CoOccurrence of Depression and Medical Illness

It is often assumed that if a patient is depressed after a serious medical event, then the depression must be due to the medical event. In many cases, however, the patient was already depressed when the event occurred and/or had a prior history of depressive episodes. For example, 44% of patients who met the criteria for major depression after being diagnosed with CHD had had a prior major depressive episode (Freedland, Carney, Lustman, Rich, & Jaffe, 1992). This is not surprising, in that the incidence of depression rises sharply in adolescence and early adulthood (Kessler et al., 2003), many years before the usual onset of most chronic illnesses. CHD, for example, usually appears after age 50 in men and age 60 in women (American Heart Association, 2004).

Depression may also precede major medical events, such as stroke, because it is a risk factor for them (Larson, Owens, Ford, & Eaton, 2001). Conversely, stroke patients are also at high risk for depression (Whyte & Mulsant, 2002). Patients can also become depressed before, during, or after a major medical event for reasons having little or nothing to do with the medical illness.

It is important to assess the course of the patient's depression and compare it to the course of his/her medical illness, and to determine whether this is the latest in a series of recurrent depressive episodes or the patient's first. A major medical event, such as the diagnosis of cancer, can precipitate a depressive episode even in patients who have never been depressed before, but such salient stressors can overshadow equally important diatheses. Cerebrovascular disease, for example, may have an etiological role in late-onset depression, even when the depression seems to have been precipitated by an unrelated medical event (Krishnan, Hays, & Blazer, 1997). Although the efficacy of CT for vascular depression has not been studied, it would be surprising if it were as efficacious for vascular depression as it is for the more common forms of depression that affect younger individuals. Clinical trials of antidepressants for patients with vascular depression have found these patients do not respond as well as other depressed patients (Kales, Maixner, & Mellow, 2005). Thus, it is not safe to assume that CT is necessarily be easier to administer or more efficacious for medical patients who are having their first depressive episode than for those who have struggled for years with chronic or recurrent depression.

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