Ask a PH Specialist: What can PH patients and Their Medical Providers do to Help Them Deal With Depression?
Upon receiving a diagnosis of pulmonary arterial hypertension (PAH), many patients are able to “adjust” and perform their activities of daily living to their capacity. For other patients this “adjustment” can be more cumbersome, taking a psychological toll on them and their family members and making them vulnerable to depression. This association may work in two directions, indicating that depression can worsen symptoms of PAH or vice versa. While symptoms of PAH develop gradually, fear of the unknown and the perceived burden can result in profound behavioral changes. It may not come as a surprise that many patients may start having feelings of resentment, frustration, anger and/or social isolation once a diagnosis of PAH is confirmed.
The association between depression and PAH has not been thoroughly explored. A recent study found that only 25 percent of PAH patients were on any antidepressant therapy (McCollister et al. Psychosomatic 2010 51(4): 339-339 e8). Screening for depression can present challenges because depressive symptoms such as loss of appetite and/or fatigue can be overlooked as part of the underlying disease process. Moreover, when symptoms are recognized, they may be ignored because they are sometimes considered part of “normal” coping mechanisms. Depression may be associated with a stigma and may be considered a sign of personal weakness. Treating physicians need to understand that a patient’s personal and cultural beliefs may impact their willingness to admit or seek treatment for depression.
Treating physicians may not always have the necessary training or time to investigate whether symptoms of depression are part of PAH or something else that is confounding its medical management. Yet undiagnosed depression can undermine management of PAH. Depression can lead to decreased compliance with medications, aggravate symptoms and even adversely affect the six minute walk distance. The association between PAH and depression is challenging and requires a multi-disciplinary approach that includes a pulmonologist, cardiologist and primary care physician. If necessary, physicians can refer patients to mental health specialists who can ascertain how patients are coping with their disease.
Depression screening tests that have been validated by research and used extensively in other chronic conditions are available. Based on these tests, physicians can assess promptly patients who show any signs of depression. Some of the screening tools available are the Zung Selfrating Depression Scale, Center for Epidemiologic Studies-Depression Scale (CES-D), Patient Health Questionnaire-9 (PHQ-9) and Beck Depression Inventory (BDI). These scales are simple to complete and can be administered while patients are waiting to be seen by a physician.
Many patients don’t recognize that depression is a treatable condition. A combination of psychotherapy and antidepressants has been more effective than psychotherapy or medication alone. Psychotherapy involves behavior, family, cognitive-behavioral and interpersonal therapies. Patients can also benefit from exercise as it can relax both mind and body while improving mood.
Support groups are another positive way to deal with depression. By joining a support group, patients can share their experiences and the challenges they face every day. They can provide moral support, counsel each other on ways to deal with their circumstances, and end isolation. Having strong family support can also have a positive effect since families can encourage patients to maintain a positive attitude.
Finally, in light of the potential implications of depression on PAH symptoms, screening for depression can only be beneficial. Treating physicians should make every effort to properly educate patients about their disease, make screening for depression a regular part of disease management and have in place appropriate plans for patient assistance.
Answer provided by Sameer Verma, MD; Sophy Dedopoulos, NP; and Arunabh Talwar, MD; North Shore-LIJ Health System Pulmonary, Critical Care and Sleep Medicine; New Hyde Park, N.Y.
This article first appeared in Pathlight Winter 2014.