Part Two: Depression and Anxiety
By Christina Gentile, MS, Clinical Psychology doctoral student
Two of the most common mental health problems are depression and anxiety. Symptoms related to these disorders have been identified as major causes of poor adherence to the gluten-free diet and poor acceptance of celiac disease. An overview of depressive and anxiety disorders will be discussed as these are common problems that also cause secondary issues (i.e. sleep disturbances and low energy).
Depression: What is it? How common is it in individuals with celiac disease?
In general, depression is a mood disorder in which feelings of sadness, anger, low energy, sleep disturbances, or loss of appetite interfere with daily life and may last for several weeks or longer. According to the National Alliance on Mental Illness (NAMI), depression is persistent and can interfere with a person’s thoughts (cognitions), emotions (affect), behaviors, activity, mood, and physical health. In the general population, depression occurs twice as frequently in women than in men (APA, 2000, p. 354)
Researchers have observed an association between celiac disease and depression that dates back to the 1980s. In 1982, Swedish researchers reported, "depressive psychopathology is a feature of adult celiac disease,” as they found depressive symptoms in patients recently diagnosed with celiac. The researchers concluded that the depressive symptoms were the result of untreated celiac disease, possibly due to malabsorption (Hallert & Aström, 1982). A 1998 study reported one-third of individuals diagnosed with celiac disease also suffer from depression (Ciacci, Iavarone, Mazzacca, & De Rosa, 1998). Adolescents with celiac disease also have higher than normal rates of depression: 31% compared to 7% of adolescents without celiac disease (Carta, Hardoy, Usai, Carpinello, & Angst, 2003).
Researchers are still exploring the link between celiac disease and depression. Most recently, a survey of 177 women with celiac disease found that 37% met the threshold for depression and 22% met the threshold for disordered eating (Arigo, Anskis, & Smyth, 2011).
What are depressive disorders? Are there different types of depression?
Major depression, best known as clinical depression or unipolar depression, is a type of depressive disorder. A major depressive episode is characterized by symptoms lasting for most of the day for at least 2 weeks. Symptoms include a depressed or low mood and a decrease in interest or pleasure in activities. In addition, four of the following must be present at some point during the 2-week period: feelings of worthlessness, excessive guilt, hopelessness, weight loss/weight gain, disturbance in appetite (increase or decrease in eating), sleep disturbance, fatigue/loss of energy, difficulty thinking/concentrating, or repeatedly thinking about death or suicide (APA, 2000, p. 349-350).
Dysthymia is a chronic depression in which a person’s mood is regularly low, but the mood is not as severe. The main symptoms are hallmarked by a low or sad mood on most days for at least 2 years. It is accompanied by 2 of the following symptoms: appetite disturbance, decrease or increase in sleep, hopelessness, low energy, poor self-esteem, poor concentration, and fatigue. Children and adolescents may report feeling irritable, which may last for at least 1 year (APA, 2000, p. 380).
People with both major depression and dysthymia may have a negative view of themselves, their future, life events, and interactions with friends and family. Any type of problem may seem more difficult to solve.
Depression in individuals with celiac disease
Undiagnosed celiac population:
Many individuals with celiac disease report feelings of depression prior to diagnosis. Often, these feelings are related to the toll untreated symptoms such as gastrointestinal distress, migraines, fatigue takes on an individual’s social and physical well-being.
Nutrition deficiencies resulting from malabsorption may also play a role in depression. For example, a deficiency in B vitamins has been linked to depression, specifically B12 and folic acid (Leyse-Wallace, 2008).
Diagnosed celiac population:
Living with a chronic condition like celiac disease may lead to feelings of grief, sorrow, fear, anger, and irritability. The gluten-free diet can be frustrating and isolating, especially when most social situations involve eating. Concerns about cross-contamination can intensify fear, while the loss of favorite foods can prompt grief or anger.
If these feelings continue and begin to interfere with daily life, a depressive disorder may be a result, and could cause further disruptions to an individual’s well-being. Behavioral reactions could include:
- Decreased adherence to the gluten-free diet and supplementation
- Withdrawal from social activities
- Disordered sleep (sleeping too much or too little)
- Decreased contact with family and friends
- Difficulty functioning in school or occupation settings
- Poor eating habits
- More likely to drink and smoke
- Lack of physical activity or exercise
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