Depression - Comorbidity

Assessment | Biopsychology | Comparative | Cognitive | Developmental | Language | Individual differences | Personality | Philosophy | Social |
Methods | Statistics | Clinical | Educational | Industrial | Professional items | World psychology |

Clinical: Approaches · Group therapy · Techniques · Types of problem · Areas of specialism · Taxonomies · Therapeutic issues · Modes of delivery · Model translation project · Personal experiences ·

---

Major depression frequently co-occurs with other psychiatric problems. The National Comorbidity Survey (US) reports that 51% of those with major depression also suffer from lifetime anxiety. Anxiety symptoms can have a major impact on the course of a depressive illness, with delayed recovery, increased risk of relapse, greater disability and increased suicide attempts. American neuroendocrinologist Robert Sapolsky similarly argues that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically. There are increased rates of alcohol and drug abuse and particularly dependence, and around a third of individuals diagnosed with attention-deficit hyperactivity disorder develop comorbid depression. Post-traumatic stress disorder and depression often co-occur.

Depression and pain often co-occur; one or more pain symptoms is present in 65% of depressed patients, and anywhere from 5 to 85% of patients with pain will be suffering from depression, depending on setting. There is a lower prevalence in general practice, and higher in specialty clinics. The diagnosis of depression is often delayed or missed, and outcome worse.. To that point, a study by Heim and Nemeroff et al., of Emory University, found that depressed and anxious women with a history of childhood abuse recorded higher heart rates and the stress hormone ACTH when subjected to stressful situations.

Hypomania

Hypomania, as the name suggests, is a state of mind or behavior that is "below" (hypo) mania. In other words, a person in a hypomanic state often displays behavior that has all the earmarks of a full-blown mania (e.g., marked elevation of mood that is characterized by euphoria, overactivity, disinhibition, impulsivity, a decreased need for sleep, hypersexuality), but these symptoms, though disruptive and seemingly out of character, are not so pronounced as to be considered a diagnosably manic episode.

Another important point is that hypomania is a diagnostic category that includes both anxiety and depression. It often presents as a state of anxiety that occurs in the context of a clinical depression. Patients in a hypomanic state often describe a sense of extreme generalized or specific anxiety, recurring panic attacks, night terrors, guilt, and agency (as it pertains to codependence and counterdependence). All of this happens while they are in a state of retarded or somnolent depression. This is the type of depression in which a person is lethargic and unable to move through life. The terms retarded and somnolent are shorthand for states of depression that include lethargy, hypersomnia, a lack of motivation, a collapse of ADLs (activities of daily living), and social withdrawal. This is similar to the shorthand used to describe an "agitated" or "akathitic" depression.

In considering the hypomania-depression connection, a distinction should be made between anxiety, panic, and stress. Anxiety is a physiological state that is caused by the sympathetic nervous system. Anxiety does not need an outside influence to occur. Panic is related to the "fight or flight" mechanism. It is a reaction, induced by an outside stimulus, and is a product of the sympathetic nervous system and the cerebral cortex. More plainly, panic is an anxiety state that we are thinking about. Finally, stress is a psychosocial reaction, influenced by how a person filters nonthreatening external events. This filtering is based on one's own ideas, assumptions, and expectations. Taken together, these ideas, assumptions, and expectations are called social constructionism.

On a final note, researchers at the University of California, San Diego, under the guidance of Hagop Akiskal MD, have found convincing evidence for the co-occurrence of hypomanic symptoms associated with a diagnosis of depression where the diagnosis does not meet criteria for Bipolar Disorder.^{[How to reference and link to summary or text]} Symptoms under consideration, such as irritability, misdirected anger, and compulsivity, also may not present sufficiently to be considered a hypomanic episode, as described by a Bipolar II Disorder. As noted in the Frank study ^{[How to reference and link to summary or text]} mentioned above, this particular course of the disease, with the breakthrough of anxiety, may have a significant impact on the overall course of the depression.

This idea of co-occurring anxiety and depresion is supported in a study by Giovanni Cassano MD of the University of Pisa and his collaborators on the Spectrum Project, who found a correlation between lifetime hypomanic and manic symptoms and the severity of the depression.^{[How to reference and link to summary or text]}

"The presence of a significant number of manic/hypomanic items in patients with recurrent unipolar depression seems to challenge the traditional unipolar-bipolar dichotomy."

These authors, along with many other researchers,^{[How to reference and link to summary or text]} argue in support of a revision of the approach to psychiatric diagnosis into what is being called the mood spectrum, so as to "[make] more accurate diagnostic evaluation[s]." This approach, although controversial, has begun to be given consideration by many behavioral health professionals.

General medical conditions associated with depression

Depression often co-occurs with other serious illnesses, such as heart disease, stroke, diabetes, cancer, and Parkinson's disease. Depression can and should be treated when it co-occurs with other illnesses, for untreated depression can delay recovery from or worsen the outcome of these other illnesses.

• Depression and Cancer
• Depression and Diabetes
• Depression and Heart Disease
• Depression and HIV/AIDS
• Depression and Parkinson's Disease
• Depression and Stroke

• Alcoholism or other substance abuse/dependence
• Endocrinopathies (Cushing's, adrenal insufficiency, hyperparathyroidism, carcinoid)
• Chronic disease (CHF, diabetes, SLE, RA)
• Hypothyroidism
• Infections (hepatitis, mononucleosis, influenza or other viral illnesses)
• Dementia.
• Post-cardiac surgery
• Post-cerebrovascular accident
• Sleep disorders
• Fibromyalgia / Chronic Fatigue Syndrome
• B12 or folate deficiency

Key Texts – Papers

• Roose SP, et al. (2001). Relationship between depression and other medical illnesses. JAMA, 286(14): 1687–1690.