14 Both genetic predisposition and exposure to childhood adversity, such as physical or sexual abuse, have been shown to be vulnerability factors for development of depression.15 Stressful life events are more likely to precipitate initial episodes of depression in patients with one or more of these vulnerability factors.16 In addition, exposure to childhood adversity may lead to maladaptive attachment patterns which may result in lack of social support and problems with interpersonal relationships. This lack of support can also precipitate or worsen depressive episodes.17,18 Maladaptive attachment Inhibitors,research,lifescience,medical may also affect the quality of the doctor-patient relationship – as reviewed below.

Both childhood adversity and development of depression in adolescent or early adult years

are also associated with adverse health behaviors such as poor diet, Inhibitors,research,lifescience,medical obesity, sedentary lifestyle, and smoking , which increase the risk of development of diabetes and CVD.11,19,20 These behaviors add to biological factors that have been shown to be associated with both depression and childhood adversity, such as high cortisol levels or increased profind more inflammatory factors that may lead to early development of chronic medical disorders such as diabetes or CHD. Once people develop chronic medical illness, comorbid depression is associated with increased symptom burden21 Inhibitors,research,lifescience,medical and additive functional impairment.22 The aversive symptoms Inhibitors,research,lifescience,medical and functional impairments associated with chronic medical illness may also precipitate or worsen major depression. Comorbid depression may also worsen the

course of chronic medical illness because of its adverse effect on adherence to self-care regimens (diet, exercise, cessation of smoking, taking medications as prescribed)23 and Inhibitors,research,lifescience,medical direct pathophysiological effects on inflammatory and metabolic factors, hypothalamic pituitary axis and autonomic nervous system.24 The effects of these risk factors may be buffered by social and environmental support and access to quality mental health and physical health care. Figure 1. Bidirectional interaction between depression and chronic medical disorders. Reproduced from ref 14: Katon WJ. Clinical and health services relationships between second major depression, depressive symptoms, and general medical illness Biol Psychiatry. 2003;54:216-226. … Patient-physician relationship Managing chronic illness often requires close collaboration between patients and physicians as well as patients and family members. Primary care physicians rate patients with depression as more difficult to evaluate and treat compared with patients without affective disorders.25 Patients with depression make approximately twice as many health care visits – often for vague physical symptoms – but also miss more visits.