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Depression and Chronic Illness: Which Comes First?
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Depression and Chronic Illness: Which Comes First?

Which comes first—depression or chronic illness? While the connection works both ways, one thing's for sure: treatment can make a difference.

Jennifer was 26 years old when her doctor diagnosed her with high blood pressure. But it wasn't until she learned that she also suffered from polycystic ovary syndrome that she began her slide into depression. Like many other patients with chronic illnesses, she hid her depression from her doctor, even as she underwent fertility treatments and a high-risk pregnancy.

"It's so hard to deal with a chronic illness," says Jennifer, now 29. "Many people are afraid to admit that they need help."

After the birth of her son, she broke down and told her doctor of her depressive symptoms—her self-imposed isolation from others, withdrawal from relationships, sleeplessness, and feelings of hopelessness. He helped her understand that like her other chronic conditions, her depression was not her fault. She began taking an antidepressant, and her outlook improved.

"It has helped tremendously," she explains. "I needed it to keep things in perspective for me, which it did."

When Illness Triggers Depression

When faced with a potentially life-changing diagnosis of a chronic condition, it can be easy for depression to set in.

"Any illness that in some way seems to increase an individual's helplessness and hopelessness will also be a trigger for depression," says Jeremy Kisch, PhD, senior director of clinical education at the National Mental Health Association. Depression is easy to overlook in part because some of its symptoms—like fatigue or change in energy levels—mimic those of some chronic illnesses.

When Depression Leads to Illness

In cases like Jennifer's, it's pretty clear that the illness led to depression. But for scores of other patients with conditions like heart disease and diabetes, the connection can be the reverse.

People with a history of depression are at least three times more likely to suffer from heart attacks than their non-depressed peers, according to William Eaton, PhD, professor of mental hygiene at the Johns Hopkins School of Hygiene and Public Health. "That ranks depression in the same strength as a risk factor as high cholesterol or family history of heart disease," he says.

Depression also predicts type 2 diabetes, Dr. Eaton explains, adding that the links between depression and these illnesses likely work on different levels. "It could be behavioral—depressed people eat differently or exercise differently," says Dr. Eaton. "But it's also possible that it may work under the skin. In a person who is depressed, the blood clots differently, the immune system works differently, the heart beats with a different variation."

The Diagnosis Dilemma

Experts say that as many as 50% of people who suffer from depression go undiagnosed, many of them among the ranks of patients who regularly see their doctors for other reasons, like heart disease, diabetes, or asthma.

Dr. Kisch believes that at least some of the minimalization of depression stems from the patients themselves. "It seems to be a natural consequence of what they're struggling with physically," he says. "They don't realize that it's depression."

For many chronically ill patients who are depressed, it's a Catch-22. Their depression saps their energy, leaving them withdrawn and less likely to actively seek help from their healthcare providers.

Dr. Kisch says family and friends can play an important role in helping bring depression to light in patients with ongoing health problems. "It requires someone on the outside to be able to say, 'Maybe you're having more difficulty because you're depressed in addition,'" he says.

Dr. Eaton, on the other hand, sees doctors becoming more aware of the importance of screening for depression, and incorporating it into their daily routines. "It's as easy to screen for depression as it is to take a blood pressure," he says. "Depression has got to be brought into medical care generally."

Depression's Devastating Effects

No matter when depression strikes, if it accompanies some chronic illnesses, the ramifications can be serious.

  • Diabetes—Depressed people with diabetes may not take their medications as diligently. This will lead to more problems controlling their blood sugar, which in turn leaves them more susceptible to serious complications.
  • Heart Disease—Patients with heart disease who are also depressed might stop paying as much attention to their diets, thereby putting themselves at greater risk for heart attacks. People with heart disease that suffer from depression during the early days of their recoveries are more likely to die within a year of their attack than patients who do not get depressed.
  • AsthmaA study by Carol Mancuso, MD, of New York Presbyterian Hospital, measured asthma patients' quality of life, using psychological instead of physical measures of depression. The study showed that patients who recorded more mental signs of depression, like feelings of helplessness or worthlessness, also suffered more from their asthma. "If they co-exist," she concludes, "asthma is worse with depressive symptoms [than without]."

Although not all chronic diseases are as closely related to depression as diabetes, heart disease, and asthma, the way depression exacerbates symptoms makes it a particularly dangerous risk factor.

Treatment for Depression

Kisch, Eaton, Mancuso and other experts don't believe that any single factor ties depression with chronic illness. The complex cause-and-effect relationships may never be completely understood, though studies are aimed at pinpointing specific risk factors and discovering optimal treatments. For example, some studies have shown that antidepressants increase the activity of the immune system in people suffering from depression and physical illness.

In the meantime, the doctors say that raising awareness of the prevalence of depression in patients with chronic illness may help more of them receive appropriate treatment, whether it's psychotherapy, an antidepressant, or some combination of the two.

Already, doctors have seen that successful treatment of co-occurrences of depression shows promising benefits. This doesn't surprise Jennifer, who continues to manage her depression daily. After taking control of her depression, she has been better able to accept and deal with her other chronic illnesses. She thinks it's unfortunate that depression is not better understood and its treatment more accepted by the general public. "Depression is a medical condition, just like other conditions," she explains. "It's okay to ask for help."

Symptoms of Depression

According to Dr. Kisch, doctors and patients should look for the following symptoms as clues of depression, especially in the presence of other medical conditions.

  • Persistent sadness that lasts more than two weeks
  • Lack of interest in family and other close relationships
  • Change in eating habits (eating more or less than usual)
  • Change in sleeping habits (sleeping more or less than usual)
  • Loss of energy, fatigue
  • Sense of hopelessness, helplessness
  • Lack of interest in taking medications or staying on required healthcare regimen
  • Missed doctor's appointments
  • Exacerbation of chronic illness symptoms (which can signal an increased vulnerability to depression)

RESOURCES:

American Psychological Association
http://www.apa.org/

Mental Health America
http://www.mentalhealthamerica.net/

CANADIAN RESOURCES:

Canadian Psychiatric Association
http://www.cpa-apc.org

Canadian Psychological Association
http://www.cpa.ca/cpasite/home.asp

References:

American Diabetes Association website. Available at: http://www.diabetes.org.

Co-occurrence of depression. National Institute of Mental Health website. Available at: http://www.nimh.nih.gov/publicat/cooccurmenu.cfm.

Detre KM. Coronary bypass surgery improves heart attack survival in people with diabetes. N Engl J Med . 2000;342:33-43.

Lustman PH, Anderson RJ, Freedland KE, et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care . 2000;23:934-942.

Mancuso CA, Peterson MG, Charlson ME. Effects of depressive symptoms on health-related quality of life in asthma patients. J Gen Intern Med. 2000;15:301-310.

National Mental Health Association website. Available at: http://www.nmha.org.

Pratt LA, Ford DE, Crum RM, et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation . 1996;94:3124-9.



Last reviewed February 2008 by Ryan Estévez, MD, PhD, MPH

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.


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