Diabetes, Depression and Stress

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.



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)


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


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


  • 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


  • 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.


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


  • 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.


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



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.



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


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