Depression is rarely treated as the condition that determines whether a chronic care plan will work.
In many clinical settings, it is screened for, documented and referred out, while care for diabetes, COPD, heart failure or chronic pain continues on its own track. Dr. Arun Veera, a board-certified family medicine physician with more than 14 years of clinical experience, says that separation reflects system design more than clinical judgment—and that it quietly distorts outcomes.
“Depression doesn’t just coexist with chronic illness,” Veera said. “It amplifies it.”
That observation lands in a healthcare system where multimorbidity is now the norm. Using 2023 data, CDC analyses estimate that roughly half of U.S. adults live with multiple chronic conditions. Many of those same patients are also navigating ongoing mental health symptoms. Yet chronic care pathways are often built as if mood, sleep and motivation are background variables rather
When chronic care becomes a workload
Clinical guidelines tend to be additive: one condition, one pathway, one set of targets. Depression does not behave like a clean extra diagnosis. It affects sleep, attention and energy—factors that shape whether any care plan is workable, particularly when chronic illness already demands daily effort.
“When someone is depressed, routine care costs more,” Veera said. “Not just financially. The effort required to keep up with basic health maintenance can feel dramatically higher.”
Research in diabetes care illustrates the interaction. Reviews in *Diabetes Spectrum* have described a bidirectional relationship between diabetes and depression, linking depressive symptoms to poorer self-care, increased complications and worse quality of life. The American Diabetes Association has similarly noted associations between depression, poorer diabetes self-management and higher distress.
For clinicians, the issue is less about awareness and more about capacity. A chronic care plan is also a daily workload: medications, refills, monitoring, diet changes, labs, follow-ups and referrals—often layered on top of work, caregiving responsibilities and transportation barriers. Depression changes how much of that workload a patient can realistically carry.
When “adherence” misses the point
Missed doses and delayed follow-ups are often labeled as adherence problems. Veera does not dismiss the importance of adherence, but he questions what the term obscures when depression is involved.
“Depression changes how people relate to the future,” he said. “If tomorrow feels unreachable, long-term goals don’t land the same way.”
The effect is not purely motivational. Depression can narrow cognitive bandwidth, affecting memory, concentration and planning. Chronic disease management, meanwhile, requires more of all three. When that mismatch is framed as noncompliance, care often becomes more complex rather than more achievable.
Over time, the pattern becomes familiar: missed labs, stalled medication titration, lower tolerance for side effects and eventual disengagement. Those incremental failures accumulate into the outcomes health systems track, including higher utilization, more complications and poorer patient-reported quality of life.
Screening without a reliable next step
Primary care has improved at identifying depression. What remains inconsistent is what happens after a positive screen.
Behavioral health referrals often lead to long wait times or fragmented follow-through, while chronic disease pathways continue unchanged. The result is recognition without integration.
“We’ve gotten better at asking the question,” Veera said. “We haven’t built the same reliability in what comes next.”
That gap matters because depression and anxiety are common in high-burden clinical populations. A 2025 systematic review and meta-analysis published in *JAMA Network Open* found high prevalence estimates for clinically significant depression and anxiety among adults with chronic pain. When mental health symptoms are that prevalent among patients managing complex physical illness, treating them as secondary becomes an operational problem.
The cost of separating mental and physical care
In many organizations, mental health and chronic disease care still operate on separate workflows, staffing models and reimbursement assumptions. As a result, depression rarely alters decisions about treatment burden: how many medications are realistic, how many self-management tasks are sustainable and which goals should be prioritized now versus later.
“Nobody owns the trade-offs,” Veera said. “But that’s where patients live—between plans that don’t talk to each other.”
Those trade-offs have economic implications. Federal estimates consistently show that the vast majority of U.S. healthcare spending is concentrated among people living with chronic physical and mental health conditions. When depression worsens chronic disease trajectories, ignoring it undermines the assumptions behind quality metrics, utilization targets and value-based care models.
A different starting point for chronic care
Veera is not arguing against evidence-based guidelines. He is arguing for sequencing—calibrating care plans to patient capacity before layering on complexity.
“Instead of starting with, ‘What does the guideline say?’ start with, ‘What can this person realistically do right now?’” he said.
That shift can change the plan without lowering standards. It encourages simplification when complexity is driving failure, prioritizes function alongside biomarkers and focuses on the next achievable step rather than an idealized end state.
In practice, that can mean streamlining medication regimens, reducing the number of concurrent self-management tasks, bundling visits and labs, and aligning expectations with what patients can sustain in the short term.
What integrated care changes
The evidence base for integrated approaches is substantial. Collaborative care models in primary care settings have consistently shown improvements in depression outcomes compared with usual care.
Veera’s argument is less about endorsing a single model and more about aligning infrastructure with reality. When depression is common among patients with chronic illness, systems need dependable ways to address it without exporting responsibility entirely to a separate sector.
“You can’t build a chronic care plan on top of untreated depression,” he said, “and then act surprised when it doesn’t hold.”
Redefining quality in a multimorbidity era
Depression’s impact in the exam room is rarely dramatic in a single visit. It is cumulative: less follow-through, more setbacks and narrower margins for complex regimens. Over time, those patterns show up in the outcomes clinicians and systems measure.
In an era of multimorbidity, Veera argues, quality cannot be defined solely by how many targets are met. It must also account for whether the plan fits the patient’s capacity.
“Depression doesn’t just sit next to chronic illness,” he said. “It reshapes it. If we keep treating it as secondary, we’ll keep paying for the consequences—clinically and economically.”
