Am. J. Respir. Crit. Care Med., Volume 163, Number 2, February 2001, 306-308
Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, Divisions of Geriatrics and Neuroscience, Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, Seattle, Washington
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Sarcoidosis is a multisystem disease that commonly involves the pulmonary, cutaneous, and ocular systems, but can also affect many other systems, including the liver, heart, and nervous system (1). While sarcoidosis can be a mild and self-limited disease, it can be chronic, progressive, and even life-threatening in its more severe forms and can have profound effects on functional status and quality of life (2, 3). In this issue of the American Journal of Respiratory and Critical Care Medicine (pp. 329-334), Chang and colleagues highlight another way sarcoidosis can affect the lives of patients: it is associated with a highprevalence of depressive symptoms (4). These investigators conducted a cross-sectional study of 154 patients with sarcoidosis at six tertiary care centers in the United States. Of the 144 for whom depression-screening data were considered adequate for analysis, 60% scored above the authors' cutoff for ''clinical depression'' on an abbreviated form of an established instrument, the Center for Epidemiologic Studies Depression scale (CES-D). This high prevalence of depressive symptoms is an important finding, but should be put into context.
First, are the depressive symptoms identified by the CES-D indicative of a clinical depressive disorder that requires further evaluation and treatment? As Chang and colleagues point out, patients who screen positive on the abbreviated CES-D do not necessarily have a DSM-IV-defined major depressive illness. This adaptation of the CES-D has not been validated against formal diagnostic criteria for depression and, of the 11 items included, 5 encompass constitutional symptoms common to patients with sarcoidosis. Therefore, the results cannot be assumed to reflect the proportion of patients who require either antidepressant or psychotherapeutic treatment. Nonetheless, the high prevalence of depressive symptoms is an important finding relevant to clinicians caring for patients with sarcoidosis.
Second, how does this prevalence of depression compare with prior studies? In the only prior report on depression in sarcoidosis, Drent and colleagues found a substantially lower prevalence of depression among 64 patients identified from eight hospitals in the Netherlands (2). This study used a different screening instrument, the Beck Depression Inventory, and found the prevalence of depression to be 18%. The difference in prevalence between the two studies may be explained by several factors. The patients studied by Drent and coworkers had fewer sarcoidosis-related symptoms and no significant medical comorbidities, whereas those studied by Chang and colleagues had more sarcoid-related symptoms and included patients with comorbid conditions. Also, as Chang and colleagues point out, socioeconomic status and access to healthcare differ between the two samples. The United States sample included a substantial proportion of socioeconomically disadvantaged and medically underinsured persons who reported difficulties in accessing health care and these perceived barriers were bly associated with depressive symptoms.
Third, does sarcoidosis cause depression? While the answer to this question is not known, several potential pathogenic pathways deserve further study. These include the effect of sarcoidosis on functional status and quality of life that could lead to depressive symptoms, as well as direct effects of sarcoidosis on the central nervous system. Direct neurological effects of sarcoidosis canresult from hypercalcemia associated with abnormal vitamin D metabolism (5) and from central nervous system granulomas and inflammation (6). In addition, as many as 80% of patients with sarcoidosis have some cerebrospinal fluid abnormality, indicating CNS involvement in a majority of patients, although the clinical and pathological significance of these findings is not known (7). It is likely that neurosarcoidosis is frequently unrecognized, and the suggestion that acute neurosarcoidosis may be especially responsive to treatment (6) highlights the importance of examining CNS involvement as a potential cause of depressive symptoms. Other chronic pulmonary diseases, such as chronic obstructive pulmonary disease (COPD), affect brain function, and there is emerging evidence that depression may be one clinical manifestation of these effects (8).
One of the most interesting findings in the report by Chang and colleagues is the b inverse relationship between the patients' perceived access to health care and depressive symptoms. These authors developed a new questionnaire to assess patients' perceived access to health care. In a multivariate analysis, accessto health care remained the major predictor of depressive symptoms after controlling for race, income, and symptoms of sarcoidosis. Although this new questionnaire performed well, it is important in this study to acknowledge that depression may alter perceptions of patients concerning their access to care. Nonetheless, the authors are to be congratulated for taking on the important and difficult issue of access to health care as a predictor of depression.Access to care and socioeconomic status have been associated with depressive symptoms in patients with other chronic diseases (9) and access to care and health insurance have been associated with health status and survival in patients with chronic pulmonary diseases (12, 13). With mounting evidence that limited access to health care results in reduced quality of life and functional status, the pressure rests on health care organizations, health services researchers, and policy makers to find ways to improve access to comprehensive health care for all.
What are the clinical implications of the studies of depressive symptoms in patients with sarcoidosis? Despite the prevalence of depressive symptoms, it remains to be determined how often these symptoms reflect a depressive illness for which explicit treatment will improve patient symptoms and quality of life. Severalstudies have shown a high level of depressive symptoms among patients with COPD (14), and one suggests a positive relationship between the severity of depression and the severity of COPD (8). Although it is not clear that patients with COPD have a higher prevalence of depression than patients with other chronic diseases (18), it is clear that depressive symptoms are present in a large proportion of patients with COPD. A randomized controlled trial of antidepressants in patients with COPD formally diagnosed with major depression showed important improvements in depressive symptoms and quality of life (19). Furthermore, evidence suggests that treating depression in the primary care setting can prevent unnecessary hospitalizations and reduce health care costs (20). Further studies are needed to determine the effectiveness of diagnosing and treating depression in patients with sarcoidosis. In the meantime, clinicians who care for these patients should look for evidence of depression and consider a therapeutic trial of antidepressants and/or psychological interventions when significant depressive symptoms are identified. Furthermore, clinicians must work to increase access to healthcare as part of a comprehensive approach to disease management if they are to maximize the health status and quality of life of their patients.
Acknowledgments: Supported by grants from the Department of Veterans Affairs (Merit Review), the National Institute of Environmental Health Sciences (ES07498 and ES09607), and the National Heart, Lung, and Blood Institute (HL62628 and HL64855).
Supported by the National Institutes of Health (RO1-HL64937, RO1-HL 58115, and P6-HL58418; to B.A.F.), the American Heart Association (J.P.E.), and the Deutsche Herzstiftung (S.B).
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