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According to 2014 CDC statistics 29.1 million people in the USA, or 9.3% of the population have diabetes and 8.1 million of these are undiagnosed. In the same period 15.7 million adults in the USA had experienced one major depressive episode in the last 12-month period.
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The co-occurrence (co-morbidity) of diabetes and depression is increasingly becoming a public health concern because having the two illnesses together results in worse health outcomes and higher health costs than when these conditions occur separately.
Many family doctors find it difficult to manage these two conditions when they occur together in the same person and the person suffering from co-morbid diabetes and depression may be so focused on managing the symptoms of one of the conditions that they do not recognise the symptoms of the other.
Depression and diabetes – what we know
Depression and diabetes are common illnesses that can occur as individual conditions or together. Some studies have suggested that 13-18% of people with Type 1 and Type 2 diabetes have a diagnosis of clinical depression. Other studies have suggested the figure may be as high as 26% if not more.
Why is this important?
When diabetes and depression occur together one of the diagnoses can easily be missed, depending on which type of service the person seeks help from first. This matters because missing a diagnosis of either diabetes or depression leads to worse health outcomes for the individual concerned.
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A person who has a diagnosis of co-morbid diabetes and depression has more difficulty managing their diabetes. This can include finding it harder to keep the blood sugar control within normal limits and finding it harder to self-manage the diabetes. A person with co-morbid diabetes and depression is more likely to develop complications and impairment related to their diagnosis of diabetes and is more likely to have poorer overall outcomes, compared to a person with diabetes who does not suffer from depression.
This is also important for society because it results in clinical care being more expensive.
Poor outcome in diabetes and depression is not inevitable
Poor outcome in co-morbid diabetes and depression is not inevitable. Randomised controlled trials in 14 primary care clinics in Washington State, USA have shown is that collaborative working results in improved outcomes in both diabetes and depression when they occur together. This why it is important to make the diagnosis of co-morbid diabetes and depression early.
Improving the recognition of diabetes and depression
People who suffer from either depression or diabetes need to play their own part by making sure that they regularly attend their follow up appointments. If you have diabetes, ask your family doctor or specialist to screen you for depression and if you have depression, ask your family doctor or specialist to screen you for diabetes.
If you are a health professional that deals with either of these conditions your protocols should include questionnaires that can screen for depression and tests that can screen for diabetes. There is evidence from England to show that family doctors are getting better at screening for depression in diabetes because 83% of all patients with a recognised diagnosis of diabetes were also screened for depression in 2013. This shows that screening is possible.
Treating co-morbid diabetes and depression
The best outcomes for the treatment of co-morbid diabetes and depression are achieved by using collaborative care that engages the patient and carer in self-care and also follows the appropriate clinical guidelines for the management of each condition. This ensures that the care plan agreed with the patient addresses the management of both
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The best outcomes for the treatment of co-morbid diabetes and depression are achieved by using collaborative care that engages the patient and carer in self-care and also follows the appropriate clinical guidelines for the management of each condition. This ensures that the care plan agreed with the patient addresses the management of both the diabetes and the depression simultaneously.
Treatment with psychological and social interventions is very important. Cognitive Behaviour Therapy (CBT), whether face to face or online works. Smoking cessation for people who have diabetes and depression is essential because it is associated with a reduction in symptoms of depression, anxiety and stress and leads to improved mood and quality of life.
Antidepressant medication is effective in the treatment of depressive disorder when it occurs in diabetes but it is very important to monitor the side effects because some antidepressants can cause hypoglycemia (low blood sugar) and some SSRI (serotonin reuptake inhibitor) antidepressants have been shown to reduce blood sugar by up to 30%. Other antidepressants can lead to significant weight gain which results in poorer control of diabetes, so called ‘insulin resistance’ and some may occasionally effect libido. If possible tricyclic antidepressant should be avoided in co-morbid diabetes and depression because they can cause carbohydrate craving and affect memory.
It is important for people with a combination of diabetes and depression to be regularly monitored by their family doctor.
Key messages:
- Diabetes and depression can commonly occur together
- It is important to screen for depression in all people with diabetes
- It is important to screen for diabetes in all people with depression
- Face to face or online CBT (cognitive behaviour therapy) is also effective in managing depression co-occurring with diabetes
- If it is necessary to prescribe and antidepressant for the treatment of co-morbid diabetes and depression avoid using tricyclic antidepressants
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- All people on long term antidepressant treatment for co-morbid diabetes and depression should be monitored because there is a significant risk of developing hypoglycaemia
- Self-management and self-care including exercise, diet and smoking cessation should be part of the routine management of co-morbid depression and diabetes
- Collaborative care provides the best opportunity to bring together all the resources needed to achieve the best outcomes in co-morbid diabetes and depression
- People with lived experience of diabetes, or depression, or both can contribute to collaborative care
Co-morbid diabetes and depression is a public health issue and those who pay for services need to do more to prevent this becoming an epidemic and primary care can do more to promote good care and monitoring of people with co-morbid diabetes and depression. We all need to work together to ensure that we diagnose co-morbid diabetes and depression early when it occurs.
References:
- Ivbijaro GO, Kolkiewicz L, Enum Y. Management and treatment of co-morbid diabetes and depression. Depression in Clinical Practice. WPA Bulletin on Depression. 2015; 19 (54): 5-8
- Bryan C, Songer T, Brooks MM et al. The impact of diabetes on depression outcomes. General Hospital Psychiatry. 2010; 32(1):33-41
- Ali S, Stone M, Peters LJ et al. The prevalence of comorbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis. Diabetes Medicine. 2006; 23(11): 1165-1173
- Katon W, Lin EHB, Von Korff M et al. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine. 2010; 363 (27): 2611-2620
- Health and Social Care Information Centre. Quality Outcomes Framework 2012-2013. http://www.hscic.gov.uk/catalogue/PUB12262 (accessed 22 September 2016)
- Taylor G, McNeill A, Girling A et al. Change in mental health after smoking cessation: systematic review and meta-analysis. British Medical Journal. 2014; 348: g1151
- Goodnick PJ, Henry JH, Buki VM. Treatment of depression in patients with diabetes mellitus. Journal of Clinical Psychiatry. 1995; 56(4):128-136
- Goodnick PJ. Use of antidepressants in the treatment of co-morbid diabetes mellitus and depression as well as in diabetic neuropathy. Annals of Clinical Psychiatry. 2001; 13(1):31-34
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Professor Gabriel Ivbijaro MBE, JP
MBBS, FRCGP, FWACPsych, MMedSci, MA, IDFAPA
President WFMH (World Federation for Mental Health)
Chair The World Dignity Project
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