The affects of diabetes can be staggering. In addition to well-known complications related to cardiovascular health, kidney function, and cerebrovascular accidents, diabetes has been shown to impact mental health as well. In susceptible individuals, diabetes can trigger and/or exacerbate the severity of depression. Furthermore, depression has been shown to precipitate the onset of diabetes. In patients with diabetes, one cannot be effectively managed without taking into consideration the other. It is vital for both health and mental health professionals to have a clear understanding of how these two highly prevalent conditions interact and impact patient health.
This course is designed for all nurses, social workers, counselors, therapists, dietitians, and allied mental health professionals with a desire to better understand the mental health issues facing a person with diabetes.
NetCE is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. NetCE is approved by the California Nursing Home Administrator Program as a provider of continuing education. Provider number 1622. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is approved as a provider of online continuing education for certified nursing assistants through the California Department of Public Health Licensing and Certification Division. Nurse Aide Certification (NAC) Provider #7005.
NetCE designates this continuing education activity for 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. NetCE designates this continuing education activity for 1 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 3 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. This home study course is approved by the Florida Board of Nursing Home Administrators for 3 credit hour(s). This course is approved by the California Nursing Home Administrator Program for 3 hour(s) of continuing education credit - NHAP#1622003-5385/P. California NHAs may only obtain a maximum of 10 hours per course. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program.
In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353, (valid through December 12, 2017); California, BRN Provider #CEP9784; California, LVN Provider #V10662; Florida, Provider #50-2405; Iowa, Provider #295; Kentucky, Provider #7-0054 through 12/31/2017.
In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.
The purpose of this course is to provide nurses and allied mental health professionals with the information necessary to identify depression in patients with diabetes and to intervene to improve these patients' quality of life.
Upon completion of this course, you should be able to:
- Discuss the epidemiology and diagnosis of diabetes.
- Evaluate the pathophysiology of depression and identify types that can impact patients with diabetes.
- Analyze tools available to screen for depression in patients with diabetes.
- Identify treatment options for clinical depression in diabetic patients.
- State the educational needs for individuals with diabetes complicated by depression.
Diane Thompson, RN, MSN, CDE, CLNC, has an extensive history in nursing and nursing education. She possesses a strong background in diabetes and cardiac care, starting her professional career at the cardiac care area of the Cleveland Clinic in Cleveland, Ohio. Ms. Thompson took the knowledge and experience she learned from the Cleveland Clinic and transferred it into the home health arena in rural Ohio, after which she moved to Florida and obtained further knowledge while working as a PRN nurse in all areas, including medical/surgical, intensive care, emergency, critical care, and cardiology. With a desire to have a specific area to concentrate her profession, Ms. Thompson accepted a position as a pneumonia case manager, which led into a diabetes case manager career.
Ms. Thompson has been employed in diabetes care since 2001, when she was hired as a diabetes case manager. After the completion of 1000 hours of education to diabetes patients, Ms. Thompson earned her certification as a diabetes educator in 2003. Since 2006, Ms. Thompson has been the Director of Diabetes Healthways at Munroe Regional Medical Center in Ocala, Florida. As the director of the diabetes center, Ms. Thompson is responsible for the hospital diabetes clinicians, hospital wound care clinicians, and out-patient education program. Ms. Thompson has also lectured at the local, state, and national level regarding diabetes and the hospital management of hyperglycemia. Ms. Thompson is a member of the ADA, AADE, Florida Nurses Association, and the National Alliance of Certified Legal Nurse Consultants.
Ms. Thompson acknowledges her family as her greatest accomplishment. She is a wife of 26 years and a mother of a daughter and son, of which she is very proud. Ms. Thompson credits her husband for the support needed to see a goal and achieve it. He has been by her side through nursing school and completion of her Bachelor's degree and Master's degree, which she was awarded in 2015 from Jacksonville University in Florida.
Contributing faculty, Diane Thompson, RN, MSN, CDE, CLNC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Jane C. Norman, RN, MSN, CNE, PhD
Alice Yick Flanagan, PhD, MSW
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
- AN OVERVIEW OF DIABETES
- AN OVERVIEW OF DEPRESSION
- SIGNS OF DEPRESSION IN PATIENTS WITH DIABETES
- SCREENING FOR DEPRESSION IN PATIENTS WITH DIABETES
- IMPACT OF DEPRESSION ON DIABETES CONTROL
- TREATMENT OPTIONS
- PATIENT EDUCATION
- CASE STUDY
- Works Cited
- Evidence-Based Practice Recommendations Citations
Supported browsers for Windows include Microsoft Internet Explorer 9.0 and up, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Supported browsers for Macintosh include Safari, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Other operating systems and browsers that include complete implementations of ECMAScript edition 3 and CSS 2.0 may work, but are not supported.
#96291: Diabetes and Depression
Depression is the leading cause of disability in the world and the third most common reason for seeking healthcare advice and care, and it is 1.5 times more common among people with diabetes than it is in the general population . Major depression is present in 15% to 20% of individuals with diabetes, regardless of the type . Comorbid depression in patients with diabetes is associated with higher medical symptom burden, additional functional impairment, poor self-care, a greater number of cardiac risk factors, and increased microvascular and macrovascular complications, resulting in higher blood glucose levels, greater healthcare costs, and a higher mortality . So, the need to effectively manage depression and prevent further complications is imperative .
The large-scale international study Diabetes Attitudes, Wishes, and Needs (DAWN) assessed the role of brief empathetic listening intervention to enhance diabetes care and patient well-being . The study revealed that individuals with diabetes rated their compliance with treatment recommendations as poor and clinicians' estimations were even lower. Approximately 70% of clinicians cited psychologic problems and depression as playing a major role in inadequate psychologic well-being and adherence to treatment plans. Despite this widely acknowledged impact, only 10% of patients had received any psychologic treatment .
Depressive symptoms have also been found to predict the incidence of type 2 diabetes, with the relationship only partially explained by demographics, metabolic traits, and lifestyle factors . The involvement of neuroendocrine mediators in the stress-obesity-diabetes relationship requires further study and evaluation . Diabetes may increase the risk of depression as a result of the sense of threat and loss associated with the diagnosis and the substantial lifestyle changes necessary to avoid the development of debilitating complications .
Unfortunately, despite the known risks, depression is recognized and treated in only one-third of cases in individuals with diabetes . If depression is not treated prior to the diagnosis of diabetes, it may be underdiagnosed afterwards, particularly in patients with complex clinical pictures .
Diabetes is a progressive disease process influencing fuel metabolism by the body . Carbohydrate, protein, and fat metabolism are altered when insulin, the mediator of fuel, is not available. Insulin deficiency can result from defects in insulin secretion and/or diminished tissue response to insulin. The result of this defect in insulin secretion and/or insulin resistance is hyperglycemia . The chronic metabolic dysregulation associated with diabetes can result in long-standing damage to various organs, including the eyes, kidneys, nerves, heart, and blood vessels .
According to the Centers for Disease Control and Prevention (CDC), the prevalence of diagnosed diabetes has increased from 0.93% of the U.S. population in 1958 to 7.02% in 2014 . As of 2014, 9.3% of the U.S. population, or 29.1 million Americans, have a diagnosis of diabetes. In addition, an estimated 8.1 million people have diabetes but remain undiagnosed [10,11]. By 2025, it is predicted that 15% to 20% of all Americans will have a diagnosis of diabetes or impaired glucose tolerance .
The scope of the diabetes problem is vast and diverse, particularly among geographical regions. In 2014, the prevalence of diabetes in the United States varied from 6.9% in Vermont to 11.9% in Mississippi . Genetics, race, age, and lifestyle significantly influence the onset and progression of the disease process . Although all races and ethnicities can develop diabetes, the prevalence is greatest among American Indian/Alaska Natives [10,11]. The prevalence of diabetes, both diagnosed and undiagnosed, is 13.9% in Mexican American adults, compared to an overall national rate of 9.3% in adults . An estimated 13.2% of African Americans have diabetes. However, Native Americans/Alaska Natives present the greatest risk for the development of type 2 diabetes; it is estimated that approximately 15.9% of Native Americans/Alaska Natives older than 20 years of age have type 2 diabetes . The highest prevalence of diabetes in the United States is observed in Native Americans in southern Arizona, where an estimated 24.1% of the population has the disease .
The most common types of diabetes are type 1 and type 2. However, gestational diabetes is also relatively common and is a source of significant morbidity and mortality. Gestational diabetes is first recognized in pregnancy, usually after 24 weeks of gestation, and typically resolves after the birth of the child . Other less common types of diabetes include [12,16]:
Maturity-onset diabetes of the young: A genetic, autosomal-dominant defect of the pancreatic beta cells, resulting in insulin deficiency and decreased insulin release without the presence of insulin resistance and obesity. This form of diabetes typically develops in patients younger than 25 years of age. It is a different clinical entity than type 2 diabetes of the adolescent, which presents with insulin resistance.
Diabetes related to diseases of the exocrine pancreas, such as cystic fibrosis, and various endocrine diseases, such as Cushing syndrome, acromegaly, and chromocytoma
Drug-induced diabetes resulting from the use of certain medications, particularly high-dose corticosteroids
All adults older than 45 years of age should be screened for type 2 diabetes every three years or every two years if they have any risk factors . In addition, individuals of any age who are at risk for or are suspected of having diabetes should be screened. Established risk factors for type 2 diabetes include:
Age older than 45 years
Body mass index (BMI) greater than or equal to 25 kg/m2
Family history of type 2 diabetes
Habitual physical inactivity
Race/ethnicity (e.g., African American, Hispanic American, Native American, Alaska Native, or Pacific Islander)
Impaired glucose tolerance or elevated fasting glucose
Previous history of gestational diabetes or giving birth to a child weighing more than 9 pounds
Hypertension (i.e., blood pressure greater than 140/90 mm Hg in adults)
Abnormal lipid levels (i.e., high-density lipoprotein [HDL] level <35 mg/dL and/or triglyceride level >250 mg/dL)
Polycystic ovary syndrome
History of vascular disease
Acanthosis nigricans (most common among individuals of African descent)
The diagnostic criteria for type 2 diabetes are fairly straightforward and are based on fasting plasma glucose and postprandial plasma glucose levels (Table 1). After a diagnosis of type 2 diabetes has been definitively made, education on self-care management is necessary in order to obtain euglycemia and prevent complications related to the detrimental effects of hyperglycemia . It is estimated that as many as 90% of patients with type 2 diabetes will require oral medications to achieve adequate glucose control within five years of diagnosis . When glucose levels cannot be adequately controlled with oral medications, the use of injectable medications is necessary. If elevated blood glucose levels are untreated and continue to rise, the result can be hyperosmolar hyperglycemia syndrome and ultimately death .
DIAGNOSTIC CRITERIA FOR TYPE 2 DIABETES
Fasting Plasma Glucose Level
|Two-Hour Postprandial Plasma Glucose Level||
Glycated Hemoglobin Components
|Euglycemia||≤100 mg/dL||<140 mg/dL||<5.7%|
|Prediabetes||>100 mg/dL but <126 mg/dL||≥140 mg/dL but <200 mg/dL||5.7% to 6.4%|
|Diabetesa||≥126 mg/dL||≥200 mg/dL||≥6.5%|
|aA random blood glucose level ≥200 mg/dL with symptoms of hyperglycemia is also indicative of diabetes.|
Although much research has been conducted on the neurobiologic causes of depression, the exact underlying pathophysiology of depression (specifically major depression) remains unknown . One consistent observation is that stress or emotional trauma, especially when experienced earlier in life, is associated with increased risk of developing depression . It is believed that 40% to 50% of the risk for developing depression is due to genetic factors and that the interactions between genetic and environmental factors across the lifespan underlie depressive vulnerability in most patients . Early-life stress can result in persistent neuroendocrine, physiologic, behavioral, and psychologic changes that negatively affect the development of brain systems involved in learning, motivation, and stress response, and that may also reflect a biologic priming for the development of depression, especially with additional stress exposure [19,22].
Until recently, explanations of the pathophysiology of depression have focused on imbalance among specific neurotransmitter systems, most prominently serotonin, norepinephrine, and dopamine. Considerable evidence does support the notion that major depression involves an alteration in the balance of neurotransmitters and/or their function. A decrease in the functional balance of specific neurotransmitters has been hypothesized to cause certain types of depression; decreased norepinephrine would cause dullness and lethargy, while decreased serotonin would result in irritability, hostility, and suicidal ideation .
However, depression is now realized to be a heterogeneous disorder in which different biologic abnormalities contribute to the disruptions in sleeping, eating, energy, and emotional reactions . The four domains of cognitive function that are disturbed in persons with depression are executive control, memory, affective processing, and feedback sensitivity . Although enormous gaps remain in understanding depression and its treatment, there is an increasing focus on dysregulated neural circuitry as the underlying pathophysiology of depression, with a corresponding de-emphasis on specific neurotransmitter system dysfunction .
There are many different types of depression of varying degrees and characteristics. A full discussion of all of the various types of depression and specifiers is beyond the scope of this course, but the following section will outline some of the most common types to affect persons with diabetes.
Chronic depression can be mild to severe in its debilitation of the patient and may persist for years if untreated [5,26]. It is defined as a chronically depressed mood that is present more than half the time for a minimum of two years in adults or one year in children and adolescents [27,28].
The exact cause of mild chronic depression is unknown, although it occurs with greater frequency in women compared to men. Many individuals have a history of long-term medical conditions or mental health disorders, such as anxiety or substance abuse. Approximately half of individuals with this type of depression will experience a major depressive episode at some point in their life .
Major depression is a mood disorder characterized by feelings of sadness, loss, anger, and/or frustration that interfere with everyday life and last for weeks or longer . The essential feature of major depression is depressed mood or anhedonia (loss of interest in usual activities) experienced most of the day and nearly every day for a period of at least two weeks [2,28].
As noted, major depressive disorder has a higher incidence among persons with diabetes compared to the general public, and individuals with diabetes and depression are more likely to stay depressed than those without diabetes . Major depression is typically recurrent in individuals with diabetes; even after successful treatment, studies show it will reoccur in as many as 80% of individuals with diabetes, with an average of four episodes during a five-year period .
Individuals with chronic illnesses, including diabetes, have an increased risk of major depressive episodes with psychotic symptoms (e.g., delusions, hallucinations [typically auditory]) in comparison to the general population . Major depression with psychotic features is considered a severe form of the disease, and diagnosis can be complicated .
Seasonal affective disorder (also referred to as major depression with seasonal pattern) is a cyclic type of depression defined by depressive episodes experienced only during certain times of the year, most commonly the fall and winter [5,28]. It is more frequently noted in women than men and in younger individuals than older adults . Seasonal affective disorder is often considered to be related to a lack of exposure to sunlight and may be treated with bright visible-spectrum light therapy .
Postpartum mood disorders are generally divided into three categories: postpartum blues (or "baby blues"), postpartum depression, and postpartum psychosis. These conditions do not exist on a continuum; each category is a distinct postpartum state .
Postpartum depression (diagnosed as major depression with peripartum onset) occurs in approximately 10% of new mothers [28,29,30,31]. A study of low-income mothers found that the presence of diabetes during pregnancy was associated with an almost twofold increase in the incidence of postpartum depression compared to women without diabetes . The study did not specify if the diabetes diagnoses were present prior to the pregnancy.
Symptoms usually occur shortly after childbirth but may occur during pregnancy or as late as one year after delivery. Postpartum depression is a serious, long-lasting type of depression in women that can have harmful consequences for the mother and child if undetected and untreated.
It is common for individuals with diabetes to experience emotional distress as a result of living with the disease, its complications, and treatment and self-monitoring . The most common factor affecting psychologic well-being, reported in about one-third of individuals with diabetes, is worrying about the future and the possibility of diabetes complications. Other areas endorsed as "serious" by patients with diabetes include :
Guilt and anxiety about noncompliance with treatment
Fear and depression about living with diabetes
Being unsure if mood changes are related to blood glucose levels
Being constantly concerned about food and eating
Feeling deprived around food
Other signs of depression in patients with diabetes include appetite disturbances and weight change, sleep disturbances, physical agitation, decreased energy, feelings of worthlessness or excessive guilt, difficulty concentrating and thinking, and even suicidal thoughts .
The American Diabetes Association (ADA) has made several recommendations regarding screening for depression in patients with diabetes. Their recommendations include :
Routine screening for psychosocial problems (e.g., depression, diabetes-related distress, eating disorders)
Evaluation of cognitive function and depression screening/treatment in adults 65 years of age and older with diabetes
Stepwise collaborative care for patients with comorbid diabetes and depression
Many barriers can make detection of depression particularly challenging for healthcare providers in the medical setting. These include :
Lack of time during office visits
Somatization (i.e., physical symptoms such as fatigue, appetite changes, and sleep disruption, but no affective or cognitive symptoms)
Comorbid medical conditions that may have similar symptoms
As such, special attention should be paid to the affective components of depression, including changes in mood, loss of interest in usual activities, guilt, or suicidal ideations . If time constraints are a particular problem, the brief Patient Health Questionnaire-2 (PHQ-2) has been found to identify depressive symptoms with a sensitivity and specificity of 97% and 67% in adults and 74% and 75% in adolescents, respectively . The PHQ-2 asks just two questions [2,5,33]:
Over the last two weeks, have you been feeling down or depressed more of the time than not?
Over the last month, have you lost interest in doing things that usually bring you pleasure?
The PHQ-9 is increasingly administered for confirmation of a positive PHQ-2 result. The PHQ-9 can be completed in less than five minutes and has a demonstrated 61% sensitivity and 94% specificity in adults and 89.5% sensitivity and 77.5% specificity in adolescents . In addition to the questions included on the PHQ-2, the PHQ-9 inquires regarding sleep problems, lack of energy, changes in appetite, feelings about self, trouble with concentration, changes in speech/movement, and thoughts of self-harm or suicide . Other screening options are the Problem Areas in Diabetes (PAID)-1 scale and the Diabetes Distress Scale (DDS), both of which are self-administered questionnaires designed to help clinicians assess the emotional distress of individuals with diabetes [15,34]. The most practical tool for one's clinical setting should be used .
The PAID-1 scale is a 20-item evaluation covering a range of emotional problems frequently reported in patients with diabetes . Each item is scored based on the severity of the problem, with 100 total points possible. A higher score is indicative of greater emotional distress. Studies using this questionnaire have demonstrated the greatest worries for these patients to be related to an undefined future, the possibility of serious complications, and guilt due to treatment noncompliance . Greater emotional distress according to PAID-1 scale results is correlated to poor glycemic control .
The DDS consists of 17 items assessing levels of distress linked to diabetes and pinpointing specific patient concerns . Studies indicate that it is consistent and highly sensitive to emotional/psychologic stress related to diabetes when administered in a variety of settings.
Children with diabetes experience a rate of depression that is two to three times higher than the general population, yet the majority of research exploring diabetes and depression has been conducted in adults. Little is known about the association between adolescent-onset depression and the development of type 2 diabetes; however, researchers are beginning to identify risk factors [37,38,39]. An examination of prospective data from 92 youth from the time of diabetes diagnosis found that 47.6% met the diagnostic criteria for psychiatric comorbidity at some point during the 10-year study period . Another study found depression to be more likely in girls, with less frequent SMBG, poorer metabolic control, and greater perceived diabetes burden . The nationwide SEARCH for Diabetes in Youth Study (SEARCH study), which enrolled 2,672 youth, found that girls had higher mean depression scores than boys, and boys with type 2 diabetes were at greater risk for depression than those with type 1 diabetes . Despite the identification of some risk factors for depression in adolescents with diabetes, many youth are not quickly identified as experiencing symptoms of depression. As stated, barriers exist that make early detection difficult. However, routine screening for depression can help . Screening tools such as the Children's Depression Inventory 2 (CDI 2) and the Center for Epidemiological Studies Depression Scale (CES-D) are brief self-report measures that can help identify youth at risk for depression [43,44,45,46,47,48,49,50].
Approximately 16% of Americans will suffer a major depressive disorder at some point in their lives, although the rate is greater when other forms of depression (e.g., persistent depressive disorder) are included. A great number of Americans also have diabetes, and these two diseases can interact in harmful ways. Depression is associated with poor health behaviors, such as smoking, physical inactivity, and excessive caloric intake, that increase the risk of type 2 diabetes. Furthermore, depression is related to central adiposity, obesity, and impaired glucose tolerance [6,51]. Likewise, psychologic stress and depression have significant effects on metabolism by increasing counter-regulatory hormones, resulting in elevated blood glucose levels even in patients without diabetes . Depression is linked with worse clinical outcomes. A study of more than 900,000 U.S. veterans found that comorbid depression in patients with diabetes is associated with increased risk of developing chronic kidney disease and poor cardiovascular outcomes . Depression is also associated with physiologic abnormalities, including activation of the hypothalamic-pituitary-adrenal axis, sympathoadrenal system, and proinflammatory cytokines, which can induce insulin resistance and contribute to an increased risk for diabetes [6,53].
Depression and insulin resistance are both associated with atrophy of the limbic system of the brain as well as with difficulties with memory and attention. A reciprocal interaction between proper insulin function and cognitive abilities is strongly suggested by the persistence of insulin resistance and memory and attention problems in individuals with depression. Experts believe insulin function to be central to proper mood regulation and maintenance of memory and attention, and understanding and treatment of depression should account for this underlying metabolic dysregulation . Although it has been shown that depression and diabetes may independently increase the risk for dementia, no studies have examined whether the risk for dementia is increased in people who have both diabetes and depression. Danish researchers examined health data for more than 2.4 million individuals 50 years of age or older, including 477,133 with depression, 223,174 with diabetes, and 95,691 with both diabetes and depression . When compared with adults who did not have diabetes or depression, the risk for dementia was 20% higher in adults with diabetes alone, 83% higher in adults with depression alone, and 117% higher in adults with both diabetes and depression . This again underscores the need for better understanding and treatment of depression in individuals with diabetes.
During the day, hyperglycemia and hypoglycemia may produce feelings of fatigue or anxiety. Ensuring good control of diabetes and compliance with the treatment plan may help alleviate some depressive symptoms. It is also important to investigate when the individual felt that he/she was successful in dealing with the problem. This is the basis of cognitive-behavioral therapy—what individuals think and say to themselves determines how they feel and what they do . Helping a patient recognize negative self-talk and identify a more positive, realistic perspective can minimize the emotional distress associated with diabetes .
After possible physical causes are ruled out or addressed, referral to a psychiatrist, psychologist, psychiatric nurse, licensed social worker, and/or professional counselor is warranted. Psychotherapy or counseling should be the first-line therapy, with pharmacotherapy and other approaches used for patients with severe depression or depression that does not respond to counseling . Depression-specific psychologic treatment is more effective than general supportive counseling, and the level of glycemic control and the presence or absence of diabetes complications is predictive of the response to depression treatment . A review of available evidence indicates that psychosocial interventions, particularly cognitive-behavioral therapy, can effectively treat depressive symptoms in patients with diabetes . However, it is unclear whether these interventions are also effective in improving self-care and physical health outcomes. Studies of individuals with diabetes and major depressive disorder demonstrate improvement in symptoms of depression as well as blood glucose levels with active treatment with an effective antidepressant . In studies of comorbid diabetes and depression, nortriptyline (a tricyclic antidepressant) has led to worsening glucose control, whereas bupropion, fluoxetine, and sertraline were correlated with reductions in glucose levels .
A combination approach using psychotherapy, psychopharmacology, and diabetes education is often the most effective treatment. One systematic review found that collaborative care (compared with primary care alone) was associated with significantly better depressive outcomes and treatment adherence in patients with depression and diabetes . However, other options exist and may be indicated, including electroconvulsive therapy, herbal medications/supplements, acupuncture, sleep deprivation, and bright-light therapy . It is important to consider how these therapies might affect blood glucose or interact with diabetes medications prior to initiating treatment.
Education for any individuals diagnosed with or at risk for depression should include recognition of signs and symptoms of depression, discussing fears related to the stigma of depression, and treatment options available . When psychologic counseling is recommended, it is essential the individual understands the importance of :
Maintaining all appointments with the mental health professional(s)
Being honest and open with the counselor/therapist
Working cooperatively (e.g., completing tasks as assigned within sessions)
When an individual with diabetes is being treated for depressive symptoms, it is crucial to convey the need for self-care regardless of the severity of the depression. Steps to ensure proper self-care include [59,60]:
Sleeping at least 7 to 8 hours but not more than 12 hours
Maintaining a healthy, nutritious diet
Adding omega-3 fatty acids to one's diet
Avoiding excessive alcohol consumption
Becoming involved in enjoyable activities
Engaging in relaxation techniques
Seeking spiritual guidance, when appropriate
The patient and family or support system should be advised to be aware of signs and symptoms of worsening depression that necessitate notifying their healthcare provider or contacting emergency services. This includes [14,33,59,60]:
Thoughts of harming oneself or others
Hallucinations (visual or auditory)
Unrelenting low mood and helplessness
Withdrawal from friends and/or social activities
Loss of interest in personal appearance, hobbies, work, and/or school
Increased alcohol and/or drug use
Recent impulsiveness and taking unnecessary risks
Making a plan (e.g., giving away prized possessions, sudden or impulsive purchase of a firearm, or obtaining other means of killing oneself, such as poisons or medications)
Unexpected rage, anger, or other drastic behavior change
Recent humiliation, failure, or severe loss (especially a relationship)
Unwillingness to "connect" with potential helpers
It is imperative to inform individuals that changes to the treatment plan may be necessary in order to effectively manage depression . Antidepressants begin to work gradually, so therapy must be adhered to for several weeks before determining effect. Patients should continue antidepressant therapy even if they feel better or symptoms improve; discontinuing these medications abruptly can be dangerous. Patients should be aware that the goal of treatment is complete remission, though it may require trials of different therapies to identify the best combination .
Patient A is a white woman, 68 years of age, with a 15-year history of type 2 diabetes. She presents to her primary care provider for a three-month follow-up appointment. She is brought to the appointment by her daughter-in-law. She is 5 feet 4 inches tall and weighs 220 pounds, 10 more pounds than her last appointment. Other pertinent medical history includes hypertension, coronary artery disease, two transient ischemic attacks lasting 30 minutes each, cerebrovascular accident nine months previously resulting in right-side weakness, and peripheral neuropathy of the bilateral lower extremities.
Her vital signs are:
Blood pressure: 165/86 mm Hg
Respirations: 24 breaths per minute
Temperature: 36.2° Celsius
Blood is drawn, and the results indicate:
Hemoglobin: 11.2 g/dL
Creatinine: 0.9 mg/dL
Glomerular filtration rate: 90 mL/min/1.73 m2
Serum albumin: 3.3 g/dL
Glycated hemoglobin (HgA1c): 9.1%
Low-density lipoprotein (LDL): 155 mg/dL
HDL: 42 mg/dL
Glucose (random): 219 mg/dL
Albumin: 29 mg/g CR
Calcium: 8.8 mg/dL
Phosphorus: 4.0 mg/dL
During the visit, Patient A sits quietly and only answers questions with yes or no. When asked if she has ever received formal education to care for her diabetes, Patient A states she did when she was first diagnosed, but it was many years ago. Understanding that Patient A now qualifies to receive education for diabetes self-management under Medicare, the need for further education is discussed with the patient and her daughter-in-law. They agree, although the daughter-in-law is reluctant to participate. The primary care provider refers Patient A to an ADA-recognized education program.
Patient A's initial education appointment is delayed three weeks due to conflicts with her daughter-in-law's schedule. They arrive at the education center five minutes late. When Patient A attempts to apologize for their tardiness, her daughter-in-law snaps at her to just sit down. Patient A takes a seat and begins reading a magazine. During the assessment phase of the visit, the diabetes educator, Ms. R, asks Patient A about her support system and finds that Patient A started living with her son and daughter-in-law after the death of her husband one year ago in a car accident. The move had been a decision out of necessity. Patient A's daughter-in-law receives a telephone call and leaves the room to take it.
While the daughter-in-law is out of the room, Ms. R asks Patient A about her home life. Patient A indicates that it has been a struggle to adapt to her new life. When asked about her daily routine, Patient A states she gets up in the morning and attempts to make breakfast but it usually takes too long, which causes her daughter-in-law to get impatient and take over. When asked what she likes to do during the day, Patient A replies, "Nothing." Ms. R asks what she liked to do prior to living with her son's family. Patient A states she liked her monthly lunches with a prayer group from church and that she misses them. Patient A also recalls date nights she used to have with her husband. In addition, the couple would attend Mass every Sunday and go out to brunch with good friends afterward.
At the conclusion of the appointment, Ms. R inquires whether Patient A has anything to add. Patient A states, "What's the use? I just exist now anyway. I am so mad at my husband for leaving me here. I was supposed to go first." When Ms. R asks how long she has felt this way, she admits it has been difficult since the death of her husband, but it has been worse the past two months. Patient A states she has been sad or depressed most of the time over the past two weeks.
The daughter-in-law returns and inquires if there is anything else or if they can leave, having already made the next appointment to fit her schedule. Ms. R reassures Patient A that she will see her at the next visit. After the patient leaves, Ms. R documents the visit and calls Patient A's primary care provider to communicate her concerns that she is experiencing depression.
Patient A's physician calls and requests an appointment for the next week. Although her daughter-in-law is unhappy about the additional appointment, she agrees to drive the patient to the office.
The patient arrives to see her physician and is taken into a room; the daughter-in-law is asked to stay in the waiting room. When the physician enters, he asks Patient A about her week. Patient A only shrugs her shoulders and avoids eye contact. The physician states that he is worried about her and thinks talking to someone might help. Patient A indicates that she talks to her son when he has time, but lately he has been working long hours. The only other conversation she reports is with the nurse at the education center. The physician tells the patient that Ms. R is concerned about her as well. Due to the many changes and stressors of the past year, the physician recommends that she see a mental health professional so she can talk to someone outside her immediate family.
The daughter-in-law is then asked to join them in the examination room, where she listens to the physician's concerns and referral plan. She unenthusiastically agrees to assist Patient A attend psychiatry appointments.
Later that week, Patient A meets with Dr. M, a psychiatrist specializing in major depression. She attends the session with her son, who appears attentive and concerned about his mother. Patient A is able to verbalize her feelings and fears during the session, but she continues to experience unrelenting sadness and fatigue. So, an antidepressant is prescribed to improve her mood. Dr. M also suggests a family session involving Patient A's daughter-in-law in order to address issues in the family dynamic.
Six months later, Patient A returns to her primary care provider, who notes many improvements. Patient A is going to church regularly and has joined a prayer group and met two other women who are also widows. They now go out to dinner regularly. Her demeanor is improved, and she is engaged and more confident. The patient also reports having more energy and a better relationship with her daughter-in-law. To monitor her diabetes, blood is drawn, and the laboratory results indicate decreases in her HgA1c (7.2%) and random blood glucose (145 mg/dL).
The effects of diabetes can be staggering. In addition to well-known complications related to cardiovascular health, kidney function, and cerebrovascular accidents, diabetes has been shown to impact mental health as well. In susceptible individuals, diabetes can trigger and/or exacerbate depression. Furthermore, depression has been shown to precipitate the onset of diabetes. In patients with diabetes, one cannot be effectively managed without taking into consideration the other. It is vital for both health and mental health professionals to have a clear understanding of how these two highly prevalent conditions interact and impact patient health.
1. Westerfield J, Holcomb S Jensen S (eds). Current Trends in Diabetes Management: A Guide for the Healthcare Professional. 7th ed. Nashville, TN: Healthways; 2008.
2. Welch GW, Jacobson AM, Weinger K. Psychosocial issues and type 2 diabetes. In: Goldstein BJ, Müller-Wieland D (eds).Type 2 Diabetes: Principles and Practice. 2nd ed. New York, NY: Informa Healthcare; 2008: 83-95.
3. Katon W, Unutzer J, Fan M, Williams JW, Schoenbaum M, Lin EHB, Hunkeler EM. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care. 2006;29(2):265-270.
4. American Diabetes Association. Depression. Available at http://www.diabetes.org/living-with-diabetes/complications/mental-health/depression.html. Last accessed November 2, 2016.
5. Nelson JB, Nelson-Ward KI. Healthy coping. In: Mensing C, Cypress M, Halstenson C, McLaughlin S, Walker EA (eds). The Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, IL: American Association of Diabetes Educators; 2011: 217-238.
6. Mezuk B, Eaton WW, Albrecht S, Hill-Golden S. Depression and type 2 diabetes over the lifespan. Diabetes Care. 2008;31(12):2383-2390.
7. Mensing C, Cypress M, Halstenson C, McLaughlin S, Walker EA (eds). The Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, IL: American Association of Diabetes Educators: 2011.
8. Bardsley JK, Magee MF. Pathophysiology of the metabolic disorder. In: Mensing C, Cypress M, Halstenson C, McLaughlin S, Walker EA (eds). The Art and Science of Diabetes Self-Management Education: A Desk Reference for Healthcare Professionals. Chicago, IL: American Association of Diabetes Educators; 2011: 285-308.
9. Centers for Disease Control and Prevention. Long-Term Trends in Diabetes: April 2016. Available at https://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf. Last accessed November 2, 2016.
10. Centers for Disease Control and Prevention. 2014 National Diabetes Statistics Report. Available at http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html. Last accessed November 2, 2016.
11. American Diabetes Association. Statistics About Diabetes. Available at http://www.diabetes.org/diabetes-basics/statistics. Last accessed November 2, 2016.
12. Goldstein BJ, Müller-Wieland D (eds). Type 2 Diabetes: Principles and Practice. 2nd ed. New York, NY: Informa Healthcare; 2008.
13. Centers for Disease Control and Prevention. Diagnosed Diabetes. Available at http://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html. Last accessed November 2, 2016.
14. National Institute of Mental Health. Depression: What You Need To Know. Available at https://www.nimh.nih.gov/health/publications/depression-what-you-need-to-know-12-2015/index.shtml. Last accessed November 2, 2016.
15. American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(Suppl 1):S1-S112.
16. Childs BP, Cypress M, Spollett G (eds). Complete Nurse's Guide to Diabetes Care. 2nd ed. Alexandria, VA: American Diabetes Association; 2010.
17. Edelman SV, Henry RR. Diagnosis and Management of Type 2 Diabetes. 12th ed. New York, NY: Professional Communications, Inc.; 2013.
18. American Association of Diabetes Educators. Available at http://www.diabeteseducator.org. Last accessed November 2, 2016.
19. Heim C, Plotsky PM, Nemeroff CB. Importance of studying the contributions of early adverse experience to neurobiological findings in depression. Neuropsychopharmacology. 2004;29(4):641-648.
20. Agid O, Kohn Y, Lerer B. Environmental stress and psychiatric illness. Biomed Pharmacother. 2000;54(3):135-141.
21. Nestler EJ, Barrot M, DiLeone RJ, Eisch AJ, Gold SJ, Monteggia LM. Neurobiology of depression. Neuron. 2002;34(1):13-25.
22. Sinha R. Chronic stress, drug use, and vulnerability to addiction. Ann N Y Acad Sci. 2008;1141:105-130.
23. Krishnan V, Nestler EJ. The molecular neurobiology of depression. Nature. 2008;455(7215):894-902.
24. Gelenberg AJ, Thase ME. Performance improvement CME: improving outcomes in depression. J Clin Psychiatry. 2010;71(8):e19.
25. Drevets WC, Price JL, Furey ML. Brain structural and functional abnormalities in mood disorders: implications for neurocircuitry models of depression. Brain Struct Funct. 2008;213(1-2):93-118.
26. National Library of Medicine. Available at http://www.nlm.nih.gov. Last accessed November 2, 2016.
27. Venes D (ed). Taber's Cyclopedic Medical Dictionary. 22nd ed. Philadelphia, PA: F.A. Davis Company; 2013.
28. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
29. Misri S. Shouldn't I Be Happy? Emotional Problems of Pregnant and Postpartum Women. New York, NY: The Free Press; 1995.
30. Joy S, Templeton HB, Mattingly PJ. Postpartum Depression. Available at http://reference.medscape.com/article/271662-overview. Last accessed November 2, 2016.
31. Womenshealth.gov. Depression During and After Pregnancy Fact Sheet. Available at https://www.womenshealth.gov/publications/our-publications/fact-sheet/depression-pregnancy.html. Last accessed November 2, 2016.
32. Kozhimannil KB, Pereira MA, Harlow BL. Association between diabetes and perinatal depression among low-income mothers. JAMA. 2009;301(8):842-847.
34. Polonsky WH, Fisher L, Earles J, et al. Assessing psychosocial distress in diabetes: development of the Diabetes Distress Scale. Diabetes Care. 2005;28(3):626-631.
35. Welch GW, Jacobson AM, Polonsky WH. The Problem Areas in Diabetes Scale: an evaluation of its clinical utility. Diabetes Care. 1997;20(5):760-766.
36. Hayashino Y, Okamura S, Matsunaga S, et al. The association between Problem Areas in Diabetes scale scores and glycemic control is modified by types of diabetes therapy: diabetes distress and care registry in Tenri (DDCRT 2). Diabetes Res Clin Pract. 2012;97(3):405-410.
37. Hood KK, Naranjo D, Barnard K. Measuring depression in children and young people. In: Lloyd CE, Pouwer F, Hermanns N (eds). Screening for Depression and Other Psychological Problems in Diabetes: A Practical Guide. New York: Springer Press; 2012: 119-138.
38. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49:980-989.
39. Monaghan M, Singh C, Streisand R, Cogen FR. Screening and identification of children and adolescents at risk for depression during a diabetes clinic visit. Diabetes Spectrum. 2010;23(1):25-31.
40. Kovacs M, Goldston D, Obrosky D, Bonar L. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care. 1997;20:36-44.
41. Hood KK, Huestis S, Maher A, Butler D. Depressive symptoms in children and adolescents with type 1 diabetes: association with diabetes-specific characteristics. Diabetes Care. 2006;29:1389-1391.
42. Lawrence JM, Standiford DA, Loots B, et al. Prevalence and correlates of depressed mood among youth with diabetes: the SEARCH for diabetes in youth study. Pediatrics. 2006;117:1348-1358.
43. MHS. CDI 2. Children's Depression Inventory 2. Available at http://www.mhs.com/product.aspx?gr=edu&id=overview&prod=cdi2. Last accessed November 2, 2016.
44. CESD-R. Available at http://cesd-r.com. Last accessed November 2, 2016.
45. American Psychological Association. Center for Epidemiological Studies-Depression. Available at http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/depression-scale.aspx. Last accessed November 2, 2016.
46. Helgeson VS, Snyder PR, Escobar O, Siminerio L, Becker D. Comparison of adolescents with and without diabetes on indices of psychosocial functioning for three years. J Pediatr Psychol. 2007;32(7):794-806.
47. Cheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics. 2007;120:e1313-e1326.
48. Kovacs M. Rating scales used to assess depression in school-aged children. Acta Paediatrica. 1980;46:305-315.
49. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psycholog Meas. 1977;1:385-401.
50. Roberts RE, Andrews JA, Lewinsohn PM, Hops H. Assessment of depression in adolescents using the Center for Epidemiological Studies Depression scale. Psychol Assess. 1990;2:122-128.
51. Pearson S, Schmidt M, Patton G, et al. Depression and insulin resistance. Diabetes Care. 2010;33(5):1128-1133.
52. Molnar MZ, Novak M, Musci I, Lu JL, Kalantar-Zadeh K, Kovesdy CP. Increased risk of incident chronic kidney disease, cardiovascular disease and mortality in diabetic patients with comorbid depression. J Am Soc Nephrol. 2015;26:5A.
53. Joseph JJ, Golden SH. Cortisol dysregulation: the bidirectional link between stress, depression, and type 2 diabetes mellitus.Ann N Y Acad Sci. 2016; [Epub ahead of print].
54. Rasgon N. ClinicalTrials.gov. Insulin Resistance in Patients with Major Depression. Available at http://clinicaltrials.gov/show/NCT01106313. Last accessed November 2, 2016.
55. Katon W, Pedersen HS, Ribe AR, et al. Effect of depression and diabetes mellitus on the risk for dementia: a national population-based cohort study. JAMA Psychiatry. 2015;72(6):612-619.
56. Markowitz SM, Gonzalez JS, Wilkinson JL, Safren SA. A review of treating depression in diabetes: emerging findings. Psychosomatics. 2011;52(1):1-18.
57. Huang Y, Wei X, Wu T, Chen R, Guo A. Collaborative care for patients with depression and diabetes mellitus: a systematic review and meta-analysis. BMC Psychiatry. 2013;13:260.
58. The MacArthur Initiative on Depression and Primary Care. Depression Management Tool Kit: Appendix II: Persons Considering Psychological Counseling Treatment. Available at http://otgateway.com/articles/13macarthurtoolkit.pdf. Last accessed November 2, 2016.
59. American Diabetes Association. Depression. Available at http://www.diabetes.org/living-with-diabetes/complications/mental-health/depression.html. Last accessed November 2, 2016.
60. American Diabetes Association. Mental Health. Available at http://www.diabetes.org/living-with-diabetes/complications/mental-health/. Last accessed November 2, 2016.
1. Redmon B, Caccamo D, Flavin P, et al. Diagnosis and Management of Type 2 Diabetes Mellitus in Adults. Bloomington, MN: Institute for Clinical Systems Improvement; 2014. Summary retrieved from National Guideline Clearinghouse at https://www.guideline.gov/summaries/summary/48544. Last accessed November 8, 2016.
Mention of commercial products does not indicate endorsement.