Depression

Is He Depressed or Just Blue? And How Do I Tell the Difference?

By Laurie Fronek, Staff Writer

What is Depression?

Is Depression a Normal Part of Dying?

Depression or Preparatory Grief: Telling the Difference

What You Can Do

Herbal Medicines

When to Call a Medical Provider

Speak Up About Depression

It makes sense that someone with a serious illness might go through periods of sadness, withdrawal, hopelessness, grief, or other challenging feelings. It also makes sense that caregivers will be concerned when they see loved ones go through emotional pain and upheaval. Caregivers may wonder if the feelings are normal. Is he depressed? How can I tell if he needs help?

“People who are terminally ill are suffering a lot of losses—not only physical losses or the imminent loss of their life but loss of activities and relationships,” explains Susan McCurry, PhD, clinical geropsychologist and research associate professor in the School of Nursing at the University of Washington. For some people, these losses may trigger depression. But not always. “Certainly, not everyone who’s dying is clinically depressed,” McCurry says, even if they appear to be struggling with their feelings.

Distinguishing between depression and other reactions to dying can be difficult. Deciding whether a person needs treatment—and if so, what kind—also requires skill. As a caregiver, you can help by watching and listening for signs that your loved one is suffering mentally or emotionally. You can also help support him and connect him with professionals who know how to help, if that’s what he wants or needs.

What Is Depression?

“Depression is not one thing. It comes in many flavors.”

—Sue McCurry PhD, clinical geropsychologist at the University of Washington

Mental health professionals and other healthcare providers diagnose depression based on the four factors listed below.

The person has depressed mood or loss of interest and pleasure in usual activities most of the time for at least two weeks. (“Most of the time” means most of the day, nearly every day.)
The depressed mood or lack of interest is a change from the person’s usual state of mind.
His depressed mood or lack of interest interferes with the major aspects of his life, such as his work, relationships, and other important activities.
He also has most of these symptoms nearly every day.
Losing or gaining weight without trying, or having decreased or increased appetite.
Either having insomnia or sleeping excessively.
Either being agitated or feeling slowed down.
Feeling fatigued or having low energy.
Feeling worthless, excessively guilty, or guilty when that seems inappropriate.
Having trouble thinking, concentrating, or making decisions.
Thinking repeatedly about death or about killing himself, coming up with a plan to kill himself, or trying to kill himself.

The common features among depressed people are a depressed mood and loss of interest and pleasure in usual activities. But otherwise, depression can look a bit different in different people, and it can range from mild to severe. Even “depressed mood” can vary. It can include feeling unhappy, sad, glum, or dejected. But some people who are depressed feel their mood is more muted or numbed than sad. Some may seem more irritable or worried than anything else. In extreme cases, depressed people may barely be able to get themselves out of bed in the morning.

Just as the signs and symptoms can vary, so can the causes. Depression can be a normal reaction to a stressful or upsetting event, such as losing a spouse or receiving a terminal-illness diagnosis. In other cases, biology is a major contributor. For instance, some forms of depression run in families, and some people are more vulnerable than others to repeated episodes of depression over their lifetime because of their chemical makeup. Sometimes depression is a side effect of a physical illness or a medication.

Is Depression a Normal Part of Dying?

As for whether depression is “normal” in people who are sick or dying, it’s not normal if by normal we mean it’s inevitable or it doesn’t deserve treatment. Nonetheless, depression is not an unusual experience among people approaching death.

“When someone is dying, any response can be normal,” says McCurry. “There is no one correct way to die. The truth is that people cope with dying in many ways psychologically. Nevertheless, experts on death and dying, such as Dr. Elizabeth Kubler-Ross, have observed that most people will show signs of depression at some point in their dying process.”

Feeling depressed about poor health is natural and may even be a necessary stage of dying. This can be difficult for caregivers to witness. According to McCurry, some people will naturally move through depression to another state of mind, but others can get stuck and need help. Mental health professionals working with dying patients need to “make the room to let people die as they see fit,” says McCurry, which means walking a sometimes delicate line, carefully considering when to intervene and how best to treat symptoms of depression.,

Nevertheless, it’s important to know that there’s no reason any person, including someone with serious illness, must suffer with depression. Depression is a treatable condition.

Depression or Grief: Telling the Difference

Some symptoms and signs of depression overlap with the side effects of serious illness, making it difficult to know whether a person is depressed. For example, someone undergoing treatment for cancer may lose her appetite and be much more fatigued than normal. Insomnia is a common side effect of many medications, and also occurs in many people who have chronic pain or who need to get up frequently at night to use the toilet or take medicines. Problems with concentration and lack of interest in daily activities can be caused by Alzheimer’s disease or other kinds of dementia. People with any potentially life-threatening illness may give a great deal of thought to death.

It’s also common for dying people to go through preparatory grief (also called anticipatory grief). This is the grief people feel about the losses they expect to experience in the process of dying. They may grieve that they’ll be separated from family and friends when they die. They may grieve over events they won’t be around to see. They may grieve the loss of physical abilities and independence that they are already experiencing.

Losses like these can trigger a range of reactions, including sadness and withdrawal. This is normal, and it’s an important part of adjusting to the differences between the life the person expected to have and the one that is before her now. It’s part of her very personal, internal transition toward her death. Read more about preparatory grief.

Here are a few features that may provide clues about whether your loved one is depressed or experiencing preparatory grief.

Depression tends to affect all aspects of a person’s life nearly constantly. Grief tends to come and go in waves. Between and maybe even during the waves, a grieving person can still experience pleasure and hope.
Without treatment, depression tends to linger and not improve. Grief tends to improve over time, even though there may still be intense waves occasionally.
Interacting with friends and family who want to “cheer you up” may not make someone with depression feel much better in the absence of other treatments for depression. Grieving people may withdraw at times in order to process what’s happening to them, but they are more likely to seek out the support of others.

It Takes Training to Diagnose

Based on what you know about your loved one, you may feel it’s fairly clear whether she is depressed or going through preparatory grief. But if you’re unsure, that’s not surprising. It takes training and experience for healthcare providers to tease apart these experiences.

If you have concerns, try not to feel that you have to “diagnose” your loved one’s reaction and figure out what to do about it. Ask her how she’s doing, talk with her about your concerns, and encourage her to explore these topics with her healthcare team. To tell whether a person is depressed, a healthcare provider needs to consider the patient’s unique situation. Her overall health and treatment provide a context for understanding her mood.

What You Can Do

Here are the most important things you can do about depression.

Watch for signs and symptoms.
Speak honestly with your loved one if you see or hear things that make you suspect depression. Some people worry that talking about depression may make it worse. Actually, a frank conversation is often the first step toward getting treatment.
Encourage your loved one to talk with a medical provider if he seems depressed. If he resists, talk to a professional yourself about your concerns.

Talk therapy and antidepressant medicines are the most common treatments for depression, and they do help most people who seek treatment. The best options for your loved one depend on his unique situation, including how long doctors expect him to live. For example, some antidepressant medicines take several weeks to start working or have undesirable side effects that may make them inappropriate for a person nearing the end of her life. In contrast, one of the best kinds of therapy for depression—helping people have more pleasant moments in their day and fewer unpleasant ones—can happen at any point in a terminal illness.

Even when medicines are part of the treatment plan, it’s also important to “acknowledge the needs of the person who’s dying,” says McCurry. Be a good listener if the person wants to talk. Other measures that can help, according to McCurry, are: “Helping the person find meaning in their suffering, helping them come to closure in relationships or in unfinished business, helping them find ways to maintain dignity or a sense of control—all of those things can be as important as medicine for a person in that situation.”

“Try to get a sense of what the person wants,” says McCurry suggests, which may mean helping them figure out what they want.

Here are some other ways to support someone who may be depressed.

Keep the person connected to family, friends, and usual activities. Take advantage of good days to do things he enjoys. To the extent possible, help him fill his days with pleasant events.
Let the person make as many decisions as he can. This engages him in daily life and gives him some control over what’s happening. “Focus on doing things that will help the person make the most of the time that he has left in a way that he would consider productive,” says McCurry.
Practice good listening skills. Invite the person to talk about his feelings. Listen quietly and acknowledge what you hear. A simple but sincere “uh-huh” can show that you are paying attention. Saying, for example, “It sounds like this feels really hard” can show that you grasp his words and the feelings behind those words. Resist the urge to give advice or try to fix things. You can do a lot just by being a sounding board.
Treat the person as you always have. This doesn’t mean pretend that nothing’s wrong. But do be genuine. Be yourself, and recognize he is the same person you have always known, even though times may be challenging right now.
Refrain from trying to cheer up the person or get him to snap out of it. Being falsely or overly cheerful can feel dismissive to someone who is struggling emotionally. Instead, try to be pleasant and consistently supportive.
If the person has connections to a faith community or tradition, ask whether he would like to speak with a minister or other representative. Depression in the terminally ill can be tied to guilt or regrets about the past, and for some people, spiritual ministry is a critical part of end-of-life care.

Herbal Medicines

Some people with depression try herbal remedies, like St. John’s wort. Herbs like these may interact with your loved one’s medicines. For example, St. John’s wort interacts with some cancer medicines, some AIDS medicines, and some antidepressant medicines. Before trying an herbal remedy, encourage your loved one to talk with her healthcare team about the risks and benefits.

When to Call a Medical Provider

If you are ever concerned that your loved might be depressed, that’s a good reason to talk with her and with her healthcare team or a mental health professional. Look back at the four factors listed under “What Depression Is.” Consider seeking help if your loved one seems to meet those criteria for at least a couple of weeks, if she has signs or symptoms of depression that seriously interfere with her usual activities, or if she is considering or talking about suicide.

Besides relying on your loved one’s healthcare team, you can contact the American Psychological Association www.apa.org or American Psychiatric Association www.psych.org for help finding a mental health professional. Hospice programs also can connect you with mental health professionals who have expertise treating depression in people who are terminally ill.

Speak Up about Depression

Many of us value being resilient and strong willed. So it can be hard to admit to feeling depressed and being unable to overcome it. Your loved one may try to put on a happy face or may act stoic, pretending that everything’s fine. She may feel unmotivated to seek or accept help for depression precisely because she is depressed. Stigma also keeps some sufferers quiet. They don’t want to admit to feeling depressed, because they fear others will see them as crazy or weak.

Being depressed is not a sign of weakness or a character defect. It’s a treatable medical condition. Most people who seek treatment improve. But to get treatment, we have to be willing to talk about it.

Many of us were taught not to speak openly about our troubles. Some families and cultures consider it bad form to share personal woes, even with people who are close to us. There’s nothing wrong with valuing privacy. But when a person is depressed, her health is at stake. Depression can make other illnesses worse and interfere with the effects of pain medicine. Often depression triggers physical symptoms, such as unusual tiredness and unexplained aches and pains. These are very good reasons to speak up and to reach out for help.

If your loved one seems uneasy talking about depression, give encouragement. Show through your words and actions that you want to assist her in getting help.