Caring for patients with diabetes and depression
Module overview
As the population ages, an increasing number of people are developing long-term conditions. This is a challenge for healthcare systems in terms of funding and support, and comorbidities add to the economic burden. This module considers the comorbid conditions diabetes and depression, which healthcare professionals increasingly encounter in clinical practice. It explores the reasons why diabetes and depression are associated, the influencing factors, and the bi-directional causes of diabetes and depression. In addition, the effects that a diagnosis of depression might have on a person having difficulty managing their diabetes are examined, and potential treatment strategies identified.
Keywords
depression, diabetes, mental health
Aims
This module aims to enhance the reader’s awareness of the association between diabetes and depression and provide strategies for prevention and treatment.
Intended learning outcomes
After reading this module and completing the time out activities you should be able to:
- Discuss the causes of comorbid diabetes and depression.
- List similarities in the signs and symptoms of diabetes and depression.
- Explain how these signs and symptoms might be misinterpreted when diagnosing diabetes and/or depression.
- Discuss the effects of depression on diabetes self-care and management, and vice versa.
- Evaluate the accuracy and practicalities of different depression assessment tools.
- Explain the treatment options and strategies for people with comorbid diabetes and depression.
Introduction
Comorbidity – where two or more diseases occur together in the same individual – is a challenge for healthcare systems (Holt and Katon 2012). Diabetes and depression is an increasingly common comorbidity, which is perhaps unsurprising given the demands of diabetes management. A person with poorly controlled diabetes may be required to manage numerous comorbidities as complications of diabetes develop. These might include cardiovascular disease, peripheral vascular disease, neurological disease and renal disease.
Comorbidity has negative implications for a person’s physical and mental wellbeing (Holt and Katon 2012). Patients are often referred to the relevant specialist units to treat their conditions. However, healthcare professionals in specialist units might be reluctant to deal with the comorbid condition, even when they are aware of it (Sartorius and Cimino 2012). This can result in fragmented planning of care, disjointed healthcare management and the potential for the patient to receive conflicting advice. Holt and Katon (2012) found morbidity and mortality increase disproportionately in patients with comorbid conditions, resulting in a reduction in quality of life for the individual, as well as significant cost to healthcare systems.
Learning Points
- Comorbidity – where two or more diseases occur together in the same individual – is a challenge for healthcare systems.
- Diabetes and depression is an increasingly common comorbidity, which is perhaps unsurprising given the demands of diabetes management.
- Healthcare professionals in specialist units might be reluctant to deal with the comorbid condition, even when they are aware of it. This can result in fragmented planning of care, disjointed healthcare management and the potential for the patient to receive conflicting advice.
- Morbidity and mortality increase disproportionately in patients with comorbid conditions, resulting in a reduction in quality of life for the individual, as well as significant cost to healthcare systems.
Causal factors
It is important to recognise that while diabetes is a physiological condition affecting many systems of the body, the management of the condition is unique.
Behavioural approach in managing diabetes
Diabetes management is based largely on a behavioural approach in which the individual is able to establish nearly complete control of their condition, as long as they have been equipped with the appropriate knowledge and skills. However, diabetes control is a demanding task that requires commitment, motivation and problem-solving from the patient, to maintain blood glucose levels between 4mmol/L and 7mmol/L (Holt 2009).
Advice on diet and exercise
Diet and exercise advice often requires major alterations to a person’s routine and a complete change in personal habits. It can be difficult for the person to alter these behaviours, because they have been established over a lifetime and are based on what the individual believes and values.
Depression
Depression is a major global health concern and it is estimated that 24% of people with diabetes will exhibit depressive symptoms compared to 17% of people in the general population who do not have diabetes (Goldney et al 2004). People with type 1 or type 2 diabetes are equally at risk of becoming depressed, and depression is more common in those who have higher glycated haemoglobin (HbA1c) levels. Bot et al (2012) reported that 45% of the 646 participants with diabetes who took part in their study admitted to having at least one or more depressive symptoms, and this appeared to be linked to them also having a HbA1c of 61mmol/mol, higher than the recommended 48mmol/mol (Diabetes UK 2015a). However, it does not appear to be the high blood glucose levels that alter pathophysiology and lead to depression. Rather, it appears that depression is associated with the onset and development of diabetes-related complications, resulting from elevated
Diabetes causing depression
There are around 3.9 million people in the UK who have a diagnosis of diabetes (Diabetes UK 2015b). However, it is estimated that there are a further 590,000 people in the UK who have type 2 diabetes but are not aware of it because they have not developed any of the classic symptoms of diabetes such as thirst, polyuria and lethargy (Diabetes UK 2015b).
Effect of perceiving diabetes as a disability
An unexpected diagnosis of diabetes can be devastating for some people. They may have previously viewed themselves as relatively fit and healthy, and now they have a chronic illness that requires management for the rest of their lives. For many people, this is perceived as a disability that places a high psychological burden on them. This is particularly noticeable for individuals with low levels of family and social support (Renn et al 2011).
Effect of environmental factors
Diabetes is one of the few medical illnesses in which the patient can largely control their condition. However, it is influenced by many factors over which the person does not have control, including the weather, emotions, hormones and unpredictable physiological responses to external stimuli such as infection, which makes diabetes a demanding condition to manage psychologically and behaviourally. This may lead to frustration and avoidance behaviours that are not conducive to effective diabetes control.
Effect of emotional and psychological changes
There is evidence to suggest a depressive disorder can occur as quickly as four weeks after a diagnosis of diabetes, but may take up to two years (Perveen et al 2010). Studies indicate that important emotional and psychological changes occur during the period following diagnosis of type 2 diabetes, regardless of whether the person has developed complications (Lloyd et al 2012). As awareness of the association between diabetes and depression has increased, more patients with diabetes are being screened for depression, and more cases are being identified (Renn et al 2011). This might skew research figures. However, there does appear to be an association between the two conditions.
Lack of interest
A person who is diagnosed with depression as well as diabetes has a considerable task in managing a condition in which they may feel no interest. Often, the depression takes precedence and diabetes control deteriorates. This results in a domino effect, triggered by a lack of interest in diet and/or exercise, which leads to a rise in blood glucose levels and poor metabolic control, increasing the risk of developing microvascular and macrovascular complications. The development of diabetes-related complications may further exacerbate the depression (Hermanns et al 2013).
glucose levels (Bot et al 2012).
The causes of diabetes and depression are likely to be bi-directional, meaning diabetes can cause depression and vice versa (Figure 1) (Golden et al 2008).
Figure 1. Association of depression and diabetes
Complete time out activity 1
Imagine you visit your GP with a relatively minor ailment, but based on the results of blood glucose tests that were required for the minor ailment, you are told that you have diabetes.
- How do you think you might feel?
- Would you be angry?
- Would you look for a reason or a trigger?
- Would you want to blame someone?
- Would you tell others?
- Would you take a pragmatic and realistic approach?
Learning Points
- Diabetes management is based largely on a behavioural approach in which the individual is able to establish nearly complete control of their condition, as long as they have been equipped with the appropriate knowledge and skills.
- Domino effect is noticed due to depression that is triggered by a lack of interest in diet and/or exercise, which leads to a rise in blood glucose levels and poor metabolic control, increasing the risk of developing microvascular and macrovascular complications.
- Consequences of significant biochemical changes associated with diabetes are poor eyesight because of retinopathy, neuropathy, stroke and/or myocardial infarction.
- Loss of pleasure, weight loss and low energy levels are common symptoms of depression, but can be attributed to diabetes, where high blood glucose levels can cause lethargy that might lead to loss of pleasure and weight loss.
Effect of biochemical changes
Living with diabetes requires the person to develop their problem-solving and coping mechanisms rapidly. This can be a challenging and frightening process for many people because they have to cope with the consequences of significant biochemical changes associated with their diabetes, which can result in poor eyesight, neuropathy, stroke and/or myocardial infarction. These changes can lead to chronic neuropathic pain, which is difficult to control and can significantly alter sleep patterns.
Mobility may be reduced because of neuropathic pain, limb amputation or loss of co-ordination following a stroke. Deteriorating eyesight because of retinopathy might mean the person is no longer permitted to drive. This can affect their job and family income, as well as social and recreational activities (Holt 2009). The consequences of such complications are intrusive and life-changing. They affect the individual with diabetes, and also have negative effects on family and friends.
Effect of insulin therapy
Starting insulin therapy might cause distress in people with both type 1 and type 2 diabetes. The person with type 1 diabetes might believe their body is beginning to fail them, since they have to cope with the complexity of taking insulin every day for the rest of their lives to stay alive. The person with type 2 diabetes may assume they have failed in their aim to control blood glucose levels, despite attempts to modify their diet and lifestyle and take medications, since they may not understand the progressive nature of diabetes and the consequences of their actions.
There is a strong correlation between depressive symptoms and poor glycaemic control, particularly in patients who are required to undertake frequent monitoring of blood glucose levels and/or require three or more insulin injections per day (Renn et al 2011). Such requirements increase the complexity of the self-care regimen and require careful thought, organisation and diagnostic intervention by the individual (Renn et al 2011).
Complete time out activity 2
Access the following depression assessment tools: Patient Health Questionnaire (tinyurl.com/7uszg6y), Beck’s Depression Inventory (tinyurl.com/p2g654f) and the Hamilton Rating Scale for Depression (tinyurl.com/axsl4).
Consider each of the items or questions in the tools and determine how easy they would be to answer for a person with diabetes. Identify any potential ambiguities and discuss with a colleague. Consider how accurate they are in diagnosing depression in a person with diabetes.
Complete time out activity 3
List the signs and symptoms that a person with depression might exhibit. Compare your answers with Box 1. Now make a list of the signs and symptoms of high blood glucose levels a person with diabetes may experience. Identify the similarities in the two lists, and select three signs or symptoms common to the conditions. Imagine how each of these signs or symptoms would be described and interpreted by a patient who had depression, and how the same signs or symptoms would be interpreted by a patient who had diabetes.
Depression causing diabetes
In a meta-analysis conducted by Barnard et al (2006), clinical depression was found to be present in 12.0% of participants with type 1 diabetes in studies that had a control group, compared to 3.2% in the control group. For the studies with no control group, the prevalence of depression in people with type 1 diabetes was 13.4% (Barnard et al 2006). This is compared to 17.6% of people with type 2 diabetes identified as depressed compared to 9.8% of people who did not have diabetes (Ali et al 2006). Diabetes is diagnosed by assessing the frequency and severity of a range of symptoms (Box 1).
Box 1. Signs and symptoms of depression
A diagnosis of depression may be made if a person experiences four or more of the following symptoms for most of the day, every day for more than two weeks (referral to the GP should be made without delay):
- Tiredness and loss of energy.
- Sadness that does not go away.
- Loss of self-confidence and self-esteem.
- Difficulty concentrating.
- Lack of enjoyment in things that are usually pleasurable or interesting.
- Feelings of anxiety all the time.
- Avoidance of other people, sometimes even close friends.
- Feelings of helplessness and hopelessness.
- Sleeping problems – difficulties getting to sleep or waking early.
- Strong feelings of guilt or worthlessness.
- Difficulties functioning at work.
- Loss of appetite.
- Loss of sex drive and/or sexual problems.
- Physical aches and pains.
- Thoughts of suicide and death.
- Self-harm.
(Adapted from Mental Health Foundation 2015)
There is considerable overlap in the symptoms of prolonged hyperglycaemia and depression. This can lead to diagnoses being missed because symptoms may be accounted for by the patient in different ways, depending on whether they focus on their depression or their diabetes.
Physical symptoms
Loss of pleasure, weight loss and low energy levels are common symptoms of depression, but can be attributed to diabetes, where high blood glucose levels can cause lethargy that might lead to loss of pleasure and weight loss. Physical symptoms are often ignored or not taken seriously in people with mental health problems. Physical symptoms may be considered by the healthcare team to be part of the patient’s mental health problems, rather than the result of an additional physical illness. This can lead to a delay in diagnosing diabetes (Holt and Katon 2012) and the instigation of appropriate management strategies.
Sleep disorder
Sleep disorder is a common symptom of depression, and is an independent risk factor of type 2 diabetes. Reduced sleep over a long period causes a decrease in carbohydrate tolerance, an increase in insulin resistance and elevated cortisol levels, which necessitate increased insulin secretion (Yaggi et al 2006). High levels of circulating cortisol increase insulin resistance and, if the body is unable to meet the demand for extra insulin, blood glucose levels will rise and the person will develop type 2 diabetes.
Sleep may also be a contributory factor to the negative changes in lifestyle that a person with depression may adopt over a period of time. Lack of sleep stimulates the production of the hormone ghrelin, which increases appetite and decreases the release of leptin, which signals when a person is full, resulting in more calories being consumed and subsequent weight gain (Spiegel et al 2004).
Reduced self-care
Self-care is also often reduced in people with depression, leading to poor nutritional choices and adoption of a convenience-food diet that is typically high in fat and calories. This, coupled with the lower energy levels a person with depression experiences, results in a more sedentary lifestyle that is associated with obesity, insulin resistance and type 2 diabetes.
Smoking
Cigarette smoking is an independent risk factor in the development of diabetes and is common in people who are depressed. Will et al (2001) reported that as the number of cigarettes a person smoked increased, so did the incidence of diabetes, in both men and women. Men who smoked 40 cigarettes per day or more were found to have a 45% higher diabetes rate than men who had never smoked and this increased significantly to 74% in women.
Medication prescribed for depression
Treatments prescribed for depression may be contributory factors to the development of diabetes. Sleep difficulties and insomnia are a common side effect of selective serotonin re-uptake inhibitors (SSRIs), serotonin and noradrenaline re-uptake inhibitors, and monoamine-oxidase inhibitors (MAOIs). Lack of quality sleep can cause physiological changes contributing to insulin resistance and type 2 diabetes (Spiegel et al 2004). In addition, weight gain is a common side effect of tricyclic antidepressants such as amitriptyline and doxepin.
Excess abdominal fat
Excess abdominal fat releases non-esterified fatty acids that have a detrimental effect on the action of insulin. Blood glucose levels rise as a result, and this triggers the production of more insulin in an attempt to lower blood glucose levels. However, the requirement for excess insulin cannot be sustained by the body over time. Consequently, beta cells producing insulin become exhausted, blood glucose levels continue to rise and type 2 diabetes develops (Holt 2009). This process can potentially be avoided, if a healthy weight can be achieved and maintained.
Early detection and treatment of depression is important, since this could prevent or delay the onset of type 2 diabetes (Renn et al2011). However, a diagnosis of depression and effective treatment of the condition could also be a contributory factor to developing diabetes.
Reduced self-care
Self-care is also often reduced in people with depression, leading to poor nutritional choices and adoption of a convenience-food diet that is typically high in fat and calories. This, coupled with the lower energy levels a person with depression experiences, results in a more sedentary lifestyle that is associated with obesity, insulin resistance and type 2 diabetes.
Smoking
Cigarette smoking is an independent risk factor in the development of diabetes and is common in people who are depressed. Will et al (2001) reported that as the number of cigarettes a person smoked increased, so did the incidence of diabetes, in both men and women. Men who smoked 40 cigarettes per day or more were found to have a 45% higher diabetes rate than men who had never smoked and this increased significantly to 74% in women.
Medication prescribed for depression
Treatments prescribed for depression may be contributory factors to the development of diabetes. Sleep difficulties and insomnia are a common side effect of selective serotonin re-uptake inhibitors (SSRIs), serotonin and noradrenaline re-uptake inhibitors, and monoamine-oxidase inhibitors (MAOIs). Lack of quality sleep can cause physiological changes contributing to insulin resistance and type 2 diabetes (Spiegel et al 2004). In addition, weight gain is a common side effect of tricyclic antidepressants such as amitriptyline and doxepin.
Excess abdominal fat
Excess abdominal fat releases non-esterified fatty acids that have a detrimental effect on the action of insulin. Blood glucose levels rise as a result, and this triggers the production of more insulin in an attempt to lower blood glucose levels. However, the requirement for excess insulin cannot be sustained by the body over time. Consequently, beta cells producing insulin become exhausted, blood glucose levels continue to rise and type 2 diabetes develops (Holt 2009). This process can potentially be avoided, if a healthy weight can be achieved and maintained.
Early detection and treatment of depression is important, since this could prevent or delay the onset of type 2 diabetes (Renn et al2011). However, a diagnosis of depression and effective treatment of the condition could also be a contributory factor to developing diabetes.
Complete time out activity 4
There is an association between depression and diabetes. Identify the factors a person with diabetes should address on a daily basis to control their blood glucose levels, and consider how these could lead to the person becoming depressed. Talk to a person with diabetes if you get the opportunity, and discuss with them the difficulties of managing their condition and how this makes them feel.
Learning Points
- Biochemical changes can lead to chronic neuropathic pain, which is difficult to control and can significantly alter sleep patterns. Mobility may be reduced also due limb amputation or loss of co-ordination following a stroke.
- Reduced sleep over a long period causes a decrease in carbohydrate tolerance, an increase in insulin resistance and elevated cortisol levels, which necessitate increased insulin secretion.
- Lack of sleep stimulates the production of the hormone ghrelin, which increases appetite and decreases the release of leptin.
- Some of the symptoms of depression include tiredness, sadness, loss of self-confidence, loss of enjoyment, difficulty concentrating, anxiety, helpless, hopeless, sleeping problems, guilt, loss of appetite, physical aches and pains, suicide, self-harm.
- Treatments prescribed for depression, which may contribute to the development of diabetes, are selective serotonin re-uptake inhibitors (SSRIs), serotonin and noradrenaline re-uptake inhibitors, and monoamine-oxidase inhibitors (MAOIs).
Effect of depression on diabetes control
Diabetes control is achievable, but often requires a determined approach by the individual, because various elements are involved that may be interlinked or unrelated. A person may achieve excellent blood glucose control on one day, and poor blood glucose control on a different day, despite repeating the same actions. The motivation to control diabetes is complicated by depression.
Poor diabetes control
A healthy diet and regular exercise are the basis of diabetes control. Diminished interest or pleasure in activities, appetite dysregulation and constant fatigue can make people with depression less likely to engage in healthy lifestyle behaviours, resulting in poor diabetes control (Renn et al 2011). Poor diabetes control necessitates increased anti-diabetes pharmacological intervention, which may create additional problems.
Adverse drug reaction
The increasing number of pharmaceutical agents available to assist the person to control their blood glucose levels may lead to many different drugs being prescribed. This can increase the risk of adverse drug interactions, or of a person taking medications at the wrong time of day or not taking them at all (Wolff et al 2002). This may be exacerbated for people with diabetes because they are often prescribed additional drugs to control hypertension and/or hypercholesterolemia. There is evidence of an increase in depressive symptoms when more intrusive treatment regimens are introduced that require a higher level of compliance and concordance (Gois et al 2012).
Adverse effects of smoking
Individuals with depression are also more likely to smoke (Renn et al 2011). The association between smoking and macrovascular disease is well known, but this risk is heightened in a person who has diabetes because they are already at an increased risk of vascular disease.
Hypertension, hyperglycaemia and dyslipidaemia are present in people with type 2 diabetes and are thought to contribute to the development of endothelial injury, which can progress to atherosclerosis and myocardial infarction and/or stroke (Holt 2009). The risk of macrovascular disease is increased further in a person who is depressed because they are more likely to have poor glycaemic control and smoke tobacco heavily (Gois et al 2012). Additionally, tobacco smoking increases catecholamine levels, which worsens existing hypertension and gives rise to microalbuminuria. Smoking is associated with accelerated progression of diabetic nephropathy and a higher mortality rate for those who have end-stage renal failure and are being treated with dialysis (Holt 2009).
People with comorbid depression and diabetes report a poorer quality of life compared to people with either depression or diabetes alone. Those with diabetes and depression report a greater number of sick days from work and more frequent and longer duration hospital admissions than people with diabetes only (Hermanns et al 2013).
Learning Points
- Diminished interest or pleasure in activities, appetite dysregulation and constant fatigue can make people with depression less likely to engage in healthy lifestyle behaviours, resulting in poor diabetes control.
- Depressive symptoms are increased when more intrusive drug treatment regimens are introduced that require a higher level of compliance and concordance.
- Hypertension, hyperglycaemia and dyslipidaemia are present in people with type 2 diabetes and are thought to contribute to the development of endothelial injury, which can progress to atherosclerosis and myocardial infarction and/or stroke.
- People with comorbid depression and diabetes report a poorer quality of life compared to people with either depression or diabetes alone.
Treatment
If a person with diabetes and depression is able to manage their diet, lifestyle and blood glucose levels more effectively, they will become more positive and their psychological state might improve. Alternatively, if treating the depression is made a priority, this will enable the person to become more positive and proactive in managing their diabetes.
There is considerable overlap in the treatment options for diabetes and depression. Both conditions require a healthy eating regimen, regular exercise and behaviour modification. Therefore, it would seem prudent to treat both conditions concurrently. In practice, this is often difficult, because psychological care is not generally given priority in the diabetes multidisciplinary team framework and patients may have to wait a long time to see a member of the mental health team. Therefore, it is important that all healthcare professionals involved in diabetes care are aware of general principles of treatment that can be adopted to maintain and enhance a patient’s mental wellbeing.
Communication and self-management strategies
Effective communication between the healthcare professional and patient is essential to understand the patient journey and the challenges they face in implementing the prescribed self-care and management regimen. In a study by Beverley et al (2012), 97% (308/316) of patients felt that honest communication with their diabetes doctor was ‘very important’, yet 30% (95/316) of these patients admitted to withholding information and not being totally truthful in discussions related to their diet, exercise plan, blood glucose level monitoring and medication regimen.
Patients with depression are thought to be poor historians (Holt and Katon 2012) and may not give an accurate account of their self-care actions. Over-estimating their level of blood glucose monitoring and under-reporting of their blood glucose levels is common, as is an inaccurate description of their dietary intake. These parameters may be checked by viewing the person’s blood glucose monitoring machine and measuring their HbA1c level, but the difficulty for the doctor is in dealing with the misinformation. The doctor does not want to belittle or embarrass the person because this will damage the therapeutic relationship. Therefore, this should be addressed diplomatically.
Beverley et al (2012) recommended incorporating specific doctor-patient communication skills in medical training and the use of strategies that engage patients to take an active role in their self-care. Doctor-patient communication may be enhanced by:
- Consistency of information given.
- Repetition of information.
- Providing positive reinforcement and feedback to the person on their self-care behaviours.
These principles would be equally applicable in all healthcare professional training programmes.
Learning Points
- Psychological care is not generally given priority in the diabetes multidisciplinary team framework and patients may have to wait a long time to see a member of the mental health team.
- Effective communication between the healthcare professional and patient is essential to understand the patient journey and the challenges they face in implementing the prescribed self-care and management regimen.
- Doctor-patient communication may be enhanced by consistency of information given, repetition of information, and providing positive reinforcement and feedback to the person on their self-care behaviours.
Behavioural and pharmacological therapies
Diabetes self-management education coupled with psychotherapy has been found to be effective in treating people with depression and diabetes, with cognitive behavioural therapy (CBT) providing the most improvement (Fisher et al 2012). Cognitive restructuring is a specific type of CBT that can be relevant to a person with diabetes, because it aims to change negative thought patterns. This can assist the person to consider their negative feelings, for example frustration or the daily burden of having diabetes, and convert them to more positive thoughts that might be translated into a more proactive and beneficial approach towards managing their diabetes (Sabourin and Pursley 2013).
A desire on the part of the patient to change is required and should be assessed by the healthcare team. Making changes to factors such as diet, lifestyle, and medication adherence is difficult for the individual and they should be able to demonstrate they are willing and motivated.
Self-help CBT programmes
The National Institute for Health and Care Excellence (2009) recommends the use of self-help CBT programmes in treating mild-to-moderate depression, which can be accessed via an individual self-help guide or as an online package. Active engagement with this would signify that the person is receptive to the concept of self-help and to dealing with the challenges of depression. This may translate into the person enhancing their self-help strategies when dealing with their diabetes management, which would result in better blood glucose control. The positive feedback of improved mental wellbeing could lead to favourable diabetes decisions, actions and control, which may in turn enhance mood and mental health.
Goal-setting
Goal-setting is a useful tool in self-help. However, the goals set should be ones that can be controlled directly by the patient, such as increasing the amount of walking they do. A person is more likely to adopt goals they have set for themselves, than those which have been set for them by the healthcare team (Sabourin and Pursley 2013).
Pharmacological therapy
Antidepressant pharmacological therapy may be prescribed in addition to behavioural therapies. SSRIs are the most appropriate line of treatment in a person with diabetes and depression. In particular, escitalopram 10mg/day has been found to be efficacious in reducing depressive symptoms: it has been described as weight-neutral and has a positive effect on reducing blood glucose levels (Gehlawat et al 2013). Tricyclic antidepressants and MAOIs can be effective in treating depression in people with diabetes, but there is evidence that these drugs threaten glycaemic control and can cause weight gain (Nicolau et al 2013).
In determining the most appropriate treatment for people with comorbid depression and diabetes, it is important to ensure a healthy sleep routine, nutritionally balanced diet and regular exercise, while the depression is treated appropriately.
Learning Points
- A form of CBT known as cognitive restructuring assists the person to consider their negative feelings, for example frustration or the daily burden of having diabetes. These might be translated into a more proactive and beneficial approach towards managing their diabetes.
- Improved mental wellbeing could lead to favourable diabetes decisions, actions and control, which may in turn enhance mood and mental health.
- Tricyclic antidepressants and MAOIs can be effective in treating depression in people with diabetes, but there is evidence that these drugs threaten glycaemic control and can cause weight gain.
- In determining the most appropriate treatment for people with comorbid depression and diabetes, it is important to ensure a healthy sleep routine, nutritionally balanced diet and regular exercise, while the depression is treated appropriately.
Conclusions
- There is an association between diabetes and depression, and it is feasible the causes are bidirectional.
- Diabetes is a demanding condition to manage, and its management becomes more arduous when the person is diagnosed with depression.
- There are many similarities in the symptoms and treatment of diabetes and depression, and a pragmatic approach to treating both conditions simultaneously seems appropriate. However, this would appear to favour a reactive strategy, when a more proactive approach could be adopted.
- Diabetes and depression prevention schemes should be developed and supported financially, to reduce the incidence of both conditions and reduce their comorbidity.
Acronyms
CBT: cognitive behavioural therapy
HbA1c: glycated haemoglobin
MAOIs: monoamine-oxidase inhibitors
SSRIs: selective serotonin re-uptake inhibitors
Glossary
Comorbidity: two or more coexisting medical conditions or unrelated disease processes.
Depression: mood disturbance characterised by feelings of sadness, despair, and discouragement resulting from and normally proportionate to some personal loss or tragedy.
Dyslipidaemia: abnormal amounts of lipids and lipoproteins in the blood.
Hyperglycaemia: a condition associated with greater than normal amount of glucose in the blood.
Myocardial infarction: necrosis of a portion of cardiac muscle caused by an obstruction in a coronary artery resulting from atherosclerosis, a thrombus, or a spasm.
Neuropathic pain: pain that results from direct stimulation of the myelin or nervous tissue of the peripheral or central nervous system, generally felt as burning or tingling.
Polyuria: is the excretion of an abnormally large quantity of urine.
Retinopathy: a group of non-inflammatory eye disorders.
Author
Paula Mayo, Lecturer in diabetes care, School of Healthcare, University of Leeds, Leeds, England.
Short description
Explore the association between diabetes and depression, and discover potential treatment strategies.
Detailed description
As the population ages, an increasing number of people are developing long-term conditions. This is a challenge for healthcare systems in terms of funding and support, and comorbidities add to the economic burden. This learning module considers the comorbid conditions diabetes and depression, which healthcare professionals increasingly encounter in clinical practice. It explores the reasons why diabetes and depression are associated, the influencing factors, and the bidirectional causes of diabetes and depression. In addition, the effects that a diagnosis of depression might have on a person having difficulty managing their diabetes are examined, and potential treatment strategies identified.
References
Bot M, Pouwer F, de Jonge P, Tack CJ, Geelhoed-Duijvestijn PHLM, Snoek FJ (2012) Differential associations between depressive symptoms and glycaemic control in outpatients with diabetes. Diabetic Medicine. 30, 3, e115-e122. CROSSREF
Diabetes UK (2015a) Testing. tinyurl.com/pqsy76c (Last accessed: September 29 2015.)
Diabetes UK (2015b) Diabetes Facts and Stats (May 2015). tinyurl.com/ola4do9 (Last accessed: September 29 2015.)
Holt P (2009) Diabetes in Hospital: A Practical Approach for Healthcare Professionals. Wiley-Blackwell, Chichester.
Mental Health Foundation (2015) Depression. tinyurl.com/bnc3yye (Last accessed: September 29 2015.)
National Institute for Health and Care Excellence (2009) Depression in Adults: The Treatment and Management of Depression in Adults. Clinical guideline No 90. NICE, London.
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