Depression and Anxiety from Caregiving

As a family caregiver, you may be experiencing depression and/or anxiety due to the complexity of caregiving. Learn about the causes and symptoms of depression and anxiety, and what successful treatment looks like.

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Depression

Could the sadness, loneliness, or anger you feel today be a warning sign of depression? It is not unusual for caregivers to develop mild or more serious depression as a result of the constant demands of caregiving. Caregiving does not cause depression, nor will everyone who provides care experience depression. However, the stress of caregiving may trigger depression. 

Everyone has negative thoughts or feelings that come and go over time. For family caregivers, the feelings may become more intense and leave them drained of energy, tearful, or irritable towards the person they care for. These feelings may be a warning sign of depression. When sadness, emptiness, fatigue, crying, and hopelessness don’t go away, it is time to get help. Ignoring or denying your feelings will not make them go away.

In general, depression is a common problem among older adults, but clinical depression is not a normal part of aging. In fact, studies show most older adults feel satisfied with their lives, despite having more illnesses or physical problems than younger people. However, if you’ve experienced depression as a younger person, you may be more at risk of having a recurrence as an older adult. 

What are the risk factors of depression?

Risk factors for depression are numerous, including physical, genetic, and environmental. For some people, changes in the brain can affect mood and result in depression. Other people may experience depression after a major life event, such as a medical diagnosis, moving, or grief from a loved one’s death. Sometimes, those under a lot of stress, especially people who care for loved ones with a serious illness or disability, can experience depression. Others may become depressed for no clear reason.

Research has shown that these factors are related to the risk of depression, but do not necessarily cause depression:

  • Medical conditions, such as stroke, cancer, diabetes, and even the many forms of dementia
  • Genes – people who have a family history of depression may be at higher risk
  • Stress, including caregiver stress
  • Sleep problems
  • Social isolation and loneliness
  • Poor nutrition
  • Lack of exercise or physical activity
  • Functional limitations that make engaging in activities of daily living difficult
  • Addiction and/or alcoholism —included in Substance-Induced Depressive Disorder
  • Other factors 

Types of depression

Adults may experience several types of depression:

  • Major Depressive Disorder – includes symptoms lasting at least two weeks that interfere with a person’s ability to perform daily tasks
  • Persistent Depressive Disorder (Dysthymia) – a depressed mood that lasts more than two years, but the person may still be able to perform daily tasks, unlike someone with Major Depressive Disorder
  • Substance/Medication-Induced Depressive Disorder – depression related to the use of substances like alcohol or pain medication
  • Depressive Disorder Due to A Medical Condition – depression related to a separate illness, like heart disease or multiple sclerosis.

Family caregivers may identify with more than one type of depression. Proper diagnosis by a trained professional is essential.

Symptoms of depression 

People experience depression in different ways. Some may feel classic symptoms, like sadness and hopelessness. Others may have signs such as extreme fatigue or irritability. The type and degree of symptoms vary by individual and can change over time. Consider these common symptoms of depression. Have you experienced any of the following over several weeks?

  • Feeling sad, tearful, empty, hopeless
  • Changes in eating habits—weight loss and no appetite or cravings with weight gain
  • Changes in sleep—too much sleep or not enough
  • Ongoing physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic neck and back pain
  • Feeling tired all the time, having difficulty being motivated to do anything
  • Crying uncontrollably
  • Loss of memory
  • A loss of interest in people and/or activities that once brought you pleasure
  • Feeling unworthy or guilty
  • Feeling numb
  • Becoming easily agitated or angered
  • Feeling that nothing you do is good enough
  • Increase in alcohol or drug consumption
  • Excessive time on the Internet
  • Trouble concentrating, focusing, thinking, or planning
  • Neglecting your physical well-being and appearance
  • Thoughts of running away, or escaping from the situation
  • Thoughts of death or suicide, ideas of how to end your life

Normal life circumstances can cause some of these experiences. When you experience several symptoms over a period of time, it may be time to talk to a medical professional. Instead of ignoring symptoms, acknowledge and recognize them. 

What to do – Depression

What do you do if you recognize some symptoms of depression in yourself or the person you care for?

Start with an appointment with the primary care physician. It may be time for a complete physical evaluation, including blood work. Take the list of symptoms from the list above, adding others that you identify in yourself or your care receiver.

Many of the symptoms can be also caused by medical problems. As we age, many people experience urinary tract infections (UTIs) and show signs of depression, anxiety, and even dementia. Infections like UTIs can be successfully treated.

For depression, some primary care doctors have assessments that they use in the office, including the standardized Patient Health Questionnaire – PHQ-9. The PHQ-9 is a brief self-report instrument, commonly used for screening and diagnosis by mental health professionals. The patient rates 9 statements, evaluating them from “not at all” to “every day.” PHQ-9 has been successfully used in many studies in primary care settings, as well as with older individuals and with those who have physically disabling conditions. Primary care and mental health professionals use responses from the PHQ-9 with to help identify a diagnosis so that they can recommend treatment.

Mental health professionals also use the DSM-V-TR The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published in 2022, which lists symptoms for a number of mental health disorders.¹

Anxiety

In the world of mental health care, professionals consider anxiety and depression as two distinct disorders and people can experience them separately.

Most people experience anxiety triggered by changes such as starting a new job, having health concerns, relationship or family issues, or experiencing financial problems. Anxiety is one of the most common experiences people have, especially during and after the COVID pandemic. 

While anxiety and depression have their own symptoms and clinical features, there is some overlap. Feeling depressed can cause us to worry and worrying can cause us to experience depression. Many people can have a diagnosis of both an anxiety disorder and clinical depression. In fact, most mood disorders present as a combination of anxiety and depression. Surveys show that 60-70% of those with depression also have anxiety. And half of those with chronic anxiety also have significant symptoms of depression.

Anxiety Symptoms

Anxiety symptoms may include:

  • Feeling nervous, restless or tense
  • Having a sense of impending danger, panic or doom
  • Having difficulty concentrating
  • Being irritable
  • Having an increased heart rate
  • Being easily fatigued
  • Breathing rapidly (hyperventilation)
  • Sweating
  • Trembling
  • Feeling weak or tired
  • Trouble concentrating or thinking about anything other than the present worry
  • Having trouble sleeping, such as difficulty falling or staying asleep
  • Experiencing gastrointestinal (GI) problems
  • Having difficulty controlling worry
  • Having the urge to avoid things that trigger anxiety
  • Having headaches, muscle aches, stomachaches, or unexplained pains
  • Difficulty controlling feelings of worry

Notice several of the symptoms of anxiety are similar to the symptoms of depression.

Treatment

If not recognized and treated individually or together, symptoms can become more chronic and day-to-day functioning can become affected. Also, untreated depression and anxiety can raise suicide risk in older adults. Fortunately, symptoms of both conditions usually improve with psychological counseling (psychotherapy), medications, such as antidepressants, or both.

When treating anxiety disorders, antidepressants, particularly the SSRIs and some SNRIs (serotonin-norepinephrine reuptake inhibitors), have been shown to be effective. Other anti-anxiety drugs include the benzodiazepines, such as as alprazolam (Xanax), diazepam (Valium), buspirone (Buspar), and lorazepam (Ativan).¹

The best outcome for treating depression is a combination of antidepressant medication and psychotherapy (also referred to as counseling, mental health therapy, and talk therapy). These treatments may be used alone or in combination with one another.

Some people are surprised when they find out that primary care doctors can prescribe medications to treat depression. However, medical causes need to be evaluated. A complete physical, including lab work (blood, urine, etc.) may identify physical causes for symptoms. If physical reasons are ruled out, ask the physician about medications. He or she may prefer to refer you to a psychiatrist or the physician may prescribe an anti-depressant and then change the dosage or try another anti-depressant if the first dosage does not help improve symptoms. The physician may recommend seeing a psychiatrist who has experience with different anti-depressant medications. 

Many people are prescribed one of many choices of SSRIs (selective serotonin re-uptake inhibitors). SSRIs are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders. Other medications may be used based on your health and history.

Antidepressants

There are a number of antidepressants available that work in slightly different ways and have different side effects. When prescribing an antidepressant that’s likely to work well for you¹, your doctor may consider:

  • Your particular symptoms. Symptoms of depression can vary, and one antidepressant may relieve certain symptoms better than another. For example, if you have trouble sleeping, an antidepressant that’s slightly sedating may be a good option.
  • Possible side effects. Side effects of antidepressants vary from one medication to another and from person to person. Bothersome side effects, such as dry mouth, weight gain or sexual side effects, can make it difficult to stick with treatment. Discuss possible major side effects with your doctor or pharmacist.
  • Whether it worked for a close relative. How a medication worked for a first-degree relative, such as a parent or sibling, can indicate how well it might work for you. Also, if an antidepressant has been effective for your depression in the past, it may work well again.
  • Interaction with other medications. Some antidepressants can cause dangerous reactions when taken with other medications.
  • Pregnancy or breast-feeding. A decision to use antidepressants during pregnancy and breast-feeding is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is low. Still, certain antidepressants, such as paroxetine (Paxil, Pexeva), may be discouraged during pregnancy. Work with your doctor to find the best way to manage your depression when you’re expecting or planning on becoming pregnant.
  • Other health conditions. Some antidepressants may cause problems if you have certain mental or physical health conditions. On the other hand, certain antidepressants may help treat other physical or mental health conditions along with depression. For example, venlafaxine (Effexor XR) may relieve symptoms of anxiety disorders and bupropion may help you stop smoking. Other examples include using duloxetine (Cymbalta) to help with pain symptoms or fibromyalgia, or using amitriptyline to prevent migraines.
  • Cost and health insurance coverage. Some antidepressants can be expensive, so it’s important to ask if there’s a generic version available and discuss its effectiveness. Also find out whether your health insurance covers antidepressants and if there are any limitations on which ones are covered.

Types of Antidepressants

Certain brain chemicals called neurotransmitters are associated with depression — particularly serotonin (ser-o-TOE-nin), norepinephrine (nor-ep-ih-NEF-rin) and dopamine (DOE-puh-meen). Most antidepressants relieve depression by affecting these neurotransmitters, sometimes called chemical messengers, which aid in communication between brain cells. Each type (class) of antidepressant affects these neurotransmitters in slightly different ways.

Many types of antidepressant medications are available to treat depression, including:

  • Selective serotonin reuptake inhibitors (SSRIs).
    Doctors often start by prescribing an SSRI. These medications generally cause fewer bothersome side effects and are less likely to cause problems at higher therapeutic doses than other types of antidepressants are. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).
  • Serotonin and norepinephrine reuptake inhibitors (SNRIs).
    Examples of SNRI medications include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq) and levomilnacipran (Fetzima).
  • Atypical antidepressants.
    These medications don’t fit neatly into any of the other antidepressant categories. More commonly prescribed antidepressants in this category include trazodone, mirtazapine (Remeron), vortioxetine (Trintellix), vilazodone (Viibryd) and bupropion (Wellbutrin SR, Wellbutrin XL, others). Bupropion is one of the few antidepressants not frequently associated with sexual side effects.
  • Tricyclic antidepressants.
    Tricyclic antidepressants — such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin and desipramine (Norpramin) — tend to cause more side effects than newer antidepressants. So tricyclic antidepressants generally aren’t prescribed unless you’ve tried other antidepressants first without improvement.
  • Monoamine oxidase inhibitors (MAOIs).
    MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan) — may be prescribed, often when other medications haven’t worked, because they can have serious side effects. Using an MAOI requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles, and wines — and some medications, including pain medications, decongestants, and certain herbal supplements. Selegiline (Emsam), an MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs. These medications can’t be combined with SSRIs.
  • Other medications. 
    Your doctor may recommend combining two antidepressants, or other medications may be added to an antidepressant to enhance antidepressant effects.

Antidepressants and risk of suicide

Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers, and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

Making antidepressants work for you

To get the best results from an antidepressant:

  • Be patient. Once you and your doctor have selected an antidepressant, you may start to see improvement in a few weeks, but it may take six or more weeks for it to be fully effective. With some antidepressants, you can take the full dosage immediately. With others, you may need to gradually increase your dose. Talk to your doctor or therapist about coping with depression symptoms as you wait for the antidepressant to take effect.
  • Take your antidepressant consistently and at the correct dose. If your medication doesn’t seem to be working or is causing bothersome side effects, call your doctor before making any changes.
  • See if the side effects improve. Many antidepressants cause side effects that improve with time. For example, initial side effects when starting an SSRI can include dry mouth, nausea, loose bowel movements, headache and insomnia, but these symptoms usually go away as your body adjusts to the antidepressant.
  • Explore options if it doesn’t work well. If you have bothersome side effects or no significant improvement in your symptoms after several weeks, talk to your doctor about changing the dose, trying a different antidepressant (switching), or adding a second antidepressant or another medication (augmentation). A medication combination may work better for you than a single antidepressant.
  • Try psychotherapy. In many cases, combining an antidepressant with talk therapy (psychotherapy) is more effective than taking an antidepressant alone. It can also help prevent your depression from returning once you’re feeling better.
  • Don’t stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause significant withdrawal-like symptoms unless you slowly taper off your dose. Quitting suddenly may cause a sudden worsening of depression.
  • Avoid alcohol and recreational drugs. It may seem as if alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or drug problems.

Medications

If drug therapy is recommended, a certain amount of trial and error is necessary to find the right type and dosage of medication, and it may take several weeks before you might feel significantly better. Good communication between you and the doctor is important. Older adults should be especially careful to watch for medication side effects caused by too high a dosage or interactions with other medications. Psychiatrists often treat patients who are not responding to medications prescribed by the primary physician or if the person has a complex health history, such as multiple chronic diseases.

Psychotherapy and Counseling

Doesn’t it make sense that the healthier you are the better your caregiver situation? Discussing your situation with a therapist gives you a chance to talk candidly about your situation as a caregiver. Therapy can help you make self-care a priority and develop balanced and healthier lifestyle practices. Exercise, improved nutrition, and learning stress management skills can significantly improve the quality of life for you as a caregiver. And the healthier you are, the better you are able to care for a loved one.

The emotional and physical experiences involved with providing care can strain even the most capable person. The resulting feelings of anger, anxiety, sadness, isolation, exhaustion—and then guilt for having these feelings—can take a heavy toll.

When choosing a therapist, read their profiles online or ask about their experience working with family caregivers. Do they have an understanding of caregiving-related stressors? Having experience working with older adults is also a plus.

Find a therapist by using your health insurance behavioral health benefit. The phone number is on the back of your insurance card. Your insurance company will have a list of providers, probably online. Medicare also provides behavioral health benefits. 

Paying for Treatment

Private health insurance and Medicare will typically pay for some mental health care. It’s best to call the mental health professional directly to find out if they accept your insurance for payment. Medicare recipients will find the booklet titled “Medicare and Your Mental Health Benefits” a helpful source of information. Veterans can call the VA.

The “covered services” of the insurance plan will specify mental health or behavioral health coverage for inpatient (hospital, treatment center) and outpatient (professional’s office) care, how many visits are paid for, and at what rate of reimbursement.

Caregivers without health insurance or who pay out of pocket for care will find that fees vary by professional, with psychiatrists charging at the higher end of the fee scale and psychologists, social workers, and licensed counselors offering their services in the range of $100-$150 per session. Most counselors have a sliding scale and may work with you to find an affordable rate.

Community mental health options funded by federal or state money may be limited, have waiting lists, require evidence that someone cannot pay usual fees, or be non-existent. Call 2-1-1 or contact your local Area Agency on Aging.

Resources for Caregivers

  • Call 2-1-1 throughout Texas for information and access to health and human service information for all ages.
  • Call 800-252-9240 to find local Texas Area Agency on Aging.
  • ADRCs – Aging and Disability Resource Centers
  • Call 800-677-1116 – Elder Care Locator service to find help throughout the U.S.

Use resources such as Area Agency on Aging (AAA). Types of assistance provided by AAAs:

  • Information and referral
  • Caregiver education and training
  • Caregiver respite
  • Caregiver support coordination
  • Case management
  • Transportation assistance

Although not all services are available in all communities, assistance may be available through AAAs for persons age 60 and older may include:

  • Benefits counseling
  • Ombudsman – advocacy for those who live in nursing homes and assisted living facilities
  • Home-delivered meals
  • Congregate meals   
  •  Light housekeeping
  • Other services for that community

Be sure to check out our Resource Directory, FAQ, and Educational Events Calendar for more great information! Permission is granted to duplicate any and all parts of this page to use in education programs supporting family members caring for elders. 

Revised November 2022

Sources: Accepting Depression and Anxiety; Anxiety and Depression Together ; ¹Depression (major depressive disorder); Depression and Older Adults; Depression and Caregiving; Anxiety vs. Depression; Anxiety disorders; Antidepressants: Selecting one that’s right for you

Written by Zanda Hilger, M. Ed., LPC

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