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Depression and Diabetes
Major depression in the UK population at any one time is about 5%, although as many as one person in three may experience an episode of depression in their lifetime. The presence of other illnesses may complicate or worsen depression and vice versa.
Research has shown that depression may occur in:
· Up to 60% of stroke patients
· Up to 40% of people with Parkinson’s disease
· Up to 42% of cancer patients
· Up to 21% of people with irritable bowel syndrome
· Up to 14-18% of people with diabetes
A study by Brazilian researchers, presented at the American Diabetes Association Conference 1998, showed that among a group of people with diabetes those whose HbA1c levels averaged less than 9%, only 21% tested positive for depression according to the results of a standardised test. By comparison of those with HbA1cs over 9%, 42% tested positive for depression. Other research has shown that people with chronic conditions including diabetes are three times more likely to suffer depression than the general population.
The researchers used cognitive therapy to reverse the depression. In those people where depression improved, there was an average HbA1c of 8.3% while those who showed little improvement had an average of 11.3%.
Research now suggests an association between higher blood glucose levels and depression which can increase the risk of diabetic complications. It is also possible that high blood sugars cause the depression rather than depression causing high blood sugars.
An international report showed that having diabetes and depression has the greatest negative on quality of life compared to diabetes or depression alone, or other chronic conditions. [Lancet 2007;370:851-8]
Research in young adults with Type 1 diabetes
Research in Australia surveyed 92 young adults with Type 1 diabetes with an average age of 22 and found that 35% of them reported depressive symptoms. Importantly those with depression tended to have poorer blood glucose control than those without depressive symptoms, so putting those with depression at greater risk of complications such as cardiovascular disease. [Diab Med, 2008;25:91-6] The study concluded that as many young adults reported significant levels of psychological distress health teams caring for young adults with Type 1 diabetes should provide psychological assessment and support.
Research in older people with diabetes
Research in Canada has shown that people with heart disease maybe at risk of further attacks if they suffer from depression or anxiety. People with diabetes are more at risk of developing heart disease so this study again emphasises the importance of treating depression in people with heart disease as well as those with diabetes. [Arch Gen Psychiatry 2008;65:62-71]
Research in the US looking at the relationship between diabetes and depression found that depression treatment reduces mortality by half in older people with diabetes. Again this emphasises the need to diagnose and treat depression in people with diabetes. [Diab Care 2007,30:3005-10]
These studies highlight the need to ensure that depression does not go undiagnosed and also highlights the need to provide children, adolescents and adults with diabetes with greater psychological support and where necessary, a psychological assessment and treatment for depression.
How do you know if you are depressed?
The signs of depression include the following:
· No longer enjoying or being interested in most activities.
· Feeling tired or lacking energy.
· Being agitated or lethargic.
· Feeling sad or low much of the time.
· Weight gain or weight loss.
· Sleeping too little or too much.
· Difficulty paying attention or making decisions.
· Thinking about death or suicide.
Depression link with poor blood glucose control
The recent research showed in young people with Type 1 diabetes depression tended to be linked to poorer blood glucose control. This could be through hormonal changes but it is thought that the most likely cause is the negative effects that depression has on people making self-management of their diabetes more difficult:
· lack of exercise
· increased smoking and alcohol consumption
· lack of or poor blood glucose monitoring.
Research using questionnaires has shown that depression in people with both Type 1 and Type 2 diabetes may have the following effects:
· They are less likely to eat the types and amounts of food recommended.
· Less likely to take all their medications.
· Less likely to function well, both physically and mentally.
· Greater absenteeism from work.
[Archives of Internal Medicine, Nov 27, 2000]
Note: Depression is also associated with increased weight and obesity and depression itself can cause Type 2 diabetes.
Recent estimates suggest that up to three quarters of cases of depression in people with diabetes may go undiagnosed. This may be because of poor detection rates but it could also be that some people with diabetes don’t report their symptoms of depression because they see them as ‘just part of having diabetes’.
Screening for depression [not specifically for people with diabetes] has been recommended by national and international bodies and now in the UK, the Dept of Health recommends that all GPs use two simple questions to screen for symptoms of depression:
· During the last month, have you been bothered by feeling down, depressed or hopeless?
· During the last month, have you often been bothered by having little interest or pleasure in doing things?
If people answer ‘yes’ to either of these questions, they are given a questionnaire to answer to measure the extent and nature of the symptoms. It is important that similar methods are used in diabetes hospital clinics where many people with Type 1 diabetes receive their treatment.
Treatment for depression in people with diabetes has been shown to be effective and has the additional benefits of improving blood sugar control. The evidence suggests that cognitive behaviour therapy and anti-depressant medicines are as effective in people with diabetes as in those without diabetes. One study found that not only did treatment improve blood sugar control but during treatment there was an improvement in mood and weight. So treatment for depression can improve blood sugar control, so reducing the risk of complications but importantly, it also improves quality of life.
So if you answer ‘yes’ to the two questions above or you have more mild symptoms, you are not alone and the clear message from research is to seek help from your doctor because there is a good chance that your life will improve.
How does depression affect people with diabetes?
Research [Ref 1] using questionnaires has shown that depression in people with both Type 1 and Type 2 diabetes may have the following effects:
· They are less likely to eat the types and amounts of food recommended.
· Less likely to take all their medications.
· Less likely to function well, both physically and mentally.
· Greater absenteeism from work.
Ref 1 Archives of Internal Medicine, Nov 27, 2000
Depression in parents of children with diabetes – is it surprising?
A study [ref 1] has looked at depressive symptoms in parents of children with diabetes treated with intensive therapy [multiple daily injections] and with conventional therapy [twice daily injections]. It has shown that there are no significant differences in depressive symptoms in parents between those with children treated intensively and those treated conventionally.
The study did not show that parents’ depressive symptoms correlated with their child’s metabolic control, the duration of diabetes, age of the patient, age of the parent, family size or family income. The authors concluded that switching children to intensive therapy did not reduce the depressive symptoms in parents because in their study there was no reduction in depressive symptoms in the intensively treated group compared with the conventionally treated group. They suggest that because hypos are more common in intensive therapy this may be a source of additional stress for the parents and have psychological effects, so adding to their depressive symptoms.
The reality of what the study shows is that many of the things that were thought to cause parental depression actually don’t. It is also interesting because it does show that the depressive symptoms experienced at diagnosis in some parents do not go away as time passes.
As a parent could I dare to suggest that simply having a child with diabetes is something we never quite get over and this is why we show depressive symptoms. May be we don’t have to deeply search into why it happens! Let’s take a harsh look at the reality:
· Your child is diagnosed with diabetes - a life long condition for which there is no cure.
· You have to face the reality that this is not a condition that even stays the same – there are always the risks of the complications at the back of your mind.
· You have to live with the day to day worries of bringing up your child with diabetes and keeping the rest of the family happy.
· You have to face the worries of hypos, at night, at school, when they are out socially, when they eventually leave home - this list is endless.
· You feel a huge responsibility for your child’s future health and wellbeing and you can never quite get away from the feeling of guilt.
· The longer you all live with diabetes, the more obvious it becomes that the hoped for cure is not around the corner and you even start to wonder whether there is real incentive to find that cure. You question the way in which research money for diabetes is spent.
· It seems incredible that the things that would make life easier and safer for your child, like continuous blood monitoring with warning beeps, are not treated as top priority for research spending.
· We read that the death rates in people with diabetes have not reduced, so we have to question the effectiveness of present day treatment with all the apparent improvements such as home blood monitoring.
Is it surprising that we feel a bit depressed and that this depression is nothing to do with blood sugars, with time, with the age of our children or ourselves, with our income or our family situation? Some of these things may make it worse from time to time but underneath we can never get away from the realities of diabetes. We need to be given some real hope. We need to see that research is going in the direction of making life better for those who already have diabetes as well as research into prevention. We need to be understood and heard and we need to see real progress in the treatment of diabetes for the sake of our children.
Ref 1 Diab Care, Vol 22, No 8 August 1999, 1372-1373 Depressive symptoms in parents in intensively treated children with diabetes compared to those conventionally treated
GE
insulin,
hypoglycaemia and depression – a connection?
A PERSONAL EXPERIENCE
Colleen Fuller, Canada
Two weeks ago I switched to pork insulin, and there are two main changes in myself that I've noticed. The first is that I haven't had diarrhea for the first time in 3 years. That might not be associated with the insulin – and it's only been the last several days, but I notice it, and I'm watching. I know that diarrhea can be a complication of diabetes, but I never had experienced it on an on-going basis until I began using GE insulin, and now it seems to be changing.
The second big thing is that my mind is energized. I just don't know how else to explain it. When I switched to Humulin in 1996 I experienced six comas in a period of about one month and was hypoglycaemic most of the time for about six or seven months. My behaviour definitely did change and the one who felt the brunt of it was my husband. I became extremely aggressive and I also began accusing him of trying to control me and disempower me. This was based on one simple fact: I had no control! I could no longer tell when I was hypoglycaemic, but John, my husband, often could at that time. By the time I began showing symptoms I was long gone and helpless. So John would say "You need some orange juice" and I would begin screaming at him: "how would you know, you're not a diabetic". I was terrible, even telling him on several occasions how much I hated him. It was awful, awful, awful and I was miserable.
I began seeing a psychiatrist in 1997 and she diagnosed me with clinical depression. There was a lot in my own past that also came up during this time, including an ex who had committed suicide in 1974. But as I look back on it now, my view of this period is changing. One of the things I complained to the psychiatrist about was my inability to focus on anything. I was finishing a book, but I was really struggling with it. She said that was a symptom of depression. The doctor linked my depression to consistent hypoglycaemia. At that time I had depleted any reserves of glucose in my body - next to nothing in my muscles, organs or brain. This, she said, affected the seretonin levels in my body. Ergo: depression. The answer? Zoloft. No one recommended I stop taking GE insulin. But for a long time I refused to take an anti-depressant. I just didn't want to take any more drugs - I couldn't handle it. GE insulin was enough!
By then after blood tests showed that no, I wasn't miraculously producing my own insulin and that was not the reason for the problems I was having - my endocrinologist wanted to switch me to Humalog and to an insulin pump. You have to understand that I was desperate, and also I now believe that my brain wasn't functioning properly - otherwise I would have began insisting on being switched back to animal insulin. (I unquestioningly accepted that I "couldn't" take it any longer because it was being withdrawn - something completely out of character. I didn't even research the subject, and research is what I do for a living.)
Anyway, I did accept his advice and switched to Humalog and to the pump. After two days on the pump I was still hypoglycaemic all the time. I remember sitting at the table in our dining room all alone, in tears. I felt overwhelmed with diabetes and I thought "my life used to be more than this".
Diabetes had always been there, but it had never dominated my life – my life was made up of other things like love and work. My logic then proceeded like this: I don't want this life, but is there another life for me? Is it this life or no life? I felt there was no other life, and that I would forever more be poking my fingers every 30 minutes and chugging apple juice, waking up surrounded by paramedics and that I would lose my autonomy and independence. I wanted to die - I don't know if I wanted to commit suicide, but I definitely didn't want to live my life any longer.
I didn't tell my husband I was feeling this way, but when I saw my psychiatrist I told her and she seemed upset, and really insisted that I begin taking the Zoloft. So I did, because I was upset, too. Suicide was something I'd had to deal with in the past, and so it frightened me to think of myself veering in that direction. She also counselled me to give the Humalog and the pump a chance. These things all probably helped me: the Zoloft, my psychiatrist and the insulin pump, not to mention my family and my husband.
Then about six months ago I began to experience this inability to concentrate or to focus on anything. I don't know exactly how else to describe it. But I'd stopped seeing the psychiatrist by then, and I'd been off the Zoloft for a while. I didn't want to get back into that routine, I guess I just wanted to get on with my life. So I ignored it. But it got worse and worse, and ultimately this is what forced me to finally switch back to pork insulin. I'd been reading quite a lot about GE insulin and its possible link to depression in some people. I could feel myself moving in that direction again, mainly, I think, because of this focus thing. I can't write when I can't focus. I'd been missing deadlines during this period, which is really terrible.
Lo and behold! I have been more productive in the last week than I have been for months. It might have nothing to do with the insulin, but that's the only thing that's changed for me. I feel energetic and very, very focused.
Perhaps that sounds all airy-fairy, but it's how I feel. When I told my endocrinologist, who I credit with saving my life and who I greatly admire and like, that I wanted to switch back to pork, he was surprised. He didn't even know animal insulins were still available. But he said the only important thing is how I feel. My blood sugars have always been excellent, both on animal insulin and on GE insulin - except during that bad period when my HbA1C's were extraordinarily low. (That's when they began testing me for endogenous insulin.) So, he said, as long as my overall control is good, he himself is not wedded to the GE insulin. "I'm not a salesman for the drug industry," he said.So there's my story with insulin and depression. I'd never been depressed before I went on to GE insulin, or at least I'd never been diagnosed with it. I feel that by switching back to pork insulin I've been able to avoid taking an anti-depressant. I feel better and more energetic and more focused. I should also just add that the other night I woke up sweating and hypoglycaemic. I was so happy! This hasn’t happened for quite a long while. I trotted downstairs and gulped down a glass of orange juice!
I will never, ever go back to taking GE insulin.
DEPRESSION IN ADULTS WITH DIABETES
Major Depressive Disorder is present in 15 to 20% of adults with diabetes and even after successful treatment depression will reoccur in as many as 80% of people with diabetes. Depression itself reduces the quality of life but has additional importance in diabetes because it is associated with poor compliance, poor glycaemic control and an increased risk of vascular complications. This paper points out that despite its importance in diabetes, depression is recognised and treated in only one third of people affected. It further points out that there are diagnostic systems that are sensitive and valid for detecting depression even in people with unstable diabetes that may produce some of the same symptoms of depression. The authors suggest that even though data about treating depression in people with diabetes is very limited, it does suggest that treatment is important and has beneficial effects on mood, glycaemic control and overall quality of life.
Semin Clin Neuropsychiatry 1997 Jan; 2[1]:15-23
INJECTION RELATED ANXIETY IN INSULIN TREATED PATIENTS
This study set out to look at whether the presence of injection related anxiety and phobia influences compliance, glycaemic control and quality of life in people with diabetes. 115 unselected insulin treated people, 80 with Type1 and 35 with Type 2 diabetes, completed a standardised questionnaire providing injection anxiety scores and general anxiety scores. The results showed that in14% of cases injections had been avoided because of anxiety and 42% expressed concern at having to inject more frequently. A significant correlation was found between injection anxiety scores and general anxiety scores. The latter was significantly associated with injection avoidance and expressed concern at increased injection frequency. No significant correlation was seen with HbA1cs and either type of anxiety. The authors conclude that symptoms relating to injection anxiety and phobia have a high prevalence in an unselected group of people with diabetes and are associated with higher levels of general anxiety.
Diabetes Res Clin Pract 1999 Dec;46 [3]:239-46
PERSISTENCE OF DEPRESSIVE SYMPTOMS IN DIABETIC ADULTS
The aim of this study, carried out in the USA, was to identify the level and pattern of persistent depressive symptoms in adults with diabetes and to try to identify factors that are associated with an increased risk of it occurring. A symptom inventory questionnaire was given to 245 patients at the beginning and the end of an intensive education programme [referred to as the initial time points] and at the 6-month follow up visit. 13% of the participants were persistently depressed. At the 6-month follow up the rate was 10% for those negative for depression symptoms at either of the initial time points, 36% for those positive at one initial point and 73% for those positive at both initial end points. The people at risk of being persistently at risk of persistent depression were those who did not graduate from high school, had more than two complications of diabetes and were not treated with insulin. The authors conclude that persistent depression is present in a substantial number of people with diabetes and can be effectively predicted during initial contacts.
Diabetes Care 1999Mar; 22[3]: 448-52
PREVALENCE OF SYMPTOMS OF DEPRESSION AND ANXIETY IN A DIABETES CLINIC POPULATION
While waiting for their routine hospital appointment adults with Type 1 and Type 2 diabetes were asked to fill in a questionnaire to measure psychological symptoms and the perceived need for psychological support. From the patients records the presence of complications was recorded and the HBA1 was also recorded. The response rate was high [96%]. The presence of psychological symptoms was also high with 28% of the participants reporting moderate to severe levels of depression or anxiety or both. Men were more likely to report moderate to severe depression symptoms and women more moderate to severe anxiety symptoms. There was a significant link between depressions and poor gylcaemic control, as measured by the HbA1, in men but not in women. A third of the participants reported that at that moment they would be interested in receiving counselling if it was currently available in the diabetes clinic. The authors conclude that there is a significant proportion of people who require psychological support which, if available, might help to improve glycaemic control and so overall wellbeing.
Diabetic Medicine, March 2000, 17; 198-202