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Depression and Chronic Illness
Comorbidity of Depression and Chronic Illness Acquired During Adulthood
Steven Gemignani
California School of Professional Psychology
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Depression and Chronic Illness
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Chronic illnesses and disabling conditions affect approximately 54 million
Americans. Of this number, more than 9 million Americans are unable to work or attend
school due to their disabilities (Livneh & Antonak, 2005). The impact of these illnesses
on individuals is profound. Individuals with chronic illness and disabilities face many
challenges in their lives. These challenges include functional limitations, impaired ability
to perform daily activities, uncertain prognosis, prolonged course of treatment and
interventions, psychosocial stresses, impact on family and friends, and negative impact
on financial resources. Not surprisingly, a large volume of data exists which
demonstrates high rates of comorbidity of depression and chronic illness. While the
incidence rate of depression is approximately 10-15% for the general population, the rate
for those with chronic illnesses has been estimated to be between 25-50% (Chronic
Illness and Depression, 2003). This paper examines the comorbidity data, reviews the
critical factors and variables that define the relationship between chronic illness and
depression, and presents current treatment alternatives.
According to Rodgers and Bland (1996), chronic illness and disability is generally
associated with a disease (e.g., multiple sclerosis, cancer, heart disease) or a traumatic
injury (e.g., brain or spinal cord injury). These illnesses are also described as either
congenital or are acquired after birth, later in life. This paper focuses on the psychosocial
adjustment to chronic illness and disability acquired during adulthood.
Table I provides the estimated incidence rate of depression for each chronic
illness in this report as provided by Davis and Gershtein (2003) and in Chronic Illness
and Depression (2003).
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Table I
Chronic Illnesses with Rates of Depression
______________________________________________________
Illness
Rate of depression
______________________________________________________
Chronic fatigue syndrome (CFS)
40%-60%
Heart attack
40%-60%
Multiple sclerosis (MS)
40%-50%
Parkinson’s disease (PD)
40%-50%
Rheumatoid arthritis (RA)
27%
Cancer
25%
Diabetes
25%
Thyroid
24%
Stroke
10%-27%
_______________________________________________________
In addition to these much higher rates of depression among chronic illness
sufferers, data also supports increased severity among this population. In 2005, Dalton
and Heinrichs found that more than 50% of MS sufferers had higher levels of depressive
symptoms than controls. Rao, Huber and Bornstein (1992) discussed similar findings for
suffers of PD. In addition, Feinstein (2004) found that 30% of MS sufferers had
experienced suicidal intent and that their suicide rates are 7 times higher than rates in the
general population.
It is apparent that depression more greatly affects the chronic illness population.
Available research supports the critical role of several variables and factors in this
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relationship, namely illness intrusiveness, illness uncertainty, and neurological factors.
Let us consider each of these variables and factors.
Mullins et al. (2001) defined illness intrusiveness as the extent to which illness
adversely impacts valued activities. There are two paths by which illness intrusiveness
affects quality of life: by reducing positive experiences due to decreased participation in
valued activities, and by reducing perceived control over important outcomes. It has
been shown that illness intrusiveness is significantly and uniquely correlated with
depressive symptoms, and other quality-of-life measures. This relationship has been
shown across a variety of chronic illnesses including end-stage renal disease, MS, RA,
diabetes and laryngeal cancer (e.g., Mullins et al., 2001; Devins and Binick, 1996; Devins,
Binick, Hutchinson, Hollomby, Barre & Guttman, 1983; Devins, Edworthy, Guthrie &
Martin, 1992; Devins, Mandlin, Hons, Burgess, Klassen, Taub, Schorr, Letourneau &
Buckle, 1990; Talbot, Nouwen, Gingras, Belanger & Audet, 1999). In fact, in several
different studies, researchers found that illness intrusiveness mediates the psychological
adjustment to chronic illness. For example, Talbot et al. (1999) found that illness
intrusiveness was not only strongly correlated to depressive symptoms in Type 2 diabetes,
but that it actually mediated depression. In this study, Talbot et al, found illness
intrusiveness had a direct effect on depressive symptoms and an indirect effect mediated
by personal control (i.e., perceived internal locus of control). This model accounted for
65% of the variance in depressive symptomology. Devins and colleagues consistently
found that illness intrusiveness mediated psychological adjustment to chronic illness (e.g.,
Devins et al., 1992; Devins et al., 1996). However in several studies, researchers were
unable to satisfy the statistical conditions to support that illness intrusiveness serves as a
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mediator variable for psychological adjustment and depressive symptoms. For example,
Mullins et al. (2001) found that illness intrusiveness was significantly correlated to
psychological distress, but not to the level to establish intrusiveness as a mediator
variable.
A component of illness intrusiveness is the physiological burden chronic illnesses
place on individuals. These individuals suffer from symptoms which limit their physical
or cognitive abilities and activities, and negatively affect their body image. We would
expect to see a strong correlation between higher levels of physical symptoms and higher
levels of psychological distress. Generally, research data supports this expectation. In
addition to the findings of Talbot et al. (1999), Gatchel (2004) discusses findings that
demonstrate a correlation of 0.5 between psychological distress scales and physical
symptom measures. He also states that patients with anxiety and depressive disorders
have more physical symptoms, and as the number of symptoms increases, so does the
occurrence of mood disorders. Guereje, Simon and Von Korff (2001) studied more than
5,000 patients across 15 sites in 14 counties and found that there was a fourfold increase
in mood disorders in patients suffering from persistent pain (i.e., more than six months).
Interestingly, there is quite a bit of conflicting data surrounding the hypothesis
that physiological symptom severity is correlated with psychological distress. When
examining the relationship between disease severity and depression, some studies have
shown weak correlation, no correlation or negative correlation. For example, depression
severity was found to be lower for individuals with higher rates of disability who suffered
from MS (Dalton et al., 2005). Rao et al. (1992) discuss findings for PD, where there
was only a modest correlation. Huber, Paulson, & Shuttleworth (1988) found that there
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was no correlation between disease severity and depression, and Rao et al. (1992) note
that investigators have not found a direct relationship between disability (or illness
severity) and depression in PD patients.
Researchers have suggested that locus of control and perceived helplessness could
help explain this seemingly confusing relationship between disease severity and
depression (e.g., Rao et al., 1992; Dalton et al., 2005). However, there does not appear to
be definitive data supporting this hypothesis. Chaney et al. (1996) did find that decreased
perceptions of daily illness control accentuate the adverse influence of negative event
appraisal in patients with RA. They stated, “Our results suggest that emotional
adjustment in RA is compromised when individuals simultaneously assume personal
responsibility for negative outcomes across a wide variety of life domains (i.e., internal
and global attributions) and perceive that they have minimal control over daily aspects of
their illness.” However, even though Shnek, Irvine, Stewart, and Abbey (2001) found
that helplessness and self-efficacy were significantly associated with depressive
symptoms. Neither factor was significantly associated in the final regression analysis. So
this complex relationship between disease severity and depression is still not fully
understood.
Mullins et al., (2001) defined illness uncertainty as “an individual’s perception of
ambiguity around his or her diagnosis, prognosis, relationship with caregivers, a lack of
adequate information about one’s illness, and unpredictability of illness course.”
Research across a variety of diseases has consistently demonstrated the link between
lower levels of psychological adjustment and increased levels of perceived illness
uncertainty (Mullins, et al., 1997; Mullins et al., 2001). Mullins et al. (2001) discuss that
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it was further discovered that the greater the illness uncertainty (in MS), the higher the
risk that patients will interpret the effects of their illness as adversely affecting their mood
– regardless of their functional abilities. In this study, the cognitive appraisal of illness
uncertainty was uniquely and positively correlated to psychological distress. In addition,
McNulty, Livneh, and Wilson (2004) write that illness uncertainty was found to be
associated with diminished mood and hopefulness. The results of their study indicated
that illness uncertainty was uniquely and significantly correlated to overall psychosocial
adjustment to chronic illness in MS. Interestingly there is a small amount of conflicting
data. When Sanders-Dewey, Mullins, and Chaney studied perceived uncertainty and
distress in individuals with PD in 2001, they did not find perceived uncertainty to be a
predictor of psychological distress. Their multiple regression analysis found that
uncertainty did not make a significant contribution to psychological distress.
There are some unique facets to neurological diseases that warrant discussion.
Since these illnesses impact the central nervous system, they may exert an influence over
specific brain functions and, therefore, directly impact an individual’s mood. It is
interesting to note that emotional disorders have been found to be more common and
more severe in neurological illnesses than in illnesses which cause a similar level of
disability. Rao et al. (1992) confirmed this assertion for MS and PD patients, and noted
that in some cases the depressive episodes occurred prior to an onset of motor symptoms.
Researchers have proposed several different theories to explain this increase in
mood disorders for individuals who suffer from neurological conditions. Feinstein (2004)
states that MS patients suffering from depression were found to be more likely to have
greater hypointense lesion (i.e., larger, dark lesions which indicate significant axonal
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damage) volume as well as discrete areas of cerebral atrophy. It was found that
combining the effects of hypointense lesion load, cerebral atrophy and hyperintense
lesions (i.e., newer, smaller lesions) accounted for 40% of depression score variance.
However, Rao et al. (1992) describe the results of a study in which the severity of
psychiatric morbidity was not significantly correlated to total lesion score. This may be
explained by the fact that MS is a subcortical disease that most often involves the frontal
lobes. Rodgers (1996) states, these lobes are significantly involved in cognitive,
characterological, and affective functioning. Thus damage (e.g., lesions or atrophy)
involving the frontal lobes can negatively impact an individual’s mood state.
In the case of PD, there is strong evidence suggesting the PD may be related to
serotonin depletion (Rao et al., 1992). Levels of the principal serotogenic metabolite (5HIAA) have been found to be significantly lower in depressed PD patients compared
with non-depressed PD patients. However, research has not clearly demonstrated a
strong correlation between severity of depression in PD patients and levels of 5-HIAA,
and it is not clear why some PD patients with low levels are not depressed (Rao et al.,
1992).
Several approaches to treating depression associated with chronic illness are
supported by research. The use of antidepressant medications (e.g., SSRIs) has been
found to be effective at reducing depressive symptoms in patients with chronic illness
(Cleveland Clinic Health Systems. 2003, Feinstein, 2004 Rao et al, 1992). In addition,
psychosocial interventions have also been found to be effective in treating depression and
improving patients’ quality of life (QOL). In fact, research has found that psychosocial
interventions have the following positive effects on patient suffering from chronic illness:
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reduction in chronic pain symptoms, lowering distress, reducing stress and cortisol levels,
increasing sense of personal control, improving problem-focused coping and sense of
efficacy, improved optimism and reduced hopelessness, aided benefit finding and
enhanced life meaning, and generally improved QOL. In addition, psychosocial
interventions have also been found to have a positive impact on mortality, disease
progression and several biological factors associated with improved health
(Schneidermann, 2004; Schneidermann, Antoni, Saab, & Ironson, 2001).
Several types of psychosocial interventions have been found to be effective.
There is extensive research supporting the efficacy of Cognitive Behavioral Stress
Management (CBSM), supportive expressive therapy, existential/experiential therapy,
and psychoeducational therapy (Devins et al, 1996; Schneidermann et al, 2001).
Interestingly, research does not yet provide strong support for the inclusion of family in
psychosocial treatment, even though this approach has face validity (Martire & Schultz,
2007).
Psychosocial interventions found to be effective include individual and group
treatment modalities. Individual interventions allow for treatment to be specifically
tailored to the individual needs of each patient and for treatment of greater intensity.
Group interventions provide patients with context which serves to normalize their
experience. The group format also allows patients to learn from each other and benefit
from the social support of the other members (Schneidermann et al, 2001).
Overall, there should be no question that depression is more prevalent among
individuals who suffer from chronic illnesses. The research data mentioned in this report
speak for themselves, and there is no conflict among the research supporting the
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increased incidence rate. Research also clearly supports the benefits of medication and
psychosocial interventions to reduce depressive symptoms, improve mortality rates, slow
disease progression, improve several biological factors associated with improved health,
and improve overall QOL.
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