Good Information On Depression And Chronic Illness

[doctorguest]

Hi everyone,

I received this by E-mail as part of the Continuous Medical Education (CME). I think it's great that there is more information for physicians to recognize and treat depression in patients with chronic illness. My hope is that better education on how to recognize and treat autonomic dysfunction becomes available for physicians in the future.

http://www.medsitecme.com/(sadkgo2rzkcnno4...1//patient.aspx

[lalalisa]

Hello,

I don't know if it's just my computer or not but I can't seem to visit this link at the moment.

Thanks,

Lisa

[DancingLight]

Lisa,

I just got a general page to come up, but nothing specific to what doctorguest was saying. Hmmmm....

Doctorguest,

I haven't yet had a chance to thank you for your services and dedication to DINET. I'm a little behind, as always! Thank you for chiming in with a medical standpoint on topics and for your commitment to helping not only our 'little community,' but people with ANS disorders in general.

I wasn't able to read the article you posted either, but I have been very blessed with a wonderful ANS doctor. And he is very sensitive to the issue of depression and anxiety in chronic illness and ANS disorders. I had been hesitant to say anything to him, even though I knew he would NOT dismiss me or minimize me. When I finally said, I'm really having a hard time right now and I don't even want to admit it. He just said, 'Okay, you admitted it. So now let's do something about it!'. We then worked to find meds that helped. He is also very supportive of any counseling or other psychiatric services.

I do think it is so important to realize that depression is so often a symptom/consequence of chronic illness and not the cause. I am not well enough to leave the house for counseling anymore, but I did do it for the first 7 years of my illness and I feel that it was an absolute LIFESAVER. I am pursuing options to have someone come to my home, and also work with someone else who counsels me a great deal (spiritual counselor and massage therapist in one! lol).

I think just having you state that depression is an issue for many with chronic illness is important, and perhaps will help more of the folks on the board to feel validated as well as feel that they are not inadequate if they do struggle with depression.

I've been sick for almost 9 years and am homebound and very ill...Most days I'm very 'up' but I have times when the grief hits hard. It would be, in my opinion, incongruent to feel like crappola and not ever get down about it! I have more of a tendency to anxiety than towards depression, but acknowledging that I do get depressed and I do need medication to stay more level has helped a great deal to have one less thing to feel guilty about or to have to deal with unmanaged (like all of the rest of my symptoms! lol)

Okay, that's my two cents.

Another jabbermouth here on the boards...

Welcome and thank you.

Emily

[doctorguest]

Sorry about the general page. Let's see if this link works. At the bottom of the page, choose any specialty and continue on to the discussion.

http://www.medsitecme.com/(ylwr0amactpjti4...1//sponsor.aspx

Emily, thank you for your words. I am sorry that you have been affected for so many years. I am glad you found a good ANS doctor who understands your needs.

[pat57]

http://www.medsitecme.com/(l1layoapwzyknfz...)/Sections.aspx

testing!

go to Psychiatry

then

Depression & Chronic Disease: Understanding the Vital Link

but still no page, I think one has too registar

[PattiL]

Hi Doctorguest,

I still wasn't able to log onto that web page either. I went to the www.medsitecme.com and it listed different categories to click on, i.e., cardiology, pediatrics, etc., I went to 'psychiatry' and I believe I found the article you were referring to. It might be logged on differently for us since we are not registered as Dr.'s??...anyway maybe this link will work for others.

Patti

http://www.medsitecme.com/(jcwgvju0o1lafmi...escription.aspx

[doctorguest]

OK, sorry about this link not working. I got the link through my E-mail, then I copied and pasted it here. When I tested the link on this thread, it did work from my computer. Yes, PattiL, that's the article I was talking about. Thank you for fixing it. Hope others can access it as well and benefit from the information.

[Tammy]

http://www.medsitecme.com/(x23lev45ndjj51z...1//patient.aspx

For those who are unable to pull up the link here's the information from the above link. Hope it's okay I copied it

Depression & Chronic Disease: Understanding the Vital Link

Background

Approximately 20.9 million American adults, or 9.5% of the US population aged 18 years and older, have a mood disorder (major depressive disorder, dysthymic disorder, or bipolar disorder) (NIMH, 2006). Clinical depression is a chronic, serious, and costly mental illness, but it can be effectively treated with medication, psychotherapy, or a combination of both in more than 80% of people (NMHA, 2000). The risk of depression is higher in individuals with serious medical illnesses (eg, heart disease, stroke, cancer, diabetes, chronic pain); the more severe the condition, the more likely the patient will experience depression (NMHA, 2000; RWJF, 2004). Alone, depression can be incapacitating, but comorbid medical illness makes outcomes worse for both conditions. Comorbidity is associated with greater distress, role function impairments, poor self-care, less ability to follow lifestyle recommendations, and poor adherence to medical treatment recommendations (NMHA, 2000; RWJF, 2004; DiMatteo, 2000; Managing depression in primary care: achieving remission, 2006; Evans, 2003, 2005).

Depression can occur in association with other diseases for a number of reasons (Goodwin, 2006; ICSI, 2006):

Medical disorders may contribute biologically to depression (eg, thyroid disorder, stroke) (NMHA, 2000; Goodwin, 2006)

Medically ill people may become clinically depressed as a psychological reaction to the prognosis, pain, and/or incapacity caused by the illness or its treatment, or difficulties coping with a medical condition (NMHA, 2000; Goodwin, 2006)

Drug treatments for comorbid illness (eg, interferon, corticosteroids) can cause depression (Patten, 2000)

Depression may contribute biologically to a comorbid medical disorder. It can cause or exacerbate somatic symptoms, and it may also affect behavior.

Physicians should be aware of the increased incidence of depression in patient with such conditions as chronic pain, diabetes, cancer, and cardiovascular disease. Although depression is a treatable cause of pain, suffering, disability, and death, primary care physicians detect depression in only one third to one half of their patients with major depression (ICSI, 2006). Minority patients, in particular, are more likely to obtain mental health care from their primary care physician than from a mental health specialist (Snowden, 2002; DHHS, 2006). However, in primary care, minority patients are even less likely than white patients to be identified as depressed and, even when identified, their depression is less likely to be actively managed (Gallo, 2005; Kessler, 2005; Das, 2006; Borowsky, 2000; Yeung, 2005).

The following two cases illustrate the important of screening for and treating depression in patients with comorbid conditions.

Daniel is a 21-year-old white man in whom type 1 diabetes mellitus was first diagnosed at the age of 18. His pediatrician identified the disease from the smell of acetone on his breath due to ketosis and directed him to the emergency department (ED). Daniel was admitted to the intensive care unit for five days to stabilize his disease. He was angry and found it difficult to accept that he had diabetes, particularly that the diabetes would affect his ability to eat, drink alcohol, and ?party.? He also found it difficult to deal with his medication and testing regimens?in his words, ?I couldn?t have imagined anything harder to deal with.?

Discussion: The prevalence of depression in patients with diabetes is approximately double that of patients without diabetes (RWJF, 2004; Managing depression in primary care: achieving remission, 2006; ICSI, 2006; Lin, 2004; Anderson, 2001). Depression in patients with diabetes is thought to result from interactions between biologic factors and psychosocial factors associated with the hardships imposed by a chronic illness (Lustman, 2005; Talbot, 2000). When depression accompanies diabetes, there is often evidence of poor glycemic control and more diabetic complications (eg, retinopathy, nephropathy, neuropathy, macrovascular changes, sexual dysfunction) (RWJF, 2004; ICSI, 2006; Lin, 2004; Katon, 2004a), and depression is strongly associated with mortality (minor depression: RR 1.67; major depression: RR 2.30) (Katon, 2005). In addition, depressed patients with diabetes have total healthcare expenditures 4.5 times higher than those without depression (RWJF, 2004).

Routine screening for depression should be performed in patients with diabetes (Silverstein, 2005). However, depression is only recognized in approximately half of patients with diabetes and appropriately treated in less than 25% (Katon, 2004b).

Daniel perceived that the diabetes dramatically reduced his quality of life and interfered with his relationship with his girlfriend. He acknowledged that he was not adhering to his diet and medication regimens, and that he was leading an unhealthy lifestyle, partly in an attempt to deny he had diabetes. At other times, he was angry or guilty, believing he was responsible for the diabetes. He fell into a cycle of not sleeping, being unproductive, and feeling hopeless, together with guilt that he was not able to break this cycle.

At the request of his family, Daniel reluctantly sought psychiatric help, but he had self-imposed barriers to accepting such care, such as denial, embarrassment, and the feeling that depression was a weakness. He disagreed with the psychiatrist?s determination that he seemed suicidal: ?Maybe I?m just a little sad about being diabetic.? Antidepressants were prescribed, but he was resistant to taking them, particularly because they would not be immediately effective, and he was overwhelmed by the addition of another agent to his medication regimen. As a result, Daniel was nonadherent, only taking the antidepressants every third day for a week.

Discussion: For a patient such as Daniel?who is rebellious, resistant to antidepressants, and at risk for adherence problems related to multiple medications?cognitive behavioral therapy (CBT) would be a more appropriate initial treatment that would not add to the complexity of his diabetic care regimen. Cognitive behavioral therapy has been shown to be effective in patients with depression, including adolescents (Melvin, 2006; Lustman, 1998).It also has the advantage of specifically targeting perceptions and behaviors that are likely to improve diabetes-related self-care in addition to depression (Piette, 2004). However, in one study of patients with diabetes, only 7% of those with comorbid depression received four or more psychotherapy sessions during a 12-month period (Katon, 2004b). Once the patient is stabilized on CBT, it may be appropriate to discuss adding antidepressants to CBT, explaining that a combination of both may be more effective than either treatment alone (Pampallona, 2004).

All patients?but particularly an angry, resistant, and depressed young patient such as Daniel?would benefit from continuity of care, coordination of care and communication among providers, and proactive patient monitoring (Piette, 2004). This would help to identify problems, provide problem-solving counseling, ensure engagement in treatment, and provide effective education to explain how the interaction between depression and diabetes might result in adverse outcomes (Gask, 2006). Primary care physicians are well positioned to provide integrated care for depression and diabetes, but they face many barriers (Williams, 2004). Organizational barriers to high-quality care include brief visits and competing clinical priorities. The psychological problems of a patient such as Daniel may seem overwhelming to deal with during a short encounter; however, the physician should still intervene, which may require scheduling the patient to return for a longer visit.

Several evidence-based programs designed to improve depression treatment in primary care may help efforts to incorporate depression management into disease management programs for chronic disease (RWJF, 2004). These include the Robert Wood Johnson Foundation?s Depression in Primary Care Project (www.wpic.pitt.edu/dppc/), the IMPACT program developed by the John A. Hartford Foundation, the California Health Care Foundation, the RWJ Foundation, the Hogg Foundation (www.impact.ucla.edu), and the RESPECT model developed by the MacArthur Foundation (www.depression-primarycare.org).

Physicians can further support patient self-management by making changes in practice systems. Given the large number of primary care patients with more than a single chronic condition and the potential advantages of coordinating care across multiple conditions, primary care practices could increase efficiency by developing extended care management interventions for several chronic conditions in which the same generic patient barriers impede optimal outcomes (Nutting, 2002). Group visits could be scheduled for interested patients with comparable chronic illnesses so that they can discuss self-managing their illnesses with others who are in similar situations (Coleman, 2005; Masley, 2000). This also allows physicians to deliver extensive education and self-management instruction while possibly increasing financial productivity (Jaber, 2006). Group visits in adults with chronic diseases have been shown to reduce ED visits, hospitalizations, and primary care visits

...

Summary

Depression is a common, serious, and costly comorbidity with chronic disease. As these two cases illustrate, lack of recognition and appropriate timely treatment of depression can adversely affect and/or prolong comorbid medical disease.

The US Preventive Services Task Force found that asking the patient two simple questions about the presence of depressed mood and anhedonia (?Over the past two weeks, have you felt down, depressed, or hopeless? and ?Over the past two weeks, have you felt little interest or pleasure in doing things??) appears to perform as well as longer instruments for detecting depression (Pignone, 2002). These two questions can be effective in opening up dialogue and beginning treatment of comorbid depression, which may involve pharmacotherapy, psychotherapy, or a combination of both.

[pat57]

yours worked for me tammy.

[flop]

DoctorGuest,

thank you very much for highlighting such an important issue. I wish that reading these sort of articles was compulsory for doctors rather than them being able to choose topics of interest.

I feel that the second story of the pain/depression cycle is more commonly identified than the chronic illness/depression scenario.

I wish that when a patient with a chronic illness was diagnosed with depression that others would understand that it is living with the chronic illness that has triggered the depression and not that "having depression shows that you are a psychiatric patient and therefore all of your problems must be psychiatric/psychosomatic".

I also think that the issue of depression in chronic disease is different to the previously hotly debated topic of using antidepressants to treat the actual chronic disease, rather than an accompanying depression.

Doctors need to understand that: some of us take antidepressants for depression; some take them to treat their POTS; some take them for both POTS and depression; and there are a lot of POTS patients with undiagnosed depression. I think that most "normal" people would end up depressed if they had to continually deal with the symptoms faced by many of us on a daily basis.

Rant over,

Flop

[morgan617]

My doctor said he'd be worried if I wasn't depressed and dysthymic. Very supportive, and it makes a world of difference.

I was talking to a friend and we discussed how antidepressants, on their own, are not nearly as effective as therapy and medications. It would be nice to have some kind of parameters...if a doctor only gave them in conjunction with therapy. That's pretty much impossible I know, but sometimes it seems like a band aid on an arterial bleed. I guess the meds alone are better than nothing, and the doctor understanding the underlying reason for the depression, is essential.

It's refreshing to see these articles....now just get them to listen and agree...LOL Thanks for the article! morgan

[Maxine]

Thanks so much for the article.

Interestingly, I have had doctors blame my illness on depression, and I never really had any clinical depression or anxiety problems until I became very ill. Now that there is "proof" that I'm ill, doctors dismiss me when I tell them how depressed all this is making me because I'm so overwhelmed with one thing after another happening to my body.

I was able to open this article once, but then it wasn't there.....so thanks for the copy and paste Tammy---

Also, thank you doctorquest for the link----------------interesting...

It's definately one comorbidity that needs to be taken seriously, as it can only complicate one's physiological illness more.

Maxine :0)