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.

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