What You Need To Know About Depression And Diabetes

By Ken Rehm, DPM

Diabetes is considered one of the most psychologically and behaviorally demanding of the chronic medical illnesses. Patients with diabetes are particularly vulnerable to depression. Indeed, up to one in every three diabetics has depression at a level that impairs functioning and quality of life, and lowers adherence to glucose monitoring, exercise, diet, medication regimes and glycemic control. As a result, depression increases the risk of long-term diabetic complications.
When you use self-reporting surveys as a gauge, you’ll find an even broader spectrum of depressive illness in diabetics. These problems may include dysthymic disorder, minor depression or symptoms that reflect comorbid psychiatric illness. Anxiety, substance abuse disorders or general distress are more common in diabetics than nondiabetics.
The onset of depression precipitated by a patient’s diabetes may be secondary to socioeconomic factors and/or the functional, social and psychological hardships of accepting or dealing with advancing diabetes. The severity of diabetes, uncontrolled blood sugar, hypoglycemia and associated endocrinopathies all play a possible role. In addition, there is evidence that diabetes-related abnormalities in neurohormonal, neurotransmitter or vascular disease affecting the brain may be responsible for some of the depression found with this disease.
Also keep in mind that depression alone can affect the onset and the severity of diabetic complications. Evidence from studies in the U.S. and Japan indicates depression doubles the risk of incident type 2 diabetes. In patients with preexisting diabetes, depression has been shown to be an independent risk factor for coronary heart disease and can accelerate its onset. Other studies have shown depression is directly associated with an increased risk of diabetic complications, especially retinopathy, microvascular complications and increased neuropathic pain.
Regardless of whether it is initially a cause or effect, depression has been shown to be antagonistic toward adherence to proper treatment and dietary regimens, making proper lifestyle choices and achieving normoglycemia. This lack of compliance in the depressed diabetic patient is moderated through both behavioral and physiologic pathways, as studies have revealed these patients have poorer mental and physical functioning.
Recognizing The Problem
When the depression is treated successfully, it does help facilitate improved compliance and glycemic control. Two recent randomized control studies show that antidepressants and cognitive-behavioral therapy can be especially helpful in reducing depressive symptoms in diabetic patients.
However, it is interesting to note two of every three cases of depression are left untreated by primary care physicians. It is essential that all clinicians who treat diabetic patients become better at recognizing the signs of depression in order to make appropriate referrals and help facilitate improved treatment outcomes.
Be aware that studies show a higher incidence of depression in patients with retinopathy and this was linked to elevated levels of microalbumin, Total and LDL cholesterol. Particularly relevant for podiatrists is the finding of a higher incidence of depression in patients who suffer from neuropathy and wound healing problems.
Understanding The Potential Psychological Impact
During a 1995 lecture at the Gillis W. Long Hansen’s Disease Center in Carville, La., Paul Brand, MD, explained that neuropathy can cause depression. The sense of touch is considered our validating sense, according to Dr. Brand. Upon seeing something unfamiliar, our first desire is to touch the item, as opposed to smelling it, hearing it or tasting it.
This sense of touch makes the object real. Without it, the patient may not be able to confirm or validate the object or idea. When a patient loses foot sensation, he or she may regard the feet and any associated problems (i.e., ulcerations) as “unreal.”
Patients then become detached from their foot problems. David Viscott, MD, a psychiatrist who lectured extensively on the psychology of diabetes before succumbing to the disease, recognized it is only natural psychologically to deny the presence of such a disease. This denial is often associated with depression.
Sometimes, it’s the combination of negative feelings about the condition that can become overwhelming. Patietnts feel a sense of loss and at the same time, feel disgusted with the deformed body part. They may be angry about the problem, sick and tired of dealing with it and resigned to feeling there is no help or solution. You’ll find these feelings of exasperation and desperation are intensified even more when severe pain is involved or the patient is limited in participating in activities he or she previously enjoyed.
The shock of being labeled with a chronic disease also poses a risk for depression. Often, patients have heard horror stories of tragic outcomes of diabetes, such as gangrene, amputation, blindness, impotence and a host of other problems. They are afraid of what the future may bring.
For these patients, diabetes is not just a disease but a new and unwelcome identity. The patient feels lost, thinking, “What am I now that I am a diabetic?” A subtle panic and depression might set in until a new sense of identity develops. The patient may not like this new identity, longing to return to the old self. He or she may despise and not want to care for the new self.
Emphasizing Encouragement, Empowerment And Exercise
This scenario of detachment, disgust, resignation, exasperation, desperation, shock, loss of identity, denial and depression often leads to lack of motivation for compliance, posing serious obstacles to diabetes treatment and encouraging neglect of serious complications. To be optimally effective in treating the diabetic patient, podiatrists must adopt a way of practice in order to deal with these psychological issues.
First, we should encourage patients to “like” their feet and identify with them. Offering positive observations (e.g., compliments for nicely kept toes, a well-shaped foot, healthy-feeling skin or patent circulation) counteracts some of the negative feelings and detachment patients feel toward their feet.
Being optimistic, perhaps through a reassuring touch, can be empowering for the patient. Explain to the patient all is not lost and he or she does have some control over the disease process. Motivating pep talks might sound trivial but it’s important to encourage the patient to take responsibility for his or her own health care. This could involve performing daily foot inspections, instituting an appropriate exercise routine, applying foot cream at home, using techniques aimed at curbing pain, attending diabetes education classes or using appropriate cooking techniques.
Instituting a physical conditioning regime not only gives the patient a sense of control, but the physiological and physical benefits empower him or her to deal with any depressive symptoms more effectively. For the patient, understanding physical fitness as it applies to diabetes requires adherence to a disciplined fitness regimen. In order for this program to be a success, it is important to emphasize clarity, simplicity and reasonable goals.
Specifically, the best programs for optimizing both mental and physical health should promote cardiovascular (circulation to the foot and leg and working the calf-venous pump mechanism) and metabolic health (diet, exercise, weight control). The program should also help the patient maintain flexibility (thus decreasing the effects of glycosylation and maintaining proper joint biomechanics) and muscle mass, tone and strength (to minimize the effects of motor neuropathy).
Choosing the appropriate exercise program is crucial. If a patient has loss of sensation in his or her feet, for instance, running would be a poor choice of exercise. With that disclaimer, experts claim the benefits of regular exercise can go a long way toward counteracting depression.
Knowing What We Can Do And When To Make Appropriate Referrals
If all the patient is concerned about is relieving his or her foot pain, then certainly there is an array of treatment courses we can offer. Nerve blocks, oral medications, referral to a pain specialist, employing physical therapy modalities, focusing on biomechanics, proper fitting and comfortable shoes are all appropriate avenues for dealing with diabetes-related foot pain.
As podiatrists, we also must be part of the team that helps the patient reframe what it means to have diabetes and understand the potential benefits of diabetes control. This means making the appropriate referrals to mental health professionals, dietitians, social workers and diabetologists when necessary.
People are afraid of the unknown. That is true as it relates to patients finding out they have a disease they know nothing about. Hearsay, rumors and myths might immediately occupy the thoughts of someone who is faced with a diagnosis of diabetes. This label seems vague, scary and often depressing.
Diabetes educators and patients say a classroom offering an interactive support group atmosphere can help reframe and clarify what it means to be a person with diabetes. This works as a form of cognitive therapy, a very effective method of dealing with the negative emotions of having diabetes, including depression.
What Works In Diabetes Education Classes
These classroom situations would certainly benefit from podiatrist participation, as a lot of patient concerns regarding diabetes relate to the foot. We can also learn from the successes of the diabetes educators and apply it to our practices. Surveys taken at three San Diego medical centers that host diabetes education classes suggest the DPM’s approach to foot care instruction either can promote unswerving compliance and motivation or turn the patient off.
Lectures with focused, clear-cut and understandable slides garnered the most positive response. Lectures focusing on what patients can do to improve their lives (i.e., proper shoes, orthotics and general foot care) scored high in acceptance and were likely to motivate the participants to make positive changes in their lives. Lectures that got the best marks from diabetes educators focused on such “must-dos,” such as foot hygiene, daily foot checks and regular toenail trimming. Educators also favored lectures that gave patients some leeway to make their own decisions, and those that took lifestyle and economic limitations into consideration.
Patients did not want to see pictures of amputated or gangrenous limbs or be frightened into compliance with statistics, according to the surveys. These tactics tended to scare patients, creating denial and even depression in some. Educators said we need to empower and uplift our patients, emphasizing how much better their feet can be if they follow through with proper preventive measures.
Final Notes
As specialists who often orchestrate multidisciplinary team care for the patient with diabetes and often are the first health-care provider to encounter symptoms of depression, we have a responsibility to take an active role in the patient’s mental health. We must be astute at picking up symptomatology and making appropriate referrals. We must be educators and motivators as well as true patient advocates.

Dr. Rehm is a Diplomate of the American Board of Medical Specialties in Podiatry and is board-certified in the prevention and treatment of diabetic foot wounds.


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