by Dan Kavanaugh, M.S., social worker, National Institute for Neurological Disorders and Stroke (NINDS), Bethesda, Maryland, one of the U.S. National Institutes of Health

Last summer my youngest daughter broke her leg in a playground accident when another child ran into her. We took her to the physician and the X-rays confirmed a break. The healing process began when the cast was placed on her leg. What if I had taken my daughter to the physician and instead of putting a cast on her leg he had just said "That’s understandable that she broke her leg." Suppose the physician had left it at that — no further medical intervention, no cast, just the words "That’s understandable." Wouldn’t that be a fairly shocking response? Yet when a person who is diagnosed with a chronic illness begins to express feelings of depression, they are often met with the words "That’s understandable" and are not offered the opportunity to have the depression treated.

Prevalence of Depression

Depression is one of the most common complications of chronic illness. According to one survey it is particularly common in those with recent heart attacks (45%), hospitalized cancer patients (42%), recent stroke survivors (40%), and diabetes (33%). In fact it is not unreasonable to view chronic illness and depression as a two-way street — a diagnosis of a chronic illness can be depressing and the increase in depressive feelings can exacerbate the illness. The risk of depression increases in proportion to the severity of the illness and the life disruption it causes. My daughter’s broken leg was certainly sad and it was disturbing to see her in pain, but being diagnosed with a life-threatening tumor can be severely depressing.

Risk of depression

The risk of depression also increases with the possible complications of a chronic illness. A person may be successfully managing a chronic illness, but the illness may have so many possible complications (frequent hospitalizations, depletion of financial resources, decreased ability to maintain gainful employment) that even one who is in control of the disease may have a high rate of depression.

Signs and symptoms of depression

What are some of the signs and symptoms of depression?

1) Depressed mood most of the day, nearly every day

2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day nearly every day.

3) Significant weight loss or gain when not dieting or decrease/increase in appetite nearly every day

4) Insomnia or hypersomnia nearly every day

5) Fatigue or loss of energy nearly every day

6) Feelings of worthlessness, or excessive or inappropriate guilt, nearly every day

7) Diminished ability to think or concentrate

8) Recurrent thoughts of death (not just fear of dying) or of suicide without a specific plan, or a suicide attempt or specific plan for committing suicide

As you read the list of symptoms above it is important to keep in mind that many physical illnesses produce some of the symptoms of depression. Cancer, for example, is associated with weight loss, sleep disturbance, and low energy.

That is why it is imperative that a person who is otherwise known to be healthy get a medical workup when they are experiencing these types of symptoms. Often once the presenting physical ailment is treated, then the depression is also eliminated.

Deciding whether or not to seek professional help

There are times when a person who is experiencing depression will get better without treatment. How does a person decide whether to seek professional help? Some questions for the person to consider are:

1) Is the distress level intense enough that they want to do something about it?

2) Do they feel that they are no longer able to problem-solve on their own? Do they feel the need for more support?

3) Is the level of distress such that it is negatively affecting their relationships, usual activities, or work? and

4) Are they contemplating suicide?

A person who answers yes to one or more of these questions may benefit from entering a counseling relationship with a mental health professional.

Who treats depression?

What types of professionals treat depression? Psychiatrists, clinical social workers, psychologists, and psychiatric nurse specialists are the primary treatment providers for depression. In addition, there’s a wide range of professionals who can also help people with depression, including members of the clergy and school guidance counselors who are trained to detect the disorder, and can provide referrals.

Treatment options

There is a wide range of treatment options for depression, but they can generally be divided into three categories: Antidepressant medication alone, psychotherapy alone, or a combination of antidepressant medication and psychotherapy.

There are a variety of antidepressant medications available, but they can be separated into three main categories: Tricyclics (TCA’s), Monoamine oxidase inhibitors (MAOI’s), and Selective serotonin reuptake inhibitors (SSRI). Medications within these categories work differently on the brain and have different side effects. Unfortunately, there is not a definitive way of knowing beforehand which medications will be most effective. A depressed person may have to try a few different medications before finding one that is effective. This is not to say that prescribing medications is just guesswork. Certain depressive conditions may respond better to particular antidepressants. It is important that the physician and patient work closely together in order to determine an appropriate regimen.

The term "Psychotherapy" refers to psychological treatment for depression. Under the broad category of psychotherapy there are over a hundred schools of "talk therapy." The two main categories within these different schools can be classified as insight-oriented therapy and cognitive-behavioral therapy. Insight-oriented therapy is focused on helping the patient to gain a greater understanding of their unconscious motivations and increase insight into the root of the problem. It is focused on reviewing the past for clues into current behavior. Cognitive-behavioral therapy is more focused on the present; looking at current behavior and thought processes, and how to change behavior and thinking that may be contributing to depressive feelings.

"How do I know which practitioner to see and which type of therapy will work for me?"

Basically, it is impossible to say that any one specialty is superior to another. The main difference is that only psychiatrists can prescribe medications. However, these professions often work collaboratively to treat a person. For example, a clinical social worker may work in conjunction with a psychiatrist where the social worker provides the psychotherapy (or counseling) and the psychiatrist takes responsibility for prescribing the appropriate anti-depressant.

It is difficult to predict which type of therapy will work for any one person. The most important factor to consider is that you are working with a person who is willing to explore a variety of treatment options. A person may encounter health professionals who will say "medication only" and others who might say "psychotherapy only." My own view is that practitioners ought to tailor the treatment to the needs of the patient and not enter into the healing process with an "either/or" view.

"How do I find a mental health professional in my community?"

A good place to start may be with the physician who knows you best. You are probably not the first person to ask this question, and he or she may have a few names to recommend. If you have health insurance, check to see if mental health services are covered. For a person who is taking antidepressants and engaging in psychotherapy they may find that the medication costs are covered or reimbursed, but that the psychotherapy is not. While there are moves at the state and federal level to achieve greater parity between treatment for physical and mental health it is safe to say that coverage for mental health services such as psychotherapy are more restrictive than medical treatment for illness. Some policies may cover individual therapy, but not group or family therapy. The bottom line is to find out what your insurance will pay for or will not pay for. If cost is not an issue a person may choose the professional they believe will be most effective in treating them and agree to self-pay and not submit for insurance reimbursement.

I have found that there are many agencies across the country that provide excellent services to people coping with depression as it relates to chronic illness. These agencies are usually a mixture of private and public funding and have a sliding-fee scale. That is, the amount the patient pays is based upon income and is not a flat fee. While there is not enough space to list all the agencies that I have referred people to over the years, I find Jewish Social Services and Catholic Charities to provide high quality counseling to patients who could not otherwise afford the usual fees charged for counseling (up to $100 an hour or more in some parts of the country). Even individuals in private practice may be willing to consider a fee lower than their established rate, but you will not know unless you ask.

One can also contact the following professional organizations than can assist in finding a mental health professional in the United States:

American Psychological Association 1-800-964-2000
American Psychiatric Association 202-682-6000
American Psychiatric Nurses Association 202-857-1133
National Association of Social Workers 1-800-638-8799
Cancer Care 1-800-813-HOPE

Similar resources exist in other countries.

Dan Kavanaugh, LCSW-C, BCD, is a clinical social worker at the National Institutes of Health Clinical Center, Bethesda, Maryland.

As printed in the VHL Family Forum 8:2, June 2000. For permission to reprint, please contact VHL Family Alliance, editor@vhl.org. Further information is available from the VHL Family Alliance, info@vhl.org.