January 16, 2013

Depression Affects the Patient’s Brain, Body, and Social System

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J. Sloan Manning, MD

University of North Carolina, Chapel Hill, and Moses Cone Family Practice Center, Greensboro, NC


The study of mood disorders over the last decade has improved our understanding of depression in clinically meaningful ways. We tend to think about mood disorders as primarily emotional illnesses. Certainly so, but research is dissolving the boundaries between the brain and the body (see Depression, Pain, and Comorbid Medical Conditions). It can now be said with confidence that mood disorders are inflammatory disorders, too, or at least disorders with significant pro-inflammatory effects. There is strong evidence of a bidirectional impact of the brain on the body and vice versa. Neuroendocrine disruption in the CNS is not isolated to emotional symptomatology; the impact of this brain-body unity is far-reaching. People are whole and must be assessed and treated holistically. People are also connected in social systems, which are themselves impacted by the health of their members.

Physical symptoms are a prominent part of the experience of mood disorders, and mood symptoms often accompany physical illnesses. Conditions often comorbid with depression include obesity, type 2 diabetes, and chronic pain, among others, which leads to several questions:

  • Why did the comorbidity of cardiovascular illness and depression in the Nurses’ Health Study result in a doubling of the relative mortality risk over the presence of cardiovascular illness alone?
  • Why is depression so common in those suffering from rheumatoid arthritis?
  • Why should interferon-alpha (INF-α), used to treat chronic hepatitis C, have adverse effects that include severe major depression?
  • Why is major depression an ominous comorbidity in acute myocardial infarction and such a strong predictor of early mortality?

The brain-body connection and the effect of inflammatory mediators such as INF-α, tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6), among others, may provide answers to these questions.

The search is on for a biomarker that will allow clinicians to track the biochemical presence of major depression and permit treatment to biological remission. Such remission would promote functional wellness and hopefully reduce or extinguish the negative additive health risks resulting from depressive illness.

Until that search is fruitful, clinicians must focus on treatment to symptomatic remission. This is best accomplished by an active approach to management and the use of a validated metric for assessment of symptoms. One would never treat hypertension without measuring blood pressure or treat diabetes without measuring HgbA1c. There are established goals for the treatment of hypertension and diabetes based upon the reduction of risk for morbidity and mortality. By analogy, the utility and necessity of measuring depressive symptoms by some validated metric seems obvious. The goal of symptomatic treatment of depression is to extinguish symptoms completely. Remission is foundational for functional restoration and wellness—both of the individual and his or her social system.

An example of a social system is a mother and her family. One of the most powerful findings to come from the STAR*D studies of major depression documented the effects of residual depressive symptomatology on the children of mothers in the study. Remission of maternal major depression was found to have significant positive effects on the children studied. This seemingly obvious finding nevertheless reminds us that one way to improve the health of children is to target the mental health of mothers. Those of us in family practice who are moving to patient-centered medical homes (PCMH) would do well to consider maternal mental health as a chronic illness condition in meeting the 2011 PCMH standards for inclusion of a behavioral health focus.

The future of depression management may be brightest with the integration of mental health services into the primary care setting. Not mere co-location, the integration of primary care and mental health care is an active, team-based approach that honors the realities and pace of the busy primary care office. While the focus on depressive illness is enhanced through the use of a case manager, patient registry, validated metric tools, and consultation with a mental health expert, the primary care clinician’s principal role as team leader in care decisions is preserved. The IMPACT model, developed and researched by Jϋrgen Unϋtzer and colleagues at the University of Washington, is perhaps the best example of this team approach.

Financial disclosure:Dr Manning has been a consultant for Eli Lilly, Pearson, AstraZeneca, PamLab, Takeda, and Lundbeck and has been a member of the speakers/advisory boards for Eli Lilly and AstraZeneca. ​

Category: Depression , Pain
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7 thoughts on “Depression Affects the Patient’s Brain, Body, and Social System

  1. As a Clinical Psychologist and Neuropsychologist I find that there is a strong link between mood and physical health. Too long has our medical system ignored the link between such things as anxiety and depression and health. A way to reduce overall costs to the system, as well as to patients, is earlier, more effective mental health intervention to help with stress reduction, reduction of mood disorders, and increase positive coping and better life-style habits.
  2. I have suffered much at the hands of many psychiatrists–they told me that my depression was my fault and that it was also my fault that the medications did not work.
  3. I am an RN and a clinically licensed therapist and I have always approached my patients looking through the lenses of brain, body, spirit, social; or maybe one on top of the other…!
    Personally, I don’t know how else to make sense out of the person’s health and to formulate an appropriate treatment plan. I find that sometimes the patients PCP or family practice MD aren’t quite on the same page.
  4. Depression has quite wide spectrum_ feeling depressed for short while on loss/setback; depression as syndrome related to many disorders; the so called major depression. Depression is related to many biochemical changes in brain mainly monoamines (physically speaking) and there are psychosocial theories. Many physical illnesses and substances (therapeutic or recreational) cause depressive illness and many depressed people develop physical illnesses (ignoring self care, their treatment and ? immunological problems). So depression has to be seen from many angles and requires management of depression per se and that of associated physical aspects.
  5. This is absolutely true that the whole person must be treated. To begin, it is often difficult to find the underlying depression, but it may be there whether slight or hidden. Without the talking, the pain cannot go away. This is my experience personally, and in practice with others who are in pain and/or “sad”.
    Pain is nature’s warning system and we must trust it. The proof is often when, upon relieving the pain and having a “good day” or a “pain free” day, realization dawns that this is the goal we have to reach. And we have to find out the who/what/how/when combination so those days happen again and again till we are no longer “sad” or so much.
  6. This is the main reason WHO integrates mental health into primary health care like the WHO mental health gap etc.

    I think we need to train family physicians to screen patients for any co morbid psychiatric illnesses.

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