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Depression

Treating Depression in Patients with Chronic Disease

Psychotherapy and several anti-depressants work and are safe.

Key points

  • People with chronic disease and depression should access psychotherapy and/or start an antidepressant, based on their preference.
  • It is important to have regular follow-ups with your healthcare team who may add treatments, increasing dosages, or change medications.
  • Exercise, as is delivered in chronic disease management programs, is an important adjunct to support long-term remission of depression.
Design Ecologist/Unsplash
Source: Design Ecologist/Unsplash

For Part 1 of this two-part series, see Identifying Depression in Patients with Chronic Disease.

So you are feeling down, no longer derive pleasure from your favorite activities, feel worthless, tired and/or your appetite or activity level have changed. For chronic disease patients, this is all too common, so you are not alone. Fortunately, there are depression treatments that work, and are safe for patients with chronic disease. You will want to work with your primary care provider, hopefully in conjunction with your specialist, if you are going to start an anti-depressant in particular, to make sure it is safe for you and that you are followed up to monitor your response.

As we discussed in part 1 of this post, you will have had a diagnostic interview, and so the severity of your depression would have been determined. If your depression is considered “mild," an excellent first option is exercise. It is proven to improve your mood, has no side effects, is free, easily-accessible, and also helps with your chronic condition. However, it is difficult for some patients to get started because of depression symptoms like anhedonia and psychomotor retardation. In this case, you might want to join a cardiac rehabilitation, and/or start another treatment option first and then add this on in a few weeks. If your depression is moderate, this is an excellent adjunct therapy, to augment your depressive symptom reduction and to support long-term remission.

The two main “first-line” treatments (i.e., with best evidence for effectiveness, and are acceptable to patients) for moderate to severe depression are psychotherapy and anti-depressant medications. Consider what coverage you have for psychotherapy and medications, the waiting time to access a quality therapist, and your preferences. You can even start with both as they are quite complementary, and then discuss stopping either upon consultation with your provider when you feel it is a good time.

Psychotherapy

There are several forms of psychotherapy; we will only discuss those that are standardized and established as effective through gold-standard research, including in chronic disease patients specifically. Remember to find a regulated mental healthcare provider in your jurisdiction, and ensure they specialize in depression and have some experience working with patients with chronic disease. Most important for your ultimate improvement, be sure you have a good rapport with the therapist; if not, try another one.

The best evidence is for the psychotherapeutic approach known as cognitive-behavioral therapy (CBT). This type of therapy has been around for several decades, and has been improved upon over time. You will have approximately 8 to 12 hour-long sessions with your provider in which you learn specific skills related to your thinking, and do homework between sessions to practice the skills in your day-to-day life. The current “3rd wave” CBT approach focuses on awareness of thoughts and accepting them in a non-judgmental way.

The behavioral aspect of CBT relates to supporting patients to identify pleasant activities and make plans to engage in them. Relaxation therapies and, again, exercise also support patients in feeling better.

Some patients might not find CBT to be a good fit for them. Interpersonal psychotherapy does not always seem to be the best choice for chronic disease patients, but Acceptance and Commitment Therapy (ACT) can be.

Depending on coverage or affordability, you may need a longer course of psychotherapy. In the future, you may also wish to go back and have a few appointments with your psychotherapist if your life situation changes or you would like to refresh your skills.

With the pandemic, much therapy has moved online, and the data suggest outcomes are similarly positive in this delivery mode.

Anti-depressants

Anti-depressant medications target chemical messengers in your brain related to your mood. They take 4 to 6 weeks to exert their effect, so, again, you might want to consider starting an exercise program or using some online CBT resources during that time.

Your provider will likely start you on a lower dose than what is needed to bring your depression into remission, so that you can adjust. You would need to go back to see your doctor after a couple of months to see how you are feeling, and how you are tolerating the new medication. Your doctor can then make an adjustment to the dose if needed, change you to a different medication, or even add another one if needed. You should follow up with your doctor regularly until your depressive symptoms come down. Your doctor will hopefully monitor your response to the medications using a survey such as the PHQ-9, which was discussed in Part 1.

Several classes of medications can reduce the effects of depression. Selective serotonin reuptake inhibitors (SSRI) are the most effective and safest for heart disease patients, taking into consideration the many other medications those patients need to take. Unfortunately, these medications can come with sexual side effects that some patients cannot tolerate; you can talk openly to your doctor about this.

Some newer classes of anti-depressants work on the serotonin and norepinephrine chemical messengers (SNRIs) as well as the dopamine and norepinephrine neurotransmitters (NDRI) that would be tried next. Some antidepressants also affect your energy level or help in reducing anxiety or cravings for tobacco, so talk to your doctor about what would be best for your situation.

The length of time you would stay on an antidepressant will depend on the severity of your symptoms and whether your depression might come back if you stop taking the drug; psychotherapy and exercise can work to mitigate this. Be sure to speak to your doctor before you stop taking an anti-depressant. You will want to taper off slowly rather than stop cold-turkey so your mind and body can adjust, and any withdrawal symptoms will be minimized.

Final thoughts

Depression treatment should be based on your preferences. It should be stepped, meaning you would add a modality or change a dose until your symptoms are reduced to a subclinical level. You should have regular follow-up appointments with your provider so your well-being can be assessed and monitored.

If you work closely with your provider and go to follow-up visits, significant reductions in depression symptoms can be achieved. There are some patients, however, for whom this is not the case. Newer approaches such as transcranial magnetic stimulation show promise, and other classes of drugs can be added, such as Quetiapine.

A final important point is to try to access an outpatient chronic disease management program such as cardiac rehabilitation. Participation tends to result in significantly lowered depression symptoms, as well as better health outcomes such as living a longer life. It is one-stop shopping, with caring support over several months, and linkage to your primary care provider.

References

Hurley, M.C., Arthur, H.M., Chessex, C., Oh, P., Turk-Adawi, K., & Grace, S.L. (2017). Burden, screening and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: A prospective study. BMC Women’s Health;17:11.

Doyle et al., (2021). Hybrid systematic review and network meta-analysis of randomized controlled trials of interventions for depressive symptoms in patients with coronary artery disease. Psychosomatic Medicine;83:423-431.

Jha, M., et al. (2019). Screening and management of depression in patients with cardiovascular disease. Journal of the American College of Cardiology;73(14):1827-1845.

van Agteren, J. et al., (2021). A systematic review and meta-analysis of psychological interventions to improve mental wellbeing. Nature Human Behavior;5:631-652.

Rutledge, T., et al. (2013). A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease. Psychosomatic Medicine;75(4): 335-349.

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