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Depression - Comorbidity

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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.[1] 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.[2] American neuroendocrinologist Robert Sapolsky similarly argues that the relationship between stress, anxiety, and depression could be measured and demonstrated biologically.[3] There are increased rates of alcohol and drug abuse and particularly dependence,[4] and around a third of individuals diagnosed with attention-deficit hyperactivity disorder develop comorbid depression.[5] Post-traumatic stress disorder and depression often co-occur.[6]

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.Cite error: Closing </ref> missing for <ref> tag.. 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, 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.

  • 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

See also


Key Texts – Books

Additional material – Books

Key Texts – Papers

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

Additional material - Papers

  1. Kessler RC, Nelson C, McGonagle KA, et al. (1996). Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. British Journal of Psychiatry 168 (suppl 30): 17–30.
  2. Hirschfeld RMA (2001). The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care. Primary Care Companion to the Journal of Clinical Psychiatry 3 (6): 244–254.
  3. Sapolsky Robert M (2004). Why zebras don't get ulcers, 291–98, Henry Holt and Company, LLC.
  4. Grant BF (1995). Comorbidity between DSM-IV drug use disorders and major depression: Results of a national survey of adults. Journal of Substance Abuse 7 (4): 481–87.
  5. Hallowell EM, Ratey JJ (2005). Delivered from distraction: Getting the most out of life with Attention Deficit Disorder, pp. 253–55, New York: Ballantine Books.
  6. Cite error: Invalid <ref> tag; no text was provided for refs named NIMHPub

External links

Types of depression
Depressed mood | Clinical depression | Bipolar disorder |Cyclothymia | |Dysthymia |Postpartum depression | |Reactive | Endogenous |
Aspects of depression
The social context of depression | Risk factors | Suicide and depression | [[]] | Depression in men | Depression in women | Depression in children |Depression in adolescence |
Research on depression
Epidemiology | Biological factors  |Genetic factors | Causes | [[]] | [[]] | Suicide and depression |
Biological factors in depression
Endocrinology | Genetics | Neuroanatomy | Neurochemistry | [[]] | [[]] | [[]] |
Depression theory
[[]] | Cognitive | Evolution | Memory-prediction framework | [[]] |[[]] | [[]] |
Depression in clinical settings
Comorbidity | Depression and motivation | Depression and memory | Depression and self-esteem |
Assessing depression
Depression measures | BDI | HDRS | BHS |CES-D |Zung |[[]] |
Approaches to treating depression
CAT | CBT |Human givens |Psychoanalysis | Psychotherapy |REBT |
Prominant workers in depression|-
Beck | Seligman | [[]] | [[]] |
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