Recognizing and treating depression in hospital patients

More than 16 million — or nearly 7 percent — of American adults experience at least one major depressive episode in a given year. And numerous studies have shown that the rates of depression among hospital patients are higher than the non-patient population.

As a psychiatrist at MedStar Washington Hospital Center, I encounter depression in patients from two sides:

  • Patients who have depression already and develop a medical condition that requires hospitalization. In some severe cases, a suicide attempt may be the reason for hospitalization.
  • Patients who develop a depressive disorder during the course of diagnosis, treatment and recovery from a medical condition.

Depression can cause people to pay less attention to their health, leading to a higher risk of chronic illnesses, such as high blood pressure, diabetes or heart disease. If depression develops after a diagnosis, it can reduce their ability to manage the condition, such as not taking medications as directed or missing doctor’s appointments.

It’s essential that we recognize and treat depression as soon as possible. Let’s take a look at what depression is, how we treat it, and what you can do if a loved one is exhibiting signs of depression.

LISTEN: Dr. Karen Johnson further discusses depression in hospital patients on this Medical Intel podcast.

What are the signs of depression?

Depression is as much a disease as diabetes or cancer. And while the terms sadness, stress and depression often used interchangeably, there’s a difference.

Sadness is something we all encounter periodically during our lives. It’s a normal reaction to loss, unhappiness or struggle. Stress is an emotion we experience in response to adverse or demanding circumstances.

Depression is more serious and long-lasting than sadness or stress. And it’s something people have no control over. A depressive episode is characterized by feeling sad and down most of the day, almost every day for a minimum of 12 to 15 days.

Depression symptoms can include:

  • Persistent sad or anxious mood
  • Feelings of hopelessness, helplessness or worthlessness
  • Loss of interest in hobbies or activities
  • Decreased energy
  • Difficulty concentrating or making decisions
  • Changes in sleep pattern, such as sleeping too much or experiencing insomnia
  • Appetite or weight changes
  • Pain, headaches or digestive problems without a clear cause
  • Thoughts of suicide

It can be difficult to recognize depression in patients because some medical conditions or medications can cause some of these same physical symptoms. But it’s important to be aware of these signs of depression so you or your loved one can begin treatment as soon as possible.

Why some people develop depression in the hospital

Let’s say you’ve had diabetes for 10 to 15 years. The disease has progressed to end-stage renal disease, meaning your kidneys no longer function as they should. Your doctor recommends beginning dialysis, which can have a significant impact on your life. Initially, you may be shocked or saddened by the thought of being on dialysis. But over time, you may develop a major depressive disorder.

Unfortunately, this story is fairly common. Depression often accompanies illness. You may need to grieve a diagnosis or adjust your expectations for your future. It also can strain your relationships and finances. And depression won’t necessarily disappear after recovery, as you may continue to deal with lingering side effects or a fear of relapse.

The good news is that depression is treatable. But it’s not something you can do alone, so it’s important to get help.

How we treat patients experiencing depression in the hospital

Our consult-liaison team diagnoses and treats depressive disorders whether they are the primary reason for hospitalization or a co-existing condition. The first thing we try to do is connect with our hospitalized patient, so they feel comfortable talking with us, all while being considerate of the fact that they’re very sick.

As with anything in medicine, the first step is to identify what is wrong. Many patients are not even aware of their depression because they’re more concerned with the pressing medical emergency. But when we start talking to them, they begin telling us not just about what’s happening to them in that moment, but also about past life events that may be impacting what’s going on.

In diagnosing depression, we’ll also talk to the patient and their doctors about conditions or medications that may be causing the depression. For example, depression may be a side effect of some steroids or medications to treat high blood pressure, and some thyroid conditions can cause depressive symptoms.

Depression often is treated with a combination of medication and psychotherapy, also known as therapy or counseling.

By starting a patient on an antidepressant while they’re in the hospital, we can monitor them closely for their response to it. We’ll work with their doctor to find an antidepressant that won’t aggravate the patient’s medical condition or interact with other drugs they’re taking.

Psychotherapy works to help you learn constructive ways to deal with problems or issues in your life. You can learn to recognize when your medical condition or other external factors can impact your mood and develop coping skills around it.

Some patients tell me they’re not interested in psychotherapy because they’ve tried it before and it didn’t work. I’ll often respond that I understand, but ask them to consider it with a more focused approach. Perhaps they take three things they’ve identified as needing to be addressed and deal with just those in therapy.

There also are a few other lifestyle changes and interventions that may help patients deal with depression, including:

  • Taking part in regular exercise
  • Spending time with family and friends
  • Getting enough sleep
  • Keeping a journal
  • Setting realistic goals and not expecting your mood to improve overnight

When a patient is about to be discharged with the hospital, we want to make sure they’re linked to the services they’ll need. This could be an outpatient behavioral health program, support group or perhaps even a workshop designed to help adults living with chronic conditions take charge of their health — physical and emotional.

How to help a loved one with depression

Often, it’s not the patient who first recognizes a depressive disorder, it’s those around them. Identifying symptoms of depression early can lead to your loved one receiving treatment before the disease progresses to a point where they may harm themselves. For example, you may notice a change in personality, that they’re becoming withdrawn or isolating themselves. Or maybe they’re not eating or sleeping as well as they used to.

While we respect patient’s privacy, we always encourage them to include family or friends in their medical care. That way the patient has support in managing their treatment plan and taking care of themselves.

There’s always an opportunity to include family in treatment. For example, if a patient has significant developmental or childhood issues in their background, family members may be integral in treatment. Marital counseling or family therapy may be encouraged in some cases.

Finally, hospital patients often are pressured to “keep a positive outlook.” While we want to foster hope, it’s important to allow your loved one a safe space to discuss their fears and anxieties. Be supportive, but not demeaning or condescending.

Illness, especially when it’s serious enough to require hospitalization, can cause distress. But you’re not alone. If you or a loved one is experiencing signs of depression, request an appointment or call 844-833-DOCS.

Stress: As dangerous as high cholesterol and blood pressure

According to a study released in January 2017 by the Centers for Disease Control and Prevention (CDC), heart disease is the leading cause of death in the United States. Many of my patients know they’re at risk for heart disease, and we work together to lower their risk by controlling their risk factors, including high blood pressure and high cholesterol.

But these aren’t the only risk factors to watch out for. People with constantly high levels of stress double their risk of heart disease. That’s equal to the risk from high cholesterol and high blood pressure. And according to real estate blog Movoto, Washington, D.C., is the most stressed-out city in the nation.

How stress may affect the heart

We’ve known about the link between stress and heart health for some time. Experts at the American Heart Association note the importance of managing stress to prevent heart disease. And in 2015, an international group of researchers identified emotional shocks as the second leading cause of stress cardiomyopathy, or broken-heart syndrome. This condition is a special kind of heart attack that isn’t caused by blockages in the heart arteries. Instead, broken-heart syndrome can happen when someone sees or learns of something traumatic, such as the death of their child.

Though we’ve known that stress can affect heart health for some time, we haven’t understood the mechanics behind how this happens. But we may be close to a breakthrough in that area of research. In January 2017, researchers showed the area of the brain called the amygdala is associated with the risk of heart disease and stroke. The amygdala contributes to the brain’s processing of emotions and helps communicate with the rest of the body on whether to get away from stress or handle it head-on. This is what many people know as the “fight or flight” response.

So we know stress is dangerous, and we have an idea of why. The question then becomes: What do we do about it? I wish I could say that we should just not have any stress. The reality is that sort of advice isn’t practical. We can’t avoid all stress in our lives.

But when it comes to your heart’s long-term health, not all stress is created equal. Some types of stress are much worse than others. It’s important to recognize these different types of stress so you can get help from your doctor before your heart is at risk.

Types of stress

I think most people would agree with me that stress is bad for you. And I think most people also would agree that stress is a part of life we simply can’t avoid. Stressors like a bad commute, a rough day at work or an argument with your spouse are part of what life throws at us.

Most sources of stress are like these. They pop up, we deal with them, and we move on. These short, intermittent episodes of stress aren’t really a problem for your heart. Even stress that comes up on a regular basis, such as rushing to get the kids to soccer practice every Tuesday, isn’t that bad for you.

The main danger of stress to your heart is when you’re constantly in a stressful situation you can’t control or get away from. We call this uncontrolled, unrelieved stress. Some examples of these types of uncontrolled stress include:

  • A terrible work environment
  • An abusive relationship
  • Ongoing depression
  • Ongoing serious financial trouble

Though these are very different causes of stress, your body can’t tell the difference. In these situations, all your body knows is that you’re under severe chronic stress that you don’t feel you can escape. And that’s a major red flag for your heart health. You need to talk to your doctor if you’re in these or similar types of stressful situations.

Get help to find stress relief

Patients don’t talk to their doctors enough about stress. A lot of patients don’t like to talk about stress with their doctors—certainly not doctors who aren’t psychiatrists or psychologists. There’s not enough time in the course of a normal visit, or they don’t think it’s a medical problem. But stress absolutely is a medical problem!

And just as patients should be willing to talk to their doctors about stress, we doctors should be asking our patients about stress. That should be part of our care for people’s overall heart risk.

When a patient brings up a source of severe stress with me, I’m always grateful. I try to point them toward resources or come up with strategies for stress management. That’s part of my job as their doctor.

It might be tempting to think, “But you can’t help me get out of my debt. You can’t fix the stress. Why bother?” And no, we can’t remove sources of stress that way, but if we identify it as a problem for your heart, it might be something you can focus on to find a solution.

We also can refer patients to get professional help for their stress from mental health professionals, if necessary, or find other ways to resolve these sources of anxiety and worry. But if it’s really to that level that you feel like you can’t control this stress, you probably need to get some help.

Recognize and address stress

Some people are more aware of stress than others. Just like beauty, stress is in the eye of the beholder. What one person might think of as no big deal could be a source of extreme stress for another person.

But some people who think they’re handling their stress might just be ignoring or suppressing it. That’s a big problem, because those people aren’t recognizing the effects of their stressors on their lives or doing enough to address it.

Whether or not you think you’re stressed, use these simple assessments to measure the stress levels in your life. You might be surprised by what you find. If your stress levels are high, talk to your doctor about it, especially if you’re already being seen by a cardiologist for a heart condition.

Stress isn’t just in your head. It’s a real, physical, medical problem. And leaving severe stress untreated could lead to your heart paying the price.