Disability and depression – walking on broken glass!

How can spiritual, life – wellness – health coaching, and holistic and integrative therapies help?

Generally, severe depression first hit people with acquired disabilities compared with people with hereditary disabilities. Acquired disability, whether from a chronic disease, acute disease, severe injury, or the late and full expression of a genetic syndrome, creates extreme, sudden life-changing conditions with plenty of challenges in the future of everyday life. People are adjusting and challenged to acquired disability conditions. Suddenly, either way, disability can generate very adverse conditions, such as depression, that involve persistent feelings of sadness, uselessness, and hopelessness.

Disabled people are still heavily dependent on primary caregivers

Disabled people are getting heavily reliant on their primary caregiver, either a spouse/husband, partner or friend, for transportation, paying medical and other bills, providing housing and food, etc. Interestingly, the saving account for the majority of disabled people is getting “dry” very quickly because, in the first two years of the disability, the person is not eligible for Medicare or Medicaid (with some exemptions), so the saving account is getting dry very quickly paying individual health insurance premium and medical bills for two years until they get eligible for Medicare or Medicaid. Independent living movement works probably well in a big city metro area where public transportation is available, and automatically paratransit transportation is possible because of compliance with the ADA-AA. However, suppose a disabled person lives outside a big city metro area. In that case, they become heavily dependent on their primary caregiver regarding transportation. In addition, disabled people live in health disparities. Some healthcare providers do not accept Medicare or Medicaid, so predominantly disabled people have insufficient access to health care, either preventive or curative.

A homebound lifestyle is one additional contributor to severe depression, feeling fatigued, pain with or no apparent cause, loss of appetite, and a person becoming easily irritable and forgetful; the altered sleeping pattern is pervasive as well. Life is getting significant stress full of challenges and barriers! Unfortunately, the primary caregiver for a disabled person plays the central role in the presence of a person with a disability providing the crucial resources for a decent life and advocating for the disabled person daily. Still, there are no specific help or support resources to make the primary caregiver’s life easier, less demanding, and more stressful.

Depression as a co-morbidity in the population of people with disability

If we observe better already, a person with a disability is getting co-morbidity, and that is depression. According to the Social Security Administration, depression is listed as a disability as well. Thus, already disabled person is getting more disabled with the other co-morbidity major depressive disorder. Depression, isolated by itself, is the second most common medical condition listed on Social Security disability applications and, worldwide, is the leading cause of disability. Being comfortable in new social circumstances, such as lack of transportation, employment, and an isolated and homebound lifestyle, lead to dysthymia and severe anhedonia.

Why disability leads to depression

One of the problems most disabled people stated is a loss of a life direction or purpose. This devastating loss could quickly open the door to severe depression. Unfortunately, the lack of appropriate vocational rehabilitation services significantly contributes to this condition. It is a primary factor that the majority of people with disability is losing a life direction and cannot see the explicit purpose of their life in the future. Most state vocational rehabilitation services operate by approximately 76% of the federal fund; 18% is a state contribution, and the rest is from Social Security Administration for the program “Ticket to Work” and other donations. Life is getting so complicated and stressful.

Over time a person with a disability will express the first signs of decreased self-esteem; lack of confidence is a new phenomenon that we can observe. Furthermore, the loss of autonomy is a devastating factor significantly contributing to reduced self-esteem and severe depression. Moreover, sadness, grievance, and frustration because of career loss are devastating and challenging for disabled people, either with an acquired or hereditary disability. Sometimes depression is an “isolated entity,” hidden for a long time, and disability simply triggers a full expression of depression (mainly in the population where depression has a solid genetic background).

The homebound lifestyle that most disabled people face is an additional contributor to the development of severe depression. Quality of life often decreases; losing independence is evident with a homebound lifestyle and heavy dependence on a primary caregiver. In addition, most disabilities leave people homebound with few opportunities to interact with others. Sometimes disabled persons are at home alone all day while the primary caregiver, either spouse, husband, the living partner, is at work, or in another scenario, the person with a disability is confined to an assisted living center where community activities do not match either age or interests and a person with a disability is getting more depressed.

Why disability raises depression risk?

Depression induced by disability can make the disability even worse. Mostly, depressed, disabled people find it challenging to take care of their health and preventive health care, mostly missing intentionally or unintentionally essential physician appointments and annual checkups with a primary care physician. Additionally, people with disability and depression as their co-morbidity do not take their medications as directed and on time. Untreated or unproperly treated depression in the population of disabled people will eventually lead to the first suicidal thoughts. Some evidence suggests that if the first episode of depression goes untreated, a person with disability and depression as co-morbidity has a 50% chance of experiencing a recurrence. In an untreated scenario, an episode of severe depression can probably last six months to a year.

Indeed, disability is a challenging and life-altering condition enough to cope with. Developing related depression as co-morbidity to disability will make the life of a disabled person even more complex and challenging. Psychotherapy is also available and sometimes can be very successful and helpful, sometimes even worse. According to the standards, most people are placed into the chronic treatment of CBT (cognitive behavioral therapy) instead of 6 -16 sessions. However, there is one problem, and that is who will pay for the long-term treatment. Mostly, primary caregivers are paying for psychotherapy sessions, or if the psychotherapist accepts Medicare or any other health insurance, that would be a perfect option.

“A substantial body of research shows that family members who provide care to individuals with chronic or disabling conditions are themselves at risk. Emotional, mental, and physical health problems can arise from complex caregiving situations and the strains of caring for frail or disabled relatives” (National Center on Caregiving, 2017).

Some research data are available regarding suicide in the population of disabled people. Depressive symptoms frequently occur in people with multiple sclerosis, and their rates of suicidal thoughts are higher than in the general population. Also, the presence of depressive symptoms directly influences the risk of suicide (1 – 6). Generally, physically ill health, disability, and feeling of heavy dependence lead to depression (7 – 9), and long-term work disability and absenteeism significantly contribute to depression (10). There is evidence for a direct association between disability and depression, disability and suicidal thoughts or ideation, and depression and suicide ideation (11, 12). There is some scientific evidence on how sight loss has an emotional impact and how readjustment may not occur, and suicide may result from depression and disability (13, 14). Suicidality in the population of people with intellectual disabilities has been the focus of several investigators (15, 16). Disability affects health-related quality of life and dysphoria symptoms such as helplessness, hopelessness, worthless, dissatisfaction with life, depression, and suicidal ideation. Generally, research data exhibited that physical disability is associated with a higher risk of lifetime suicidal ideation (17 – 20).

Additionally, there is fascinating research performed by Fishbain D.A., and colleagues in 2012, preferences for death over disability are associated with passive and active suicidal ideation and actual suicidality in patients with chronic pain (21). Generally, chronic pain is associated with an elevated risk of suicide (22). Holley J.M. and colleagues in 2014 stated that chronic pain might facilitate the development of a critical risk factor for suicide, fearlessness about death (22).

Depression alone is a disability even without a primary cause of disability, and it is a leading cause of disability globally (23). Coshal S. and colleagues 2017 stated in their article that one-half of the patients with depression do not receive adequate treatment (23). Klonsky E.D. and colleagues 2016 published an article explaining that suicidal behavior is a leading cause of death and disability. Very clearly, they describe the process of development of suicide attempts. They talked about three distinct steps: the development of suicidal ideation and the progression of ideation to suicide attempts. They are separate entities or distinct phenomena with different explanations and predictors (24). As they explained in their research, depression, hopelessness, most mental diseases, and even impulsivity predict ideation. However, these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide generally; depression, even episodic, result in lasting disability, distress, and burden (25).

How can life, wellness, health coaching, and holistic and integrative therapies help?

In the last blog related to disability, I discussed several phases of disability, “the beginning,” “hitting the wall,” “turning around,” “letting go,” “opening up,” “letting in,” and “the gift of “healing.” Certainly, in the phase “the beginning” we cannot expect from the disabled person to be cooperative and open for any kind of the treatments for improvements of life, wellness, health. Still, the person is in the state of “shock,” grief, anger, depression, mourning…However, how time passes the person will start to live life with multiple questions such as “what is the purpose and meaning of my life in this condition”, “there are no resources to help me, and they promised to me”, “this is a fake hope, nothing happened after several months”, “I am getting heavily dependent on you, I am so sorry, I am a burden”, “I feel hopeless, worthless, helpless” and many more.

In this condition, it is essential to approach the disabled person with the question, “what do you feel and think you can work? What would you like to work?” Finding skills and pulling them out “on the surface” is vital in this condition. Even gaining some new skills is an excellent solution. Taking the courses and continuing education courses, certifications, etc.. would be an ideal solution. This will open the “magical door” to the disabled person. Getting out of the house is essential, breaking a homebound lifestyle and heavy dependence on a primary caregiver. Taking yoga sessions with mindfulness meditation is extremely helpful (which is very well documented in peer review medical journals). Do not worry; even if you cannot do regular yoga, there is yoga in the sitting position, so there is no excuse for such a thing. Tai Chi and Qi Gong are extremely helpful for balancing body-mind-soul. Many mental health professionals are trained in life coaching. Sessions with a life coach can help find a new meaning and purpose in life, even a new career, pull out skills and talents that potentially could be a new job or profession, taking actions that eventually will result in motivation and focus.

Regular physician office visits are crucial. Lack of transportation in your area is not a good excuse. Most undetected co-morbidity is a potential trigger for additional disability and chronic illnesses. Integrative Psychiatry will provide you with more comprehensive and targeted therapeutic approaches and treatments. Importantly you will not be treated “treatment as usual – TAU.” Integrative Psychiatry considers your genetic background, biology/physiology/pathophysiology, family history, previous treatments, socioeconomic status, spiritual life, and many more.

The most important thing is finding a reasonable plan to spend every day productively. It does not have to be physical work such as gardening, cleaning the house, or cooking. It could be arts and crafts, creative writing, writing blogs and articles, advocacy work, voluntary contributions to local hospitals, religious and spiritual organizations, churches, etc. Feeling productive is extremely important. A job search should be everyday work for at least one hour.

The team at Holistic Healthful can provide you with a non-medical, spiritual consultation, finding your hidden skills and talents that potentially could be a new career or job in disability, job search, and job readiness in disability / chronic illness. In addition, Dr. Miroslav Sarac is conducting sessions with disabled people, their families, and primary caregivers. Importantly, we can explain and help you with disability from the spiritual point of view! Helping is healing!

Respectfully,

Holistic Healthful

References:

1. Tauil CB, Grippe TC, Dias RM, Dias-Carneiro RPC, Carneiro NM, Aguilar ACR, Silva FMD, Bezerra F, Almeida LK, Massarente VL, Giovannelli EC, Tilbery CP, Brandão CO, Santos LMB, Santos-Neto LD. Suicidal ideation, anxiety, and depression in patients with multiple sclerosis. Arq Neuropsiquiatr. 2018 May;76(5):296-301.

2. Lewis VM, Williams K, KoKo C, Woolmore J, Jones C, Powell T. Disability, depression and suicide ideation in people with multiple sclerosis. J Affect Disord. 2017 Jan 15;208:662-669.

3. Moore P, Hirst C, Harding KE, Clarkson H, Pickersgill TP, Robertson NP. Multiple sclerosis relapses and depression. J Psychosom Res. 2012 Oct;73(4):272-6.

4. Pompili M, Forte A, Palermo M, Stefani H, Lamis DA, Serafini G, Amore M, Girardi P. Suicide risk in multiple sclerosis: a systematic review of current literature. J Psychosom Res. 2012 Dec;73(6):411-7.

5. Moore S. Major depression and multiple sclerosis – a case report. J Med Life. 2013 Sep 15;6(3):290-1.

6. Chwastiak L, Ehde DM, Gibbons LE, Sullivan M, Bowen JD, Kraft GH. Depressive symptoms and severity of illness in multiple sclerosis: an epidemiologic study of a large community sample. Am J Psychiatry. 2002 Nov;159(11):1862-8.

7. Meltzer H, Bebbington P, Brugha T, McManus S, Rai D, Dennis MS, Jenkins R. Physical ill health, disability, dependence, and depression: results from the 2007 national survey of psychiatric morbidity among adults in England. Disabil Health J. 2012 Apr;5(2):102-10.

8. Meltzer H, Brugha T, Dennis MS, Hassiotis A, Jenkis R, McManus S, Rai D, Bebbington. The influence of disability on suicidal behavior. European Journal of Disability Research. 2012. 6: 1, 1 -12.

9. Lecrubier Y. Depressive illness and disability. Eur Neuropsychopharmacol. 2000 Dec;10 Suppl 4: S439-43.

10. Hendriks SM, Spijker J, Licht CM, Hardeveld F, de Graaf R, Batelaan NM, Penninx BW, Beekman AT. Long-term work disability and absenteeism in anxiety and depressive disorders. J Affect Disord. 2015 Jun 1;178:121-30.

11. Stensman R, Sundqvist-Stensman UB. Physical disease and disability among 416 suicide cases in Sweden. Scand J Soc Med. 1988;16(3):149-53.

12. Walsh SM, Sage RA. Depression and chronic diabetic foot disability. A case report of a suicide. Clin Podiatr Med Surg. 2002 Oct;19(4):493-508.

13. De Leo D, Hickey PA, Meneghel G, Cantor CH. Blindness, fear of sight loss, and suicide. Psychosomatics. 1999 Jul-Aug;40(4):339-44.

14. Hine TJ, Pitchford NJ, Kingdom FA, Koenekoop R. Blindness and high suicide risk? Psychosomatics. 2000 Jul-Aug;41(4):370-1. 

15. Dodd P, Doherty A, Guerin S. A Systematic Review of Suicidality in People with Intellectual Disabilities. Harv Rev Psychiatry. 2016 May-Jun;24(3):202-13.

16. Lunsky Y, Raina P, Burge P. Suicidality among adults with intellectual disability. J Affect Disord. 2012 Nov;140(3):292-5.

17. Båtstad HS, Rudmin FW. Suicidal tendencies as correlates of disability measures. J Health Psychol. 2016 Dec;21(12):3037-3047.

18. Russell D, Turner RJ, Joiner TE. Physical disability and suicidal ideation: a community-based study of risk/protective factors for suicidal thoughts. Suicide Life Threat Behav. 2009 Aug;39(4):440-51.

19. Le Strat Y, Le Foll B, Dubertret C. Major depression and suicide attempts in patients with liver disease in the United States. Liver Int. 2015 Jul;35(7):1910-6.

20.  Kerkhof A. Calculating the burden of disease of suicide, attempted suicide, and suicide ideation by estimating disability weights. Crisis. 2012 Jan 1;33(2):63-5.

21. Fishbain DA, Bruns D, Meyer LJ, Lewis JE, Gao J, Disorbio JM. Exploration of the relationship between disability perception, preference for death over disability, and suicidality in patients with acute and chronic pain. Pain Med. 2012 Apr;13(4):552-61.

22. Hooley JM, Franklin JC, Nock MK. Chronic pain and suicide: Understanding the association. Curr Pain Headache Rep. 2014;18(8):435.

23. Coshal S, Saunders J, Matorin AA, Shah AA. Evaluation of Depression and Suicidal Patients in the Emergency Room. Psychiatr Clin North Am. 2017 Sep;40(3):363-377. 

24. Klonsky ED, May AM, Saffer BY. Suicide, Suicide Attempts, and Suicidal Ideation. Annu Rev Clin Psychol. 2016;12:307-30.

25. Deshpande SS, Kalmegh B, Patil PN, Ghate MR, Sarmukaddam S, Paralikar VP. Stresses and Disability in Depression across Gender. Depress Res

Treat. 2014;2014:735307.