Diabetes and Depression Offers Big Challenges

Depression Elevates Cortisol

| Jul 5, 2011

If you have diabetes, you're more likely to be depressed than people without the disease.

That simple fact, confirmed by a University of Adelaide study in 2004, should put all people with diabetes and their doctors on notice. Both type 1s and type 2s should be alert for the ways in which their chronic illness can lead to depression. And doctors should know that patients' moods are critical components of their health.

How bad is it? According to that 2004 study (published in the journal Diabetes Care), 24 percent of people with diabetes are depressed. That's nearly one in four. In the general population, only 17 percent of people suffer from depression.

Burrowing further into the data, researchers found substantial quality of life differences between depressed and non-depressed diabetics. They also found that depressed diabetics were worse off than nondiabetics who were also depressed. In other words, having both diseases made both of them worse.

But why is that the case? How do diabetes and depression relate to one another? What can medical professionals and patients do to turn this grim reality around?

For help with those big questions, we turned to two mental health professionals who have worked with diabetic patients. Dr. Frank J. Sileo practices health psychology in New Jersey. John Lee is a licensed independent clinical social worker who has worked as a therapist in urban Boston.

Both men answered the same questions, offering their unique insights and practical advice to Diabetes Health readers. They agree that the combination of diabetes and depression offers big challenges and that everyone---patients, medical doctors, and mental health workers---has to work together. Their answers have been edited and condensed for readability.

Let's start with the most basic question: In what ways can diabetes lead to issues with depression?

Lee: "Eating is a very social activity. Most people have been warned about needed changes in their diet and lifestyle, but some people are just not able to make those changes. When their diabetes gets out of control and they are forced to give up all the food that they enjoyed ---as well as see others be able to eat all the foods they enjoyed without the complications of diabetes---it's tough for people.

"On the flip side, many people eat to cope with feelings or to feel better. Typically people eat unhealthy foods or make poor choices when they are eating their way through their feelings/stressors. So sometimes untreated depression is the precursor to obesity and diabetes, which becomes a complicated and cyclical effect."

Sileo: "Any individual diagnosed with a chronic illness is always at a higher risk of developing emotional issues such as depression. Having a chronic illness like diabetes can be overwhelming and stressful. Individuals may feel they have lost control and may feel alone, isolated, and different. Some recent studies have found if you have been diagnosed with diabetes, you may have an increased risk of developing depression.

"Moreover, the studies have also indicated that if an individual has depression, they have a greater chance of developing type 2 diabetes. The relationship between depression and diabetes is not quite fully understood at this point. However, it is understood that the difficulty in managing diabetes can be extremely stressful and may lead to symptoms of depression. It has been noted that diabetes can cause other problems, such as diabetic neuropathy, which may worsen symptoms of depression."

Could you elaborate on how depression causes problems with diabetes?

Lee: "I touched on this issue earlier. The other issue is that psych medications have horrible side effects, one of the more common side effects being weight gain due to increased appetite."

Sileo: "Individuals who are depressed have elevated levels of cortisol (a stress hormone), which may lead to problems with glucose or blood sugar metabolism, increased insulin resistance, and the development of belly fat, which are all diabetic risk factors. Individuals with diabetes may experience feelings of a decreased quality of life, which may exacerbate feelings of depression.

"When people are depressed, they may not engage in proper self-care, which can be dangerous to the diabetic patient, such as not watching their diets, not checking their blood sugar on a regular basis, and not taking medications on a prescribed and consistent basis. It can become a vicious cycle."

What are some challenges that your patients face in dealing with both diabetes and depression?

Lee: "Culturally, some ethnic foods don't really cater to the diet that a diabetic should have. For instance, Latinos eat yellow rice that typically has some oil or butter, and fried meats are typical meals. For people to adopt new cuisine, learn a different way of cooking, subtract certain spices, flavors, it's a huge adjustment. Dietitians who are also culturally sensitive are very important. Medication costs and remembering to take meds, those are all concerns too."

Sileo: "I see patients struggling with accepting the diagnoses of diabetes and depression. They view themselves as defective and damaged. Oftentimes, they do not want to accept the medical diagnosis, and it is the goal of treatment to help them integrate the diagnosis into who they are. I try to teach my patients that the diagnosis is a part of them. It does not become their entire identity.

"Oftentimes individuals with a medical diagnosis ignore the emotional aspects of things. They see depression as part of the medical diagnosis. People will get the best medical care for their conditions, but often will not seek the assistance of a mental health profession in coping with the depression or anxiety of the medical problem. This is a problem because depression can have a very negative effect in coping with and achieving a healthier, more balanced outlook and lifestyle in their lives."

What advice do you offer your patients grappling with both of these problems?

Lee: "As a therapist, I try to motivate and get them to understand the dire consequences of their indifference or lack of motivation to change. At the end of the day, it is their choice whether they would like to be healthy or not healthy, just like an alcoholic who is indifferent about quitting or a smoker who needs to quit."

Sileo: "One of my goals is helping them accept the diagnosis. I help them with coping with stress, anxiety, and depression through cognitive behavioral therapy. I also help individuals with medication and treatment adherence. Oftentimes, patients will feel better and then stop taking their medications or engage in destructive lifestyles. Psychologists can be very helpful in educating patients to continue on the journey of healing despite feeling well at a particular time.

"It is important for psychologists to work in collaboration with primary care physicians, specialists, dietitians, and other professionals interfacing with the patient to provide a team approach and to work together on behalf of the patient's overall well-being and care. Medical doctors need to be open to the mental health aspects of medical illness and to educate their patients and refer patients to mental health professionals on an ongoing basis. Early intervention for treating depression is key."

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Categories: Anxiety, Blood Glucose, Blood Sugar, Diabetes, Diabetes, Dietitians, Food, Medications, Stress, Type 1 Issues, Type 2 Issues

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Posted by Anonymous on 7 July 2011

Just wanted to point out that essentially the entire conversation devolved to T2 issues. I'd like something that addresses depression in T1s -- clearly and explicitly.

Posted by Anonymous on 7 July 2011

The comments by John Lee, the social worker in Boston, are a good example of what is WRONG with diabetes treatment - "if you don't watch your diet, you're going to go impotent, lose a leg, go blind, etc...". That's what I heard after I was diagnosed and tried to go to endocrinologists and other 'specialists' for help. That certainly depressed me, and I pretty much resigned myself that that's just the way it would be. After years of researching the disease and learning as much as I could about it, I got myself to a point where I was responsible for my own care and did as much as I could to slow the onset of complications, no thanks to any doctors.
I would HATE to be a newly diagnosed type-1, and my first experience with learning about the disease came from Mr. Lee. That approach and attitude is far too pervasive in diabetes treatment. Instead, find a good certified diabetes educator through a referral. When you learn about the disease and how to treat it FIRST, rather than going the "scared to hopelessness" route, you will learn there is MUCH you can do to live a good life. Everything in moderation...

Posted by Anonymous on 8 July 2011

I wonder how much is cause and effected (because of new stress or things related to diabetic occuring depresses them) correlation vs an actual psylogical link (chemical imbalances).

Posted by Anonymous on 8 July 2011

Thank you for this article. I have both illness and it is a struggle.

Posted by Anonymous on 8 July 2011

Type 1 diabetes is an insidious disease that will eventually get the best of you! While you can do things to manage it or slow down its negative effects, you can't avoid them! Unless you have the GENETICS to. This has been proven in many studies. Depression from this illness is because of all the lies, media hype and irresponsible reporting by the likes of; media outlets, JDRF, ADA, and etc. who keep reporting headlines with "Close to a cure", "Breakthrough", and etc. The fact of the matter is that 90 years later we inject insulin multiple times per day, we must prick our fingers 5x per day and there really isn't anything on the horizon that will change this treatment methodology. And, please don't point to the artificial pancreas (won't be for everyone) or some research that they think will work because all we have is what we use today. Injections and fingersticks...... Insulin pumps are not much better than injections, they are still invasive. I'd be depressed too and until you eliminate the disease, the depression will ALWAYS be there.

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