DEPRESSION: A Common and Treatable Condition in Individuals with Diabetes

By Paul Ciechanowski, MD, MPH

Depression is a common condition that can be debilitating. However, depression is highly treatable. Depression is twice as common in those with diabetes as the general population. About one third of people with diabetes will have an episode of significant depression sometime during their life. Depression is important to recognize and treat because it can lead to declines in function. In those with diabetes, depression often leads to worsening of physical symptoms, poorer adherence to treatment and self-care, and poorer health status overall.

How can depression have such a large impact on people who have it?

Depression: More than sad mood

People think of depression as a condition in which someone has a sad or “blue” mood for weeks at a time. This is true, but it explains only part of the many symptoms that people may experience when they are clinically depressed. In fact, some depressed people may not even experience a sad mood! For example, some people with depression may lose their interest in things that used to bring them pleasure, such as having hobbies or being with friends, but they might not have a depressed or sad mood.

Clinically depressed people also have other important symptoms, such as abnormal sleep patterns. This abnormal sleep may happen when the person is feeling depressed, or may happen before the person feels depressed. Some people with depression can’t sleep well early in the evening or during the night, and others cannot seem to get enough sleep.

Depression can have a large impact on appetite. Most people with depression aren’t hungry and lose weight. But others are often hungry, crave carbohydrates (carbs) and gain weight. Clearly, such appetite changes can impact people with diabetes who are trying to maintain their blood sugars.

Other common symptoms of depression include fatigue, poor concentration, nervousness and irritability, worsening of physical symptoms and pain, and loss of sex drive. Twenty percent of depressed individuals experience panic, or anxiety attacks. Often, in people with diabetes, these symptoms are mistaken for worsening of diabetic symptoms. This leads to frustration because patients and their families believe that their diabetes is getting worse. For the depressed patient, the increased guilt and lack of hope that often accompanies depression may make the person more frustrated.

Untreated depression can also lead to very serious consequences. Some people with depression can become so hopeless that they may think about taking their own life. Some unfortunately do.

What causes depression?

Why depression occurs in people with diabetes varies from patient to patient. For example, a family history of depression, overuse of alcohol or other substances, or marital stress or loss of a loved one can all contribute to depression. Certain thought patterns and coping styles can also make someone likely to get depression or continue to have depression. The stress of coping with a chronic illness such as diabetes can contribute to depression. For example, dietary restrictions, recurrent hospitalizations or long-term complications may all lead to increased stress and cause the person to get depressed. Current research suggests that changes in the brain’s neurotransmitters [NOO-row-TRANZ-mit-terz] (nerve cell chemicals) are what cause depression.

What does depression cause?

People who don’t get treated for their depression may be less productive, miss work, feel physical and emotional distress, and are likely to go to their doctor much more often. People with diabetes and untreated depression are likely to not monitor their blood sugar properly or take their medications regularly, may not follow their diet or exercise program, and may lose their concentration and feel hopeless. All of this can affect blood sugar control and cause diabetes complications. Depression can also worsen physical symptoms. In other words, people with medical symptoms, such as burning pain of the feet, can become unable to deal with their symptoms when they’re depressed. Overall, untreated depression can negatively influence one’s quality of life in significant ways.

Diagnosis and treatment of depression

Doctors are trained to recognize and diagnose depression. However, in the early stages of depression, the patient or patient’s family needs to alert the doctor about the symptoms, since these early symptoms are not always clear to others. The doctor will look for signs and symptoms of depression and will also ask about the patient’s past medical and psychological health, and about depression in blood-related family members. Doctors may want to do a physical examination. They may order laboratory tests to rule out medical causes of symptoms that seem like depression or cause depression.

Patients are usually treated with antidepressant medications and/or psychotherapy [sike-oh-THER-a-pee] (e.g., counseling). These kinds of therapy can be done alone or together, but they usually work better together. The newer antidepressant drugs target more specific neurotransmitters in the brain, such as serotonin, than older antidepressant agents. These newer agents are safer, more easily tolerated, and have fewer side effects than the previous types of antidepressants. Just like oral hypoglycemic medications and insulin can decrease diabetes symptoms by making blood glucose levels normal, so too can antidepressant medications gradually minimize symptoms of depression and restore function by changing the levels of neurotransmitters. Antidepressant medications are usually taken by mouth once or twice a day. They’re not addicting and patients usually feel better in two to six weeks. Patients and their families need to realize that it may take this long to get relief, so they shouldn’t get discouraged. Psychotherapy done at the same time as medication therapy helps speed up relief of symptoms and makes it less likely that depression will come back.

Treatment of depression gradually restores one’s mood. It can also restore normal sleep and eating habits, increase one’s energy level, and improve concentration, among other things (see Box). Treating depression also helps people with diabetes manage their symptoms and blood sugars better.

If you or a family member is experiencing symptoms of depression, bring it up with your health care provider. Depression is recognized more and more as a serious condition that can adversely affect individuals with diabetes. Fortunately, depression is also a condition that can be effectively treated.

Dr. Paul Ciechanowski is an Associate Professor of Psychiatry at the University of Washington where he is also Associate Director of the Psychosomatic Medicine fellowship. He was a board-certified family physician before becoming a psychiatrist and was recently funded through a NIDDK Career Development Award to study patient-provider relationships, treatment adherence and outcomes in diabetes and other chronic illnesses. He has published extensively in the area of depression and diabetes and combines his experience in psychiatry and primary care in his clinical psychiatric work in the Diabetes Care Center at the University of Washington.