Elsevier

General Hospital Psychiatry

Volume 29, Issue 2, March–April 2007, Pages 147-155
General Hospital Psychiatry

Symptom Research
The association of depression and anxiety with medical symptom burden in patients with chronic medical illness

https://doi.org/10.1016/j.genhosppsych.2006.11.005Get rights and content

Abstract

Background

Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses.

Methods

MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes.

Results

Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures.

Conclusions

Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.

Introduction

Multiple community-based and primary care studies have shown that respondents with DSM-IV anxiety and depressive disorders report significantly higher numbers of medically unexplained physical symptoms compared to those without psychiatric disorders [1], [2], [3], [4], [5]. Studies have also shown a ‘‘dose–response’’ relationship with an increasing number of DSM-IV anxiety and depressive disorders associated with a linear increase in medically unexplained physical symptoms [6], [7].

Far less research has examined the association of comorbid DSM-IV anxiety and depressive disorders with medical symptoms in patients with chronic medical illnesses such as diabetes and cardiopulmonary disease. Limited data have suggested that depression and anxiety may prevent habituation to aversive physical symptoms of chronic illnesses such as pain [8]. Several studies have also reported amplification of chronic disease symptoms in patients with chronic medical illness who have comorbid anxiety or depressive disorders [9], [10], [11].

The purpose of this study was to review existing literature to examine the association of comorbid depression or anxiety with medical symptom burden in patients with arthritis [both rheumatoid arthritis (RA) and osteoarthritis (OA)], diabetes, heart disease [both coronary artery disease (CAD) and congestive heart failure (CHF)] and pulmonary disease [both asthma and chronic obstructive pulmonary disease (COPD)]. These illnesses were chosen because of their high prevalence rate and public health importance with each present in over 12 million Americans [12].

Section snippets

Methods

We searched the MEDLINE database from 1966 through 2006 using the combined search terms of each medical illness (diabetes, CAD, CHF, asthma, COPD, OA, RA) with depression, anxiety and symptoms. Articles were also identified from a manual search of bibliographies from all retrieved articles. Articles were limited to studies reported in English.

Studies were eligible for inclusion if they addressed each medical illness, depression and/or anxiety and physical symptoms. Articles were included if

Results

Thirty-one studies involving 16,922 patients met our inclusion criteria (see Table 1). These included seven studies (n=5943) of diabetes, nine studies (n=2593) of pulmonary disease, nine studies (n=5900) of cardiac disease and six studies (n=2486) of arthritis. The designs included 18 cross-sectional studies, 11 longitudinal studies and 2 randomized trials.

Discussion

Our review found that patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of disease. Across the common medical disorders examined, somatic symptoms, including pain, were at least as consistently and strongly associated with depression and anxiety as were the physiologic measures that are typically felt to be more objective measures of

Acknowledgments

This study was supported by grants from the National Institute of Mental Health to Dr. Katon (MH-067587 and MH-069741) and Dr. Kroenke (MH-071268).

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