Depression Research and Treatment

Depression Research and Treatment / 2014 / Article

Research Article | Open Access

Volume 2014 |Article ID 828965 |

Esme Fuller-Thomson, Marla Battiston, Tahany M. Gadalla, Yael Shaked, Ferrah Raza, "Remission from Depression among Adults with Arthritis: A 12-Year Followup of a Population-Based Study", Depression Research and Treatment, vol. 2014, Article ID 828965, 6 pages, 2014.

Remission from Depression among Adults with Arthritis: A 12-Year Followup of a Population-Based Study

Academic Editor: Janusz K. Rybakowski
Received30 Jul 2013
Revised27 Oct 2013
Accepted29 Oct 2013
Published27 Jan 2014


Individuals with arthritis are vulnerable to depression. In this study, we calculated time to remission from depression in a representative community-based sample of depressed Canadians with arthritis who were followed for 12 years. We conducted secondary analysis of a longitudinal panel study, the National Population Health Survey, which was begun in 1994/95 and has included biennial assessment of depression since that time. Our analysis focused on a total of 216 respondents with arthritis who were depressed at baseline. The mean time to remission from depression was calculated using the Kaplan-Meier procedure and compared across categories of each of the potential predictors. The percentage of those no longer screening positive for depression was calculated at two years after baseline. At two years after baseline, 71% of the sample had achieved remission from depression. Time to remission was significantly longer for those depressed adults who were under the age of 55, those who reported more chronic pain at baseline, those with comorbid migraine, and those who experienced childhood physical abuse or parental addictions. These findings highlight the importance of screening for these factors to improve the targeting of interventions to depressed patients with arthritis.

1. Introduction

Arthritis and associated conditions affect one in five adult Americans and approximately half of older adults [1]. Individuals with arthritis are particularly vulnerable to depression [2]. A study of community-dwelling Canadians showed that those with arthritis had twice the odds of depression in comparison to their peers without arthritis [3]. Depression among individuals living with arthritis may have many negative outcomes including increased functional disability [4], increased absenteeism [5], lower adherence to medical recommendations for treatment [6], and a higher prevalence of suicidal ideation in comparison to those with arthritis who are not depressed [3].

The literature identifies several factors which are associated with depression among those diagnosed with arthritis. Individuals with arthritis who are younger [7], single [7], and female [7, 8] and those who are poorer [7] have an increased prevalence of depression. People with higher levels of physical disability and pain [3, 9, 10] as well as individuals who identify daily stressors and limited social support [9] have higher rates of depression. Individuals with arthritis who also suffer from comorbid chronic health conditions have higher odds of depression than those without comorbid conditions [3].

In order to assist health care professionals in providing treatment for those living with both depression and arthritis, it is important to identify factors that are associated with remission from depression in this population. Improved knowledge of these factors can be used to inform outreach and intervention initiatives for the most vulnerable in this group. Due to the sparse research focused on remission among individuals with arthritis, we must draw upon research identifying factors associated with remission from depression in the general population.

Poorer self-rated health [1113] and limitations in Activities of Daily Living [14] are all associated with lower rates of remission from depression in the general population. Although we are unaware of a study specifically examining whether arthritis is associated with a longer time to remission from depression, several studies have established that the presence of any chronic physical illness is negatively associated with duration of depression [15, 16]. Demographic characteristics such as marriage, gender, and age have been studied to determine their impact on remission from depression. Marriage has been reported to be a protective factor [17, 18] and gender may not be a significant factor in remission from depression [17]. Younger age has been reported to indicate higher remission rates in some studies [15, 17, 19], but younger age at first onset may also predict a more chronic course of depression [20]. Less is reported in the literature about the effect of adverse childhood experiences (e.g., childhood abuse and parental addictions) on remission from depression. Individuals with these experiences have higher rates of depression in general [21]. Recent evidence suggests those who were maltreated in childhood have worse treatment outcomes for depression as adults in comparison to their nonmaltreated peers [22, 23].

There is a clear gap in the literature regarding information on factors associated with remission for those living with arthritis. The aim of this paper is to address this issue by using data from a regionally representative Canadian sample to obtain an understanding of the factors associated with remission from depression amongst those living with arthritis in the community. Identifying these factors is important to inform interventions for those with depression and arthritis.

2. Methods

2.1. Data Source

The National Population Health Survey (NPHS) is a nationally representative, longitudinal panel study of the Canadian population that began in 1994 [24]. The first wave of the survey was conducted in 1994/1995 and included 17,276 respondents. Every 2 years subsequently, attempts were made to resurvey these respondents. This study draws on information gathered up to 2008/2009, wave 8. In wave 1, the response rate was 83.6%. Of these respondents, 92.8% responded to the survey again in wave 2. By waves 7 and 8, the response rates were 77.0% and 70.7%, respectively [25].

2.2. Sample

The sample was comprised of two groups. A total of 138 respondents with arthritis who were aged 18 and older in wave 1 and who were classified as depressed comprised the first group. In order to increase the power of our analyses, we included a second group of 78 adults with arthritis who were not depressed in wave 1 but who were depressed in wave 2 (1996/97). Of the 216 respondents in the combined sample, 169 were women and 47 were men. In order to determine time to remission, each of the groups was followed for 12 years (from wave 1 to wave 7 for group 1 and from wave 2 to wave 8 for group 2).

2.3. Measures

The Composite International Diagnostic Interview-Short Form (CIDI-SF) developed by Kessler et al. was used to assess depression biennially [26]. The CIDI has excellent interrater reliability and good test-retest reliability and validity [27]. In comparison to the CIDI, the sensitivity and specificity of the CIDI-SF are 89.6% and 93.9%, respectively [27]. Each respondent was asked if he or she had “any of the following long-term conditions that have been diagnosed by a health professional.” On the list was “Arthritis or rheumatism.” Respondents were not asked to identify which type of arthritis they had.

Baseline demographic characteristics investigated included sex, age group (<55 years or ≥55 years), marital status (married/common law versus single/divorced/separated), and highest level of education (≤high school or >high school).

Social support was measured by the respondent endorsing that they had “someone (they) can confide in, or talk to about (their) private feelings or concerns.”

Two adverse childhood experiences were examined: childhood physical abuse and parental addictions. They were assessed by asking the respondent to refer to events that happened in childhood or adolescence, before they left home. Respondents were asked “Were you ever physically abused by someone close to you?” and “Did either of your parents drink or use drugs so often that it caused problems for the family?”

Health factors assessed for physical comorbidities and the presence of pain. Comorbid chronic conditions were identified by the respondent through a checklist of a number of chronic conditions “that had lasted or are expected to last six months or more” and that had been “diagnosed by a health professional.” We included the assessment for two common chronic conditions: back pain and migraines. General pain was measured by the respondent’s endorsement of the question “Are you usually free of pain and discomfort?”

Physical activity level was assessed as active, moderate, and inactive based on a sum of daily recreational physical activities lasting more than 15 minutes.

2.4. Analyses

We investigated remission using survival analysis, based on a biennial measurement of depression over a 12-year observation period. This period started in 1994/1995 and ended in 2006/2007 for the 178 individuals with arthritis who were depressed at wave 1. For the 78 individuals with arthritis who were not depressed at time 1 but were depressed at time 2, the assessment period began in 1996/1997 and ended 2008/2009. Censoring occurred if the respondent died or was lost to followup before remitting or if they were consistently depressed in each wave until the end of the 12-year observation period. Remission was defined at the wave in which the respondent no longer met the criteria for depression. The percentage of those no longer screening positive for depression was calculated at 2 years after baseline. The mean time to remission was generated using the Kaplan-Meier procedure and compared across categories of each of the potential predictors. Analyses were conducted using SPSS Version 18.

3. Results

Within two years of baseline, 70.8% of depressed individuals with arthritis in this study had achieved full remission. For men with arthritis, the remission rate was 63.8% and for women it was 72.8% (please see Table 1). The mean time to remission was 3.42 years (95% CI 2.7, 4.2) for males and 3.14 years (95% CI 2.8, 3.5) for females, but this was not significantly different ().

Mean to depression free
Lower CIUpper CI value% in remission at 2 years

 55 or older2.62.52.982.4
Marital status
 HS grad or less3.
 Some postsecondary3.32.93.764.9
Social support
 Yes confidant3.
 No confidant3.22.63.765.9
Adverse childhood experiences
Childhood physical abuse
 Yes physical abuse3.93.14.659.3
 No physical abuse2.
Parental addictions during respondents’ childhood
 Yes parental addictions3.82.94.662.2
 No parental addictions3.
 Usually free from pain2.
 Not usually free from pain3.53.03.966.7
Back pain

CI: confidence interval; Values with are highlighted in bold font.

Significant differences were found in mean time to remission by age, pain level, migraine, and exposure to childhood physical abuse and parental addictions. Approximately four of five adults with arthritis over age 55 were in remission from depression at two years in comparison to three out of five individuals who were 55 or younger. Approximately, four in five individuals who were usually free from pain at baseline were in remission from depression at two years in comparison to only two-thirds of those who reported at baseline that they usually had pain. Seventy-six percent of those who did not suffer from migraine at baseline were in remission at two years, while only 58.5% of those who suffered from migraines were in remission.

Individuals who reported a history of physical abuse in their childhood had a mean time to remission of almost a year more than those who did not report childhood physical abuse. Approximately three quarters of those who were not physically abused were in remission at two years in comparison to 59% of those who reported childhood physical abuse. Individuals exposed to parental addictions also had a lower prevalence of remission by two years in comparison to those without addicted parents (62.2% versus 72.3%).

4. Discussion

The findings of this study highlight a positive prognosis for this population. Although individuals with arthritis are more vulnerable to depression, 71% of depressed community dwelling individuals with arthritis in this representative study experienced full remission from depressive symptoms within two years. In the general population it has been found that after two years 80-81% of clinical patients are in remission from depression symptoms and that after 10 to 15 years this number rises to 93-94% of patients [28]. This is a hopeful message, especially in light of the serious consequences of depression to both the individual and society.

This study also provides important information about factors that may impact the course of depression for those experiencing both arthritis and depressive symptoms. Not surprising, those who were not usually free of pain at baseline had a longer time to remission than those who were usually free of pain. This is consistent with the literature regarding pain and depression in the general population where it has been reported that the presence of pain can lead to worse depression outcomes [17, 29, 30]. However, pain is a complicated issue in this population, as the severity of pain associated with arthritis may lead to common misconceptions regarding expectations and outcomes. It is possible that some clinicians and the patients themselves may consider that in the context of pain, depressive symptoms are inevitable with the expectation that they must be tolerated. The result of these misconceptions leads to the perception that treating the depression will not be effective, or even appropriate [31]. Despite these beliefs, studies have reported positive outcomes and effective depression treatment strategies for individuals with arthritis [32]. In one study where enhanced depression care management was employed in comparison to patients receiving usual care, a range of positive outcomes was evident after one year including improved arthritis related pain and functional outcomes, fewer depressive symptoms, as well as better general health status, and overall quality of life [33]. Focused pain management strategies may also be important for more effective depression treatment [34]. Although the presence of pain in those with arthritis is common, our findings underline that the patient’s experience of the intrusiveness and consistency of that pain is an important factor to monitor and strive to ameliorate.

Comorbid migraines, in this sample of depressed individuals with arthritis, were found to have a strong influence on the course of depression. Migraines are associated with depression in the general population [35]. Both migraine and depression uniquely impact work productivity [36] and lead to increased medical costs [37, 38]. Our finding that comorbid migraines increase the time to remission from depression among those with arthritis speaks to the importance of screening for migraines in this population.

Childhood adversities appear to cast a long shadow on physical and mental health outcomes for those who experience childhood physical abuse and parental addictions [39]. Children of parents with addiction issues were found to have a higher number of other adverse experiences in childhood; subsequent adult depression in this group was found to be largely a result of these adverse childhood experiences [40]. Childhood maltreatment may impact the onset of depression as it has been found to increase the risk for adolescents and young adults in developing depression [41]. A meta-analysis of 16 epidemiological studies and 10 clinical trials on childhood maltreatment and depression [23] found that adverse childhood experiences, such as abuse and family violence, were associated with an increased risk of developing persistent or recurrent depression and worse treatment response [23]. Clearly, individuals who had experienced childhood physical abuse in our sample of depressed individuals with arthritis show a similar pattern of prolonged time to recovery. Our findings that experiences of childhood abuse and having had an addicted parent lead to longer times to remission indicate that adverse childhood experiences are still significant even in the presence of arthritis and comorbid health conditions and remain a developmental risk factor for a more chronic course of depression. Although assessment of early childhood adversities has not traditionally been included in clinical interviews with depressed patients, increased screening for these issues and more intensive treatment of depression in those with these early life experiences may be warranted.

Regarding demographic factors, our findings indicate that older adults remit faster than their younger peers. Although this is in contrast to some of the literature [15, 17, 19], other studies suggest that younger age of initial onset of depression may result in more severe symptoms of depression across the life course and account for longer time to remission [20]. In a study of adults over 55, individuals aged 65 and older were more likely to be in remission than those aged 55–64 [13]. Despite the well-established link between female gender and increased prevalence of depression [42], our findings indicate that once depressed, males and females with arthritis have a similar time to remission. It appears that although gender is protective against initial onset of depression [42] it does not play a significant role in the course of remission in those who have succumbed to depression, findings which replicate several recent studies [17, 37].

Findings should be treated with caution because of several important limitations of this study. The community-based sample for the NPHS does not include anyone institutionalized for depression and those experiencing the most severe levels of depression in the community may be less likely to participate in the survey at baseline. Therefore our findings may exclude those individuals with the most severe cases of depression, which may have biased the mean time to remission downward. Furthermore, the NPHS does not include information on the length of time since diagnosis with arthritis. It is probable that those facing a new arthritis diagnosis may be particularly vulnerable to depression, while they come to terms with the disease and its ramifications on their life. We could also not examine the type of arthritis the respondents had, nor disease severity, because this information was not investigated in the NPHS. These factors probably play a role in depressive outcomes. Due to the sampling strategy of the survey, the respondents should be a representative sample of community dwellers with arthritis, probably predominantly comprised of individuals with osteoarthritis or rheumatoid arthritis. Future research should consider the type, severity, and time since diagnosis of arthritis, and the relationship of these factors to depressive symptomatology.

Despite these limitations, there are several important strengths to this study, including its large representative community-based sample of depressed individuals with arthritis rather than a reliance on clinical samples, its unusually long follow-up period of 12 years of data, with biennial measurements of depression, and its examination of the role of early childhood adversities in remission. Thus, the study’s findings provide new, representative information to improve the targeting of interventions for depressed community dwelling adults with arthritis.

5. Conclusions

Given the complexities of the comorbid conditions of depression and arthritis, it is a very positive finding that seven out of ten individuals in our representative community based study experienced remission from depression within two years. The findings also highlight the importance of considering the depressed individual’s experience of pain, the presence of migraines, and experience of early childhood adversities. Given the higher rates of depression among those with arthritis as compared to the general population [2], this information is needed for professionals looking to track the chronicity of depression and to improve the screening and treatment of their particularly vulnerable patients with arthritis who are suffering from depression.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.


This research was undertaken, in part, thanks to support for the first author from the Sandra Rotman Endowed Chair at the University of Toronto.


  1. National Center for Chronic Disease Prevention and Health Promotion, “Arthritis: Data and Statistics,” 2008, View at: Google Scholar
  2. J. Kekow, R. Moots, R. Khandker, J. Melin, B. Freundlich, and A. Singh, “Improvements in patient-reported outcomes, symptoms of depression and anxiety, and their association with clinical remission among patients with moderate-to-severe active early rheumatoid arthritis,” Rheumatology, vol. 50, no. 2, pp. 401–409, 2011. View at: Publisher Site | Google Scholar
  3. E. Fuller-Thomson, M. Stefanyk, and S. Brennenstuhl, “The robust association between childhood physical abuse and osteoarthritis in adulthood: findings from a representative community sample,” Arthritis Care & Research, vol. 61, no. 11, pp. 1554–1562, 2009. View at: Publisher Site | Google Scholar
  4. M. I. Bisschop, D. M. W. Kriegsman, D. J. H. Deeg, A. T. F. Beekman, and W. van Tilburg, “The longitudinal relation between chronic diseases and depression in older persons in the community: The Longitudinal Aging Study Amsterdam,” Journal of Clinical Epidemiology, vol. 57, no. 2, pp. 187–194, 2004. View at: Publisher Site | Google Scholar
  5. F. M. Vali and J. Walkup, “Combined medical and psychological symptoms: impact on disability and health care utilization of patients with arthritis,” Medical Care, vol. 36, no. 7, pp. 1073–1084, 1998. View at: Google Scholar
  6. R. G. Harper, R. C. Chacko, D. Kotik-Harper, J. Young, and J. Gotto, “Self-report evaluation of health behavior, stress vulnerability, and medical outcome of heart transplant recipients,” Psychosomatic Medicine, vol. 60, no. 5, pp. 563–569, 1998. View at: Google Scholar
  7. National Center for Health Statistics, Data File Documentation, National Health Interview Survey of Disability, Phase I, National Center for Health Statistics, Hyattsville, Md, USA, 1996.
  8. J. M. McIlvane, K. M. Schiaffino, and S. A. Paget, “Age differences in the pain-depression link for women with osteoarthritis. Functional impairment and personal control as mediators,” Women's Health Issues, vol. 17, no. 1, pp. 44–51, 2007. View at: Publisher Site | Google Scholar
  9. P.-F. Tsai, S. Tak, C. Moore, and I. Palencia, “Testing a theory of chronic pain,” Journal of Advanced Nursing, vol. 43, no. 2, pp. 158–169, 2003. View at: Publisher Site | Google Scholar
  10. T. Covic, B. Adamson, D. Spencer, and G. Howe, “A biopsychosocial model of pain and depression in rheumatoid arthritis: a 12-month longitudinal study,” Rheumatology, vol. 42, no. 11, pp. 1287–1294, 2003. View at: Publisher Site | Google Scholar
  11. H. Herrman, D. L. Patrick, P. Diehr et al., “Longitudinal investigation of depression outcomes in primary care in six outcomes: The LIDO Study. Functional status, health service use and treatment of people with depressive symptoms,” Psychological Medicine, vol. 32, no. 5, pp. 889–902, 2002. View at: Publisher Site | Google Scholar
  12. H. Viinamäki, A. Tanskanen, K. Honkalampi et al., “Recovery from depression: a two-year follow-up study of general population subjects,” International Journal of Social Psychiatry, vol. 52, no. 1, pp. 19–28, 2006. View at: Publisher Site | Google Scholar
  13. E. Fuller-Thomson and M. Battiston, “Remission from depressive symptoms among older adults with mood disorders: findings of a representative community sample,” Journal of Gerontological Social Work, vol. 52, no. 7, pp. 744–760, 2009. View at: Publisher Site | Google Scholar
  14. G. E. Simon, M. von Korff, and E. Lin, “Clinical and functional outcomes of depression treatment in patients with and without chronic medical illness,” Psychological Medicine, vol. 35, no. 2, pp. 271–279, 2005. View at: Publisher Site | Google Scholar
  15. R. H. S. van den Brink, J. Ormel, B. G. Tiemens et al., “Predictability of the one-year course of depression and generalized anxiety in primary care,” General Hospital Psychiatry, vol. 24, no. 3, pp. 156–163, 2002. View at: Publisher Site | Google Scholar
  16. A. Ciudad, E. Álvarez, M. Roca et al., “Early response and remission as predictors of a good outcome of a major depressive episode at 12-month follow-up: a prospective, longitudinal, observational study,” Journal of Clinical Psychiatry, vol. 73, no. 2, pp. 185–191, 2012. View at: Publisher Site | Google Scholar
  17. K. Barkow, W. Maier, T. B. Üstün, M. Gänsicke, H.-U. Wittchen, and R. Heun, “Risk factors for depression at 12-month follow-up in adult primary health care patients with major depression: an international prospective study,” Journal of Affective Disorders, vol. 76, no. 1–3, pp. 157–169, 2003. View at: Publisher Site | Google Scholar
  18. T. I. Mueller, M. B. Keller, A. C. Leon et al., “Recovery after 5 years of unremitting major depressive disorder,” Archives of General Psychiatry, vol. 53, no. 9, pp. 794–799, 1996. View at: Google Scholar
  19. J. C. Nelson, Q. Zhang, W. Deberdt, L. B. Marangell, O. Karamustafalioglu, and I. A. Lipkovich, “Predictors of remission with placebo using an integrated study database from patients with major depressive disorder,” Current Medical Research & Opinion, vol. 28, no. 3, pp. 325–334, 2012. View at: Publisher Site | Google Scholar
  20. L. Hölzel, M. Härter, C. Reese, and L. Kriston, “Risk factors for chronic depression—a systematic review,” Journal of Affective Disorders, vol. 129, no. 1–3, pp. 1–13, 2011. View at: Publisher Site | Google Scholar
  21. E. Fuller-Thomson, R. B. Katz, V. T. Phan, J. P. M. Liddycoat, and S. Brennenstuhl, “The long arm of parental addictions: the association with adult children's depression in a population-based sample,” Psychiatry Research, vol. 210, no. 1, pp. 95–101, 2013. View at: Google Scholar
  22. E. Fuller-Thomson, M. Battiston, T. M. Gadalla, and S. Brennenstuhl, “Bouncing back: remission from depression in a 12-year panel study of a representative Canadian community sample,” Social Psychiatry and Psychiatric Epidemiology, 2014. View at: Publisher Site | Google Scholar
  23. V. Nanni, R. Uher, and A. Danese, “Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: a meta-analysis,” American Journal of Psychiatry, vol. 169, no. 2, pp. 141–151, 2012. View at: Publisher Site | Google Scholar
  24. Health Statistics Division, Statistics Canada, “National Population Health Survey 1994-95: Overview,” 2013, View at: Google Scholar
  25. Statistics Canada, “National Population Health Survey—Household Component—Longitudinal (NPHS),” 2013, View at: Google Scholar
  26. R. C. Kessler, G. Andrews, D. Mroczek, T. B. Üstün, and H. Wittchen, “The World Health Organization Composite International Diagnostic Interview Short Form (CIDI-SF),” International Journal of Methods in Psychiatric Research, vol. 7, pp. 171–185, 1998. View at: Google Scholar
  27. G. Andrews and L. Peters, “The psychometric properties of the Composite International Diagnostic Interview,” Social Psychiatry & Psychiatric Epidemiology, vol. 33, no. 2, pp. 80–88, 1998. View at: Publisher Site | Google Scholar
  28. D. Richards, “Prevalence and clinical course of depression: a review,” Clinical Psychology Review, vol. 31, no. 7, pp. 1117–1125, 2011. View at: Publisher Site | Google Scholar
  29. M. J. Bair, R. L. Robinson, W. Katon, and K. Kroenke, “Depression and pain comorbidity: a literature review,” Archives of Internal Medicine, vol. 163, no. 20, pp. 2433–2445, 2003. View at: Publisher Site | Google Scholar
  30. J. F. Karp, J. Scott, P. Houck, C. F. Reynolds III, D. J. Kupfer, and E. Frank, “Pain predicts longer time to remission during treatment of recurrent depression,” Journal of Clinical Psychiatry, vol. 66, no. 5, pp. 591–597, 2005. View at: Google Scholar
  31. A. Rifkin, “Depression in physically ill patients: don't dismiss it as ‘understandable’,” Postgraduate Medicine, vol. 92, no. 3, pp. 147–153, 1992. View at: Google Scholar
  32. C. Dickens, L. McGowan, D. Clark-Carter, and F. Creed, “Depression in rheumatoid arthritis: a systematic review of the literature with meta-analysis,” Psychosomatic Medicine, vol. 64, no. 1, pp. 52–60, 2002. View at: Google Scholar
  33. E. H. B. Lin, W. Katon, M. Von Korff et al., “Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial,” The Journal of the American Medical Association, vol. 290, no. 18, pp. 2428–2429, 2003. View at: Publisher Site | Google Scholar
  34. K. Kroenke, J. Shen, T. E. Oxman, J. W. Williams Jr., and A. J. Dietrich, “Impact of pain on the outcomes of depression treatment: results from the RESPECT trial,” Pain, vol. 134, no. 1-2, pp. 209–215, 2008. View at: Publisher Site | Google Scholar
  35. E. Fuller-Thomson, M. Schrumm, and S. Brennenstuhl, “Migraine and despair: factors associated with depression and suicidal ideation among Canadian migraineurs in a population-based study,” Depression Research and Treatment, vol. 2013, Article ID 401487, 10 pages, 2013. View at: Publisher Site | Google Scholar
  36. R. Kessler, L. A. White, H. Birnbaum et al., “Comparative and interactive effects of depression relative to other health problems on work performance in the workforce of a large employer,” Journal of Occupational and Environmental Medicine, vol. 50, no. 7, pp. 809–816, 2008. View at: Publisher Site | Google Scholar
  37. D. V. Sheehan, “Establishing the real cost of depression,” Managed Care, vol. 11, no. 8, supplement, pp. 7–10, 2002. View at: Google Scholar
  38. J. Pesa and M. J. Lage, “The medical costs of migraine and comorbid anxiety and depression,” Headache, vol. 44, no. 6, pp. 562–570, 2004. View at: Publisher Site | Google Scholar
  39. V. J. Felitti, R. F. Anda, D. Nordenberg et al., “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine, vol. 14, no. 4, pp. 245–258, 1998. View at: Publisher Site | Google Scholar
  40. R. F. Anda, C. L. Whitfield, V. J. Felitti et al., “Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression,” Psychiatric Services, vol. 53, no. 8, pp. 1001–1009, 2002. View at: Publisher Site | Google Scholar
  41. J. Brown, P. Cohen, J. G. Johnson, and E. M. Smailes, “Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality,” Journal of the American Academy of Child and Adolescent Psychiatry, vol. 38, no. 12, pp. 1490–1496, 1999. View at: Google Scholar
  42. G. Parker and H. Brotchie, “Gender differences in depression,” International Review of Psychiatry, vol. 22, no. 5, pp. 429–436, 2010. View at: Publisher Site | Google Scholar

Copyright © 2014 Esme Fuller-Thomson et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

More related articles

 PDF Download Citation Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

We are committed to sharing findings related to COVID-19 as quickly as possible. We will be providing unlimited waivers of publication charges for accepted research articles as well as case reports and case series related to COVID-19. Review articles are excluded from this waiver policy. Sign up here as a reviewer to help fast-track new submissions.