Or Does Depression Increase The Risk Of Diabetes?
Through several of my patients, I’ve had the opportunity to learn more about specific challenges facing Veterans, their struggle with Depression, and how Diabetes plays a role in their lives every day.
Meet David – A US Veteran
David is a veteran of the Vietnam War, and shared with me some of the conditions he experienced.
Many of the troops, including David, were drafted, and clearly didn’t want to be there. Couple that with a significant lack of US home front support – growing social unrest and antiwar sentiment – as well as the unclear objectives of the US government, and the soldiers’ morale were powerfully impacted from the moment they arrived.
David served in combat in Vietnam, in thick jungles and mountainous terrain, swamp and bogs, monsoons and swollen rivers. They often felt enormous distress when they had difficulty identifying the enemy. And as a result, many troops were lost to ‘friendly fire’. David saw this on a regular basis. Along with the rest of them, he held in his feelings of shock, shame and remorse. Instead, he focused on surviving and helping other soldiers in his unit.
David also saw horrific and deeply grievous events of war, including the loss of comrades. He didn’t dwell on them. In fact, he rarely spoke about it. The Vietnam War ended in April 1975 – over 40 years ago.
In the intervening years, David came back to the US, raised a family, and worked a regular job. He has also gained over 80 pounds and has been diagnosed with Type 2 Diabetes.
What is Diabetes?
Diabetes is an illness that affects the way the body uses digested food for energy. Most of the food we eat is broken down into a type of sugar called glucose. Glucose is an important source of fuel for the body and the main source of fuel for the brain. The body also produces a hormone called insulin. Insulin helps cells throughout the body absorb glucose and use it for energy. Diabetes reduces or destroys the body’s ability to make or use insulin properly. Without insulin, glucose builds up in the blood, and the body’s cells are starved of energy.
What Are Some Of The Symptoms Of Diabetes?
People might have SOME or NONE of the following symptoms:
- Frequent urination
- Excessive thirst
- Unexplained weight loss
- Extreme hunger
- Sudden vision changes
- Tingling or numbness in hands or feet
- Feeling very tired much of the time
- Very dry skin
- Sores that are slow to heal
- More infections than usual
Millions of Americans are unaware that they have diabetes, because there may be no warning signs.
What’s Involved in Self Care for Diabetes?
Diabetes is a complex disease that requires intensive self-care. It involves:
- adherence to prescribed medications,
- monitoring of blood glucose,
- adherence to dietary and physical activity recommendations,
- preventive foot care,
- attendance at medical appointments and
- regular screening for complications.
It has been estimated that approximately two hours per day are required to meet the American Diabetes Association recommended guidelines for self-care for patients taking oral hypoglycemics. Patients who have been depressed may need an intervention that targets adherence to this demanding regimen in addition to treatment for their depression alone. Comprehensive treatment with emphasis on both the diabetes and the depression may be required for optimal outcome.
David Seeks Help
David came to see me recently because, as he stated simply, “My thinking is bad.” I asked David to describe how that felt. “Well, I get confused a lot. I used to be really great at making lists and prioritizing the things I wanted to get done. Now, I make lists, and forget to look at them. Or, I start in on one of the tasks on the list and I get sidetracked and forget was I was doing. It happens all the time … several times a day. In fact, I have to be constantly aware so it doesn’t happen. I just don’t have good thinking.”
“I also feel foggy and overwhelmed a lot. Not like a few years ago when I thought everything was a snap. Now I feel like I’m on a treadmill, and there is no end – and that nothing is even worthwhile.” These are feelings I hear from patients just about every day. They strike a chord for many depressed patients.
David had even more to divulge, and I was pleased that he was so willing to talk about it. “Sometimes I feel really dark, hopeless and worthless. I try to muscle through it, and hope that tomorrow will be better. It used to be. But now it seems I feel that way more often than not.”
The Combination of Diabetes and Depression
Depression in patients with diabetes is prevalent, associated with increased functional disability, and reduced quality of life.
In addition to possibly increasing the risk for depression, diabetes may make symptoms of depression worse. The stress of managing diabetes every day and the effects of diabetes on the brain may contribute to depression. In the United States, people with diabetes are twice as likely as the average person to have depression.
At the same time, some symptoms of depression may reduce overall physical and mental health, not only increasing the risk for diabetes but making diabetes symptoms worse. For example, overeating may cause weight gain, a major risk factor for diabetes. Fatigue or feelings of worthlessness may cause people to ignore a special diet or medication plan needed to control their diabetes, thus worsening their diabetes symptoms.
Studies have shown that people with diabetes and depression have more severe diabetes symptoms than people who have diabetes alone.
How Are Veterans Affected?
In my quest to gain insights that might help David, I turned to the Veterans Administration (VA). Department of Veterans Affairs researchers declare that they are “locked in battle with an enemy that is quietly maiming and killing thousands of Americans who have served their country. It’s not post-traumatic stress, depression or traumatic brain injury.” The culprit is Type 2 Diabetes.
“Type 2 diabetes is at epidemic proportions among the Veteran population,” noted Dr. Tim O’Leary, acting director of VA’s Office of Research and Development. “It affects nearly 20 percent of Veterans who use the VA health care system, compared to 8.3 percent of the general population. This means that diabetes — and with it, the risk of heart disease, stroke, blindness, renal disease and amputation — affects more than one million Veterans at any given time.”
To make matters worse, millions of people don’t even realize they have the disease, since it can start out so subtly. “This is of tremendous concern for us at VA,” O’Leary said, “and why we’re doing research that not only helps Veterans avoid developing diabetes in the first place, but also helps them avoid developing those several other conditions I just mentioned.” He noted that VA already has an extensive research portfolio when it comes to diabetes, and is adding to it all the time.
What Kind of Research is Conducted at the VA?
“Let me tell you about a few of the hundreds of studies we have underway,” O’Leary said. “Many of our researchers are studying weight management, since being overweight or obese are significant risk factors for developing diabetes and are also epidemic among the Veteran population. Approximately three-quarters of Veterans are overweight,” he observed, “and nearly 40 percent are obese.”
O’Leary said VA has participated in a number of large clinical trials, such as the Diabetes Prevention Program, where it was shown that losing weight and increasing exercise can reduce the progression from pre-diabetes to type 2 diabetes. “This effort,” he said, “has contributed to VA’s national weight management program, called MOVE, and has also been used beyond VA to improve the health of all Americans.”
Does the VA Offer Help?
“We have robust telehealth and eHEALTH programs here at VA. No matter where you are, we can connect with you and give you the support you need. You’re never alone.”
- Learn more about VA diabetes research
- Find out more about VA’s telehealth program
- Get more information about VA’s eHEALTH program
- Learn more about VA’s MOVE! Weight Management Program for Veterans
How Is Depression Treated In People Who Have Diabetes?
Treating depression can help manage diabetes and improve overall health. Scientists report that for people who have diabetes and depression, treating depression can raise mood levels and increase blood glucose control.
At present, the most common treatments for depression include:
- Cognitive behavioral therapy (CBT), a type of psychotherapy, or talk therapy, that helps people change negative thinking styles and behaviors that may contribute to their depression
- Selective serotonin reuptake inhibitor (SSRI), a type of antidepressant medication that includes citalopram (Celexa), sertraline (Zoloft), and fluoxetine (Prozac)
- Serotonin and norepinephrine reuptake inhibitor (SNRI), a type of antidepressant medication similar to SSRI that includes venlafaxine (Effexor) and duloxetine (Cymbalta).
Some antidepressants may cause weight gain as a side effect and may not be the best depression treatment if you have diabetes. These include:
- Monoamine oxidase inhibitors (MAOIs)
- Paroxetine (Paxil), an SSRI6
- Mirtazapine (Remeron)
While currently available depression treatments are generally well tolerated and safe, talk with a knowledgeable health care provider about side effects, possible drug interactions, and other treatment options. For the latest published information on medications, visit the U.S. Food and Drug Administration website . Not everyone responds to treatment the same way. Medications can take several weeks to work, may need to be combined with ongoing talk therapy, or may need to be changed or adjusted to minimize side effects and achieve the best results.
Evidence suggests that depressive symptoms and heightened distress, even in the absence of a diagnosis of clinical depression, are associated with worse diabetes self-care and poorer diabetes control. Furthermore, the relationship between depressive symptoms and poorer self-care appears to be linear.
Is Treatment Effective?
Recognizing and treating depression in patients with diabetes may help avoid downstream adverse health-related outcomes. Research has shown that depression is consistently associated with increased hyperglycemia and increased risk of diabetes complications, including:
- diabetic retinopathy,
- macrovascular complications, and
- sexual dysfunction.
How Does Self-Care Impact Diabetes Progression?
Self-care in diabetes is extremely important for the prevention of poor health outcomes. Adherence with treatment guidelines decreases rates of mortality and morbidity in diabetes and helps achieve good diabetes control. Self-care activities (e.g., increasing physical activity and maintaining healthy nutrition) can slow disease progression.
Diabetes self-care behaviors themselves may have an impact on mood. If a patient has low self-efficacy regarding his or her diabetes self-care (e.g., believes that he or she is unable to perform adequate self-care), or negative thoughts about the future regarding his or her disease, struggles with diabetes self-care may worsen mood, because these negative thoughts are triggered.
If, on the other hand, a patient can learn to reframe his or her thoughts to see diabetes self-care as a positive step toward taking care of his or her health, he or she may experience a sense of mastery, and thus mood improvement, from engaging in diabetes self-care activities.
Non-adherence, which is more common in patients with depression, on the other hand, intensifies disease burden. Therefore, effective treatments for depression in patients with diabetes may not only improve depression and quality of life, but also indirectly improve disease outcomes and illness burden.
Studies also indicate that depression treatments are effective in reducing glycosolated hemoglobin A1c (HbA1c) levels by an average of .54%, which is clinically meaningful, and improving quality of life in patients with diabetes.
What Interventions Are Effective?
The psychosocial intervention that has received the most attention is Cognitive Behavioral Therapy (CBT), a short-term, skills-based intervention designed to change negative thinking and increase positive behavior, such as problem-solving and relaxation, which has been shown to be effective for the treatment of depression.
Among pharmacological interventions, the selective serotonin re-uptake inhibitors (SSRIs) are the most commonly prescribed antidepressants because of their safety profile and their efficacy. They have been recommended in depressed patients with diabetes, because they may cause hypoglycemia and weight loss in addition to their antidepressant properties. Fluoxetine, for example, can improve glycemic control. Bupropion, a norepinephrine/dopamine reuptake inhibitor, is as effective for in the treatment of depression as the SSRIs, and has shown favorable effects on weight in patients with obesity and depressive symptoms and on glycemic control in patients with diabetes.
Other effective antidepressant medications, however, have been linked to side effects that are particularly undesirable in patients with diabetes. For example, monoamine oxidase inhibitors (MAOIs) can cause weight gain, and tricyclic antidepressants (TCAs) can cause hyperglycemia, both of which can be problematic in individuals without diabetes, but are especially counterproductive and even dangerous in patients with diabetes.
Should We Treat For Depression to Improve Diabetes Control?
Finally, although the issue of whether treating depression could improve diabetes control directly is an important research question, we should not underestimate the importance of treating depression as an end in itself in patients with diabetes.
TMS – An Alternative to Psychosocial and Pharmacological Interventions?
TMS (Transcranial Magnetic Stimulation) therapy is a new therapy that involves no drugs and has been proven safe and effective. TMS is free of the negative side effects often associated with taking antidepressants.
TMS Therapy is an FDA-cleared non-invasive medical treatment for patients with major depression who have not benefited from antidepressant medication.
TMS is precisely targeted at a key area of the brain known to be underactive in depression sufferers. TMS uses highly focused magnetic pulses to stimulate that area to restore it to normal function and lift depression.
- TMS Therapy has been proven safe and effective in the treatment of depression
- TMS Therapy is free of side effects typically experienced with antidepressant medications. The most common side effect associated with treatment is discomfort at or near the treatment area – generally mild to moderate.
- Each TMS Therapy treatment takes less than an hour and is conducted in your doctor’s office, five days a week, for approximately four to six weeks
- NeuroStar patients are awake and alert during treatment and are able to resume normal activities upon leaving the treatment sessions.