Depression is not generally listed as a complication of diabetes. However,
it can be one of the most common and dangerous complications. The rate of
depression in diabetics is much higher than in the general population.
Diabetics with major depression have a very high rate of recurrent
depressive episodes within the following five years. (Lustman et al 1977)
A depressed person may not have the energy or motivation to maintain good
diabetic management. Depression is frequently associated with unhealthy
appetite changes. The suicidal diabetic adolescent has constant access to
potentially lethal doses of insulin.
At this point in time, it is well accepted that
psychological factors and psychiatric conditions can affect the course of
medical illnesses. There is some suggestion that the stress of depression
itself may lead to hyperglycemia in diabetics. The interaction between
cardiovascular disorders (such as heart attack and high blood pressure)
and depression has been extensively studied. Anxiety and depression can
also affect other conditions including irritable bowel syndrome, headache
and skin diseases. Treatment of anxiety and depression may lead to a
better medical prognosis and well as a better quality of life.
For over
three hundred years, physicians have suspected an interaction between the
emotions and the course of diabetes mellitus. Studies have examined
whether stressful events or psychiatric illness might precipitate either
Type I (insulin-dependent) or Type II (Non-insulin dependent) diabetes. So
far, study results are not conclusive.
Now that
we have more accurate methods of measuring glucose control, it has become
easier to measure both short-term and long-term effects of emotional
factors on blood glucose level. One study found that children judged to
have a “Type A” personality structure had an increased blood
sugar elevation in response to stress. Children with a calmer disposition
had a smaller glucose rise when stressed. (Stabler et al. 1987) A 1997
study suggested that Type I patients with a history of a psychiatric
illness might be at increased risk for developing diabetic retinopathy.
Those patients with a psychiatric history were found to have a higher
average glycosylated hemoglobin. (a measure of long term diabetic control)
(Cohen et al. 1997) Children whose relatives made more critical comments
had significantly poorer glucose control. Interestingly enough, emotional
overinvolvement between family members was not correlated with poor
diabetic control. (Koenigsberg et al. 1993) Diabetic adolescents had a
higher incidence of suicidal ideation than expected. Those with suicidal
ideation took poorer care of themselves. Not living in a two-parent home
was associated with poorer long-term diabetes control. (Goldston, et al.
1997)
Recent
studies have suggested that effective treatment of depression can improve
diabetic control. In a study by Lustman and colleagues, glucose levels
were shown to improve as depression lifted. The better the improvement,
the better the diabetic control. (Lustman et al. 1997a)
Being
diagnosed with diabetes is a major life stress. It requires a large number
of physical and mental accommodations. The individual must learn about a
complex system of dietary and medical interventions. Lifestyle, work, and
school schedules may have to be altered. This can consume a lot of energy
for both the individual and his or her family. Just as important, are the
psychological adjustments. One must adjust to a new view of oneself. For
those who liked to see themselves as invincible, this may be particularly
difficult.
Many newly diagnosed diabetics go
through the typical stages of mourning. These are denial, anger,
depression and acceptance.
- Denial: This can be one of
the more dangerous stages of the grief process. It may not occur
only once. Many individuals cycle back to this phase several times.
The honeymoon phase, associated with early Type I diabetes, may
reinforce denial. Denial is a common stance for adolescent
diabetics.
- Anger: It really does seem
unfair. The type II diabetic, trying to lose weight, may envy
heavier people who seem to enjoy good health. One might erupt at
someone who innocently offers a desert. Unfortunately, anger can
drastically affect glucose levels.
- Depression: Mild depressive
feelings are a normal part of grieving and adaptation. As long as
they are not pervasive or prolonged, they may not be harmful.
However, when the depression lasts a long time, becomes severe or
interferes with diabetic management, one should seek prompt
treatment.
- Acceptance: Individuals
achieve different degrees of acceptance and inner peace. Some will
need to experience the denial, anger and depression several times as
they move through different phases of life and different stages of
diabetes. Some people move through a chronic disease to a state of
much greater self-knowledge. They may actually say that the diabetes
was, in part, a blessing. Through their close attention to diet and
exercise, and their close monitoring of stress levels, they have
arrived at a deeper understanding of themselves and their relations
to others. They realize that for all human beings, life is
vulnerable and precious.
Often,
individuals with depression do not realize that they are depressed. It is
easy to attribute the symptoms of depression to the diabetes. This is
particularly difficult since depressed diabetics may have poorer glucose
control. Sometimes a spouse or close friend can give good feedback.
However, medical professionals or mental health clinicians may be the best
ones to determine what is the diabetes and what is due to depression. A
psychiatrist has had medical training before specializing in mental
health. He or she can sort out the diagnosis, communicate with your
regular doctor and help coordinate the treatment of the depression with
treatment of the diabetes.
Symptoms of Depression: These are
based on the Diagnostic and Statistical Manual of the American
Psychiatric Association, 4th Edition. (DSM-4)
- Depressed mood for most of
the day
- Decreased pleasure in
normal activities
- Difficulty sleeping or
significantly increased need to sleep
- Weight loss or weight gain.
- Feelings of guilt or
worthlessness
- Low energy level
- Difficulty making decisions
of concentrating
- Suicidal thoughts
Treatment of Depression:
The most
important starting point is an accurate diagnosis. There have been major
advances in the treatment of depression. There are specific medications
and specific psychotherapy techniques that have been shown to help
depression. Often individuals do well with a combination of antidepressant
treatment and psychotherapy. Be sure that your clinician is willing to
take the time to communicate with your diabetes team. Ideally, the mental
health clinician should be familiar with your type of diabetes.
Antidepressants: Today, we have a much wider variety of antidepressant
medications than were available fifteen years ago. Because we have more
medication choices, we can often minimize annoying side effects. The older
tricyclic antidepressants can increase glucose levels in non-depressed
diabetics. However, when depressed diabetics take them, diabetic control
improves. (Lustman et al. 1996) Selective Serotonin Reuptake Inhibitors (SSRIs
such as Prozac and Zoloft) are easier to administer and have fewer side
effects, so they are more often used as the first line antidepressants.
Sometimes they can cause decreased sexual desire. This may be a sensitive
issue for some diabetics, especially those who have some sexual difficulty
due to their diabetes. This is not a reason to avoid treatment. Keep an
open dialogue with your psychiatrist. If the medication does affect sexual
functioning, dose adjustment or a switch to another type of antidepressant
can usually take care of the problem. Often, treatment of the depression
can result in much better sexual functioning. Other types of
antidepressants, such as Bupropion (Wellbutrin) or Venlafaxine (Effexor)
add to our treatment options. Some people respond to the first medication.
Other people may have to try several medications before they hit upon the
right one.
Psychotherapy:
Recently, researchers have made an effort to do good psychotherapy outcome
studies. It turns out that several forms of psychotherapy really do work
better than simple “tincture of time.” Cognitive psychotherapy is one of
the methods that has demonstrated good results for depression. In this
type of therapy, the individual identifies thought patterns associated
with a depressive, hopeless outlook. Frequently these thought patterns are
based on erroneously assumptions about self and others. The therapist
helps the patient monitor such thoughts and to replace them with more
effective positive ways of thinking. Cognitive therapy can also be helpful
in non-depressed individuals who are having trouble with their diabetic
management.
Anxiety
and stress can also cause large jumps in blood glucose levels. Panic
attacks may resemble hypoglycemic episodes and vice-versa. (When in doubt,
treat it as hypoglycemia.) People respond differently to stressful
situations. Given the same subjective level of stress, one diabetic may
have a different glucose response from another. Because of this, one
should monitor blood glucose more frequently during periods of stress. On
the positive side, a conscientious diabetic may have a unique barometer of
stress unavailable to the general population. There are a number of
specific anxiety disorders that are treated differently. As with
depression, there are specific medications and therapies that have been
shown to work. If anxiety is severe, it is important to identify the
specific type, so that one can embark on the right treatment. We will not
cover all of these treatments in this article. The following are some
general suggestions for dealing with stress and mild to moderate anxiety.
- Examine your lifestyle for
sources of stress. Are there stressers that can be eliminated?
- Learn relaxation
techniques. Yoga, meditation, prayer, and hypnosis may help.
- Make sure that you are
getting enough sleep
- Exercise. The body’s
primitive stress response was designed to prepare the individual
to fight or to run away. In our society, we do not usually respond
to stress with physical activity. Exercise helps our bodies deal
with the physiological results of stress.
- Make a list of the things
that are worrying you. When you have a concrete list, the problems
often look more manageable.
Many people do not like the idea
that they may have emotional difficulties. Some find it easier to
attribute everything to physical problems or life circumstances. However,
good diabetic management is dependent on the development of
self-knowledge. Many of the things that other people’s bodies do
automatically, diabetics must do consciously. This includes closer
monitoring of both one’s blood glucose and one’s emotional state.
Ultimately, the years of deliberately imitating natures beautiful and
complex feedback systems can lead to a greater understanding and
appreciation of body and mind.
References:
1 Lustman, PJ, Griffith, LS,
Freedland, KE, Clouse, RE; The course of Major Depression in Diabetics
Gen Hosp Psychiatry 1997; 19(2) 138-143.
2 Stabler B, Surwit, RS, Lane JD,
et al. Type A Behavior pattern and blood glucose control in diabetic
children Psychosomatic Medicine 1987; 49: 313-316.
3 Cohen, ST, Welch, G, Jacobson,
AM, et al The Association of Lifetime Psychiatric Illness and Increased
Retinopathy in Patients with Type I Diabetes Mellitus Psychosomatics 1997;
38: 98-108.
4 Koenigsberg, HW, Klausner, E,
Pelino, D et al. Expressed Emotion and Glucose Control in
Insulin-Dependent Diabetes Mellitus American Journal of Psychiatry 1993.
5 Goldston, DB, Kelley, AE,
Reboussin, DM Suicidal Ideation and Behavior and Noncompliance with the
Medical Regimen among Diabetic Adolescents American Journal of Child
and Adolescent Psychiatry 1997.
6. Lustman, PJ, Griffith,
LS, Clouse, RE et al. Effects of Nortryptiline on depression and glycemic
controlin diabetes: Results of a double-blind, placebo-controlled trial.
Psychosomatic Medicine 1997;59(3) 241-250.
More information on Diabetes:
Diabetes at WebMD.com
Search
This Site By Key Words
For Our Site