and Bodenheimer concluded that “…primary care physicians need a new environment in which to work, a climate less permeated with stress and overwork…that is intertwined with systems of care that improve access and quality while they relieve physicians’ work load.”(6) The Future of Family Medicine Project sponsored by the American Academy of Family Practice is an important step in that direction. The on-line supplement to this issue of the Annals of Family Medicine about “New Models of Care in Family Practice” is one example of the type of work that needs strong support from family physicians across the country.(7) Developing these new models of care may be important not only for improving the quality of life of our patients with depression, but also our own quality of life as family physicians.

Michael L. Parchman, MD, MPH Associate Professor Department of Family & Community Medicine University of Texas Health Science Center, San Antonio

References 1.Rost K, et al The role of competing demands in the treatment provided to primary care patients with major depression. Arch Fam Med 2000;9:150-154; 2.Nutting P, et al. Competing demands from physical problems: Effect on initiating and completing depression care over 6 months. Arch Fam Med 2000;9:1059-1064 3.Redelmeier DA, et al. NEJM 1998;338:1516-1520 4.Moore KJ. Fam Pract Management 2004;11:23. 5.Rost K, et al. Managing depression as a chronic disease: a randomized trial of ongoing treatment in primary care. BMJ 2002;325:934-940. 6.Grumbach K, Bodenheimer T. A primary care home for Amercians: Putting the house in order. JAMA 2002;288:889-893. 7.Michener L. New models of care in family practice. Ann Fam Med 2004;2:613.

Competing interests:   None declared

This article presents important information about the relative contribution of depression severity and medical comorbidities to measures of physical and mental functioning, disability and quality of life in a sample of elderly depressed patients. Depression severity explains more of the decrements in mental functioning, disability and quality of life than do coexisting medical illnesses. Perhaps not unexpectedly, coexisting medical conditions explain more of the decrements in physical functioning. These are important findings for primary care providers to consider since effective treatments are available for depression, while most of the chronic medical illnesses examined can be managed but not eliminated by treatment. Thus, primary care physicians treating older patients should be on the lookout for depression in their patients with chronic medical illnesses. The low rates of detection in such patients may be due to the perception by patients and/or providers that recovery from depression is a low priority relative to recovery from chronic medical conditions. However, these results as well as others pertaining to patient utility and preferences suggest that depressed patients have a strong desire to recover from depression. Thus, quality improvement programs and patient education about depression are important steps toward improving patient’s quality of life.

Competing interests:   None declared

Dr. Noel et al's report on the severe impact of late life depression on quality of life is timely. Depression's impact is likely partly due to its chronic nature of relapse, remission, partial response and recurrence. The severity of impact, particularly compared to other chronic illnesses, forces us to confront this illness aggressively.

The IMPACT, PROSPECT, and PRISMe trials(ref 2-3) all demonstrate the effectiveness of integrating depression care with primary care using care management and a systematized approach. The primary care setting remains the place the vast majority of elderly (>90%) seek and are comfortable with their mental health care.

Our office has had success achieving similar response rates to IMPACT (@50% of patients achieving >50% improvement in severity score) using "The Chronic Care Model" to promote system change in delivering care: using a standardized severity score (PHQ-9 of PRIME-MD), monitoring outcomes, feeding data back to providers and teams of care, and constantly trying PDSA cycles (Plan, Do, Study, Act) to effect change.

I have come to think of comorbid psychiatric illness (particularly depression) and other chronic medical illness (DM, COPD, CAD, CHF, Cancer....) as the "Dual Diagnosis" of the 21st century. Poorly controlled depression markedly impacts other chronic illness and vice versa. Lack of treatment of either, impacts ability to achieve response to treatment for either disease. Single (or simplistic) models or guidelines can fail (ie recent failure of citalopram to show any impact on late life depression (ref #1)). Good care is achieved with the patient at the center, not the disease. Some of the best treatments improve the outcomes for the vast majority of chronic medical illnesses as well as depression (positive self care, social interaction, exercise, diet, pleasurable activities, stress management, medication adherence...- ref#4).

Using systematized approaches to support providers to take the time to appropriately screen, diagnose, treat and refer, with particular emphasis on individual self care, clearly leads to improved quality of live for patients as well as significantly improved patient-provider relationships and satisfaction.

References 1. Am J Psych. 2004;161:2050-2059 2. JAMA 2002; 288:2836-2845. 3. JAMA 291(9):1081-91, 2004 4. JAMA 2004;291:1569-1577, 1626-1628

Competing interests:   None declared

These investigators are to be applauded for their enormous effort and statistical presentation. Psychometric studies are usually difficult and ethereal in their methods and conclusions. The authors, with this exceptionally sufficient study sample, undertake an intricate topic in trying to “compare the relative association of depression severity and chronicity with functional status, quality of life, and disability compared with comorbid psychiatric illness and coexisting medical illnesses”.

The significance of this type of research is the questions it raises and the evolving elucidation of clinical relevance and utility. Numerous prior studies have indicated that depression is negatively associated with general health indicators1 and have documented that physicians do not provide preventive care at the level recommended by national organizations2. Therefore, I wonder what the authors are saying. Does their conclusion indicate some form of depression screening should be performed as part of any "intake information" collected when patients report medical problems that are severe enough to require a physician's visit?

Further development of this significant project might include investigating the two unexpected findings. First, why is the quality of life improved as the depression severity increases in patients with heart disease (goes against intuitive thinking and requires explanation)? For example, does the disease attract increased support? It has been shown that, “A history of major depression is a potent independent predictor for the future risk of CHD events, with an odds ratio of approximately 6.0, placing it among the strongest of cardiovascular risk factors. Depression has been associated with elevated resting heart rate, decreased heart rate variability, impaired vagal control, and elevated levels of plasma norepinephrine, suggesting chronic inappropriate activation of the sympathetic nervous system.3”

Secondly, missing is exploration into why African-Americans with chronic depression have better mental health functioning than other groups. For example, could there be something in their lives providing them with coping mechanisms? Might this group have minimized their symptoms? In view of recent controversies over race based care this topic takes on new meaning and should be advanced.

Detailing the Measures in a research journal is appropriate. Unfortunately, in my opinion, this technically complex article struggles to find its clinical assessment and meaning in the broad stream of family medicine literature. This study does not appear to control for prior level of functioning, physical impairment or illness experience. Self reporting and describing only post depression experience could weaken final conclusions. How were participants functioning prior to the study? Researching and discussing the level/degree of depression would provide important insight i.e. how far each individual had to go to end their depression? Was the depression pre-existing or was it related to physical illness?

Not directly addressed in this manuscript, but revealed between the lines, is how complicated the industrious practice of primary care is. The authors delve into that mysterious arena of why primary care providers continually fail to fully recognize depression but leave the reader hanging. Can we trust family physicians to diagnose and treat these indexed patients? Expanding on this would add needed clinical relevance to their investigation. Other areas that might be extended include: discussion of clinical solutions (i.e. chronic pain appears to be the key indicator). Discussing how the concept of severity was operationalized would be helpful.

The effort invested in the study is significant; however what useful new clinical information is elucidated, in my opinion, remains to be established. I anticipate this endeavor is a beginning.

Lawrence I. Silverberg, DO

1. George A. Gates, MD; Michael Murphy, MD; Thomas S. Rees, PhD; and Arlene Fraher, MA. Screening for handicapping hearing loss in the elderly. The Journal of Family Practice • January 2003 • Vol. 52, No. 1

2. Marjorie A. Bowman, MD, MPA; Mark Dignan, PHD, MPH Sonia Crandall, PHD; AND MONIKA BAIER, MS. Changes in functional Status Related To health Maintenance Visits To Family Physicians. J Fam Pract 2000; 49:428-433

3. Curtis, Brian M. MD; O'Keefe, James H. Jr MD. Autonomic Tone as a Cardiovascular Risk Factor: The Dangers of Chronic Fight or Flight. Mayo Clinic Proceedings. Vol 77(1) January 2002 pp 45-54.

Competing interests:   None declared