Why So Blue? A Look at Depression as a Chronic Illness

According to the U.S. Centers for Disease Control and Prevention (CDC), one in six Americans has a chronic illness. One in four has two chronic illnesses. While definitions for what constitutes a chronic illness vary, many people are surprised to learn that some mental and behavioral health conditions are in the same category. Patients expect their primary care clinics will care for these conditions like they do other chronic conditions, like hypertension and diabetes. Rates of depression are rising, and more people need help. Healthcare providers must do more to educate themselves and their patients about what depression as a chronic illness looks like and how patients can receive the best care possible. 

Welcome to MetaStar’s two-part series, Why So Blue? A Look at Depression as a Chronic Illness. The first part of the series will focus on three topics: the difference between acute and chronic depression, how primary care clinics can be the leaders in treating chronic depression, and self-management of depressive symptoms. Part two will look at depression in a specific population: our older citizens, for whom depression is often considered “a part of getting older.” MetaStar is proud to be a voice in the chronic illness community, offering solutions and education for over 50 years.

I’m In My Blue Period: What Is Depression? 

A depression diagnosis can be categorized into three types: episodic, chronic, and double. Episodic depression consists of symptoms that last more than two weeks. Mia Croyle, MA, Behavioral Health Project Specialist in the Health Transformation department at MetaStar, explained this is called a “major depressive episode.” It can potentially be more debilitating than chronic depression due to the intensity of the symptoms. To use a climate analogy, think of it as a thunderstorm rolling into an area that is usually warm and sunny.

According to the Diagnostic and Statistical Manual V (DSM-V), to be diagnosed with a major depressive disorder, a patient must show a depressed mood and a lack of interest or pleasure in activities that were previously enjoyed. Three other symptoms must also be present: sleep disturbance, change in rate of speech (faster or slower), fatigue or loss of energy, feelings of worthlessness or hopelessness, difficulty concentrating or making decisions, and recurrent thoughts of death or suicide.

“When we say ‘chronic depression,’ we mean ‘ongoing,’” Croyle said. Chronic depression refers to a depressive mood that persists for over two years. It is potentially milder than episodic depression but more persistent, which is where the challenge lies. “Symptoms can vary in severity, but the condition is still present,” said Croyle. In the climate analogy, think of chronic depression as the weather in a place where every day is gray, and sometimes it rains.  

Symptoms of chronic depression are similar to those of episodic depression. The main criterion is a depressed mood most days for over two years. Additional symptoms are the same as those associated with episodic depression (with the inclusion of low self-esteem), and two of six must be present for a diagnosis (DSM-V).

Lastly, there’s double depression, which is when a person with chronic depression experiences an episode of intensified symptoms. In the climate analogy, double depression is comparable to a gray, rainy place experiencing a major thunderstorm for one day—low-level climate traits occur daily, but a more intense weather event happens only for a short period.

Blue’s Clues: The Science Behind Depression, Simplified 

The human brain is full of neurons (nerve cells) that use chemical messengers called neurotransmitters to carry messages to other neurons. They carry their messages across small gaps called synapses. The most important neurotransmitters that regulate mood and emotion are 

• Serotonin, which helps with mood, sleep, appetite, pain, and emotional regulation
• Dopamine, which helps with pleasure, motivation, focus, and reward 
• Norepinephrine, which helps with energy, alertness, and stress response 

In depression, the system the neurons and neurotransmitters use to communicate isn’t working correctly. First, the body might not be making enough neurotransmitters. Second, the neurotransmitter may go through a process called “reuptake.” Reuptake happens when the body “cleans up” the transmitters. If the neurotransmitter doesn’t stay around long enough, it can’t pass on its message. Third, the receptors might not be working well enough to receive the message from the neurotransmitter. Lastly, the whole system can become imbalanced, usually for multiple reasons, leading to too much or too little of any of the three neurotransmitters

Antidepressant medications help by preventing the reuptake of one of the neurotransmitters. If they stay around longer, they have more time to pass on their messages. The common ones are selective serotonin reuptake inhibitors (SSRIs). There are also serotonin-norepinephrine reuptake inhibitors (SNRIs) and norepinephrine-dopamine reuptake inhibitors (NDRIs). Antidepressant medications address only one of the four potential issues occurring in the brain. This is why medication alone only helps about 50% of people, according to Croyle. When combined with therapy and self-management, many more people can feel relief from depression.

Seeing Blue Skies: Management of Chronic Depression in Primary Care 

“With the advent of antidepressant medications and how popular they’ve become, a lot of people think they can just pop a pill and magically erase their depression,” said Croyle. Most people with chronic depression are going to need more help than a pill can offer. Cognitive behavioral therapy has proven effective in helping ease symptoms of depression. Additionally, self-management strategies can be helpful when a therapist isn’t available or when an episodic bout of depression appears.

Mental health treatment has long been siloed into psychiatrists’ offices and psychology departments. Various factors make this arrangement unsustainable. There is a concerning lack of mental health care providers, and many patients desire integrated physical and mental health care. Due to this, patients frequently turn to primary care providers for depression care. More than half of people receiving depression treatment do so from their primary care provider. This treatment is mostly medication-based, according to Croyle. If this trend continues, depression needs to have a place next to diabetes and hypertension in the chronic illness lineup. Clinics should apply the following chronic illness care best practices. 

• Employing a care manager who ensures those with chronic depression are getting the care they need 
• Establishing a registry that includes all patients with chronic depression for follow-up and reporting purposes 
• Reminding patients to follow their treatment regimen
• Teaching patients about their condition 
• Teaching patients about self-management 

In a recent study of primary care clinics, “they found about a third of them kept registries for chronic depression patients,” Croyle reported. “Less than 10% had patient reminders or taught any self-management.” Tools already in place for other chronic illnesses—like registries, software, or care managers’ expertise—can help clinics address chronic depression. Croyle also recommends that providers monitor symptoms on a regular basis and keep working with medications until the dosage and combination are found that give the person the most relief from symptoms. The Patient Health Questionnaire-9 (PHQ-9), which consists of nine questions about depression symptoms, could track patients’ symptoms in addition to serving as a reliable screening tool.

Blues Control: Ways Health Care Providers Can Encourage Self-Management of Chronic Depression 

Antidepressant medication is one part of treatment for chronic depression. How primary care clinics handle depression as a chronic illness is another. The third leg on the three-pronged stool of chronic depression care is self-management. Self-management is the “use of self-regulation skills to manage chronic conditions or risk factors for these conditions” (Duggal). Just like every chronic pain flare doesn’t need a trip to the emergency department and every high blood sugar reading doesn’t need a clinic visit, patients can self-manage chronic depression if they have the tools to do so. These tools, such as online learning and reviewed mental health apps, can be provided by the doctor or other clinic staff. Suggested self-management teaching topics for chronic depression include:

• Sleep management 
• Relaxation techniques and meditation 
• Eating delicious, filling foods 
• Enjoyable movement and exercise 
• How being in nature helps depression 
• Identifying symptoms and signs to watch for 
• Preventative strategies 
• Coping techniques 
• Ways to expand a support (not social) network 
• Resources in the community or contact information for a social worker 

Self-management is about more than reading a handout and going for a walk. Identifying problems, setting goals, decision-making, self-monitoring, self-evaluations, and celebrating milestones can also help patients feel like a more empowered partner in their healthcare.

Our next article will concentrate on older individuals, a demographic that rarely receives attention when discussing depression care. Depression doesn’t have to be an inevitability of aging. Come back next month for more.

If you’re struggling, have thoughts of hurting yourself or others, or just need someone to talk to, please call or text 988 in the United States. Deaf/hard of hearing and chat options are available at https://988lifeline.org/. 

Mia has been with MetaStar for over seven years. She loves the variety her job gives her—there’s always something new to dig into. As part of MetaStar’s work with Superior Health Quality Alliance, Mia put on her superhero cape and helped fight stigma around substance use disorder through a series of podcasts.