Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Unipolar depression in adult primary care patients and general medical illness: Evidence for the efficacy of initial treatments

INTRODUCTION

Depression is highly prevalent. Community surveys in 14 countries have estimated that the lifetime prevalence of unipolar depressive disorders is 12 percent [1]. In patients with general medical illnesses such as diabetes or coronary heart disease, the prevalence of major depression is estimated at 10 to 20 percent [2].

In addition, disability due to depression is common. The World Health Organization ranks unipolar major depression as the 11th greatest cause of disability and mortality in the world, among 291 diseases and causes of injury [3]. In the United States, major depression ranks second among all diseases and injuries as a cause of disability, and dysthymia ranks 20th [4].

Major depression is also highly recurrent. Following recovery from one episode, the estimated rate of recurrence over two years is greater than 40 percent; after two episodes, the risk of recurrence within five years is approximately 75 percent [5].

This topic reviews the efficacy of standard therapies for the initial treatment of depression in primary care patients and in patients with general medical illnesses. The choice of therapy for the initial treatment of depression and the general evidence of efficacy of standard therapies are discussed separately, as are the general principles and prognosis for the initial treatment of depression, and the evidence for therapies that are not typically used. Continuation and maintenance treatment of major depression, the treatment of resistant depression and refractory depression, and the clinical manifestations and diagnosis of depression are also discussed elsewhere.

(See "Unipolar major depression in adults: Choosing initial treatment".)

               

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jul 2014. | This topic last updated: May 21, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Kessler RC, Ormel J, Petukhova M, et al. Development of lifetime comorbidity in the World Health Organization world mental health surveys. Arch Gen Psychiatry 2011; 68:90.
  2. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003; 54:216.
  3. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2197.
  4. US Burden of Disease Collaborators. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA 2013; 310:591.
  5. Solomon DA, Keller MB, Leon AC, et al. Multiple recurrences of major depressive disorder. Am J Psychiatry 2000; 157:229.
  6. Marcus SC, Olfson M. National trends in the treatment for depression from 1998 to 2007. Arch Gen Psychiatry 2010; 67:1265.
  7. Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry 2008; 69:1064.
  8. Mulrow CD, Williams JW Jr, Chiquette E, et al. Efficacy of newer medications for treating depression in primary care patients. Am J Med 2000; 108:54.
  9. Arroll B, Elley CR, Fishman T, et al. Antidepressants versus placebo for depression in primary care. Cochrane Database Syst Rev 2009; :CD007954.
  10. Gartlehner G, Thaler K, Hill S, Hansen RA. How should primary care doctors select which antidepressants to administer? Curr Psychiatry Rep 2012; 14:360.
  11. Ramsberg J, Asseburg C, Henriksson M. Effectiveness and cost-effectiveness of antidepressants in primary care: a multiple treatment comparison meta-analysis and cost-effectiveness model. PLoS One 2012; 7:e42003.
  12. Mitchell AJ. Depressed patients and treatment adherence. Lancet 2006; 367:2041.
  13. Simon GE, VonKorff M, Heiligenstein JH, et al. Initial antidepressant choice in primary care. Effectiveness and cost of fluoxetine vs tricyclic antidepressants. JAMA 1996; 275:1897.
  14. Chong WW, Aslani P, Chen TF. Effectiveness of interventions to improve antidepressant medication adherence: a systematic review. Int J Clin Pract 2011; 65:954.
  15. Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996; 53:924.
  16. Katon WJ, Von Korff M, Lin EH, et al. The Pathways Study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004; 61:1042.
  17. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995; 273:1026.
  18. Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999; 56:1109.
  19. Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:CD006525.
  20. Ciechanowski P, Wagner E, Schmaling K, et al. Community-integrated home-based depression treatment in older adults: a randomized controlled trial. JAMA 2004; 291:1569.
  21. Simon GE, Ludman EJ. Should mental health interventions be locally grown or factory-farmed? Am J Psychiatry 2013; 170:362.
  22. Katon W, Unützer J, Wells K, Jones L. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry 2010; 32:456.
  23. Ekers D, Murphy R, Archer J, et al. Nurse-delivered collaborative care for depression and long-term physical conditions: a systematic review and meta-analysis. J Affect Disord 2013; 149:14.
  24. Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006; 166:2314.
  25. Agency for Healthcare Research and Quality. August 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm (Accessed on June 22, 2013).
  26. Watson L, Amick HR, Gaynes BN, et al. Practice-based interventions addressing concomitant depression and chronic medical conditions in the primary care setting. Comparative Effectiveness Review No. 75. AHRQ Publication No. 12-EHC106-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012.
  27. Dobscha SK, Corson K, Hickam DH, et al. Depression decision support in primary care: a cluster randomized trial. Ann Intern Med 2006; 145:477.
  28. Fortney JC, Pyne JM, Mouden SB, et al. Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: a pragmatic randomized comparative effectiveness trial. Am J Psychiatry 2013; 170:414.
  29. Simon GE, Ralston JD, Savarino J, et al. Randomized trial of depression follow-up care by online messaging. J Gen Intern Med 2011; 26:698.
  30. Bortolotti B, Menchetti M, Bellini F, et al. Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials. Gen Hosp Psychiatry 2008; 30:293.
  31. Wolf NJ, Hopko DR. Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review. Clin Psychol Rev 2008; 28:131.
  32. Cuijpers P, van Straten A, van Schaik A, Andersson G. Psychological treatment of depression in primary care: a meta-analysis. Br J Gen Pract 2009; 59:e51.
  33. Polsky D, Doshi JA, Marcus S, et al. Long-term risk for depressive symptoms after a medical diagnosis. Arch Intern Med 2005; 165:1260.
  34. Taylor D, Meader N, Bird V, et al. Pharmacological interventions for people with depression and chronic physical health problems: systematic review and meta-analyses of safety and efficacy. Br J Psychiatry 2011; 198:179.
  35. Ramasubbu R, Patten SB. Effect of depression on stroke morbidity and mortality. Can J Psychiatry 2003; 48:250.
  36. Barefoot JC, Helms MJ, Mark DB, et al. Depression and long-term mortality risk in patients with coronary artery disease. Am J Cardiol 1996; 78:613.
  37. Jackson JL, DeZee K, Berbano E. Can treating depression improve disease outcomes? Ann Intern Med 2004; 140:1054.
  38. Black SA, Markides KS, Ray LA. Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care 2003; 26:2822.
  39. Katon WJ, Rutter C, Simon G, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care 2005; 28:2668.
  40. Williams JW Jr, Katon W, Lin EH, et al. The effectiveness of depression care management on diabetes-related outcomes in older patients. Ann Intern Med 2004; 140:1015.
  41. Lustman PJ, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000; 23:934.
  42. Lustman PJ, Griffith LS, Clouse RE, et al. Effects of nortriptyline on depression and glycemic control in diabetes: results of a double-blind, placebo-controlled trial. Psychosom Med 1997; 59:241.
  43. Lustman PJ, Griffith LS, Freedland KE, et al. Cognitive behavior therapy for depression in type 2 diabetes mellitus. A randomized, controlled trial. Ann Intern Med 1998; 129:613.
  44. Lustman PJ, Freedland KE, Griffith LS, Clouse RE. Fluoxetine for depression in diabetes: a randomized double-blind placebo-controlled trial. Diabetes Care 2000; 23:618.
  45. Jorge RE, Robinson RG, Arndt S, Starkstein S. Mortality and poststroke depression: a placebo-controlled trial of antidepressants. Am J Psychiatry 2003; 160:1823.
  46. Baumeister H, Hutter N, Bengel J. Psychological and pharmacological interventions for depression in patients with diabetes mellitus and depression. Cochrane Database Syst Rev 2012; 12:CD008381.
  47. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010; 363:2611.
  48. Glassman AH, O'Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002; 288:701.
  49. Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003; 289:3106.
  50. Gill D, Hatcher S. Antidepressants for depression in medical illness. Cochrane Database Syst Rev 2000; :CD001312.
  51. Iovieno N, Tedeschini E, Ameral VE, et al. Antidepressants for major depressive disorder in patients with a co-morbid axis-III disorder: a meta-analysis of patient characteristics and placebo response rates in randomized controlled trials. Int Clin Psychopharmacol 2011; 26:69.
  52. Lespérance F, Frasure-Smith N, Koszycki D, et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA 2007; 297:367.
  53. Wise TN, Wiltse CG, Iosifescu DV, et al. The safety and tolerability of duloxetine in depressed elderly patients with and without medical comorbidity. Int J Clin Pract 2007; 61:1283.
  54. Atlantis E, Fahey P, Foster J. Collaborative care for comorbid depression and diabetes: a systematic review and meta-analysis. BMJ Open 2014; 4:e004706.
  55. Garnefski N, Kraaij V, Benoist M, et al. Effect of a cognitive behavioral self-help intervention on depression, anxiety, and coping self-efficacy in people with rheumatic disease. Arthritis Care Res (Hoboken) 2013; 65:1077.
  56. Herring MP, Puetz TW, O'Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012; 172:101.