Detecting and Treating Depression in Diabetes
Elevated glucose levels can cause significant fatigue, which may also have a negative effect on patients’ ability to engage in management of depression.
Depression is a frequent comorbidity among individuals with chronic medical illness, particularly those with diabetes.1 The reported prevalence in patients with type 1 and type 2 diabetes is 13% and 18%, respectively.2 Risk factors for depression in this population include younger age at diagnosis, poor glycemic control, disease complications, female sex, high body mass index, and lower education level or income level.
“Given the chronicity of diabetes and the involvement necessary to manage the condition — making healthy food choices, making time for regular exercise, monitoring blood glucose levels, taking medications, sometimes multiple medications and even some that require injections — individuals with diabetes are at high risk for depression,” Sandra Sobel, MD, clinical chief of endocrinology at UPMC Mercy, told Psychiatry Advisor. Depressive symptoms are also associated with difficulty in maintaining these self-care behaviors.2
Stress related to self-management of diabetes can lead to or exacerbate depression, and depression “affects an individual's ability to perform activities of daily living and properly manage the condition,” according to a 2016 study reported in Diabetes Educator.3 Patients with depression are also more likely to smoke, have a poor diet, and have a sedentary lifestyle, all of which increase risk for type 2 diabetes.2
Compared with people with diabetes and no comorbid depression, studies have found that those with depression have worse metabolic and glycemic control, worse microvascular and macrovascular complications, and more than twice the mortality risk.2 Despite professional recommendations from the American Diabetes Association (ADA), roughly two-thirds of patients with chronic illness do not undergo timely depression screening.3 The use of self-assessment questionnaires such as the World Health Organization (WHO)-5 Well-Being Index, the Beck Depression Inventory, or the Patient Health Questionnaire(PHQ)-9, can increase sensitivity for depression diagnosis >90%.4
“Inclusion of a screening for diabetes distress, such as Problem Areas in Diabetes (PAID)-5 questionnaire, which focuses on emotional responses (distress) to aspects of life with diabetes, provides considerable additional value,” wrote the authors of a review published in Primary Care Diabetes.2 “The combined approach of using the WHO-5 questionnaire (for depression) in combination with either the PAID-5 or PAID-1 questionnaire (for diabetes distress) is a simple tool for detecting depression, monitoring patient well-being over time, and guiding the extent to which the subsequent management of depressive symptoms should focus on specific aspects related to diabetes management.”
For patients in whom depression is identified, a stepped care approach is recommended, with strategies ranging from watchful waiting for those with less severe symptoms, to referral for mental health care, which may include psychological or pharmacologic approaches.2
To further explore the topic of comorbid diabetes and depression, Psychiatry Advisor interviewed Dr Sobel and Amy Werremeyer, PharmD, BCPP, associate professor in the Department of Pharmacy Practice at North Dakota State University. Dr Sobel's comments apply to both type 1 and type 2 diabetes, while Dr Werremeyer's input pertains mostly to type 2 diabetes, which has been the focus of her research in this area.
Psychiatry Advisor: What strategies should be used to identify patients with diabetes who are at risk for depression or vice versa?
Dr Sobel: Some strategies for identifying patients with diabetes who may have concurrent depression include:
- Ask. Most people are relieved when a provider is straightforward and asks whether or not the disease, or management of the disease, is causing depression.
- If someone repeatedly misses appointments or does not come with their glucose meter, there could be concurrent depression that is affecting their interest in remaining engaged in diabetes self-care.
- Diabetes control. If there are worsening glucose numbers or A1C values, that could be an indication that a person is depressed and, again, the depression could be affecting their ability to self-manage.
For the reverse, some medications [may contribute to the development of diabetes]. For example, olanzapine is occasionally used in combination with other medicines for the treatment of depression. It is known to cause weight gain and increased risk for insulin resistance, which could lead to development of diabetes. Weight gain, reports of fatigue, increased thirst, and increased urination would be ways to identify someone [in whom diabetes] may be developing.
Dr Werremeyer: All patients with diabetes should be screened for depression at least annually and likely more often for those with a history of depression. Several validated screening tools exist for identifying depressive symptoms in this population, including the PHQ-9. In addition, the potential of a contributing major depressive disorder [should be considered] among those patients who have difficulty achieving their diabetes treatment goals.
Psychiatry Advisor: What are the clinical challenges of managing depression in those with comorbid type 2 diabetes and depression vs depression or diabetes alone?
Dr Sobel: [As noted above], comorbid depression, when not well controlled, can affect one's ability to self-manage diabetes. There can be loss of interest in making proper lifestyle choices, monitoring glucose levels, and taking one's medicines. Also, elevated glucose levels can cause significant fatigue, which may also negatively affect one's ability to engage in management for depression, whether it is taking their medications for depression or following up on appointments with psychiatrists and therapists.
Dr Werremeyer: There are many challenges to managing patients with comorbid type 2 diabetes and depression. First of all, primary care practices are extremely busy, and providers and patients alike often can become overwhelmed with the many competing demands involved in trying to manage more than one chronic condition. Research has shown that even when patients with type 2 diabetes get adequate screening for depression, their depressive symptoms still often remain suboptimally treated.5 Another challenge is that patients with depression and type 2 diabetes may have lower rates of medication and overall treatment adherence than patients with type 2 diabetes who do not have depression.
Psychiatry Advisor: Do complications of diabetes tie into mental health issues in the later course of the illness and vice versa?
Dr Sobel: Absolutely — microvascular complications from uncontrolled diabetes include retinopathy, nephropathy, and neuropathy. With retinopathy, frequent visits with an ophthalmologist may be necessary, and if the retinopathy progresses, may require injections into the eye or laser therapy and even a risk for blindness. This, of course, could adversely affect depression management.
Nephropathy can be an indication of renal disease and also, if progressive, could lead to worsening renal function or even renal failure necessitating hemodialysis. Individuals on hemodialysis are known to have a high prevalence of depression. Having to make one's dialysis sessions 3 times a week for 4 to 6 hours each time can affect one's ability to properly manage depression, not to mention that some medication for depression would have to be dose adjusted due to the kidney disease.
Neuropathy is a complicated issue in which many individuals can experience pain. While we have some medications available for management of neuropathy, they may not always be sufficient to control the discomfort caused by neuropathy, and uncontrolled pain can negatively affect depression.
Individuals who may not have been depressed during the beginning stages of diabetes management, if complications set in, may develop depression as a result of the realization of the worsening of health that has ensued.
Dr Werremeyer: Yes, complications of mental health issues can contribute to problems in the later course of type 2 diabetes. It is known that patients with comorbid mental health conditions and type 2 diabetes tend to have more poorly controlled type 2 diabetes. This certainly has the potential to lead to greater type 2 diabetes-related complications down the road. Furthermore, patients with uncontrolled depressive symptoms may also be at greater risk for cardiovascular disease, potentially compounding the risk already associated with type 2 diabetes.
Finally, the higher rate of substance use disorders among patients who also have depressive disorders has the potential to further serve as a barrier to achieving type 2 diabetes treatment goals, increasing the risk for long-term type 2 diabetes-related complications. Type 2 diabetes can also complicate the course of mental health issues and lead to problems over time. For example, patients struggling with mental health issues may be disproportionately affected by the burden of needing to manage type 2 diabetes, and therefore, be at risk for worsening of mood and/or development of substance use disorders.
Psychiatry Advisor: How should clinicians approach patients with comorbid type 2 diabetes and depression to help them maintain compliance or adherence to antihyperglycemic medication?
Dr Sobel: I think it is important for providers to speak about the frequent coexistence of both medical conditions, so that patients may feel empowered to discuss depression without feeling embarrassed or ashamed. In addition, it is important to understand what [a person's] social support network is like. If someone does not have a strong social support network, introducing them to diabetes education classes or groups could be a way in which they could establish a support and find comradery with individuals who are going through similar frustrations, struggles, or successes.
I also encourage them, if they are comfortable, to bring a trusted partner with them to any appointments or group classes so that the partner can understand the involvement we are asking from the patient to help manage their medical conditions. This may offer the partner insight into the challenges and may motivate them to help, or at least help them understand why there may be good days and bad days. Lastly, I like to have a list of therapists in the area that I can refer individuals to who agree that establishing [contact] with a psychiatrist and or therapist would be helpful.
Dr Werremeyer: Clinicians should approach patients with comorbid type 2 diabetes and depression by working with patients to set individualized treatment goals for both conditions. In my experience, patients with these 2 comorbid conditions really want their providers to communicate very clearly not only what the treatment goals are, but also the rationale for these goals and for the use of certain medications in targeting particular treatment goals. Clinicians also should seek to find out from the patient what his or her goals are, not just in terms of A1c numbers, but in real-life terms, and how the myriad of treatments and treatment choices affect the patient in day-to-day living.
Clinicians could consider posing questions such as: What does being “well” look like in your life? What impact does checking your blood sugar or taking this medicine have on your life? Your work productivity? Your relationships? What does your medication-taking system at home look like? How do you remember to take your medications? Do you ever feel “fed up” with taking your medications? In my experience, these types of questions open doors into what the patient is really experiencing with regard to their treatments and their adherence with them. Conversations that stem from these questions can lead to better understanding by both the patient and the provider about what is feasible, what is desirable, and what is practical for the patient to be able to and to want to comply with.
- Thomas J, Jones G, Scarinci I, Brantley P. A descriptive and comparative study of the prevalence of depressive and anxiety disorders in low-income adults with type 2 diabetes and other chronic illnesses. Diabetes Care. 2003;26(8):2311-2317.
- Hermanns N, Caputo S, Dzida G, Khunti K, Meneghini LF, Snoek F. Screening, evaluation and management of depression in people with diabetes in primary care. Prim Care Diabetes. 2013;7(1):1-10.
- Barnacle M, Strand MA, Werremeyer A, Maack B, Petry N. Depression screening in diabetes care to improve outcomes: are we meeting the challenge? Diabetes Educ. 2016;42(5):646-651.
- Hermanns N, Kulzer B, Krichbaum M, Kubiak T, Haak T. How to screen for depression and emotional problems in patients with diabetes: comparison of screening characteristics of depression questionnaires, measurement of diabetes-specific emotional problems and standard clinical assessment. Diabetologia. 2006;49(3):469-477.
- Katon WJ, Simon G, Russo J, et al. Quality of depression care in a population-based sample of patients with diabetes and major depression. Med Care. 2004;42(12):1222-1229.