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By Mariana L. Henry, MPH

When I returned home from my first semester as a nutrition counselor for my university's student-run free clinic, my mother was diagnosed with prediabetes. I still remember her reaction when she received this news. She was anxious, her eyes were watery, and she was nervous about telling me. Having worked with many patients like my mother, I assured her that prediabetes is quite common and that we could use lifestyle measures to prevent her from progressing to type 2 diabetes. We figured out a plan. My mother, a widow and longtime sole provider for our family, was determined to live long and see my siblings and I finish our schooling, so she committed to these suggestions.

Thankfully, her health improved, and her disease did not progress. However, the anxiety from the news she received several months ago persisted. During our weekly calls, she'd tell me how worried she was about being diagnosed with type 2 diabetes, how much guilt she felt if she didn't do her scheduled walk, and how much a joke about diabetes from a friend would sting. She was anxious, and it had reached a point to which I could not console her. While I did not realize it at this time, I had witnessed a similar situation before. Shortly after I turned 10 years old, my father had his first heart attack. An immigrant from Sri Lanka who was often unemployed, he was without insurance and left with a hefty medical bill. His first heart attack greatly contributed to his already declining mental health, and it was hard for him to dedicate himself to the rushed instructions he had received upon discharge. A year later, he died of a second, more massive heart attack.

The reality is that the conditions that my parents faced are on the rise. In medical school, we frequently hear that heart disease is the leading cause of death and that chronic diseases such as cancer and diabetes are increasing in prevalence. Even with the gift of having medical knowledge through my education and the dedication to my health it has fostered, I still very much fear heart disease and prediabetes, the conditions that my parents have endured. I can see myself carrying the same feelings as them. However, I am more optimistic about my ability to manage my feelings toward such diagnoses as I see that seeking mental health care is gradually becoming the norm.

Unfortunately, my parents and many others often do not get screened for mental illness as a part of their chronic disease treatment nor do they have their feelings and anxieties regarding their conditions addressed in clinical care. Research has shown that, as compared to nonimmigrants, immigrants from Asia, Latin America, and Africa utilize mental health services at lower rates, even though they have an equivalent or greater need (1). This disparity becomes even more pronounced among men, those without insurance, and the undocumented (1). Furthermore, as compared to those without chronic diseases, people with chronic diseases are more likely to be depressed (2). This is concerning. It has been well documented within the literature that when we are depressed, it is quite easy to lose the motivation to take the necessary medications, exercise outside, and cook a healthy meal (3). A recent study found that after adjusting for factors including age, race, and income, those with severe depression were three times as likely to have worse cardiovascular health compared to those without depression (4).

Conditions such as diabetes and hypertension have become so common and manageable that it is easy to assume that patients are going to be okay following these diagnoses. However, the experiences of my parents have shown me that the diagnosis of a chronic illness itself can be traumatic. Some health systems, such as those at Veterans Affairs and Kaiser Permanente, have integrated regular screening for depression into primary care (5). Furthermore, the Centers for Medicare & Medicaid Services reimburses yearly depression screenings for Medicare beneficiaries in primary care settings that have staff-assisted depression care supports (6). However, in other systems without such screenings, these mental health conditions are often missed or undertreated in patients with chronic diseases such as type 2 diabetes (5). In one study conducted at a regional health center and a federally qualified health center (FQHC), depression-screening rates among patients with diabetes and no history of major depressive disorder (MDD) were notably low (7). Additionally, the researchers found that patients who had diabetes and no diagnosis of MDD who received care at an FQHC clinic showed more symptoms of depression than patients with a history of MDD at both study locations (7).

I believe that screening for mental health should have a wider role in the primary care of chronic diseases. Primary care physicians are at the forefront of mental health care, as they see and treat more than 50% of all cases of mental illness in the United States (8). I am inspired by the field of internal medicine because I feel that an internal medicine physician who considers the impact of chronic diseases on mental health can be a guiding light not only toward helping patients achieve good physical health but also in chipping away at the ongoing stigma toward seeking help for mental health.

True comprehensive chronic disease care is more than the list of nutrition and exercise recommendations I was taught to give as a nutrition counselor or the medications that I'm told to prescribe as a physician-in-training. Reflecting on the lessons from my parents, when I become a physician, one of the most critical questions that I hope to ask is, "How are you feeling about this?" Even those conditions considered common and manageable deserve a moment of reflection on how they may emotionally affect patients.

Thank you to Dr. Kenneth Dolkart, Dr. Roshini Pinto-Powell, and Michael Koo for their guidance with this piece.

References

1. Derr AS. Mental health service use among immigrants in the United States: a systematic review. Psychiatr Serv. 2016;67:265-274. [PMID: 26695493] doi:10.1176/appi.ps.201500004
2. Moussavi S, Chatterji S, Verdes E, et al. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007;370:851-858. [PMID: 17826170] doi:10.1016/S0140-6736(07)61415-9
3. Katon W, van der Feltz-Cornelis C. Treatment of depression in patients with diabetes: efficacy, effectiveness and maintenance trials, and new service models. In: Wayne Katon W, Mario Maj M, Norman Sartorius N, eds. Depression and Diabetes. 2010:81. doi:10.1002/9780470667309.ch4
4. Medoff B, Baird A, Herbert B, et al. Depression worsens cardiovascular health: a population-based cohort study (NHANES, 2015-16) [Abstract]. Circulation. 2020;142:A14193. Abstract 14193. doi:10.1161/circ.142.suppl_3.14193
5. Owens-Gary MD, Zhang X, Jawanda S, et al. The importance of addressing depression and diabetes distress in adults with type 2 diabetes. J Gen Intern Med. 2019;34:320-324. [PMID: 30350030] doi:10.1007/s11606-018-4705-2
6. Centers for Medicare & Medicaid Services. Screening for Depression in Adults. Accessed at on 1 October 2021.
7. Barnacle M, Strand MA, Werremeyer A, et al. Depression screening in diabetes care to improve outcomes: are we meeting the challenge? Diabetes Educ. 2016;42:646-651. [PMID: 27558266] doi:10.1177/0145721716662917
8. Tai-Seale M, Foo PK, Stults CD. Patients with mental health needs are engaged in asking questions, but physicians' responses vary. Health Aff (Millwood). 2013;32:259-267. [PMID: 23381518] doi:10.1377/hlthaff.2012.0962

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