Course Goals:
Chronic illness is a condition that lasts over a long time and typically cannot be completely cured, although it can be managed through medication and lifestyle. Diabetes, heart disease, hypertension, arthritis, HIV/AIDS, and multiple sclerosis are all examples of chronic illnesses. The leading chronic diseases in the U.S. include cancer, stroke, heart disease, respiratory disease, diabetes, Alzheimer’s disease, and kidney disease (Centers for Disease Control and Prevention [CDC], 2021). Depression is also a chronic medical illness. Depression affects how a person feels, thinks, and behaves and frequently co-occurs with other chronic conditions. Depression in chronic illness decreases a person’s quality of life and leads to a greater utilization of healthcare resources. Depression is a major risk factor for completed suicide, suicide attempts, and self-harm. One study (Ahmedani et al., 2015) found that most individuals who attempt suicide visit a health care provider in the previous month prior to the attempt. According to the CDC (2021), 6 in 10 adults in the U.S. have a chronic disease and 4 in 10 adults in the US have two or more chronic diseases. Research suggests that depressed individuals with other chronic medical conditions tend to have more severe symptoms of both illnesses (National Institute of Mental Health, 2021). Older adults account for more chronic conditions, such as diabetes, arthritis, and heart disease; 80% have at least one chronic condition, and nearly 70% of Medicare beneficiaries have two or more (National Council on Aging, 2021). The depression experienced by this population comes in the form of both formally diagnosed depressive disorders (e.g., major depressive disorder) and subthreshold or subsyndromic symptoms. Often the depressive symptoms are somatic (i.e., physical) and overlap with those of the chronic disorder, making depression difficult to assess and treat.
It is difficult to distinguish depression from the normal course of adjustment following diagnosis of a chronic illness, which is a life-changing event. Depending on the age of the person, it can mean changes to career aspirations, occupational disruption, views on mortality, and outlook on life. A diagnosis can also mean changes to physical status, role functioning, occupational status, and social networks (e.g., someone with a chronic condition can become more isolated and reliant on others for care). When changes like these occur, they are likely to cause stress that can contribute to the development of depression through direct effects on neurotransmitters or indirect effects via heightened immune function and inflammation. Furthermore, neurodegenerative conditions such as Parkinson’s disease change areas of the brain that produce dopamine, norepinephrine, and serotonin, which are involved in regulating mood, energy, appetite, motivation, and sleep (Parkinson’s Foundation, 2021).
In addition to these biological effects on the risk for depression, there are processes of adapting to the psychosocial aspects of living with a chronic illness that can affect the risk for depression. This process of adapting can be thought of as a grieving period, and if a person does not find a way to adjust to his or her life with a chronic illness, depression may result. A challenge to identifying depression in chronic illness is determining whether a person’s adaptation is proceeding in a typical way or in a way that is indicative of depression.
Depression is a highly prevalent and potentially disabling condition contributing to a significant proportion of disease burden worldwide. Depression is even more common among individuals who have chronic medical conditions, such as diabetes, heart disease, autoimmune diseases, chronic obstructive pulmonary disease, cancer, epilepsy, AIDS/HIV, hypothyroidism, and neurological disorders (National Institute of Mental Health, 2021). Depression accounts for greater healthcare costs and lower work productivity (Chow et al., 2019). In a study using data from the largest survey of physician practices in the U.S. (Bishop et al., 2016), the findings demonstrate that depression care management in primary care falls behind that for other chronic illnesses, especially diabetes. The study recommends that greater attention be given to developing policies and incentives to increase the utilization of care management processes for depression in primary care. Despite its relatively common occurrence and negative consequences, depression is underrecognized – and as a result undertreated – in individuals with chronic conditions. Although awareness of depression in medical settings has certainly improved since the mid-1990s, research on the treatment gap for mental disorders shows that clinicians are not keeping up with the rapidly growing knowledge regarding optimal depression management (Bishop et al., 2016). Consequently, only a minority of individuals with depression are being diagnosed and treated according to clinical practice guidelines (Bishop et al., 2016). Because individuals with chronic conditions are also commonly treated by physical and occupational therapists, it is essential for these clinicians to understand the impact that chronic illness has on both mental health and physical capabilities.
This basic-level course addresses this knowledge gap by providing rehabilitation professionals with an overview of the co-occurrence of depression and chronic conditions and identifying challenges in screening and referring adults with chronic conditions and depression. It provides explanations for potential causes of and contributing factors to depression unique to individuals with chronic medical conditions. Although individuals with chronic conditions are at an increased risk for depression, this course also explores factors that may enhance such individuals’ well-being and diminish the likelihood of depression.
A handful of tools are available to assist the clinician in screening for depression in chronic illness, including standardized assessments of depressive symptoms. Clinicians who have clients with chronic medical conditions can use these tools to identify depression.
This course presents clinicians with an integrated view of the biological and psychological contributors to and consequences of chronic illness using a biopsychosocial model. Designed for rehabilitation professionals, the course examines the prevalence and symptoms of depression as well as selected chronic medical conditions with which depression is often associated. Structured means of assessing depression are also presented. Contributing risk and protective factors to depression and potential treatments are also explored. Research on depression in chronic illness and applications to practice are relatively new and constantly evolving. A review of this new information can help clinicians determine their role in assisting clients in getting the help they need.
Learning Outcomes
Upon the completion of this course, the learner will be able to:
- Describe the co-occurrence of depression and chronic illness.
- Recognize the symptoms of depression and appropriate assessment tools to screen for depression.
- Identify common causes and contributing risk and protective factors for depression in individuals in medical populations.
- Compare and contrast treatment approaches for depression in individuals with chronic illness.
- Analyze the implications of chronic illness and depression on physical and occupational therapy practice.
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