During the past 2 decades, a rapidly accumulating body of neurobiologic knowledge has catalyzed fundamental changes in how we conceptualize depressive symptoms in patients with atherosclerotic vascular disease. Buttressing older investigations of type A personality, hostility, and styles of psychological coping are vital, ongoing scientific developments that flow from an increased understanding of the interplay among the immune system, vasculature, and brain. Indeed, the evolving understanding of the interplay between the neurobiology of the stress response, neuroendocrine function, and immunoinflammatory vascular pathways and resulting neurobehavioral symptoms of the heart patient represent a quintessential mind-body interface.
Depressive syndromes and major depression are exceedingly common. The most recent comprehensive studies conducted in the United States, the National Comorbidity Study Replication (NCS-R) and its predecessor, the National Comorbidity Study, reported lifetime and 12-month prevalence rates of major depression1 of 16% and approximately 7%, respectively. Minor depressive disorder (depressive symptoms subthreshold in severity compared with major depression and dysthymia) is also common in the community2 and in primary care clinics.3 The Epidemiologic Catchment Area Study of more than 18,500 individuals reported the lifetime prevalence rate of subthreshold depressive symptoms to be 23% in comparison with 6%, the sum of the prevalence rates of major depression and dysthymia.2 Not only do depressed patients experience greater difficulties in problem solving and coping with challenges, but depression adversely affects adherence to medical therapy4 and rehabilitation,5 as well as the quality of medical care received.6 Minor depressive disorder is also associated with significant functional impairment and substantial increases in healthcare utilization.2 Of note is that point prevalence rates in primary care outpatients range from 2% to 16% for major depression and 9% to 20% for all depressive disorders.7 The rates are even higher among medical inpatients: 8% for major depression and 15% to 36% for all depressive disorders8 (Table 96–1).
Table 96–1. DSM-IV Diagnostic Criteria for Depressive Disorders |Favorite Table|Download (.pdf)
Table 96–1. DSM-IV Diagnostic Criteria for Depressive Disorders
|Major depressive disorder|
|• Five (or more) of the following symptoms have been present during the same 2-wk period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.|
|(1) Depressed mood|
|(2) Markedly diminished interest or pleasure|
|(3) Significant weight loss or weight gain, or decrease or increase in appetite|
|(4) Insomnia or hypersomnia|
|(5) Psychomotor agitation or retardation (observable by others)|
|(6) Fatigue or loss of energy nearly every day|
|(7) Feelings of worthlessness or excessive or inappropriate guilt|
|(8) Diminished concentration or indecisiveness|
|(9) Recurrent thoughts of death (not just fear of dying) or suicide|
|• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.|
|• The symptoms are not because of the direct physiologic effects of a substance or a general medical condition....|
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