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Startling statistics are only one reason sufferers should get help and why research into this lethal combination must continue. On the list of deadly diseases in the United States, diabetes ranks fifth. And for so many reasons: major killers like heart attack and stroke are among a slew of 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 diabetes by 30 percent.
What's more, separate studies reveal both the odds of developing depression and the 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 diabetes suffer from depressive symptoms.
"There is a lot of evidence the connection goes both ways," says Dr. Susan Guzman of the Behavioral Diabetes Institute in San Diego. "Having diabetes makes you at higher risk for depression and depression makes diabetes worse. It's really scary."
Diabetes isn't always the first of a duel diagnosis, either. In fact, the reverse is true. Studies suggest depression increases the risk of developing type 2.
When diabetes comes first, it may be a little easier to understand the link between the two chronic illnesses. A diabetes diagnosis, as well as the stress of self-management, is overwhelming at best.
In fact, according to a study published in the October 2005 issue of Diabetic Medicine, more than 40 percent of patients with diabetes worldwide reported poor psychological well-being, with thoughts ranging from fears about the disease worsening to worries that diabetes will make it difficult for them to care for their families.
Posts from people with diabetes, caregivers and parents of children with diabetes on the subject on Diabetes Health's web site indicate several triggers that lead to depression. They range from being overwhelmed with meal planning, facing mortality and constant blood glucose testing to dealing with obesity and weight loss, the pressure of keeping health insurance and jobs, and the expense of care. The posts also suggest some sufferers have found relief through prescription medication and psychotherapy as well as a good support system including 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 relationship between diabetes and depression. Researchers have uncovered reasons for the connection that are far more complex and are still working to unravel additional mysteries.
One study, published in the May 2005 issue of Diabetes Care, found that depression appears to increase the risk of developing type 2 diabetes by more than 20 percent in young adults. And in April 2007, researchers reported in the Archives of Internal Medicine that depression is associated with an increased risk of type 2 diabetes in those older than 65. Researchers also reported that high levels of the stress hormone cortisol could contribute by reducing insulin sensitivity and increasing fat deposits around the waist.
Dr. Patrick Lustman, professor of psychiatry at Washington University School of Medicine in St. Louis, has researched the topic for more than 20 years. His research has established that the odds of depression are doubled for diabetes patients and that depression is associated with hyperglycemia and an increased risk for diabetic complications. He has also conducted clinical trials on the safety and efficacy of antidepressant treatment in diabetic patients.
His current research explores the role of insulin resistance - impacted by obesity, the central nervous system and cortisol - and depression in the development of type 2 diabetes. Another study is examining the effects of antidepressant treatment on mood and glycemic control.
Lustman, who also serves as co-director of the Center for Mind Body Research at the St. Louis school, said many questions about depression and diabetes remain unanswered.
"We don't even understand how exercise affects depression," he says. "Yes, we know it impacts mood, but why? How?
"We do know that once you have illness, hyperglycemia may reinforce the depression and make patients less responsive to treatment. The relationship is so circular. It's a spiral effect. Most people with both illnesses actually have depression before diabetes. There is a close link between depression and obesity and both are associated with the onset of type 2 diabetes."
Breaking Through Barriers
Providers say many people with diabetes and depression find relief through treatment, including antidepressant medication and counseling. Studies suggest treatment does make a difference. One published in the August 2007 issue of Diabetes Care concluded that primary care patients older than 60 who were depressed and diabetic were less likely to die during a five-year period when treated in practices with depression care management.
But beyond the stigma of mental illness that depression carries, diabetes acts as an additional barrier to treating it. It tends to make the problem more severe, more difficult to address and recur more often. Lustman says determining the right medications can be difficult since some can interfere with blood glucose control.
Providers agree a comprehensive approach is most effective.
"We have to think more about the diabetes in order for the depression to get better," Guzman says. "That is one of the more unique things about depression and diabetes as opposed to other chronic illnesses. If it's hard to get out of bed 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 you weak to get help."
Getting that help may not be easy. Providers who participated in the Diabetic Medicine-published study agreed that psychological concerns were common in their patients and that these problems contributed to poor diabetes self-management. But less than half of the providers felt able to identify and address the psychological needs of their patients.
Dr. William H. Polonsky, Guzman's partner at BDI and the author of Diabetes Burnout: What To Do When You Can't Take It Anymore, says general practitioners might also have a tendency to explain away depression or misunderstand that it is 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 I had 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 with diabetes, Dr. Beverly S. Adler has worked to increase awareness in providers throughout the Long Island area and now fills her time slots with referrals from them.
"They are not as trained to deal with these issues and they don't have the time," 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 medical community and patients agree finding a path to treatment remains the biggest issue. And limited options and access are major hurdles.
A handful of specialists, such as those quoted in this article, work to put a dent in the problem of diabetes and depression via research and treatment. Some patients are finding them - or providers who don't necessarily specialize in both illnesses - and recovering. But costs, insurance access and restrictions make 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 a system that takes care of people and is affordable. Physicians are very interested in this link between depression and diabetes, but they are overwhelmed and somewhat fearful. They don't know who to refer to or if patients can afford it. And one of the biggest predictions of depression is poverty."
Lustman says that while current treatments can be successful, they are not ideal because 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 to be taken care of. But not necessarily."
For now, providers focus on the success they are seeing. Guzman, who also has a private practice and volunteers her services for BDI, says part of the reason her treatment plans work are because patients can pay a small fee for materials to participate without insurance, thanks to funding from foundations and pharmaceutical companies. Guzman says she has seen lives transformed by the benefit of treating depression in diabetic patients.
"As a disease, it's a hopeful disease. There's a lot you can do to make a difference whereas with a lot of diseases all you can do is help them cope," she says. "With diabetes, you can turn someone's life around. I see people who have suffered with both illnesses for 20 or 30 years get help and cut their A1c in half. They say, 'If only I had known.'"
Providers agree treatment should include psychotherapy and, if necessary, medication. Guzman believes her specialized program that includes building diabetes management skills and group therapy sessions is key to recovery for her patients.
Adler uses cognitive behavioral therapy in once or twice weekly sessions with clients, some of whom also see a psychiatrist for medication, as psychologists are not licensed to prescribe drugs. She also gives presentations on diabetes and depression, the abstracts of which can be viewed on her web site at www.askdrbev.com.
"You can't change the diabetes. And focusing on things you can't change leads to anxiety," Adler says, adding that having diabetes herself helps her build rapport with clients. "My approach is to stay in the here and now, one day at a time. If you change thoughts, you can change feelings and the person is less depressed."
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 and the way one thinks about things.
A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better.
Without treatment, symptoms can last for weeks, months or years. Appropriate treatment, 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.
For more information, visit http://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. Polonsky says exercise remains a crucial aspect of diabetes management, but it can also provide relief from depression.
"It's one of the pillars of good diabetes care," he says. "Not only can it help blood sugar control, but without a doubt it has an enormous impact on mood. It's cheap and side-effect free."
Online and in-person support groups can offer another no-cost alternative for those 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 Health web site:
"I have had Type 1 for 10 years (diagnosed at 39) and have experienced both anxiety 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 make changes in my life. I just could not handle the level of stress that I had been used 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 get bouts of anxiety from trying to "do it all."Throw in a few high and low sugars and I just could not cope, even after changing to an insulin pump…which helps a lot!
So…I have since changed my life. I have left the stressful job, joined a gym and 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 in meditation to learn how to stay calm and focused. Staying calm seems to be the key 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, watching everything we put in our mouths, no unconscious eating, taking vitamins and meds every day, managing highs and lows, etc.
…I just bought the book "Diabetes Burnout, What to do when you can't take it anymore" by William Polonsky and am looking forward to reading it.…I also attend an insulin pumpers support group meeting every other month (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 announcement via the Diabetes Health web site about the magazine researching the topic of depression and diabetes:
"The chronicity of having diabetes is what is most depressing and it seems like we are far from a cure for Type 1."
"My son was diagnosed with depression in 2nd grade. Diagnosed with Type 1 diabetes in Grade 3 and was doing well. Then in the fall of this year, the beginning of Grade 6 he attempted suicide. He is one of three students in our town who suffers from both depression and Type 1 diabetes. There is no family history for Type 1 Diabetes or depression our family. We hope and pray that more research will be done about these terrible illnesses."
"Name any other disease where you have to actively think about how to handle it a 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 supportive and understanding. I hate having to think about what to eat for breakfast, what to take in my lunch to work, what things to buy at the grocery store. Is it time to prick my finger? These are all things that I never had to think about and now I 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 therapy that I can fall back on."
"I have been a type 1 diabetic for about 35 years. In that time I have had several bouts with depression. The worst one was about 10 years ago and I am still on medication…I think their [sic] is a physical link. We know about 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 felt like they would fall out…I feel like the world is closing in. I hate to be in the room with someone when they are eating cake or candy that I cannot have. I know the sugar-free is out there but it is not the same. I lost over 130 lbs. And now I feel as if I am gaining it all back." "I was diagnosed with type 2 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 work daily at trying to keep my sense of humor in tact and have a strong family support group."
"I am T2 and suffered from depression when diagnosed initially…Having a 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, researching options, etc. If a patient's insurance covers it (as mine did) I think a good doctor 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 have good Health Insurance. I don't feel like I can change fields to do something that makes me happy. I have researched different Health Insurance Options and there really are no choices out there for people like us. So I get very depressed about feeling stuck somewhere because of my condition."
"My family practitioner let me break down one day and helped me realize that it was totally understandable to be depressed when battling a chronic disease on top 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 am sometimes standing on the edge, but I have a very supportive husband and an endocrinologist that I can be open and honest with. One of the most difficult things is just never getting a break from the responsibility - not a week, not a day, not even a minute passes that diabetes is not all consuming. The guilt of not taking the best care of myself when I am going through a rough patch is also very depressing and it leads to a downward spiral. My faith and belief in God and His forgiveness is what helps me work through that."
"I had been diagnosed with depression 5 years before I was diabetic. That was mainly because I had just lost both parents; one to COPD and one to diabetes. I watched my dad struggle with the disease all of my life. He would go in and out of 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 was that I would someday be a diabetic and suffer and leave my children at a young age…All I could do was visualize my then 5 and 9 year old motherless or pushing me around in a wheel chair with no limbs. I began counseling and was put on Zoloft. I really became positive and decided to beat this thing. I followed the dietician's every word and exercised daily…I began to see how 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 to read a couple of other postings here. I thought I was the only one who had a lot to deal with including a stressful job, raising 2 kids (under the age of 4), and being a wife and manager of an active family! It seems that everyone I talk with who has type 1 diabetes and kids says that things are great. For me, it is way too 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 the depression) I was diagnosed with post partum depression after my first child and have been on Lexapro and Wellbutrin XL since."
"I have witnessed that when my depression is the worst, my numbers are all over the place and out of control. It's not that I don't care and don't want to take care of myself, it's the fact that I am depressed and don't have the capacity to self-manage. It's a deadly cycle."
"I find that living with chronic illness, living under the cloud of awaiting complications and living with severe, daily chronic pain is challenging to the spirit (let alone the body). While the converse is also true, i.e. being depressed makes it difficult to take care of one's self, (which is the demanding foundation of insulin dependent diabetes)…I have also discovered that the depths of my depression increases if I don't take care of myself because of self-guilt and because high blood sugars make me feel lethargic, both physically and emotionally. I feel blessed that I have learned to channel my discouragement, depressive feelings and emotional distress into my passions for opera, classical music, violin playing, fine literature, gardening and my love for my life partner, 12 year old daughter and mixed breed dog. I have also learned to "live in the moment" which, while challenging, is far healthier for me 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 management class/group for people with depression. It is a vicious cycle. Bad blood sugar levels 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, not trained in mental illness, to do their part is also impossible."
Jan 12, 2008