Depression can worsen diabetes, and diabetes can magnify depression. Here's how to stay a step ahead of both

Murray Pincus of Boca Raton, Fla., has devoted his post-retirement life to helping people with diabetes and answering their diabetes questions. The 78-year-old has battled type 2 diabetes himself for 50 years, "with all the complications except amputation," he says. He knows how hard it is to live with the daily struggles diabetes can bring. So for the past 22 years he has helped run support groups for people with diabetes — and one of the biggest struggles they face is depression.

"People who have diabetes are at double the risk of developing depression," says Dr. Susan Guzman, a clinical psychologist and director of clinical services at the Behavioral Diabetes Institute in San Diego. "Depression can cause so much trouble for diabetics, but it's very treatable. They don't have to suffer from it."

Guzman developed and leads a San-Diego-based educational workshop series called "Feeling Good Again: Breaking the Depression/Diabetes Connection." "I can't tell you how often during my introductory lecture someone will start to cry from sheer relief," she says. "They'll tell me, ‘I thought there was something wrong with me as a person,' or ‘I thought I was lazy, or going crazy.' They'll say, ‘Now I know that's not true. It's depression.'"

A counselor can guide you toward reasonable goals, so you know you have a plan you can achieve.

Doctors sometimes miss the warning signs of depression when someone has a chronic illness like diabetes — even though depression is often a reason why patients aren't following the doctor's recommendations. "A doctor may tell a patient, ‘Why, I'd feel depressed, too, if I had to deal with diabetes and its potential complications,' dismissing depression's signs as just normal feelings of frustration or sadness," Guzman says.

The symptoms of depression go way beyond just frustration or sadness, feelings which usually pass in a few days. According to the American Diabetes Association, depressive symptoms last for two weeks or more.

Often it's hard to recognize the problem, which is one of the trickiest things about depression. That's the case for Orrin Adler, 69, of Boca Raton, Fla., who has had type 2 diabetes for more than 15 years. "I've had depression all my life, but I don't always feel it myself. My wife tells me," he says.

Two basic screening questions

To help pinpoint depression, experts have come up with basic screening questions. They ask: Over the past two weeks, how often have you been bothered by any of the following problems? 1) Little interest or pleasure in doing things. 2) Feeling down, depressed or hopeless.

While the questions are brief, "It's a pretty scientific, good quick screening," says Dr. Richard M. Bergenstal, president-elect, medicine and science at the American Diabetes Association.

If you answer "never" to both questions, your depression risk is likely low. If you're facing these problems, talk to your doctor for a more in-depth screening — and be aware that as a person with diabetes, you may be at an elevated risk for depression.

"We don't really know the mechanism, but more and more studies are showing that if you have depression you're at more risk for type 2 diabetes, and vice versa," says Bergenstal.

"The two cardinal symptoms of depression are depressed mood and a lack of interest or pleasure in things which someone used to enjoy," Guzman says. "Depressed mood describes feelings of emptiness, irritability or just feeling really blue. A lack of interest or pleasure means a person may stop engaging in their world. They may isolate themselves from family and friends by not going to church or bypassing social engagements."

Guzman emphasizes that patients need only have one of these cardinal symptoms for her to suspect depression, and they can have a lack of interest or pleasure without having the depressed mood. In addition, other symptoms may be present. "There's a lot of concentration involved in the job of diabetes," she says, "and a lack of concentration is another very common sign of depression."

People with depression also experience a lack of energy. Feeling drained, people with diabetes may not make it to appointments, stay in touch with their health care team or get enough exercise. Depression may also cause insomnia, or the opposite, oversleeping. "It can go in both directions," says Guzman, "as can another symptom, appetite, which may decline, or a person may want to eat all the time."

The good news is that people who treat their depression often are better able to manage their diabetes, using their diabetes testing supplies, like blood glucose monitors appropriately.

People with depression may feel helpless and hopeless — as if there is no end in sight to their difficulties. They also may experience inappropriate guilt. At its most serious, depression can lead to thoughts of dying or suicide. "In seniors, such thoughts can show up as an ‘I quit' attitude," says Guzman. "The person may not have plans to harm themselves, but they think, Why bother taking care of myself anymore?"

"Depression changes how people eat, if they exercise and how they handle stress," says Dr. Wendy Satin Rapaport, a clinical psychologist and an adjunct professor of medicine and psychology at the Diabetes Research Institute at the University of Miami Miller School of Medicine. Diabetes can worsen depression symptoms too. "You can't treat one without treating the other," she says. "If you're taking care of diabetes but not depression, you'll eventually fall off the wagon."

Counseling, support can help

While some people are hesitant to take medication to treat depression, especially since they may already be taking several prescriptions, Rapaport notes that these people are likely self-medicating already. "If you're drinking [alcohol] a lot or eating a lot, you're already taking medication. Vodka is a medication, and it's also doing bad things to you," she says.

Counseling can help you both fight depression and manage your diabetes. A counselor can guide you toward reasonable goals, so you know you have a plan that you can achieve. Instead of aiming to lose 50 pounds and lower your cholesterol, for example, you might start by trimming some carbs from your diet and committing to taking your medication as prescribed.

Social support is important too. "It's so important for people to stay engaged. When they don't do that they get more tired, and it's easy to get derailed. They don't want to meet up with friends or go to the mall or join a group — depression becomes this chronic companion," says Dr. Claire Venus, a clinical psychologist, registered nurse and certified diabetes educator in Butler, N.J. Controlling diabetes can help you feel better, which in turn can help you tackle your depression. It's important to do the things your doctor asks you to do — getting regular exercise and a good night's sleep and making healthy food choices will help both conditions.

"A lot of work goes into managing diabetes, and when people are not feeling their best, doing all the things we ask them to do can be a tremendous burden — it takes a lot of effort," says Venus. "When you address diabetes' issues and answer important diabetes questions you're going to help your mood at the same time. Most mild cases of depression will respond to good health habits and social support — you don't necessarily have to go get mental health treatment."

But when depression becomes more serious — if you can't get out of bed in the morning, you're ignoring your blood sugar, avoid the diabetes testing process, you can't be bothered to take your medication, and you don't get out of the house — you need to talk to your doctor about how you're feeling and the changes you are seeing in your behavior.

"If it's too much effort to do these things, you may need to consider some treatment for depression," Venus says.
Good education and support groups can help. Murray Pincus estimates he sees as many as 300 people a month in the support groups he runs. Thanks to Pincus and people like him, people with diabetes and depression can get the support they need.

Find Out More
These Web sites offer more information about depression and diabetes.
diabetes.org
diabetespsyche-drwendy.com
behavioraldiabetes.org