By: Deanna Glick
Startling statistics are only one reason sufferers should get help and whyresearch into this lethal combination must continue. On the list of deadly diseases in the United States, diabetes ranks fifth. Andfor so many reasons: major killers like heart attack and stroke are among a slewof diabetes' potentially lethal complications.
Depression isn't typically cited among them. But it should be.
Researchers for one study, published in the June 2005 issue of Diabetes Care,reported that depression increased the risk of mortality in people with diabetesby 30 percent.
What's more, separate studies reveal both the odds of developing depression andthe rate of depression is doubled for people who have diabetes to begin with.Published reports also suggest up to one-fourth of all people with diabetessuffer from depressive symptoms.
"There is a lot of evidence the connection goes both ways," says Dr. SusanGuzman of the Behavioral Diabetes Institute in San Diego. "Having diabetes makesyou at higher risk for depression and depression makes diabetes worse. It'sreally scary."
Diabetes isn't always the first of a duel diagnosis, either. In fact, thereverse is true. Studies suggest depression increases the risk of developingtype 2.
When diabetes comes first, it may be a little easier to understand the linkbetween the two chronic illnesses. A diabetes diagnosis, as well as the stressof self-management, is overwhelming at best.
In fact, according to a study published in the October 2005 issue of DiabeticMedicine, more than 40 percent of patients with diabetes worldwide reported poorpsychological well-being, with thoughts ranging from fears about the diseaseworsening to worries that diabetes will make it difficult for them to care fortheir families.
Posts from people with diabetes, caregivers and parents of children withdiabetes on the subject on Diabetes Health's web site indicate several triggersthat lead to depression. They range from being overwhelmed with meal planning,facing mortality and constant blood glucose testing to dealing with obesity andweight loss, the pressure of keeping health insurance and jobs, and the expenseof care. The posts also suggest some sufferers have found relief throughprescription medication and psychotherapy as well as a good support systemincluding health care providers, family and friends and, in some cases,religious faith.
Clarifying a Complex Relationship
The pressure of dealing with self-care cannot fully explain the relationshipbetween diabetes and depression. Researchers have uncovered reasons for theconnection that are far more complex and are still working to unravel additionalmysteries.
One study, published in the May 2005 issue of Diabetes Care, found thatdepression appears to increase the risk of developing type 2 diabetes by morethan 20 percent in young adults. And in April 2007, researchers reported in theArchives of Internal Medicine that depression is associated with an increasedrisk of type 2 diabetes in those older than 65. Researchers also reported thathigh levels of the stress hormone cortisol could contribute by reducing insulinsensitivity and increasing fat deposits around the waist.
Dr. Patrick Lustman, professor of psychiatry at Washington University School ofMedicine in St. Louis, has researched the topic for more than 20 years. Hisresearch has established that the odds of depression are doubled for diabetespatients and that depression is associated with hyperglycemia and an increasedrisk for diabetic complications. He has also conducted clinical trials on thesafety and efficacy of antidepressant treatment in diabetic patients.
His current research explores the role of insulin resistance – impacted byobesity, the central nervous system and cortisol – and depression in thedevelopment of type 2 diabetes. Another study is examining the effects ofantidepressant treatment on mood and glycemic control.
Lustman, who also serves as co-director of the Center for Mind Body Research atthe St. Louis school, said many questions about depression and diabetes remainunanswered.
"We don't even understand how exercise affects depression," he says. "Yes, weknow it impacts mood, but why? How?
"We do know that once you have illness, hyperglycemia may reinforce thedepression and make patients less responsive to treatment. The relationship isso circular. It's a spiral effect. Most people with both illnesses actually havedepression before diabetes. There is a close link between depression and obesityand both are associated with the onset of type 2 diabetes."
Breaking Through Barriers
Providers say many people with diabetes and depression find relief throughtreatment, including antidepressant medication and counseling. Studies suggesttreatment does make a difference. One published in the August 2007 issue ofDiabetes Care concluded that primary care patients older than 60 who weredepressed and diabetic were less likely to die during a five-year period whentreated in practices with depression care management.
But beyond the stigma of mental illness that depression carries, diabetes actsas an additional barrier to treating it. It tends to make the problem moresevere, more difficult to address and recur more often. Lustman says determiningthe right medications can be difficult since some can interfere with bloodglucose control.
Providers agree a comprehensive approach is most effective.
"We have to think more about the diabetes in order for the depression to getbetter," Guzman says. "That is one of the more unique things about depressionand diabetes as opposed to other chronic illnesses. If it's hard to get out ofbed in the morning, it's hard to count carbs and test blood sugar. (We need to)start talking about depression without whispering the word. It doesn't make youweak to get help."
Getting that help may not be easy. Providers who participated in the DiabeticMedicine-published study agreed that psychological concerns were common in theirpatients and that these problems contributed to poor diabetes self-management.But less than half of the providers felt able to identify and address thepsychological needs of their patients.
Dr. William H. Polonsky, Guzman's partner at BDI and the author of DiabetesBurnout: What To Do When You Can't Take It Anymore, says general practitionersmight also have a tendency to explain away depression or misunderstand that itis a real, treatable problem in people with diabetes.
"A physician may not notice it unless a patient brings it up," Polonsky says."They think it's just because they have high blood sugars or think, 'Hey, if Ihad diabetes I'd be depressed too.' It's not the product of a weak mind. Still,depression is something people often feel ashamed about."
As a psychologist who specializes in treating depression in people withdiabetes, Dr. Beverly S. Adler has worked to increase awareness in providersthroughout the Long Island area and now fills her time slots with referrals fromthem.
"They are not as trained to deal with these issues and they don't have thetime," says Adler, who has diabetes herself. "No matter how wonderful they are,they're rushed."
Treatment Options and Access Fall Short
Regardless of how the combination of illnesses comes to be, the medicalcommunity and patients agree finding a path to treatment remains the biggestissue. And limited options and access are major hurdles.
A handful of specialists, such as those quoted in this article, work to put adent in the problem of diabetes and depression via research and treatment. Somepatients are finding them – or providers who don't necessarily specialize inboth illnesses – and recovering. But costs, insurance access and restrictionsmake treatment difficult or impossible for some.
"The need is great enough to have several centers like us all over the country,"Polonsky says. "We need to transform the health care system. We don't have asystem that takes care of people and is affordable. Physicians are veryinterested in this link between depression and diabetes, but they areoverwhelmed and somewhat fearful. They don't know who to refer to or if patientscan afford it. And one of the biggest predictions of depression is poverty."
Lustman says that while current treatments can be successful, they are not idealbecause of the complexities that come with a duel diagnosis.
"No matter what the mechanism, we are going to need better therapies," he says."People think if they get to the mental health professional, they are going tobe taken care of. But not necessarily."
For now, providers focus on the success they are seeing. Guzman, who also has aprivate practice and volunteers her services for BDI, says part of the reasonher treatment plans work are because patients can pay a small fee for materialsto participate without insurance, thanks to funding from foundations andpharmaceutical companies. Guzman says she has seen lives transformed by thebenefit of treating depression in diabetic patients.
"As a disease, it's a hopeful disease. There's a lot you can do to make adifference whereas with a lot of diseases all you can do is help them cope," shesays. "With diabetes, you can turn someone's life around. I see people who havesuffered with both illnesses for 20 or 30 years get help and cut their A1c inhalf. They say, 'If only I had known.'"
Providers agree treatment should include psychotherapy and, if necessary,medication. Guzman believes her specialized program that includes buildingdiabetes management skills and group therapy sessions is key to recovery for herpatients.
Adler uses cognitive behavioral therapy in once or twice weekly sessions withclients, some of whom also see a psychiatrist for medication, as psychologistsare not licensed to prescribe drugs. She also gives presentations on diabetesand depression, the abstracts of which can be viewed on her web site atwww.askdrbev.com.
"You can't change the diabetes. And focusing on things you can't change leads toanxiety," Adler says, adding that having diabetes herself helps her buildrapport with clients. "My approach is to stay in the here and now, one day at atime. If you change thoughts, you can change feelings and the person is lessdepressed."
Deanna Glick has worked as a writer and editor for more than a decade. Through journalism, activism and personal experience, she has developed a passion for and specialty in health problems and care. Her reporting has encompassed a spectrum of health issues, including diabetes. She has lived on both coasts of the United States and currently works from home in Virginia, just outside of Washington, D.C.
A depressive disorder is an illness that involves the body, mood and thoughts.It affects the way a person eats and sleeps, the way one feels about oneself andthe way one thinks about things.
A depressive disorder is not the same as a passing blue mood. It is not a signof personal weakness or a condition that can be willed or wished away. Peoplewith a depressive illness cannot merely "pull themselves together" and getbetter.
Without treatment, symptoms can last for weeks, months or years. Appropriatetreatment, however, can help most people who suffer from depression.
Depressive disorders come in different forms, including major depression,dysthymia and bipolar disorder or manic-depressive illness. Within these types,there are variations in the number of symptoms, their severity and persistence.
- Persistent sad, anxious or "empty" mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
- Decreased energy, fatigue, being "slowed down"
- Difficulty concentrating, remembering, making decisions
- Insomnia, early-morning awakening or oversleeping
- Appetite and/or weight loss or overeating and weight gain
- Thoughts of death or suicide; suicide attempts
- Restlessness, irritability
- Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain
For more information, visithttp://www.nimh.nih.gov/health/topics/depression/index.shtml
Source: National Institute of Mental Health
Exercise and support groups can help those who can't afford treatment. Polonskysays exercise remains a crucial aspect of diabetes management, but it can alsoprovide relief from depression.
"It's one of the pillars of good diabetes care," he says. "Not only can it helpblood sugar control, but without a doubt it has an enormous impact on mood. It'scheap and side-effect free."
Online and in-person support groups can offer another no-cost alternative forthose suffering from mild to moderate depression.
Resources for finding a group in your area:
Online support groups:
This is an excerpt from one of several comments posted at the Diabetes Healthweb site:
"I have had Type 1 for 10 years (diagnosed at 39) and have experienced bothanxiety and depression since diagnosis. Compounding type-1 with a stressful job,raising 2 kids, being a wife and manager of an active family forced me to makechanges in my life. I just could not handle the level of stress that I had beenused to on a daily level plus do a decent job of managing my blood sugars,watching my weight, getting in exercise and eating right. Mostly, I would getbouts of anxiety from trying to "do it all."Throw in a few high and low sugarsand I just could not cope, even after changing to an insulin pump…which helpsa lot!
So…I have since changed my life. I have left the stressful job, joined a gymand bought some home equipment to get lots of cardio and strength exercise,taken up yoga on a regular basis, eat nearly a vegetarian and low carb diet(with fish, poultry, eggs and low fat dairy) and am now taking a class inmeditation to learn how to stay calm and focused. Staying calm seems to be thekey to doing all of the things we need to do as diabetics – counting carbs,checking blood sugars six to ten times a day, taking insulin, watchingeverything we put in our mouths, no unconscious eating, taking vitamins and medsevery day, managing highs and lows, etc.
…I just bought the book "Diabetes Burnout, What to do when you can'ttake it anymo
e" by William Polonsky and am looking forward to reading it.…I also attend an insulin pumpers support group meeting every othermonth (I drive an hour to attend) and am hoping to start one closer to home."
The following is a sampling of comments posted as a result of an announcementvia the Diabetes Health web site about the magazine researching the topic ofdepression and diabetes:
"The chronicity of having diabetes is what is most depressing and it seems likewe are far from a cure for Type 1."
"My son was diagnosed with depression in 2nd grade. Diagnosed with Type 1diabetes in Grade 3 and was doing well. Then in the fall of this year, thebeginning of Grade 6 he attempted suicide. He is one of three students in ourtown who suffers from both depression and Type 1 diabetes. There is no familyhistory for Type 1 Diabetes or depression our family. We hope and pray that moreresearch will be done about these terrible illnesses."
"Name any other disease where you have to actively think about how to handle ita minimum of three times a day! Every meal, every meal has to be thought about.It can be overwhelming. I am very lucky that my wife is so incredibly supportiveand understanding. I hate having to think about what to eat for breakfast, whatto take in my lunch to work, what things to buy at the grocery store. Is it timeto prick my finger? These are all things that I never had to think about and nowI have to think about them all of the time."
"I experienced major depression upon diagnosis of Type 2 diabetes (4 years ago).About a year of therapy was really helpful. I learned coping skills in therapythat I can fall back on."
"I have been a type 1 diabetic for about 35 years. In that time I have hadseveral bouts with depression. The worst one was about 10 years ago and I amstill on medication…I think their [sic] is a physical link. We knowabout neuropathy, (I have severe neuropathy) it would seem reasonable that the…brain could be damaged too."
"I was told three years ago I have Type 2 and I cried so much till my eyes feltlike they would fall out…I feel like the world is closing in. I hate tobe in the room with someone when they are eating cake or candy that I cannothave. I know the sugar-free is out there but it is not the same. I lost over 130lbs. And now I feel as if I am gaining it all back." "I was diagnosed with type2 about 7 years ago. It was the most earth shattering event of my life…Depression is now just as big a part of my day as the diabetes. At this point in time I am not on any medicine for the depression and hope to never be. I workdaily at trying to keep my sense of humor in tact and have a strong familysupport group."
"I am T2 and suffered from depression when diagnosed initially…Havinga doctor recognize this and start (medication) was a very good idea in my case.It allowed me to focus on getting well, getting things organized, researchingoptions, etc. If a patient's insurance covers it (as mine did) I think a gooddoctor should recommend/advise/suggest it as part of initial treatment."
" I have to work at a job that is stressful at times just so that I can havegood Health Insurance. I don't feel like I can change fields to do somethingthat makes me happy. I have researched different Health Insurance Options andthere really are no choices out there for people like us. So I get verydepressed about feeling stuck somewhere because of my condition."
"My family practitioner let me break down one day and helped me realize that itwas totally understandable to be depressed when battling a chronic disease ontop of the normal stresses of life and raising 3 children. He put me on(medication) and that…helped me so much. I still feel as though I amsometimes standing on the edge, but I have a very supportive husband and anendocrinologist that I can be open and honest with. One of the most difficultthings is just never getting a break from the responsibility – not a week, not aday, not even a minute passes that diabetes is not all consuming. The guilt ofnot taking the best care of myself when I am going through a rough patch is alsovery depressing and it leads to a downward spiral. My faith and belief in Godand His forgiveness is what helps me work through that."
"I had been diagnosed with depression 5 years before I was diabetic. That wasmainly because I had just lost both parents; one to COPD and one to diabetes. Iwatched my dad struggle with the disease all of my life. He would go in and outof the hospital, and came close to death several times with keto-acidosis [sic].He ended up losing both limbs and died at age 52…My biggest fear wasthat I would someday be a diabetic and suffer and leave my children at a youngage…All I could do was visualize my then 5 and 9 year old motherlessor pushing me around in a wheel chair with no limbs. I began counseling and wasput on Zoloft. I really became positive and decided to beat this thing. Ifollowed the dietician's every word and exercised daily…I began to seehow a person really could live a positive life with diabetes."
"I have had Type 1 for 9 years (diagnosed at 28) and am actually relieved toread a couple of other postings here. I thought I was the only one who had a lotto deal with including a stressful job, raising 2 kids (under the age of 4), andbeing a wife and manager of an active family! It seems that everyone I talk withwho has type 1 diabetes and kids says that things are great. For me, it is waytoo overwhelming to do all of this and take care of myself. Taking blood sugars,preparing food, watching my weight (which has not gone so well, adding to thedepression) I was diagnosed with post partum depression after my first child andhave been on Lexapro and Wellbutrin XL since."
"I have witnessed that when my depression is the worst, my numbers are all overthe place and out of control. It's not that I don't care and don't want to takecare of myself, it's the fact that I am depressed and don't have the capacity toself-manage. It's a deadly cycle."
"I find that living with chronic illness, living under the cloud of awaitingcomplications and living with severe, daily chronic pain is challenging to thespirit (let alone the body). While the converse is also true, i.e. beingdepressed makes it difficult to take care of one's self, (which is the demandingfoundation of insulin dependent diabetes)…I have also discovered thatthe depths of my depression increases if I don't take care of myself because ofself-guilt and because high blood sugars make me feel lethargic, both physicallyand emotionally. I feel blessed that I have learned to channel mydiscouragement, depressive feelings and emotional distress into my passions foropera, classical music, violin playing, fine literature, gardening and my lovefor my life partner, 12 year old daughter and mixed breed dog. I have alsolearned to "live in the moment" which, while challenging, is far healthier forme than living in the past or the unknown, and sometimes frightening future."
"I have tried for many years to get my HMO to add a weight managementclass/group for people with depression. It is a vicious cycle. Bad blood sugarlevels can cause mood swings and when you wish you were dead it is hard(impossible to control diet) and back and forth. But getting a doctor, nottrained in mental illness, to do their part is also impossible."