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Diabetes & Depression: What’s Going On and

To quote the lyrics from a song long ago, “Something’s happening here, what it is ain’t exactly clear.” That there are connections between depression and diabetes has been established. The exact nature of those connections is under investigation. Obviously, we can’t sit around waiting for the last word on whether Diabetes causes Depression or vise versa before taking the connections seriously. Both conditions are life altering and life threatening and together, are cause for legitimate alarm.

From NIMH:
“Several studies suggest that diabetes doubles the risk of depression compared to those without the disorder. The chance of becoming depressed increases as diabetic complications worsen. Research shows that depression leads to poorer physical and mental functioning, so a person is less likely to follow a required diet or medication plan. Treating depression with psychotherapy, medication, or a combination of these treatments can improve a patient’s well-being and ability to manage diabetes.

Causes underlying the association between depression and diabetes are unclear. Depression may develop because of stress but also may result from the metabolic effects of diabetes on the brain. Studies suggest that people with diabetes who have a history of depression are more likely to develop diabetic complications than those without depression.”

Research on this subject can be complicated. Cause & effect must be carefully examined. As an example of potential complications, take the study published 11/03, which was done at the University of Copenhagen. It was concluded that older patients with diabetes do not seem to have an increased risk of developing severe depression compared with patients with other chronic illness. Would the same hold for a younger population? What if the criterion was moderate depression? What’s the impact of moderate depression on originating or worsening diabetes? etc., etc.

NIMH put forth this “lay” (the one in the DSM 4, issued by the American Psychiatric Association is more complicated) version of depressive symptoms that is an effective guide:

Symptoms of Depression
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 changes
Thoughts of death or suicide, or suicide attempts
Restlessness, irritability

If five or more of these symptoms are present every day for at least two weeks and interfere with routine daily activities such as work, self-care, and childcare or social life, seek an evaluation for depression.

How much of a problem is it?
According to an evaluation of 20 studies over the past 10 years, the prevalence rate of diabetics with major depression is three to four times greater than in the general population. While depression affects maybe three or five percent of the population at any given time, the rate is between 15 and twenty percent in patients with diabetes, according to the American Diabetic Association. Women, in particular are at greater risk, according to other studies.

How good are we at diagnosing Depression in a Diabetic?

From the European Depression in Diabetes Research Consortium:

“US studies estimate that only one third of people with diabetes and major depression are identified and treated, with undetected cases of depression experiencing persistently poor outcomes (Rost et al, 1998). This is particularly striking considering that depressed patients are known to spend more time with their doctors (Thompson et al, 2000).

Reasons for under-diagnosis of depression in people with diabetes may include the perception that the depression is secondary to the medical condition and thus not of independent importance, overlap between symptoms of diabetes and depression, and time-constraints in routine outpatient consultations. Patients may not consider their depressed mood to be of relevance to their diabetes treatment, have no knowledge or low expectations of therapy effectiveness, or may be reluctant to discuss their mood disorder with their doctor (Lustman et al, 1996; Salazar, 1996).

One of the difficulties of studying depressive disorders in a diabetic population is that some of the somatic symptoms of depression (e.g., fatigue, sleep problems, weight gain/loss) may be confounded with those of diabetes. Somatic symptoms are as much part of depression as cognitive symptoms and not measuring them (exclusive approach) underestimates the rate of depression while including them may overestimate it.”

A Kaiser Permanente study of some 1,680 subjects found that those with diabetes were more likely to have been treated for depression within six months before their diabetes diagnosis. About 84 percent of diabetics also reported a higher rate of earlier depressive episodes. Evidence from prospective studies in the US and Japan indicates that depression doubles the risk of incident type 2 diabetes independent of its association with other risk factors. In people with preexisting diabetes, depression is an independent risk factor for coronary heart disease, and appears to accelerate the presentation of coronary heart disease. Because there is reason to believe that depression often precedes diabetes as well as occurring afterwards, we have the opportunity to intervene both before and after the diagnosis of diabetes.

Talking With A Depressed Patient

What you may see: Less “life” in your patient than you ordinarily see. A flatness in their presentation, i.e., their mood is less excited or even disconnected when speaking of some difficulty. A particularly hopeless, sometimes quietly frantic, overwhelmed presence. The negative aspect of seemingly everything is their perspective. Things, people, circumstances aren’t working well. There is anger just beneath the surface and in some cases, flashes of anger above the surface. The response in you is often the need to cheer them up or to be very careful about not setting them off. Those who are interminably cheerful also merit a second look.

VERY IMPORTANT: All of the above in regards to recognizing depression must be approached with perspective and caution. Please don’t go suggesting anti-depressants to every cheerful person you encounter. Every clinician has, at some point, leaped to a diagnosis based on a few indicators only to have further information invalidate their first opinion. The individual as a whole, their past and present physical and mental history, their present life circumstances, must be considered before an accurate assessment can be made. The goal here is to familiarize you with depression enough to know when to reasonably approach a patient about their mood state.

In my next article, I’ll continue to help you recognize depression and will offer suggestions as to how to approach your patient.

Leonard Lipson, M.A. received his Bachelors degree in Psychology from Adelphi University and his Masters in Psychology from the New School for Social Research. He received four years of post-graduate education from The American Institute for Psychotherapy and Psychoanalysis. He has been in the private practice of psychotherapy for the past 29 years, with offices in Manhattan and Suffern, N.Y Mr. Lipson created the Medical Adherence Training program in 1995. The program helps people adhere to what is medically recommended. The program now serves patients throughout the U.S. and is in the process of being put into book form.

Mr. Lipson is a member of the Rockland County Psychological Society, The Society for Behavioral Medicine and The NYS Mental Health Counselors Association.