Depression and Diabetes: An Overview

Prepared by Dalal AlotaibiClinical Psychologist

IntroductionDiabetes and psychology are not often thought of as being

complimentary but with the use of psychology the life of a

diabetic can be improved

To understand the role that psychology has to play it is important to

understand how it can affect the life of a diabetic

For example, depression is not generally listed as a complication of

diabetes, However, it can be one of the most common and

dangerous complications

Major Depressive Disorder

DefinitionMajor depressive disorder is a mental disorder characterized by

a pervasive low mood low self-esteem

loss of interest in normally enjoyable activities

Major depression is a disabling condition which affects a person's family, work or school life, sleeping and eating habits, and general health

Depression is common. It affects nearly one in 10 adults each year - nearly twice as many women as men

It’s also important to note that depression can strike at any time but, the peak age for depression onset is 20 to 40, with the highest risk occurring in those who have a family history of the disease

Causes Family history

Genetics play an important part in depression For example, if one identical twin has depression, the other has a

70% chance of having the illness sometime in life Personality

People with low self-esteem can be easily affected by depression

Environmental factors Continuous exposure to violence, neglect, abuse or poverty

may make people depressed Biochemistry

Abnormalities in two chemicals in the brain, serotonin and norepinephrine, might contribute to symptoms of depression

Trauma and stressThings like financial problems and the breakup of a relationship can bring on depression

You can become depressed after changes in your life, like starting a new job, graduating from school, or getting married

Medical conditions For example, a brain tumor or vitamin deficiency can cause depression

Serious medical conditions like heart disease, cancer, and HIV can contribute to depression, because of the physical weakness and stress they bring on

Other psychological disorders Anxiety disorders, eating disorders, and schizophrenia

DiagnosisDepression affects 3% to 5% of the general population and 5% to 15% of the primary care population. Despite its pervasiveness research indicates that primary care clinicians fail to recognize as many as 50% of depression cases

Barriers to Diagnosis and Treatment of Depression

Patients may not accept a diagnosis of depression and may focus on the disease's physical manifestations rather than treatment

Patients or their families often underestimate the severity of depression or believe they can self-treat it which can delay treatment. So, patient education is essential in accepting the diagnosis Clinicians may lack the skills and information to handle the emotional aspects of depression

Psychological Evaluation The diagnosis of major depressive disorder is based on the patient's self-reported experiences

Diagnosis of depression may be conducted by a general practitioner or by a psychiatrist or psychologist, but psychologists will conduct a psychological evaluation

A complete psychological evaluation is needed to determine whether a person has a depressive illness. Consultation with a psychologist will include a review of one's physical health history

As a general rule, patients should never take antidepressant medication alone, without also beginning psychotherapy, or at least seeing a psychologist for an evaluation

A good psychological diagnostic evaluation includes A complete history of one's symptoms; that is

When they started How long they have lasted

How severe they are Whether you've had them before

Whether you were treated and what treatment you received

Family history of depression Lastly, the psychological diagnostic evaluation will include a

mental status examination to assess the full range of psychological symptoms and problems. This will help identify

any other psychological problems that might be present

Screening for Depression

Several questionnaires can help detect depressive symptoms such as

1 .The Beck Depression Inventory (BDI) 2 .Another approach is the Two-Question Case-Finding

Instrument. To use this method, ask the patient During the past month, have you often been depressed or hopeless? and During the past month have you often been bothered by having little interest or pleasure in doing things? If the answer to both questions is no, it's unlikely that the patient has depression. If the answer is yes, to one or both questions, follow up with the diagnostic criteria for a major depressive episode

Depression can be a chronic and recurrent disease requiring ongoing treatment

A single episode of depression isn't the norm, and the chance of having a second episode is 50% to 65%

Patients who have depression also frequently have another disorder such as anxiety

Diabetes and Depression: A Vicious Cycle

Depression and diabetes are two conditions that can sometimes go hand-in-hand

Diabetes can increase the risk of depression. In fact, having DM doubles the risk of depression, compared to people who don't have the disease (1) Depression has been found to be more common among diabetic patients than in the general population affecting 15 – 20% of patients (2, 3)

A study published in one of the major psychiatric journals (4) indicates that almost 5% of the patients (193 over 4400) who had diabetes also had panic and depression

1 .Debra Manzella, R.N., About.com Updated: January 16, 20082 .Gavard JA et al. Diabetic care 1993; 16:1167-1178 3. Kovacs M. Diabetic Care 1997; 20:45-51

4 .Journals (General Hospital Psychiatry, November 2006) 5. Debra M. Arch Int Med; April 23 2007

Conversely, depression also can increase the risk of Type 2 diabetes (1) A new study (2) suggested that chronic depression can increase the risk of developing diabetes in older adults independent of other risk factors like obesity

It looks due to cortisol hormone which is secreted in response to stress When someone is depressed, the cortisol level rises, and if depression is chronic, the cortisol level may stay consistently high

Depression can get worse as the complications of diabetes get worse, and being depressed can stop people from managing their diabetes as effectively as they need to, which can lead to increased incidence of long-term complications such as retinopathy, neuropathy or nephropathy

1 .Debra Manzella, R.N., About.com Updated: January 16, 20082 .Debra M. Archive of Internal Medicine; April 23 2007

A depressed person may not have the energy or motivation to maintain good diabetic management

Depression is also frequently associated with unhealthy appetite changes

There is some suggestion that the stress of depression itself may lead to hyperglycemia in diabetics Treatment of anxiety and depression may lead to a better medical prognosis and a better quality of life

Recent studies have suggested that effective treatment of depression can improve diabetic control

In a study by Lustman glucose levels were shown to improve as depression lifted

The better the improvement, the better the diabetic control. Lustman et al.1997

Stages of GriefMany 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

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 dessert

Stages of Grief

Depression: Mild depressive feelings are a normal part of grieving and adaptation. As long as they are not prolonged, they may not be harmful. However, when the depression lasts a long time, becomes severe or interferes with diabetic management, one should seek treatment

Acceptance

Signs Depressed mood for most of the day

Decreased pleasure in normal activities Difficulty sleeping or 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 Antidepressants

Psychotherapy: 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 erroneous 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

Conclusion 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  

Thank you