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 you face in providing care. Some caregivers experience a return of depression that they had when they were younger.
The Centers for Medicare and Medicaid Services reports that one in six persons older than 65 suffers from depression and that depression in older patients occurs in 25% of those with other physical illnesses.
Caregiving does not cause depression, nor will everyone who provides care experience the negative feelings that go with depression. The stress of caregiving may trigger depression. In an effort to provide the best possible care for a family member or friend, caregivers often sacrifice their own physical and emotional needs.
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.
Everyone has negative feelings that come and go over time, but when these feelings become more intense and leave caregivers totally drained of energy, crying frequently or easily angered by their loved one or other people, it may well be a warning sign of depression. Concerns about depression arise when the sadness, crying, fatigue, negative thinking, and even problems with memory don’t go away.
Symptoms of Caregiver Depression
People experience depression in different ways. Some may feel a general low-level sadness for months, while others experience a more sudden and intense negative change in their outlook, sleep, memory, and other changes. The type and degree of symptoms vary by individual and can change over time.
Consider these common symptoms of depression. If you have experienced any of the following for longer than two weeks, it may indicate depression.
- A change in eating habits resulting in unwanted weight gain or loss
- A change in sleep patterns—too much sleep or not enough
- Feeling tired all the time
- A loss of interest in people and/or activities that once brought you pleasure
- Becoming easily agitated or angered
- Feeling that nothing you do is good enough
- Thoughts of death or suicide, or attempting suicide
- Ongoing physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.
Coping with Caregiver Depression
Feelings of depression can sometimes be seen as a sign of weakness rather than a sign that something is out of balance. Comments such as “snap out of it” or “it’s all in your head” are not helpful and reflect a belief that mental health concerns are not real. Ignoring or denying your feelings will not make them go away.
Early attention to symptoms of depression through exercise, a healthy diet, positive support of family and friends, or consultation with a trained health or mental health professional may help to prevent the development of a more serious depression over time.
People assume that once caregiving is over, the stress from providing hands-on care will go away. Yet, researchers found that even three years after the death of a spouse with dementia, some former caregivers continued to experience depression and loneliness. In an effort to return their life to normal, former caregivers may need to seek out help for depression as well.
What to Do If You Think You Have Depression
Depression deserves to be treated with the same attention afforded to any other illness, such as diabetes or high blood pressure. If you feel uncomfortable using the term depression, tell the professional that you are “feeling blue” or “feeling down.” The professional will get the message. The important thing is to seek help.
Those with chronic illnesses also may suffer from depression. If you suspect this is the case with your loved one, look for an opportunity to share your concern with him or her. If they are reluctant to talk about it with you, encourage a trusted friend to speak with them, or consider leaving a message for their doctor about your concern before their next appointment.
How is Depression Treated?
The first step to getting the best treatment for depression is to rule out any medical conditions. Schedule a physical examination with your doctor. Certain medications, as well as some medical conditions such as viral infection, can cause the same symptoms as depression and can be evaluated by your physician during an exam. The exam should include lab tests and a discussion or assessment on mental status to determine if speech, memory, or thought patterns have been affected.
Assessment
Medicare Part B covers the fee for a required annual depression screening. The patient does not need to show signs or symptoms of depression to qualify for screening. The Patient Health Questionnaire (PHQ-9) is the most widely used screening measure in primary care. This nine-question, self-administered survey can be completed by the patient in the waiting room and then quickly scored by staff before the patient sees the physician. Alternatively, the staff or the physician can orally present the first two questions to the patient and require the full PHQ-9 only if the patient scores two or more on either item. The PHQ-9 is also online for your review, provided by the American Psychological Association.
The next step, increasingly recommended by physicians, is to meet with a mental health professional such as a psychiatrist, psychologist, licensed counselor, or clinical social worker. Most psychiatrists prescribe and manage medications to treat depression and anxiety, and do not provide therapy. (For this post, we will use the terms counselor or therapist, and generally, they provide the same mental health counseling.)
Although it is not unusual for a physician to prescribe antidepressant medication, medication alone may not be the most effective treatment for depression. The therapist or counselor will listen to your concerns, screen you for symptoms of depression, and assist you in setting up an appropriate course of treatment. Many studies and scholarly articles suggest that the most effective outcomes for treating depression are a combination of antidepressants and therapy, especially CBT (Cognitive Behavioral Counseling).
How do I find a mental health professional?
Your health insurance will likely include a behavioral health or mental health phone number on your insurance card or in your benefits package. If you are employed, check your benefits package or online to see whether your benefits include free EAP (Employee Assistance Program) counseling. These sessions may be from 1 session for assessment up to 6 sessions. If you have health insurance, you may be able to continue counseling with the same or another therapist.
Both insurance companies and EAP providers maintain lists of mental health professionals to whom they refer. You choose someone from the lists provided. A good way to learn about someone you are considering is to go online to the “Find a Therapist” section of Psychology Today. You can search by name or enter a zip code or city, and you will see a list of all providers in that area. You can then read a profile that provides information about them, including a statement they write, which gives you a better idea of the person beyond their professional credentials, education, and experience.
Other ways to find a professional include asking your doctor, a friend, or a co-worker for the name of someone they know and trust. You may also find someone by asking your minister or rabbi.
It is important to trust and feel comfortable with the professional you see. During the first session, you can determine whether the counselor meets your needs and whether you can work with that person. Generally, you will determine the cost to you before you even schedule an appointment, including who will pay for the service and how many sessions are approved, especially with EAP referrals. Evaluate your progress to ensure that it continues to contribute towards your improved health and well-being. Are you feeling better?
Treatment and Coping Options
Exercise has been found to reduce the effects of depression in some people. Walking three times a week for 30 to 45 minutes has been linked to reducing or alleviating symptoms of depression. It is unknown whether physical activity prevents the onset of depression or just helps modify the effects.
Arranging time for exercise is sometimes difficult for caregivers. It is often seen as a “value-added” activity—something to do when everything else is done. You might consider adding it to your “to-do” list, asking a friend to give you a “walk date” each week as a gift, or asking your doctor to prescribe walking or joining an exercise class. All the research shows that for a healthier life, it makes good sense to make time for exercise.
Upon review of the physical and mental evaluation, a course of treatment will be recommended. Primary treatment options are *psychotherapy* (also referred to as mental health therapy) and *antidepressant medication.* These treatments are used alone or in combination with one another.
The following are the most common treatments used today:
CBT – Cognitive and Behavioral Therapy — The therapist will focus on identifying and changing persistent, self-defeating thinking and behaviors. The ultimate goal is to help caregivers recognize and enjoy positive events in their lives, learn practical skills to address the problems they face, and improve the quality of their lives.
Medications – The most common antidepressant medications are Selective Serotonin Reuptake Inhibitors (SSRIs) (Examples: Prozac, Zoloft, Paxil) — These medications work by stabilizing serotonin levels, a neurotransmitter. Low levels of serotonin have been
linked to depression. SSRIs have fewer side effects than other antidepressants, such as Tricyclics or Monoamine Oxidase Inhibitors (MAOIs). If your physician prescribes an antidepressant, ask doctors and pharmacists or go online and do your own research.
If drug therapy is recommended, a certain amount of trial and error is necessary to find the right type and dosage of medication for each individual, and it may take several weeks before effects are felt. Good communication between the patient 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.
Complementary and Alternative Therapies – Although research is ongoing and these therapies need to be verified for effectiveness and discussed with a physician before use, you may have read about or know someone who uses them. It is highly recommended that medical care and therapy be the priorities in treating depression.
Mindfulness, meditation, and guided imagery – ongoing research suggests that these techniques can help treat depression, anxiety, and stress. The techniques involve deep breathing and shifting the person’s attention away from their thoughts and experiences, which can reduce their distress. Learn more about it here.
Meditation is a technique taught in the Stress Busting Program for Family Caregivers (SBP). SBP is an evidence-based education program through the WellMed Foundation. An evidence-based program means there is research showing that individuals experience positive outcomes. SBP may be provided through your local area agency on aging and other organizations. Call 2-1-1 or your local area agency on aging.
Phototherapy, using specially designed bright fluorescent lights for Seasonal Affective Disorder (SAD) has been shown to reverse SAD’s depressive symptoms. This is one of the better-researched therapies, with evidence that it works. Caregivers who feel “the blues” when confined indoors or in response to winter’s gray days may suffer from Seasonal Affective Disorder (SAD), also referred to as “winter depression.” As seasons change, our biological internal clocks, or circadian rhythms, shift partly in response to changes in sunlight patterns. This can cause our biological clocks to be out of sync with our daily schedules. People with SAD have a difficult time adjusting to the shortage of sunlight in the winter months. SAD symptoms are most pronounced in January and February when the days are shortest. SAD is often misdiagnosed as hypothyroidism, hypoglycemia, infectious mononucleosis, and other viral infections.
Experts believe that light therapy works by altering the levels of certain brain chemicals, specifically melatonin. Antidepressant medication, along with other treatments, including exercise, may be helpful as well. If you experience mild depressive symptoms seasonally, experiment with increasing the light in your surroundings, using lamps or other sources. If the symptoms are strong enough to impair your day-to-day functioning, talk to a doctor and a mental health professional with expertise in treating SAD.
St. John’s wort – One of the most studied alternative treatments for depressive symptoms is St. John’s wort (/Hypericum perforatum/). It is an herb used extensively in the treatment of mild to moderate depression in Europe and is now undergoing studies in the United States. St. John’s wort extract is sold “over the counter” in the U.S. as a nutritional supplement.
Its effectiveness is controversial.nnQuestions remain regarding whether St. John’s wort really does what its promoters claim. For nonprescription drugs in the U.S. there are no established criteria for determining the amount of active ingredient a company puts in their product or what dose is right for a given person.
The Food and Drug Administration issued a warning stating that St. John’s wort may affect the metabolic pathway used by many prescription drugs prescribed to treat a number of conditions, including heart disease, depression, and HIV infections. If you are taking St. John’s wort or considering its use, talk to your physician to ensure it will not interfere with any other treatment you are receiving.
It is promoted as a “natural” way to improve mood, and as a treatment for mild to moderate depression. Researchers are studying it for possibly having fewer and less severe side effects than antidepressant drugs but the data is not yet confirmed that it helps.
Paying for Treatment
Private health insurance and Medicare typically cover some mental health care. It’s best to call the mental health professional directly to find out whether they accept your insurance. 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 or treatment center) and outpatient (professional’s office) care, the number of visits covered, and the reimbursement rate.
Caregivers without health insurance or who pay out of pocket for care will find that fees vary by professional: psychiatrists charge at the higher end of the fee scale, while psychologists, social workers, and licensed counselors charge 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 the usual fees, or be nonexistent. Call 2-1-1 or contact your local ADRC (Aging and Disability Resource Center).
Private health insurance and Medicare typically cover some mental health care. It’s best to call the mental health professional directly to find out whether they accept your insurance. 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 or treatment center) and outpatient (professional’s office) care, the number of visits covered, and the reimbursement rate.
Caregivers without health insurance or who pay out of pocket for care will find that fees vary by professional: psychiatrists charge at the higher end of the fee scale, while psychologists, social workers, and licensed counselors charge 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 the usual fees, or be nonexistent. Call 2-1-1 or contact your local ADRC (Aging and Disability Resource Center).
Edited By Zanda Hilger, LPC, Founder and Program Director, Family Caregiver Information and Resources and Family Caregivers Online
Sources include
- SAMHSA (Substance Abuse and Mental Health Services Administration)
- Texas Health and Human Services Mental Health
- Family Caregiver Alliance
