Uncovering the Link Between Depression and Chronic Illness

February 2020Milenko Martinovich

What links depression and chronic illness? Do physiological factors explain the association or could sociodemographic variables, such as age, employment status and marital status, play significant roles?

Researchers at the UCSF School of Nursing are working to deepen our understanding of the factors that can lead to an increased risk for depression. 

Does Menopause Play a Role in Depression?

Women are twice as likely as men to develop depression. The risk increases as women age, and menopause is often viewed as the potential trigger. But it’s unclear whether menopause is the cause or if there are other variables, including stress or changes in socio-demographic factors, at play.

In a new research paper, School of Nursing professor emerita Kathryn Lee and Catherine Gilliss, dean of the School, used data collected every six months from their longitudinal study funded by the National Institute of Nursing Research. The study followed over 300 women and measured many aspects of women’s health in the years before menopause. Lee and Gilliss co-authored the publication with their former doctoral students, Holly Jones, now at the University of Cincinnati, and Pamela Minarik at Samuel Merritt University.  

Kathryn Lee “Most of the research on midlife women occurs after menopause, and typically those women are recruited from clinic populations when they are symptomatic,” Lee said. “We wanted a community sample of healthy women before they began experiencing menopause. 

“The dilemma is that no one can say exactly when menopause will occur, but it is typically expected that menstrual cycles will stop at around age 50 and it was thought that women of color may experience menopause at an earlier age.”

The researchers excluded women with a chronic illness or depression diagnosis from participating. At the beginning of the study, African American, Caucasian and Latina women were between 40 and 50 years old and 75 women became peri- or post-menopausal within three years. The most common physical health problems were obesity and hypertension. The risk of depression was consistent over time – 25 to 28 percent – and was not associated with increasing follicle stimulating hormone, the biological marker of menopause.

Forty percent of women with hypertension or obesity had depression measure scores that placed them at risk for depression at the study’s beginning compared to only 23 percent of women without hypertension or obesity. After three years, there was no significant difference in depressive symptoms between the two groups. 

In contrast, over half – 58 percent – of the women scoring high for risk for depression at the study’s outset had a chronic health problem three years later compared to only 36 percent for women with a low risk of depression at the study’s start. 

“Recognizing and treating depressive symptoms may help prevent or reduce the impact of chronic illness for women in midlife,” Gilliss said. “This finding can help health care providers deliver care that impacts women’s physical and mental health long term.”

The researchers found a participant’s ethnicity and marital status were associated with depression scores at the beginning, but unemployment – which varied between 13 and 16 percent – emerged as the strongest link to depression three years later. The researchers suggest that some women are in danger of falling into depression while employed, and those symptoms may likely lead to job loss.

“Are women unemployed because of their health or did becoming unemployed make them depressed?” asked Lee. “It appeared from this sample that women continued to work while living with a chronic health issue like hypertension or obesity, but when depressive symptoms were prevalent, employment became difficult to manage.”

Because depression and chronic illness are intertwined, more thorough clinical assessments are necessary, the researchers said. For example, if a woman is diagnosed with a Catherine Gilliss chronic health problem, but wishes to continue working, health care professionals should devise plans to support that goal to stave off depression.    

While the link between depression and chronic health conditions was strong, the researchers found that a woman’s reproductive stage had little to do with increased risk for depression, obesity or hypertension. Women who remained pre-menopausal did score lower on the depression measure throughout the study, but the difference between them and the peri- or post-menopausal women at the study’s end was not significant. 

The Family Caregiver’s Role in Improving Depression Care Outcomes

School of Nursing associate professor Mijung Park has spent more than a decade examining the dynamic link between depression, chronic conditions and social support. 

The link between depression and chronic conditions is complex and more likely to be bi-directional, she said. In the U.S., about 88 percent of adults age 65 and over have one or more chronic medical conditions. Comorbid depression is common among them. 

Park’s current project examines how family can play helpful roles in enhancing older adults’ ability to manage their comorbid depression and chronic conditions. The project’s origins trace back to Park’s time as a PhD student at the UCSF School of Nursing in 2007. Park interviewed Asian Americans with severe mental illness, their families, and health care providers and realized how important family can be to a patient’s well-being. 

Mijung Park “It was an epiphany for me,” Park said. “Not only about how important family is, but also how they are not included in the planning and delivery of health care.”

Based on her study of the collaborative care model as a postdoctoral scholar at the University of Washington, Park devised her own model, Family-Centered Care for Older Adults with Depression and Chronic Medical Conditions in Primary Care (FACE-PC). Park’s model has a special emphasis on family or those who patients regards as family. Park said nearly half of the participants in her clinical trial, all ages 60 and older, identified non-relatives as their caregivers. Friends and neighbors assumed caregiver roles because many of the patients’ lived alone or their children did not live close by. 

It is critical that the patient, caregiver and health care provider are all on the same page regarding patient care, Park said. If the health care provider cannot achieve buy-in from the family/caregiver, it becomes less likely that the provider’s recommendations will be met.

“In our model, families are active and meaningful partners of care,” Park said. 

Results from Park’s project are still being analyzed, but the early returns are promising. In the FACE-PC model, patients experienced a decrease in depressive symptoms and felt more confident in managing their health conditions.

While caregivers did not experience an escalation in depressive symptoms, they seemed to experience an increase in caregiver burden. That finding, however, was anticipated because not all caregivers were intensively involved with patients at the study’s enrollment. 

Park acknowledges a sanctity in the patient-health care provider relationship, and that introducing a third party – especially a non-family member – can be awkward initially. But if the result is reducing depression and successfully managing a chronic illness, it’s worthwhile.

“What I’m trying to do is essentially change the culture of health care where we can extend our partnership to people around the patient. They are meaningful, contextual components of health care,” Park said.