MEDICAL ILLNESS OFTEN is accompanied by clinical depression, although it is not often detected in patients. Recognizing and treating depression along with treating comorbid conditions can improve the quality of life of the patient and improve treatment outcomes. The Erbelding et al article 1 reveals that an alarming proportion of sexually transmitted disease (STD) clinic patients report concurrent symptoms of psychological disturbance. Although this finding is important in supporting increased attention to the mental health of patients within the STD clinic setting, there are several implications drawn from these findings that would benefit from further clarification.
As the authors point out, the instrument used in this study (the 30-item General Health Questionnaire) is a measure of overall mental health and is not condition-specific. Thus, it does not directly measure the prevalence of clinical depression, dysthymia, or bipolar disorder. Rather, the test is designed to identify short-term changes in psychiatric morbidity (including symptoms of depression, anxiety and social dysfunction) that may predict these illnesses. 2 Therefore, although there are high overall levels of psychiatric morbidity among this clinic population, the overall prevalence of depression may be significantly lower than the 39% described. The actual depression levels in this sample, however, do not in any way mitigate the fact that the STD clinic represents an important site for the identification and treatment or referral for treatment of patients with co-occurring psychiatric morbidity.
A central premise of the article is that depression may have an impact on the extent to which a given behavioral intervention program can reduce sexual risk behavior. The hypothesis that persons with depression may benefit less from an intervention makes sense to the extent that they may exhibit a compromised ability to maintain the concentration and effort necessary to process the information provided. 3 It should be noted, however, that the relationship between depression and cognition is believed to be contingent upon the severity of depression. Therefore, there are likely to be wide variations in the extent to which depression would impede the ability to process risk reduction messages.
On the other hand, the psychological factors that are targeted for change in theoretically based risk-reduction programs tend, by nature, to focus on those cognitive and behavioral factors that might be lacking or at lower levels in persons with depression. Successful risk-reduction programs often employ techniques to increase relevant knowledge, encourage positive attitudes toward less risky behaviors, foster self-efficacy and self-esteem, promote supportive norms for behavior change, and provide skills for risk reduction. In the sense that persons with depression exhibit lower preintervention levels of these factors, they may stand to profit most from these programs. This may be true even if they maintain some information processing biases.
The question of whether a clinical diagnosis of depression mitigates the amount of risk reduction following behavioral intervention is an empirical question that has yet to be adequately addressed in the prevention literature. The bottom line is that patients presenting for care at STD clinics are most in need of these preventive services, as they represent a population at higher risk of acquiring HIV, subsequent STD, or of having an unintended pregnancy. At the current time, the US Preventive Services Task Force suggests that there is insufficient evidence regarding the benefits of routine screening for depression in the primary care setting. 4 STD settings, however, may represent a unique opportunity to provide treatment for comorbid mental illness. Thus, the findings of high levels of depression or other mental illness among patients who present for STD care should not drive decision-making regarding the appropriateness of the STD clinic as a venue for behavioral prevention activities. Rather, these results demonstrate the need for ensuring screening, diagnosis, and treatment for mental health issues within these clinical settings, coupled with theoretically driven programs aimed at reducing sexual risk behavior.
1. Erbelding EJ, Hummel B, Hogan T, et al. High rates of depressive symptoms in STD clinic patients. Sex Transm Dis 2001; 28: 281–284.
2. Vieweg B, Hedlund J. The General Health Questionnaire (GHQ): a comprehensive review. J Operational Psychiatr 1983; 14: 74–81.
3. Hartlage S, Alloy L, Vazquez C, et al. Automatic and effortful processing in depression. Psychol Bull 1993; 113: 247–278.
4. US Preventive Services Task Force Guide to Clinical Preventive Services, 2nd ed. AMA Council on Scientific Affairs, 1996.