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Depression

Identifying Depression in Patients with Chronic Disease

It is common, and they are more related than you might think.

Key points

  • Depression is a significant risk factor for developing chronic diseases and is much more common in those who have a chronic condition.
  • In addition to impacting quality of life, people with both conditions have poorer health outcomes, including greater risk of death.
  • It can be more challenging to diagnose depression in people with chronic disease. There are validated online screening tests available.
Kilarov Zaneit/Unsplash
Depression symptoms in chronic disease patients can include the typical low mood and lack of pleasure or interest in activities.
Source: Kilarov Zaneit/Unsplash

As we age, many of us develop risk factors for chronic diseases such as heart disease, diabetes, stroke, peripheral arterial disease or cancer. Many of us may not be aware, but just like tobacco use or high blood pressure, depression is a risk factor for developing these chronic conditions, and results in poorer prognosis for those who do develop them. The magnitude or effect of depression as a risk factor is just as strong or even more impactful than the traditional risk factors like high cholesterol.

While everyone has the blues from time to time, by depression, we are referring to having several cardinal symptoms over more than two weeks, with their severity great enough that it interferes with your ability to carry out your role obligations like work. And bear in mind you might not be crying if you are depressed, but instead feel irritable, hopeless, or have trouble making decisions. The main symptoms are feeling down and what we call “anhedonia” (like lack of hedonism… you don’t derive pleasure from what you normally might, like meeting a friend for tea or going to see live music). Other symptoms include slowing down of thought and movement, feeling worthless, a sense of guilt that is not commensurate with the situation, or thoughts of suicide.

If you or someone you know is thinking about ending their life, talk about it. Talking about it won’t give someone the idea. If they have a plan and aim to act on it soon, you want to connect them with crisis services or a suicide helpline right away. If not, remind them it is normal to feel really down sometimes, and having thoughts about ending one’s life can be an effort to deal with pain and need for meaning or purpose in one’s life. Encourage active, healthy steps to deal with an issue. And make sure to connect them with mental health services.

Diagnosing depression in chronic disease patients can be difficult, particularly if they are in the hospital at the time. Around the time of a cardiovascular event such as a heart attack or stroke, as you can imagine it is normal to be fatigued and to have a change in appetite. It is important to have a diagnostic interview with a regulated healthcare provider who specializes in mental health but also has knowledge of chronic disease. This will ensure your mental health issues are properly identified, which will also trigger initiation of appropriate treatment, which will be the subject of Part two of this series.

How depression and chronic disease are related

Depression is more common in patients with chronic disease, at about 10%. Let’s take heart disease as an example. While about 5% of the general population suffers from depression, in heart patients on average it is 20%. Unfortunately, as in the general population, rates of depression are higher in women with chronic disease than men (but men suffer from other mental health conditions at a higher rate than women). Depression rates are even higher at around 30% in patients with a more advanced form of the disease called heart failure, and are about 40% in patients around the time of a cardiac event or procedure such as bypass surgery; some of this distress does naturally remit, but in about one-third, the depression persists. This makes sense because depression itself can be chronic and recurrent.

Of additional concern is the added risk that depression brings in the context of chronic disease. As there are no cures for most chronic diseases (we work on managing them), even with medication and acute interventions such as stents, cardiovascular patients are at higher risk of another health problem or needing to be hospitalized. But in patients who also have depression, these rates are two times higher, including death. Important to patients, having depression is associated with slower resumption of social roles after a chronic disease diagnosis or hospitalization, functional decline and lower quality of life.

There are several mechanisms linking depression and chronic disease outcomes. There are physiological mechanisms such as increased blood platelet activity, and autonomic dysregulation. Patients with depression and chronic disease often engage in unhealthier lifestyles such as using tobacco or alcohol, being physically inactive, eating an unhealthy diet and not following medical advice such as adhering to medications. Patients with both conditions also have more risk factors such as obesity, high blood pressure and diabetes, often as a consequence of their lifestyle. All of this can lead to inflammation, and then clinical events. Genes also play a role.

Addressing depression symptoms in chronic disease patients

Unfortunately, depression is under-recognized in chronic disease patients, leading to unnecessarily reduced quality and quantity of life. This is a shame, because there are now many depression treatment options that are proven to work and are safe in patients with cardiovascular diseases. We’ll discuss those in part two.

In the meantime, if you or a loved one are experiencing the depressive symptoms listed above, you can do a validated online screening test for the general population such as is available here. Regardless of the results, it may be prudent to make an appointment with your primary care provider to investigate and potentially arrange a diagnostic interview.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 contact the National Suicide Prevention Lifeline, 1-800-273-TALK, or the Crisis Text Line by texting TALK to 741741. To find a therapist near you, see the Psychology Today Therapy Directory.

References

Shanmugasegaram, S., Russell, K., Kovacs, A., Stewart, D.E., & Grace, S.L. (2012). Gender and sex differences in the prevalence of major depression in coronary artery disease patients: A meta-analysis. Maturitas, 73(4):305-311.

Grace, S.L., Abbey, S., Pinto, R., Shnek, Z., Irvine, J., & Stewart, D.E. (2005). Longitudinal course of depressive symptomatology following a cardiac event: effect of gender and cardiac rehabilitation. Psychosomatic Medicine, 67, 52-58.

Poynter, B., Shuman, M., Diaz-Granados, N., Kapral, M., Grace, S.L., & Stewart, D.E. (2009). Sex differences in the prevalence of post-stroke depression: a systematic review. Psychosomatics, 50 (6), 563-569.

Lotfaliany, M., et al., (2018). Depression and chronic diseases: Co-occurrence and communality of risk factors. Journal of Affective Disorders; 241(1):461-468.

Vaccarino, V., et al., (2020). Depression and coronary heart disease: 2018 position paper of the European Society of Cardiology. European Heart Journal; 14(17):1687-1696.

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