Diabetes and Depression

Depression is the most common psychiatric condition seen in diabetic patients. Up to 50%of diabetic patients suffer from depression. The interaction between these two conditions is complex. Depression by itself is a risk factor for developing diabetes. Conversely, diabetes may also contribute to the development of depression.

 What are the symptoms of depression?

• Depressed mood for the majority of the day.
• Lack of pleasure/interest in doing almost all activities for the majority of the day.
• An increase or decrease in appetite or weight.
• Sleep disruption – either excessive sleeping or insomnia (reduced sleep).
• Psychomotor agitation – feeling restless or tense (e.g. frequent hand wringing, fidgeting, leg shaking, pacing etc.) or psychomotor retardation – slow movements, slow speech etc.
• Lack of energy, feeling tired.
• Feelings of worthlessness or excessive guilt.
• Lack of concentration.
• Recurring thoughts of death or suicidal ideation.

If most of these symptoms are present continuously for at least 2 weeks, then the patient will receive a diagnosis of depression.

What are the common causative factors for both diabetes and depression? What are the possible mechanisms linking these two?

Depression is the result of abnormal functioning of the brain. It has long been known that emotional factors like sadness or grief could lead to the onset of diabetes. Diabetes could occur after a moderate to major depressive episode, though this is not always evident clinically, as type-2 diabetes often goes undiagnosed for many years. Depression can also occur due to metabolic effects of diabetes in the brain.

• Psychosocial factors: Hardships faced by people of low-socioeconomic standing, such as poor education, stressful life events and alack of social support, are risk factors for both depression as well as diabetes.
• Poor nutrition of the foetus during pregnancy: Lack of proper nutrition of the mother during pregnancy can lead to poor foetal growth. This can cause impaired glucose control or overt diabetes in later life. Similarly, low birth-weight babies are at risk of developing depression during early adult life or in old age.
• Genetic: Evidence suggests that there is an increased incidence of diabetes in people whose close relatives have psychiatric disorders like depression or psychosis.
• Counter-regulatory hormones: High stress levels lead to an increase inproduction of counter-regulatory hormones like adrenaline, glucagon, glucocorticoids and growth hormones. These hormones oppose the glucose lowering action of insulin, leading to increased blood glucose levels.

What is the effect of depression on diabetes and vice versa?

Self-care of one’s diabetic symptoms can be difficult in depressed patients. They are likely to find diabetic management stressful and hence are likely to neglect their health. They may lack the motivation or energy to take care of themselves. Depressed patients might not be able to think clearly and communicate clearly. They might become indecisive and suffer with extreme mood swings. They might not be able to perform simple tasks and may frequently miss doctor appointments. They might overeat, gain weight and not exercise regularly. They might not take their medicines as prescribed. They might start smoking, consuming alcohol or taking recreational drugs. All this leads to poor control of diabetic symptoms.

As a consequence, patients are prone to develop microvascular complications such as kidney problems, retinal/eye problems and neuropathy (nerve problems). It has also been found that people with depression and diabetes have an increased risk of developing macrovascular complications such as heart attacks, strokes or poor circulation in the legs.These complications can make depression worse.For example, chronic pain is not only a risk factor for depression, but depression can also amplify the experience of chronic pain. Similarly, if a depressed patient has suffered a heart attack or stroke due to diabetes, it would be difficult for them to make a quick recovery and this can worsen the experience of depression.

How can a patient suffering with both diabetes and depression be managed?

Just like any other physical problem, depression can be treated. Optimal treatment of depression can also improve a patient’s blood glucose control. Treatment for both diabetes and depression involves a co-ordinated approach.

 Regular Exercise:

Exercise releases endorphins from the brain.These are feel-good chemicals that can help the patient feel good about themselves and experience a sense of well-being. This can indirectly help with a better control of blood glucose levels. A patient who is psychologically well can take better care of their physical health problems.

A Balanced Diet:

By avoiding processed food high in fat or calories, free radical production in the body can be minimised. These free radicals have been shown to contribute to depression. By eatinga nutritious, well-balanced diet, rich with anti-oxidants, depression can be minimised. A well-balanced diet also plays a major role in controlling blood glucose levels.

Restful Sleep:

Proper sleep can ensure that the patient feels refreshed and energetic. This positive energy balances the negativity of depression, lowers the urge to snack, and helps in stabilizing blood sugar levels. Restful sleep also helps minimise stress. This reduces the action of counter-regulatory hormones, thereby decreasing blood glucose levels.

Weight loss:

For overweight patients, regular exercise and a balanced diet help to reduce weight and increase insulin sensitivity, thereby controlling blood glucose levels. Research has shown that targeted weight loss also improves symptoms of low mood in depressed patients.

Psychotherapy:

Psychotherapy, especially cognitive behavioural therapy,has been proven to help combat depression. This is a talking therapy, where the patient is made aware of their own negative thinking by the therapist.The patient is provided with positive coping skills to deal with negative thoughts.

Medication:

Anti-depressants can help with treating depression. They must be taken for at least six to nine months to prevent relapse.

Stopping substance misuse:

Adequate help through counselling or detoxification is recommended for patients who smoke, consume excessive amounts of alcohol, or take recreational drugs.

References:

• Ciechanowski PS, Katon WJ, Russo JE, Hirsch IB. The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes. General Hospital Psychiatry 2003, 25:246-252
• Renn BN, Feliciano L, Segal DL. The bidirectional relationship of depression and diabetes: A systematic review. Clinical Psychology Review. 2011;31:1239.
• De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a meta-analysis. Psychosomatic Medicine 2001, 63(4): 619-30