Years ago, I had a beloved dog who went completely blind. This was, apparently, not unusual for his breed, and he seemed to do quite well. His senses of hearing and smell were keen, and he lost little of his skill at stealing food when no humans were looking. Still, whenever I give a lecture about the challenges that people face in managing chronic conditions, I think of my dog. His blindness triggered, for me, strong feelings of sadness and loss and grieving because he would never again be the same; he would never again see. I understand why the data show that at least 30% of people who are diagnosed with a chronic disease (which by definition, will never be cured) develop depression.
Depression in medical patients is not surprising; many chronic diseases come with a loss of functioning, or a change in appearance, or the need to alter future goals. Daily life might change a lot. Medication needs to be remembered, often many times per day. Dietary habits need to be altered, and familiar, personal comfort foods may need to be avoided. Old habits need to be broken; new habits need to be formed. And life will never again be the same. Health can never be taken for granted, and more losses might follow.
Depression has a serious and detrimental effect on patients’ adherence to their chronic disease treatments. Research using meta-analysis has shown that adherence is diminished by as much as 27 percent when medical patients have untreated depression. Why? Depression fosters pessimism about the future and it interrupts effective thinking and planning, which are essential for setting and achieving health goals. When people are depressed, they tend to withdraw from the very folks –family members, friends—who might help them to follow their treatment regimens.
And yet, few providers even assess whether their chronically ill patients might be depressed. Certainly, if a patient appears to be having poor treatment outcomes, depression might be the culprit, but research suggests that among medical patients who actually are depressed (as assessed with questionnaires), only about 6 percent of their physicians take the time to ask.
Providers, practicing in an already stressed healthcare system, wonder what they can do with the little time they have with their patients. My first response is “pay attention.” If your patient seems sad, he probably is. Ask about what the patient enjoys doing. An unenthusiastic response might be a clue. Providers can make a huge difference in recognizing depression, and ideally they will have a psychologist or other behavioral professional available in their practice and on the medical team. The cost-effectiveness of clinical health psychologists is becoming more evident, and many healthcare teams benefit greatly from their inclusion (more on this topic soon).
But failing that, talk with your patient. The chronic disease is real, and it must be accepted. The sense of loss and grieving in response to a chronic disease diagnosis are real too, and the patient should not have to bear them alone. Understanding this might be the first step in helping the patient toward acceptance and effective chronic disease management.