Diabetes, Depression and Stress

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Diabetes, Depression and Stress
Carol E. Watkins, MD

Depression is not generally listed as a complication of diabetes. However, it can be one of the most common and dangerous complications. The rate of depression in diabetics is much higher than in the general population. Diabetics with major depression have a very high rate of recurrent depressive episodes within the following five years. (Lustman et al 1977) A depressed person may not have the energy or motivation to maintain good diabetic management. Depression is frequently associated with unhealthy appetite changes. The suicidal diabetic adolescent has constant access to potentially lethal doses of insulin.

At this point in time, it is well accepted that psychological factors and psychiatric conditions can affect the course of medical illnesses. There is some suggestion that the stress of depression itself may lead to hyperglycemia in diabetics. The interaction between cardiovascular disorders (such as heart attack and high blood pressure) and depression has been extensively studied. Anxiety and depression can also affect other conditions including irritable bowel syndrome, headache and skin diseases. Treatment of anxiety and depression may lead to a better medical prognosis and well as a better quality of life.

For over three hundred years, physicians have suspected an interaction between the emotions and the course of diabetes mellitus. Studies have examined whether stressful events or psychiatric illness might precipitate either Type I (insulin-dependent) or Type II (Non-insulin dependent) diabetes. So far, study results are not conclusive.

Now that we have more accurate methods of measuring glucose control, it has become easier to measure both short-term and long-term effects of emotional factors on blood glucose level. One study found that children judged to have a "Type A" personality structure had an increased blood sugar elevation in response to stress. Children with a calmer disposition had a smaller glucose rise when stressed. (Stabler et al. 1987) A 1997 study suggested that Type I patients with a history of a psychiatric illness might be at increased risk for developing diabetic retinopathy. Those patients with a psychiatric history were found to have a higher average glycosylated hemoglobin. (a measure of long term diabetic control) (Cohen et al. 1997) Children whose relatives made more critical comments had significantly poorer glucose control. Interestingly enough, emotional overinvolvement between family members was not correlated with poor diabetic control. (Koenigsberg et al. 1993) Diabetic adolescents had a higher incidence of suicidal ideation than expected. Those with suicidal ideation took poorer care of themselves. Not living in a two-parent home was associated with poorer long-term diabetes control. (Goldston, et al. 1997)

Recent studies have suggested that effective treatment of depression can improve diabetic control. In a study by Lustman and colleagues, glucose levels were shown to improve as depression lifted. The better the improvement, the better the diabetic control. (Lustman et al. 1997a)

Being diagnosed with diabetes is a major life stress. It requires a large number of physical and mental accommodations. The individual must learn about a complex system of dietary and medical interventions. Lifestyle, work, and school schedules may have to be altered. This can consume a lot of energy for both the individual and his or her family. Just as important, are the psychological adjustments. One must adjust to a new view of oneself. For those who liked to see themselves as invincible, this may be particularly difficult.

Many 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. The honeymoon phase, associated with early Type I diabetes, may reinforce denial. Denial is a common stance for adolescent diabetics.
* 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 desert. Unfortunately, anger can drastically affect glucose levels.
* Depression: Mild depressive feelings are a normal part of grieving and adaptation. As long as they are not pervasive or prolonged, they may not be harmful. However, when the depression lasts a long time, becomes severe or interferes with diabetic management, one should seek prompt treatment.
* Acceptance: Individuals achieve different degrees of acceptance and inner peace. Some will need to experience the denial, anger and depression several times as they move through different phases of life and different stages of diabetes. Some people move through a chronic disease to a state of much greater self-knowledge. They may actually say that the diabetes was, in part, a blessing. Through their close attention to diet and exercise, and their close monitoring of stress levels, they have arrived at a deeper understanding of themselves and their relations to others. They realize that for all human beings, life is vulnerable and precious.

Often, individuals with depression do not realize that they are depressed. It is easy to attribute the symptoms of depression to the diabetes. This is particularly difficult since depressed diabetics may have poorer glucose control. Sometimes a spouse or close friend can give good feedback. However, medical professionals or mental health clinicians may be the best ones to determine what is the diabetes and what is due to depression. A psychiatrist has had medical training before specializing in mental health. He or she can sort out the diagnosis, communicate with your regular doctor and help coordinate the treatment of the depression with treatment of the diabetes.

Symptoms of Depression: These are based on the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition. (DSM-4)

* Depressed mood for most of the day
* Decreased pleasure in normal activities
* Difficulty sleeping or significantly 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 of Depression:

The most important starting point is an accurate diagnosis. There have been major advances in the treatment of depression. There are specific medications and specific psychotherapy techniques that have been shown to help depression. Often individuals do well with a combination of antidepressant treatment and psychotherapy. Be sure that your clinician is willing to take the time to communicate with your diabetes team. Ideally, the mental health clinician should be familiar with your type of diabetes.

Antidepressants: Today, we have a much wider variety of antidepressant medications than were available fifteen years ago. Because we have more medication choices, we can often minimize annoying side effects. The older tricyclic antidepressants can increase glucose levels in non-depressed diabetics. However, when depressed diabetics take them, diabetic control improves. (Lustman et al. 1996) Selective Serotonin Reuptake Inhibitors (SSRIs such as Prozac and Zoloft) are easier to administer and have fewer side effects, so they are more often used as the first line antidepressants. Sometimes they can cause decreased sexual desire. This may be a sensitive issue for some diabetics, especially those who have some sexual difficulty due to their diabetes. This is not a reason to avoid treatment. Keep an open dialogue with your psychiatrist. If the medication does affect sexual functioning, dose adjustment or a switch to another type of antidepressant can usually take care of the problem. Often, treatment of the depression can result in much better sexual functioning. Other types of antidepressants, such as Bupropion (Wellbutrin) or Venlafaxine (Effexor) add to our treatment options. Some people respond to the first medication. Other people may have to try several medications before they hit upon the right one.

Psychotherapy: Recently, researchers have made an effort to do good psychotherapy outcome studies. It turns out that several forms of psychotherapy really do work better than simple "tincture of time." 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 erroneously 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.

Anxiety and stress can also cause large jumps in blood glucose levels. Panic attacks may resemble hypoglycemic episodes and vice-versa. (When in doubt, treat it as hypoglycemia.) People respond differently to stressful situations. Given the same subjective level of stress, one diabetic may have a different glucose response from another. Because of this, one should monitor blood glucose more frequently during periods of stress. On the positive side, a conscientious diabetic may have a unique barometer of stress unavailable to the general population. There are a number of specific anxiety disorders that are treated differently. As with depression, there are specific medications and therapies that have been shown to work. If anxiety is severe, it is important to identify the specific type, so that one can embark on the right treatment. We will not cover all of these treatments in this article. The following are some general suggestions for dealing with stress and mild to moderate anxiety.

* Examine your lifestyle for sources of stress. Are there stressers that can be eliminated?
* Learn relaxation techniques. Yoga, meditation, prayer, and hypnosis may help.
* Make sure that you are getting enough sleep
* Exercise. The body's primitive stress response was designed to prepare the individual to fight or to run away. In our society, we do not usually respond to stress with physical activity. Exercise helps our bodies deal with the physiological results of stress.
* Make a list of the things that are worrying you. When you have a concrete list, the problems often look more manageable.

Many people do not like the idea that they may have emotional difficulties. Some find it easier to attribute everything to physical problems or life circumstances. However, 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. Ultimately, the years of deliberately imitating natures beautiful and complex feedback systems can lead to a greater understanding and appreciation of body and mind.

References:

1 Lustman, PJ, Griffith, LS, Freedland, KE, Clouse, RE; The course of Major Depression in Diabetics Gen Hosp Psychiatry 1997; 19(2) 138-143.

2 Stabler B, Surwit, RS, Lane JD, et al. Type A Behavior pattern and blood glucose control in diabetic children Psychosomatic Medicine 1987; 49: 313-316.

3 Cohen, ST, Welch, G, Jacobson, AM, et al The Association of Lifetime Psychiatric Illness and Increased Retinopathy in Patients with Type I Diabetes Mellitus Psychosomatics 1997; 38: 98-108.

4 Koenigsberg, HW, Klausner, E, Pelino, D et al. Expressed Emotion and Glucose Control in Insulin-Dependent Diabetes Mellitus American Journal of Psychiatry 1993.

5 Goldston, DB, Kelley, AE, Reboussin, DM Suicidal Ideation and Behavior and Noncompliance with the Medical Regimen among Diabetic Adolescents American Journal of Child and Adolescent Psychiatry 1997.

6. Lustman, PJ, Griffith, LS, Clouse, RE et al. Effects of Nortryptiline on depression and glycemic controlin diabetes: Results of a double-blind, placebo-controlled trial. Psychosomatic Medicine 1997;59(3) 241-250