Research report
Associations between depression, chronic physical health conditions, and disability in a community sample: A focus on the persistence of depression

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Abstract

Background

Previous research has demonstrated that comorbid depression and chronic physical health conditions are associated with disability. The distinction between persistent and transient depression in the relationship between physical health conditions and disability, however, is poorly understood. The present study examined the interactive effects of major depressive disorder (MDD) and chronic physical health conditions on disability in a community sample; the effects of persistent or transient depression on disability were also examined.

Methods

Participants were from the Epidemiological Catchment Area of Montreal South-West Study (total N=2202). Past 12-month MDD, chronic physical conditions, functional disability, and disability days experienced within the past month were concurrently assessed. A subsample (n=1226) was used to examine the persistence of depression across three waves of data collection over approximately six years.

Results

Individuals with comorbid MDD and chronic physical health conditions were approximately thirteen times more likely to have moderate to severe functional disability and had the highest mean number of disability days compared to those without MDD or a chronic physical health condition. Persistent MDD was most strongly associated with functional disability and disability days, and persistence of MDD interacted with physical health conditions to increase likelihood of concurrent disability.

Limitations

Our study is limited by a single assessment point for disability and chronic health conditions and by the use of self-report.

Conclusions

Our findings suggest that MDD, particularly when persistent, is associated with disability among individuals with a broad range of chronic physical health conditions.

Introduction

Major depressive disorder (MDD) and symptoms of depression are highly prevalent in the general population (Kessler et al., 2009, Kessler et al., 2005) and are particularly prevalent in individuals with chronic physical health conditions (Barnett et al., 2012, Clarke and Currie, 2009, Gunn et al., 2012, Moussavi et al., 2007). The independent associations between chronic physical health conditions (Stewart et al., 1989) and depression (Hays et al., 1995, Kroenke et al., 2007) with disability are well-documented in the literature. Though chronic physical health conditions and depression are uniquely disabling, comorbid depression in individuals with chronic physical health conditions may increase the likelihood of disability.

Many studies have indeed demonstrated that symptoms of depression are associated with reduced functioning (Gili et al., 2013, Ormel et al., 1994), and that individuals with physical health conditions and comorbid depression have an even greater likelihood of functional disability and more disability days than those with neither a physical health condition nor depression (Egede, 2007, Joshi et al., 2014, Katon and Ciechanowski, 2002, Schmitz et al., 2007). The interactive effect of depression and chronic physical health conditions, such as diabetes, heart diseases, migraine headaches, asthma, and back problems, on disability appears to be synergistic (Schmitz et al., 2007), suggesting that the joint effect of depression and chronic health conditions on disability is beyond that of an additive effect.

Chronic or persistent depression may be associated with even higher odds of disability and poor functioning. Chronic depression is a common form of depression that consists of depressed mood for at least two years (Klein, 2010). Chronic depression accounts for approximately 26.8% of depression cases in Canada (Satyanarayana et al., 2009), and similar prevalence rates of chronic depression amongst individuals who are depressed have been reported internationally (e.g., Angst et al., 2009, Eaton et al., 2008, Spijker et al., 2002). Chronic depression is associated with a higher number of medical comorbidities and incapacitating medical diseases, greater health service use, and greater disability than nonchronic depression (Akiskal, 1982, Campayo et al., 2010, Satyanarayana et al., 2009). Similarly, recurrent sub-threshold depressive symptoms are associated with greater disability among individuals with type 2 diabetes compared to individuals with low depressive symptoms (Schmitz et al., 2014). Recurrent sub-threshold depressive symptoms following treatment are also associated with more severe and enduring future depressive episodes over the course of 12 years (Judd et al., 2000). However, to our knowledge, chronic/recurrent and nonchronic/nonrecurrent major depressive disorder (MDD) has not been distinguished in studies of the associations between depression, physical health conditions, and disability among individuals with a broad range of chronic health conditions. In addition, previous research on chronic MDD and comorbid physical health conditions has relied on self-reported duration of the current depressive episode (e.g., Satyanarayana et al., 2009). This assessment may be subject to recall bias, and therefore converging evidence using different methods of assessing chronicity of depressive symptoms, such as the use of repeated assessments of depression, could be informative for the study of the association between depression, chronic illness, and disability.

The aims of the present study were twofold. First, using data from the Epidemiological Catchment Area of Montreal South-West Study, we sought to replicate previous findings by comparing the prevalence of functional disability and disability days in individuals with or without MDD and with or without chronic physical health conditions. We expected that the joint effect of MDD and chronic physical health on functional disability would be synergistic, such that it would exceed the additive effect of MDD and chronic physical health conditions. Second, we aimed to examine the associations between the persistence of depression over three time points and disability, while accounting for chronic health conditions, by identifying individuals who had either persistent depression (MDD present at multiple assessment waves), transient depression (MDD present at one assessment wave), or no depression (MDD criteria not met at any assessment wave). We also examined the interactions between the persistence of depression and comorbid chronic physical health conditions on functional disability and disability days.

Section snippets

Sample

Data for this study were obtained from the Epidemiological Catchment Area of Montreal South-West Study, an ongoing study that examines the prevalence of mental disorders and their interactions with individual and environmental characteristics over time. Data were collected in-person either at the respondent׳s home or at the Douglas Mental Health University Institute by trained interviewers. Institutional ethical approval was obtained for the study and all participants provided informed consent.

Results

Table 1 describes functional disability prevalence, demographic characteristics, and health and lifestyle-related characteristics stratified by MDD/chronic physical health condition comorbidity group (wave 3). Of the total sample included in the present study, 58.6% (n=1290) reported having been diagnosed with a chronic physical health condition by a health care professional. Of those with a chronic physical health condition, 12.6% had diabetes (7.4% of total sample), 27.6% had asthma (16.2% of

Discussion

This study examined the interactive effects of MDD and chronic physical health conditions on functional disability and disability days. The results provide support for a synergistic interaction between MDD and chronic physical health conditions on disability, and suggest that having MDD in addition to a chronic physical health condition increases the likelihood of disability. Specifically, those with comorbid MDD and chronic physical health conditions were approximately thirteen times more

Role of funding source

The study was funded by the Canadian Institutes of Health Research (CTP-79839).

Conflict of interest

None.

Acknowledgments

We would like to thank the CIHR Team in Social and Psychiatric Epidemiology at the Douglas Mental Health University Institute for providing access to the study data.

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