The Elephant in the Room: Depression & Chronic Illness

Despite its many human and financial costs, depression is a chronic disease that is under-recognized, undertreated and poorly managed. Yet the prevalence of depression in the general population may be higher than previously thought—with estimates of 19% in Canadian studies. Individuals between 45 to 64 years of age are at particularly high risk according to US studies, with baby boomers being at the highest risk of suicide of any age group. On July 9th, the Population Health Improvement Learning Collaborative featured a groundbreaking presentation and discussion on depression and chronic illness with HealthSciences Institute Advisory Board Member Susan Benson, DNP, APRN, CCP. Dr. Benson shared important new developments in the genetics and neurobiology of depression, as well as practical steps for depression screening, depression and suicide risk management, evidence-based treatments, and strategies and tips for listening and talking to patients affected by depression. Based on the attendance for Dr. Benson’s presentation, as well as the great feedback and many questions we have received since, the interest in practical strategies for addressing depression among patients at risk of, or affected by chronic illness is strong.

Why is it critical for any clinician who works with patients at risk of or affected by chronic diseases to be familiar with this topic?

1. The stigma of depression is alive and well. Despite mounting evidence that depression is strongly influenced by genetic factors and the body’s neurotransmitters, depression is still viewed as a moral failing or personal inadequacy. Because of this stigma, depression is often unrecognized or untreated—and people with depression often live in shame.

2. Depression is not just another chronic disease. The fact that depression is a chronic disease is well established. But depression is much more—it impacts physical disease risk, treatment adherence, self-care, lifestyle choices and quality of life. Depression affects every aspect of our work with individuals with chronic physical conditions.

3. Depression frequently co-exists with other chronic diseases. People with chronic physical conditions and disabilities are at higher risk of depression. Depression is one of the most frequent comorbidities—affecting over 30% of diabetics, 40% of Parkinson’s patients, 40% of recent stroke patients, 43% of those hospitalized with cancer, and 45% of those recovering from a recent heart attack.

4. There are important demographic differences in depression. While women are more likely to report or be diagnosed with depression, men are less likely to admit depression, but more likely to demonstrate substance abuse, and addictive or antisocial behaviors-related to depression. Additionally the prevalence of depression varies with age and socioeconomic status—with lowest-income individuals at higher risk.

5. Depression affects self-care and lifestyle choices. While there are a number of evidence-based approaches that clinicians can use to support patient self-care and lifestyle change, depression frequently contributes to poor self-care or lifestyle practices and must be professionally evaluated and treated.

6. Mental and physical health status is closely linked. People who are depressed are often in poorer general physical health. Chronic care of the whole person requires integrated, concomitant and evidence-based care for both. Simply referring patients who are depressed to the primary care physician or to a behavioral health provider as if it were an acute condition is not enough. Often, depression must be managed for months or years.

7. Physical activity may reduce the risk of chronic diseases and depression. The link between mood and physical activity has been well established. Those who are depressed are less likely to be physically active and regular physical activity is linked with better mood in individuals affected by depression.

8. Depression can increase social isolation. Much is written on the connection between health status, social connections and healthy (and unhealthy) behaviors. While social support is key to one’s well-being, today many people report feeling socially isolated. Socially isolated or unmarried adults are at particularly high risk for depression.

9. People who are depressed may be less likely to work. Work provides many opportunities for self-fulfillment and social connections. Yet, depression can interfere with job seeking success and job tenure. Additionally, unemployment is one of the most significant stressors and can easily affect physical and mental health.

10. Depression may reduce job performance. The effects of depression on daily functioning are not just evident at home, but on-the-job. It is well known that individuals who suffer from depression miss more days of work (absenteeism) and perform more poorly on the job (presenteeism).

It’s time for all of us who work with patients with chronic diseases to take a fresh look new research and innovations in the care and treatment of this depression. We encourage all clinicians in direct care, health management and behavioral health to view a free replay of this presentation through August 6th and share this information with colleagues. The replay of this presentation and the other six learning collaborative sessions are also available at no cost to participants in the Chronic Care Professional (CCP) learning and certification program through 2010.

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