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Psychological effect of chronic illnesses

Alyshah Abdul Sultan

Introduction:
Pakistan is one of the most densely populated countries in the Eastern Mediterranean regions accounting for 30% of the regional population. The heath care system of Pakistan is characterized by high population growth rate, high infant and child mortality rate and most importantly a very high dual burden of both communicable and non-communicable diseases which gives rise to a number of chronic illnesses. These include hepatitis B, hepatitis C, AIDS, cardiovascular problems, diabetes, neurological problems and many more. (World health organization, 2006). Keeping these health problems in mind the government and many other private hospitals flourished in the country to attend to those who are affected by these in order to restore health. According to world health organization “Heath is defined as a state of complete mental, physical, social and spiritual well being not merely meaning the absent of the disease”. When an illness of any nature or magnitude strikes a person, all of the above mentioned elements are altered and it is up to the heath care team member to work for its restoration. Unfortunately, for us health care team members physical well being is of prime importance and a very little attention is paid to a person’s mental well being unless any likelihood of neurological deficit.
According to Amin, A. & Muhammad, G. (2007).

Mental illness has reached an alarming proportion over the globe and has become a vitally important issue for the nations in terms of morbidity, mortality and huge economic burden. Apart from the established biological and genetic reasons, the current disruption of social fabric as a result of changing political scenario, violence and terrorism has affected the psyche of millions of individuals in this era. 450 million people in the world suffer from a mental or behavioral disorder (W.H.O, 2003). W.H.O. “2001”, states that 33% of the years lived with disability (YLD) are due to neuropsychiatric disorders, unipolar depressive disorders alone lead to 12-13% of years lived with disability and rank as the third leading contributor to the global burden of diseases. Four of the six leading causes of years lived with disability are due to neuropsychiatric disorders like: depression, alcohol use disorder, schizophrenia and bipolar disorder. More than 150 million suffer from depression at any point in time, nearly one million commit suicides every year, 25 million suffer from schizophrenia, 38 million suffer from epilepsy and more than 90 million suffer from an alcohol or drug use disorder (World Health Report, 2001).

It is very likelihood for a person suffering from chronic illness to undergo some sort of mental stress like depression which if not attended earlier can have devastating consequences. In Pakistan there are number of studies done on depression in medical illness in which a number of chronic conditions like stroke, Parkinson’s diseases and cancer were taken into consideration, but yet there is no known research to my knowledge in Pakistan which gives a clear picture about the prevalence of depression in patients due to chronic illnesses, its proper diagnostic method, its impact on the patients family and about its interventions.

The purpose of reviewing this context is to emphasize on the diagnosis of depression and psychiatric symptoms seen in the patients with chronic illnesses to be familiarized with the causes long term impact of depression on the patients family with chronic illness

Depression in patients with chronic illnesses
The magnitude of mental illness is: 6% depression, 1.5% schizophrenia, 1% Alzheimer’s disease, 1-2% epilepsy and the other disorders. (Journal of Medicine, 2007) But the prevalence of depression and mental illness caused due to chronic illnesses in Pakistan to my knowledge is still not clearly known. In Pakistan there are numbers of studies conducted on patients with chronic illnesses like stroke, Parkinson’s and cancer which proves that the patients with these conditions undergoes some sort of depression. One study in particular was conducted by department of psychiatry military hospital Rawalpindi, which was published in Pakistan Arm Force journal (2003) whose aim was determine the frequency of anxiety, depression and cognitive impairment in Parkinson’s disease. For this study 117 consecutive cases of Parkinson’s diseases were enrolled. The hospital scale HADS was use to detect anxiety and depression. It was a 14 items self rating scale seven concerned with anxiety and seven of depression. All the symptoms were concerned with psychological symptoms and Urdu version was used. The cut off point form this scale was 11 or more. In the end it was found that 48% of the patients were found to be suffering form anxiety, depression or cognitive deficits. Out of these 31% of the patients were suffering from depression and 7% from anxiety and 10% from cognitive deficit. Though this study proved that chronic illnesses like Parkinson’s disease causes depression, but there were few grey areas identified. First of all, the DMS 4 (diagnostic and statistical manual) was not used which is of key importance in diagnosis of depression. Secondly, the HADS scale which was used was more focused on the somatic symptoms rather than non somatic. Lastly I think the symptoms mentioned in the criteria were not sufficient in diagnosis do depression because these symptoms can be due to the disease itself.

The assessment of major depression in medical setting is however problematic. First, since some sad feelings are acknowledged part of the experience of physical illness, what are the boundaries between these normal sad feelings and syndrome of major depression? Second many of the symptoms of physical illnesses (e.g. decrease energy and anorexia) are identical to symptoms of depression, and the clinician may find it difficult to determine the etiology of the symptoms.( Stoudemire & Fogel, 1993) looking into this statement we are left with the question of how to diagnose a patient for depression in chronic illness?

In order to find answer to these questions I came across another study which was published in Psychosomatics (2003) in which somatic symptoms for diagnosing major depression in caner patients were studied. The aim of this study was to clarify the somatic symptoms among the DMS 4 criteria for major depression that significantly contribute to a diagnosis of major depression by examining the interrelation among somatic and other symptoms. For this retrospective study, all the consultations referred to Psychiatry division at national cancer center hospital were reviewed. A total of 1721 cancer patient were referred during that study period out of which 220 (12.8%) were diagnosed of having major depression according to the inclusive criteria.

The author of this article stated that:
Only 1.8% of the depressed patients had psychotic feature. Regarding the significant associations between each somatic symptom and other criteria, weight loss or appetite change was positively associated with diminished interest or pleasure. Insomnia or hypersomnia and fatigue were not significantly associated with any other items. A diminish ability to think or concentrate was positively associated with diminished interest or pleasure. The result of logistic regression analyses demonstrated that weight loss or appetite change and diminish ability to think or concentrate were positively associated with diminished interest or pleasure after adjusting for possible physical confounders.

This study provided us with the association between the somatic and non somatic symptoms however in this study inclusion criteria was used in which, all possible symptoms regardless of whether or not they could be caused by underlying physical illness or depression. The main advantage of this criterion is that, it has high reliability and high sensitivity. On the other hand it can lead to over diagnosis of depression and a possible number of high false positives (low specificity) and its validity is uncertain (Stoudemire & Fogel, 1993)
Depression in patients with chronic illnesses can be caused due to number of reasons. It can be due to physical changes, role changes or bereavement and grief. One particular cause which is needs to be explored further is whether the recurrent hospitalization contributes toward further exacerbation of depression in patients with chronic illnesses? It is a known fact that patients with chronic illnesses require constant medical attention. Unfortunately, in Pakistan there is little concept of home heath which leads of frequent hospitalization of these patients.

There are number of studies available which talks about depression in hospitalized patients, not particularly talking about the patients with chronic condition. One of such study was published in Pakistan Arm Force Journal (2003) in which two hundred and ninety patients with over a week stay in hospital were screened for probable anxiety and depression during three month with hospital anxiety scale. The result of this study concluded that depression was detected in 39.26% of patients including major depression in 9.73%. The hospital stay of the patient showed significant positive relationship with depression. A similar study was conducted in the Aga Khan University Hospital published in Journal of Pakistan medical association (2007) in which 178 patients were interviewed using SQR assessment tool. In the end 30% of the people interviewed had depression; it was independent of the length of stay and comorbids. From this study we can conclude that patients admitting to hospital experience some form of depression but the question of whether this depression is dependent on the length of the stay in hospital or co morbits are yet controversial.

The question of why the patients with chronic illnesses undergo psychological stress and show physical sign and symptoms can be best answer by looking into the cognitive and behavioral model. This model stated that when we think about a certain things thoughts are generated which when not verbalize or intervene turn into feelings and therefore resulting in behaviors which are considered abnormal. (BRAIN.HE, 2006). This model was found to be integrated with anxiety (figure 1) but I think that it can also be related to depression so I have tried to integrated depression caused due to chronic illnesses in this model (figure 2). From figure 2 we can conclude that if there are certain cognitive and behavioral interventions done at the point where patient assumes some thing negative about his chronic illness along with family support we can be prevented form depression to a great extent rather than waiting for the patient to actually show the symptoms of depression. A study published in health psychology (2005) with the aim to apply cognitive behavioral model in a cancer patients revealed that by give this therapy 24% of the patient reported decreased anxiety. Although it talks about anxiety but I think it can also play a vital role in decreasing the prevalence of depression in chronic illnesses.

The experience of patients with chronic illness is quite stressful but the role of the family cannot be overlooked. “Family commonly fulfills the role of primary care provider.” (Foundation for Promotion of cancer research 2006). Due to this reason it is not surprising to know that family also goes through the same stress as the patient. Western literature suggests that approximate 10-30% of family members experience some form of psychiatric morbidity more over the need for the oncology/medical team to take care of the whole family has been increasingly anticipated. Foundation for Promotion of Cancer Research. (2006).

In order to test these two statements a study was published in Japanese Journal of Clinical Oncology (2006). The purpose of this study was to obtain preliminary findings regarding psychiatric disorders and backgrounds characteristic among Japanese family members of cancer patients. For this study all the referred psychiatric consultation of the family members of the cancer patients were looked into form the period of 2000 to 2003. The result of this study revealed that a total of 1469 referred to the psychiatry division 47 were the family members. Most of the family members had been referred for a psychiatric consultation because of depression (63.8%) followed by anxiety/fear (31.9%). These figures tell us that when ever considering psychiatric treatment for the patients with chronic medical conditions, family members should not be ignored. Although this study had many selection and institutional biases, it was quit evident that family also suffers for the same psychological stress as the patient.

Conclusion:
Depression among medical inpatients remains under-recognized and under-diagnosed. The fact that patients referred to psychiatry remain low may reflect the physicians' inability to recognize depression, their wish to treat the patient themselves or reluctance on part of patients for seeking psychiatric help, due to stigma associated with it. (Journal of Pakistan medical association, 2007) This statement tells us that it is not only because of the lack of acknowledgement of the symptoms that leads to under diagnosis of depression but the stigma attach to diagnosis of the psychiatric patients has a significant contribution. It is a known fact that in our society, depression and other psychiatric illnesses are always looked down upon by the general population. A study published in journal of Ayub Medical College Abbottabad (2006) whose aim was to know about the attitude of the university student and teacher toward the mentally ill patient in Lahore. For this purpose a questionnaire was distributed. The result of this study revealed that majority of the respondent held negative attitude towards people with schizophrenia, depression and drug and alcohol disorders the attitude who knew about some one with mental illness was similar to that that did not knew anyone. The above mention study tells us that it is not just the people who are illiterate holds a negative attitude towards the people with mental illness but educated people are also culprits. The result of this study may be having a key contribution to why depression in people with chronic illness is under diagnosed.

Depression in chronic illnesses is something which cannot be overlooked. From the above mentioned studies it is quite evident that depression is prevalent in patients with chronic illnesses like stroke, cancer and Parkinson’s disease. There is a very thin line between symptoms of depression and that of chronic illnesses. There are few of the studies one of which mentioned above which talks about the relation between somatic and non somatic symptoms of illnesses which can be helpful in diagnosing depression. Furthermore it is quite evident that patients with chronic illnesses are subjected to repeated episode of hospitalization which may contribute towards further to their psychotic symptoms but whether the length of their stay is related to depression is still questionable. It is also important that while addressing a depressed patient with chronic illnesses, the family member’s needs should also be considered because they too can be vulnerable to depression. This can be difficult due to the stigma attached to it which could lead to under diagnosis. Although there have been many researches done in Pakistan on this issue as evidenced by this literature review, still there is a lot to be done so that what ever grey areas which are identified can be addressed to. I think much more research is required in the area of accurate diagnosing depression in different chronic illnesses like hepatitis B and C etc and also the prevalence of depression caused due to chronic illness should be focused so that accurate diagnosis is made and further complications can be prevented.