Chapter 6 Sarah Alderson and Allan House Leeds Institute of Health Sciences, University of Leeds, Leeds, UK Depression and anxiety are common in people who have long-term physical conditions (LTCs) and can be more difficult to detect and treat. Less attention has been given to anxiety, but anxiety and depression often coexist, and mixed presentations are common in primary care. Anxiety symptoms can have significant overlap with those of the physical illness, particularly chest pain in those with cardiac disease and shortness of breath in chronic obstructive pulmonary disease (COPD) and asthma. Hanif’s symptoms – anger, worry, getting upset – indicate an emotional response to his illness that is associated with family tensions. Could he have a significant mood disorder? Depression can be difficult to recognise in the presence of long-term physical conditions – because there is overlap of physical symptoms such as lethargy or poor sleep; the presenting symptoms of depression are varied and not clearly defined, and patients may be reluctant to talk about emotional problems with healthcare professionals. Hanif’s non-specific symptoms should be followed up with more specific inquiry about his mood, since he is functionally impaired by his emotional state and is fearful of activity rather than being limited solely by his heart disease. Case-finding questions can help identify depression in people with LTCs, but need to be supplemented with clinical judgement as, if used alone, they overestimate the presence of coexisting depression. Depression associated with long-term conditions is associated with a significant increase in morbidity and mortality (Box 6.1). The best evidence is in conditions such as cardiac disease and diabetes, but the risks are present in any chronic condition such as psoriasis, chronic pain and COPD. There may be physiological explanations for this comorbidity – chronic depression is associated with a persistent endocrine stress response and with a low-grade inflammatory response – but more immediately relevant clinically are factors such as reduced adherence to treatment, poor diet, misuse of alcohol and limited physical activity – all exacerbated by depression. Similarly, comorbid depression can lead to poor medication adherence, difficulties in self-management and reduced physical activity (Box 6.1). People with comorbid depression and anxiety can present with functional impairment that appears to be out of proportion to the clinical severity of physical illness, and case identification should take into account not just ‘symptom count’ but the severity of emotionally related disability. People with chronic illness also suffer the same losses, role changes and stresses as the normal population, and not all anxiety and depression will be related to the physical condition. Even so, the prevalence of mood disorder in physical illness is two to three times that in the general population. This higher prevalence is usually attributed to the specific meaning for the individual and impact upon their life of the long-term condition, which may represent a threat that causes anxiety or anger and irritability in response to uncertain risk; a sense of loss for the future self, which includes facing mortality and disability; a lack of personal control over what is happening; and humiliation over the loss of position in society or family and undermining the sense of self. The psychological challenges posed by illnesses may lead to depression or anxiety if the individual is not able to mount an effective coping response. Professional views on the causes of depression associated with LTCs tend to emphasise poor coping with the challenges of the illness, increased vulnerability and poor social support. However, patients do not necessarily understand their distress as a discrete state that might be diagnosed, labelled and treated. They may be reluctant to admit their distress or fear stigmatising responses from others (including healthcare professionals); be reluctant to name their problem as ‘anxiety’ or ‘depression’, and fear further medicalisation of their situation with tablets. Patients may recognise the psychological stress of chronic illness as a cause of how they are feeling emotionally, with diagnosis often being a life-changing event that forces people to face mortality and potential disability. Adapting to a LTC is a constant source of stress to some people, with resulting difficulties in understanding how to manage it and feelings of guilt when not following lifestyle restrictions. However, not uncommonly, a person may have multiple interacting reasons for feeling low, including social factors, rather than just ill health alone. Other life events such as bereavement or relationship breakdown, unemployment and family problems may be considered as causes by sufferers, but not ‘justifiable’ ones as they could, in the mind of the sufferer, potentially be resolved by some action on the part of the person themselves. Loss of health and fear for his future are likely causes for Hanif’s distress. His view of these matters should be explored. His story also raises an important question about whether, since retirement, he has been able to establish a role for himself either in his family or in his wider social network. Systematic case-finding or screening has been advocated as a method to increase detection and improve outcomes for depression associated with long-term conditions. Case–finding differs from screening in that only those with risk factors for the disease are targeted. For example the New Zealand Guidelines Group advocates targeted screening in primary care for high-risk patients, which includes those with chronic physical disease. The Canadian Task Force on Preventative Care and the US Preventive Services Task Force also encourage screening for depression, but only where there is Collaborative Care available as a treatment intervention if depression is detected. Simple brief questions exist for both depression and anxiety in the form of the PHQ-2 and GAD-2 (see Box 6.2). The Patient Health Questionnaire-2 (or ‘Whooley questions’) has been recommended as a screening tool in the UK as it was thought that it needed little training and had few implementation difficulties.
Anxiety and Depression: Long-Term Conditions
The nature of the problem
Theories about aetiology
Case-finding
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