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Clinical Topics

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What is the relationship between common illnesses and depression? And why is the relationship so strong? What can clinicians do now to manage both the medical illness and the depression?

Here to shed light on the bidirectional relationship between the brain and other organs and the common biologic processes that affect all organs is Andrew J. Cutler, MD, who is board-certified in internal medicine and psychiatry. Dr Cutler is on the clinical faculty in the 

Department of Psychiatry at the University of Florida

. He is also CEO and Chief Medical Officer of the 

Some key points addressed in this podcast:
• People who have chronic conditions, such as heart disease or diabetes or RA, are at risk for depression. What’s underappreciated is that this is not a reactive depression: the same biologic conditions that cause the primary medical condition can also cause changes in the brain that can trigger the depression. Thus, there is a need to screen for depression in patients with chronic illness. Aggressive management of the underlying medical illness can help prevent or diminish depression.
• Conversely, aggressive management of depression can decrease the risk of a variety of medical illnesses.
• In the context of a 10-minute office visit in a patient with a chronic illness, screening tools to identify the likelihood of depression can be administered in the waiting room.
• Commonly available tools to monitor for depression include measurement CRP: if the CRP level is elevated, it signals that the patient is overproducing cytokines-a marker of inflammation and a risk factor for depression.
• Effective antidepressant therapy can sometimes reduce CRP levels.
• There is a strong association between inflammation and various medical conditions. For example, people who are overweight or obese have elevated markers of inflammation. Abdominal fat causes inflammation, which may explain the relationship between obesity and depression.
• Inflammation can prevent neurogenesis and can be toxic to nerve cells. Thus, unmanaged inflammation can “stun” the brain.
• Readers are referred to a study by 

, which showed that the TNF antagonist infliximab may improve depressive symptoms in patients with high baseline inflammatory biomarkers.

What is the relationship between common illnesses and depression? And why is the relationship so strong? What can clinicians do now to manage both the medical illness and the depression?

Managing Physical Illness and Depression

Many people with arthritis also have depression; this has been known for many years. Now it has been established that anxiety is even more common than depression among arthritis patients, in a study published in 

by authors from the Centers for Disease Control and Prevention. In this podcast, Dr. Elizabeth Lin (who was not involved with the CDC study, but has focused on comorbid depression and pain for many years) discusses  why and how the mental health problem  as well as the physical symptoms need to be addressed and resolved. 

Dr. Lin is a family medicine physician at Group Health Institute and clinical professor of psychiatry at University of Washington Medical School in Seattle.



 1. What's new about this study?
 2. Could you tell us a little bit about how the study was done and what you think of the results?
 3. What do you think doctors should do to assess their patients who have arthritis or anxiety or depression or both?
 4. What about the risk of interactions between the two drugs? Isn't it difficult to treat patients with drugs that affect their mood as well as drugs that affect their pain?
 5. Do you think that when it comes to treating these mood disorders it would be wise to refer to a mental health professional?
 6. What about followup? How frequently should a patient who has this comordibity be seen in the office?  

Arthritis, Anxiety, and Depression: Managing a Common Comorbidity

Anxiety is more common than depression among US adults with arthritis 

Generalized Anxiety Disorder 7-item scale (GAD-7)  

Effect of improving depression care on pain and function among older adults with arthritis: A randomized controlled study. 

Pharmacotherapy of pain in depressed older adults. 

Arthritis pain and disability:  Response to collaborative depressive care. 

Anxiety is even more common than depression among people who have arthritis, a new study has shown. Here to discuss the implications for diagnosis and treatment is  Eilzabeth Lin MD, a family medicine physician who is a longstanding researcher in the field of depression and pain.

Podcast:  Arthritis, Anxiety, and Depression: Managing a Common Comorbidity

Dark chocolate just got another green light. Building on research that has linked chocolate consumption to improved blood pressure, insulin sensitivity, and cholesterol levels, a new study finds that more frequent consumption of the flavinoid-rich sweet is also associated with lower body mass index (BMI). As reported in a March issue of the 

, the positive association remained after adjustment for age and sex, intake of calories and saturated fat, mood, and activity level.

Among more than 1000 men and women aged 20 to 85 years who had no known cardiovascular disease or diabetes, frequency of chocolate consumption was associated with greater intake of calories and saturated fats and higher depression scores (CES-D); (

 <.001 for each association); these all related positively to BMI. Chocolate consumption frequency was also associated with lower BMI (unadjusted 

Can you now recommend that daily dose of chocolate and “do no harm?” Is all chocolate fair game? How much “good chocolate” is enough? What is the relationship between the fat and calories in chocolate and health benefits?

Here to put this issue into perspective are Drs Christopher Cannon and Payal Kohli. Dr Cannon, a senior investigator with the TIMI Study Group, is editor-in-chief of 

. He is also Professor of Medicine at Harvard Medical School and Associate Physician in the Cardiovascular Division of Brigham and Woman’s Hospital in Boston. Dr Kohli graduated from Harvard Medical School and completed her internal medicine training in Boston and is scheduled to start her fellowship in cardiovascular medicine at the University of California San Francisco in June 2012.

Podcast: More Frequent Chocolate Consumption Linked to Lower BMI

•  Flavinoids are the active ingredient in dark chocolate and exert their positive effect on vascular and platelet function by increasing nitrous oxide availability, thereby decreasing oxidative stress

•  Dark chocolate contains more flavinol than either milk chocolate or white chocolate and therefore less milk fat and fewer calories

•  The recommended “dose” of dark chocolate is approximately 30 to 60 g/d


Golomb BA, Koperski S, White HL. Association between more frequent chocolate consumption and lower body mass index. 

Are these findings another green light for dark chocolate? Some experts say “yes” as they also point to a recommended upper daily “dose.” What does this new research add to the current data on the health benefits of the flavinoid-rich sweet? Drs Payal Kohli and Christopher Cannon discuss study results and what you should tell your patients.

Podcast: A Therapeutic Primer for Primary Care Physicians: The Value of Talk - Part 3: Anxiety, Major Depression, Bipolar Disorder

Depression

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