June 2007
by Vicki Rackner MD
"I'm at the end of my rope," Betsy told me. "My life was barely manageable when I was juggling my family and my work. Now that I'm helping Mom get through her breast cancer treatment, I have almost no energy. I feel myself getting further and further behind. I just want to sit and cry. Could this be depression?"
Betsy went to see her doctor. Her doctor did a complete evaluation and came back with good news. Yes, Betsy was sad and appropriately so given her mother's illness. The doctor explained that clinical depression is a serious medical condition that's different than the sad mood that non-medical people often describe as depression. Betsy's lack of energy was caused by an under-active thyroid. She felt like a new woman shortly after she started her thyroid medication and joined a caregiver support group.
Susan's life changed after her father's fall. She made regular three-hour trips to her home town to get her mother and father settled into an assisted living facility. Her doctor could not explain why she suddenly had stomach aches and low back pain and weight loss. Over time she stopped cooking and entertaining, even though they had brought great joy to her throughout her life. She had problems sleeping and lost interest in sex.
When Susan hardly had enough energy to get out of bed in the morning, she wondered if she might have cancer. At her friend's recommendation Susan saw a different doctor who assured her that she did not have cancer; she had clinical depression. Susan responded well to her treatment. Her aches and pains improved along with her mood and energy.
Almost all family caregivers have the expected sad moments. Others become imprisoned by their sadness. When sadness runs your life, it's time to ask whether you could be clinically depressed. Family caregivers have twice the rate of clinical depression as the general population.
Clinical depression is a real illness that causes real pain. Pain draws attention to an unmet need. It's a signal that part of the body or mind or spirit is out of balance. Hunger alerts you to the need for food, thirst alerts you to the need for water, and fatigue alerts you to the need for sleep. The pain of depression often points to the need for self-care, the need for community and the need for hope and optimism.
The family caregiver is at increased risk of depression much as a stressed, sleep-deprived person running on fast food and caffeine is at increased risk of catching a cold. Paradoxically, depression impairs an individual's ability to function as an effective caregiver.
Here's why caregiving can be a recipe for depression:
When is there time for self-care? Even for individuals who value and practice health-promoting habits such as regular exercise, socializing with friends or writing in a journal, the many demands of caregiving allow little time and energy for self-care. It's easy to understand how the alleviation of the suffering of others takes priority over maintaining one's own health; however, self-care fuels giving just as gas fuels a car. Caregivers who don't practice self-care quickly run out of gas. They try to run on empty and thus threaten their physical and mental health.
Who becomes the family caregiver? They're the family members most likely to put the needs of others above their own. Lack of self-care increases a person's vulnerability to depression. Family caregivers, almost by definition, are the family members who are at greatest risk for depression.
What is the trajectory of family caregiving over time? Parenting efforts are rewarded with children who become increasingly independent. The future looks bright. But caregivers look into the future and see losses. Aging parents or partners or friends for whom they care are destined to lose independence, lose their sense of well-being and eventually lose their lives. The losses associated with caregiving set the stage for depression.
Where is the community? Family caregiving often leads to social isolation, which places caregivers at increased risk for depression.
How will caring people manage feelings they consider unacceptable, such as anger or guilt or remorse? Many try to deny, suppress or ignore them, but that does not mean the feelings go away. Mental health professionals describe depression as anger turned inward.
Why is it so hard to hang onto hope? Some caregivers refuse to abandon the fantasy of a miraculous cure because for them it means giving up hope. They're setting themselves up for depression. Depression is a state in which there is little hope for a better tomorrow. Even when a cure is not an option, no matter how desperate the situation, there is always hope for a better tomorrow. Sometimes it requires shifting hope to outcomes that are based in reality, like helping loved ones enjoy pain-free intervals or going out for a walk or enjoying a short visit from the grandchildren.
If your days are dark, here are some ideas:
Ask your doctor, "Could I be depressed?" Feeling sad or overwhelmed is a normal response to super-sizing your job caring for others. Your doctor can distinguish an expected under-the-weather mood from true clinical depression. Sometimes it's easy to make the diagnosis of depression and other times it's tricky. We tend to view illnesses of the mind and of the body as separate. Sometimes disorders of the mind, like depression, can manifest as aches and pains in the body, and other times disorders of the body, like thyroid problems can manifest as mood changes. Many people resist the diagnosis of depression because they believe that there is shame associated with problems of the mind. You would not be ashamed if you had appendicitis or the flu or required eyeglasses. Depression is just another illness that affects a different organ system.
Go play. Your grandmother was right. Regular exercise benefits the mind and the body. Exercise changes the brain chemistry in a way that improves sad moods. Even a ten-minute walk can make a positive difference. Park a little farther away from work or the store. Take the stairs instead of the elevator. You will reap many rewards, including a sound night's sleep.
Use your stress-busters. Let's face it: caregivers live with lots of stress. While you may not be able to control the stress in your life, you decide how you respond to the stress. Make a list of five things you can do when you feel stressed. Maybe it's taking that brisk walk or writing in your journal or calling a friend. The time you most need stress-busters is the time you're most likely to forget them, so put the list on the fridge.
Rethink people-pleasing. People-pleasers go to great lengths to make others happy, avoid conflict and be seen as a nice person. They often care for others at their own expense; many take pride in their ability to ignore their own needs. They run the risk of depression both from the lack of self-care and from the futility of efforts to make another person happy. Attending to your own needs puts you in a better position to nurture others. The very first blood vessels that leave the heart feed the heart itself.
Reach out to others. Connect with friends who are good listeners. If getting out of the house is impossible, join an online community. Tell your story and see chapters of your own story told by others.
Redefine hope. It may be true that you care for someone for whom there is no hope for a medical cure or recovery of independence. Even in the face of death or long-term disability, there's always hope. Capture the joy that's always there, even in the presence of pain.
Get help. Clinical depression is a real medical condition diagnosed by a professional that improves with intervention. Treatment of depression is a high priority because it both assuages the caregiver's pain and allows the caregiver to more fully step into the role of supporting loved ones in their time of need.
> Click for information on our Caregiver Club.
Copyright © Vicki Rackner MD, 2007
Caregiving Can Be a Recipe for Depression