Treatment of depression in diabetes: Impact on mood and medical outcome☆
Introduction
Depression severely impairs quality of life and all aspects of functioning in the diabetic patient [1], [2]. It aggravates the symptoms of medical illness, worsening the perception of diabetes, of its control and of its burden [3], [4], [5], [6], [7], [8]. Meta-analysis methods have demonstrated the relationship of depression with poor glycemic control and an increased risk for diabetes complications [9], [10]. The effects are not restricted to either principal type of diabetes, despite differences in pathogenesis of the disorders [9], [10]. These observations provide an impetus for specific attention to depression in diabetes, as diabetic complications, accelerated by poor metabolic control, are largely responsible for morbidity and mortality in this disorder. Depression consequently becomes one of the best predictors of hospitalization rate in diabetic patients [11].
The traditional argument, that depression results from the hardships imposed by diabetes and its complications, is not supported by observations from longitudinal studies or from studies dating depression and diabetes onsets in Type 2 diabetes [12], [13], [14], [15]. Although the onset of depression often follows the onset of diabetes in Type 1 diabetic patients [13], other observations demonstrate the importance of depression symptoms in either type once they appear. Forrest et al. [16] showed that depression symptoms were independent predictors of coronary heart disease (CHD) in Type 1 diabetics over 6 years of observation. Likewise, major depression accelerated the presentation of CHD in Type 1 and Type 2 diabetic women attending a diabetes registry, the 10-year risk being threefold greater in the depressed subset and independent of traditional risk factors [17]. In a separate study, depression independently predicted the progression of retinopathy in children with Type 1 diabetes when followed for a median of 10 years [18].
Evolving pathogenetic models incorporate information gleaned from studies of depression in nondiabetic samples. Depression may accelerate the presentation of CHD, the major source of morbidity in diabetes, through its effects on sympathetic activity, platelet activation and aggregation, and heart rate variability [19], [20], [21], [22], [23], [24], [25], [26]. More recently, a relationship between insulin resistance and depression has been demonstrated, a relationship that can be adjusted with depression treatment [27], [28], [29], [30], [31]. Insulin resistance is strongly associated with CHD risk, is the principal abnormality in Type 2 diabetes and, conceivably, could complicate the course of the Type 1 disorder. Depression-associated insulin resistance (DAIR) could account for the doubled risk of Type 2 diabetes associated with depression in prospective population-based studies in the US and Japan [14], [32]. In patients with established diabetes, DAIR may enhance the risk of CHD and provoke the range of diabetic complications associated with poor metabolic control (Fig. 1). When these biochemical–metabolic influences are combined with depression effects on adherence to medical treatment regimens, weight, physical activity, tobacco use and other cognitive–behavioral impairments, the potential negative burden of depression in diabetes is imposing [1], [33], [34], [35].
The hardships of diabetes management and its complications may well be the thrust behind the development of depression in some diabetic subjects, and hyperglycemia can promote or accentuate psychiatric symptoms [36], [37]. From the standpoint of the importance of depression detection and treatment, however, chicken–egg arguments have become passé. A sufficient body of literature favors exploring fully the effects of depression treatment on mood, glycemic control and complications in diabetic samples. Expectations remain that favorable outcomes could extend beyond depression relief and reversal of depression-impaired quality of life to reduced morbidity and mortality from the medical illness.
Section snippets
Efficacy of depression treatment in diabetic patients
Concerns were raised initially that efficacy of depression treatment in nondiabetic subjects could not be extrapolated to the diabetic population [34], even though antidepressants are effective across a wide range of medical illnesses [38]. Etiological differences for depression episodes may impose treatment resistance in the face of diabetes [34], [39]. Both 5-hydroxytryptamine sensitivity and hypothalamic–pituitary–adrenocortical (HPA) responsiveness are affected by hyperglycemia [37], [40],
Effect of depression treatment on the course of diabetes
Diabetes takes its toll through micro- and macrovascular complications that accrue over years following initial diabetes diagnosis. Depression may accelerate the rates [16], [17], [62], the acceleration accounting for some of the increased prevalence of diabetic complications in the depressed subset in cross-sectional studies [10]. Adverse depression effects may be more pronounced for some complications. CHD becomes manifested at more rapid rates in depressed diabetic subjects or in relation to
Methodological considerations in treatment trials
A variety of methodological considerations are specific to the study of depression treatment in diabetic patients and have been reviewed previously in detail [34]. Nonpharmacologic depression treatments may be favored by the majority of patients [80], [81], [82], [83], and some may be particularly useful in diabetes [84], [85]. Nevertheless, antidepressant medications remain the mainstay in practice because they are effective in face of most medical illnesses and are simple to prescribe [86],
Conclusions
Depression, a common comorbidity in diabetic patients, responds to treatment at rates approaching those in nondiabetic samples. Intervention is important not only for conventional effects on quality of life and daily functioning, but also for the potential gains toward improving the course and outcome of diabetes and its complications [100]. Both antidepressant medications and psychotherapy appear effective, although CBT may have a particularly promising role. Depression remission and sustained
Acknowledgements
This work was co-sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Mental Health, Bethesda, Maryland, January 2001.
References (100)
- et al.
Correlation of esophageal motility abnormalities with neuropsychiatric status in diabetes
Gastroenterology
(1986) - et al.
Are predictors of coronary heart disease and lower-extremity arterial disease in type 1 diabetes the same? A prospective study
Atherosclerosis
(2000) - et al.
Depression in patients with cardiac disease: a practical review
J Psychosom Res
(2000) - et al.
Going to the heart of the matter: do negative emotions cause coronary heart disease?
J Psychosom Res
(2000) - et al.
Even minimal symptoms of depression increase mortality risk after acute myocardial infarction
Am J Cardiol
(2001) - et al.
Elevated platelet factor 4 and β-thromboglobulin plasma levels in depressed patients with ischemic heart disease
Biol Psychiatry
(1997) Enhancing central and peripheral insulin activity as a strategy for the treatment of endogenous depression—an adjuvant role for chromium picolinate
Med Hypotheses
(1994)- et al.
Relative insulin insensitivity and cortisol secretion in depressed patients
Psychiatry Res
(1981) - et al.
Insulin resistance in patients with depression and its changes during the clinical course of depression: minimal model analysis
Metabol Clin Exp
(2000) - et al.
Stress and diabetic control
Lancet
(1983)
Depression in diabetics: a critical appraisal
Compr Psychiatry
The functional significance of biochemical alterations in streptozotocin-induced diabetes
Physiol Behav
The course of major depression in diabetes
Gen Hosp Psychiatry
Predicting response to cognitive behavior therapy of depression in type 2 diabetes
Gen Hosp Psychiatry
Clinical and psychosocial factors associated with achievement of treatment goals in adolescents with diabetes mellitus
J Adolesc Health
Drug compliance in pediatrics: clinical and research issues
Pediatr Clin North Am
Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the Medical Outcomes Study
J Clin Epidemiol
Loss of hypoglycemia awareness in an adolescent with type 1 diabetes mellitus during treatment with fluoxetine hydrochloride
J Pediatr
Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study
J Urol
Excess risk of myocardial infarction in patients treated with antidepressant medications: association with use of tricyclic agents
Am J Med
Depression and diabetes: impact of depressive symptoms on adherence, function, and costs
Arch Intern Med
The effects of psychiatric disorders and symptoms on quality of life in patients with Type I and Type II diabetes mellitus
Qual Life
Psychiatric illness in diabetes: relationship to symptoms and glucose control
J Nerv Ment Dis
Depression and the reporting of diabetes symptoms
Int J Psychiatry Med
Psychological distress is linked to gastrointestinal symptoms in diabetes mellitus
Am J Gastroenterol
Gastrointestinal symptoms in diabetic patients: lack of association with neuropathy
Am J Gastroenterol
Coping, control, and adjustment in Type 2 diabetes
Health Psychol
The role of anxiety and depression in quality of life and symptom reporting in people with diabetes mellitus
Qual Life Res
Depression and poor glycemic control: a meta-analytic review of the literature
Diabetes Care
Association of depression and diabetes complications: a meta-analysis
Psychosom Med
Hospitalization and mortality of diabetes in older adults. A 3-year prospective study
Diabetes Care
A review of the relationship between depression and diabetes in adults: is there a link?
Diabetes Care
Depression in adults with diabetes: results of a 5-year follow-up study
Diabetes Care
Depressive symptoms and occurrence of type 2 diabetes among Japanese men
Diabetes Care
Biomedical and psychiatric risk factors for retinopathy among children with IDDM
Diabetes Care
The influence of anxiety and depression on outcomes of patients with coronary artery disease
Arch Intern Med
Exaggerated platelet reactivity in major depression
Am J Psychiatry
The sympathetic nervous system and ischaemic heart disease
Eur Heart J
Depression, heart rate variability, and acute myocardial infarction
Circulation
Insulin tolerance test in depression
Arch Gen Psychiatry
Glucose metabolism in unipolar depression
Br J Psychiatry
Depression and risk for onset of type II diabetes: a prospective population-based study
Diabetes Care
Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence
Arch Intern Med
Management of major depression in adults with diabetes: implications of recent clinical trials
Semin Clin Neuropsychiatry
Depressed mood is a factor in glycemic control in type 1 diabetes
Psychosom Med
The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies
Diabetes Care
Antidepressants for depression in people with physical illness
Cochrane Database Syst Rev
Metabolic and neurochemical profiles in insulin-treated diabetic rats
Am J Physiol
Twenty-four-hour cortisol profiles demonstrate exaggerated nocturnal rise in diabetic children
Diabetes Care
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Proceedings of a conference on Depression and Mental Disorders in Patients with Diabetes, Renal Disease and Obesity/Eating Disorders cosponsored by the National and the National Institute of Mental Health, Bethesda, MD, January 2001.