It is difficult to imagine what could be worse than an ailment that takes the happiness and pleasure out of living. And yet, depression is widespread and is frequently seen among people with diabetes.

Multiple large epidemiologic studies have shown that depression is twice as likely in diabetic patients compared with non-diabetics. However, a significant proportion (50 percent) of depression in adult diabetics goes unrecognized. One reason for such is because it is challenging to separate the symptoms of depression from that of poor glycemic control (fatigue, weight gain/ loss, appetite changes and sleep disturbance). Another reason may be the stigma and negative perceptions associated with depression.

The link
Diabetes and depression spell double trouble, and the nature of their relationship is quite a blur. Many agree that depression increases the risk for type 2 diabetes to some degree. Potential reasons include lifestyle issues and the role of inflammation. An uncontrolled diet and sedentary lifestyle may lead to overweight and obesity which in turn promotes diabetes. Inflammation caused by emotional distress may also lay the foundation for diabetes. There is also a suspicion that changes in the brain are the bond between the two diseases. On the other hand, diabetes sets off depression, perhaps doubling the risk, due to the stress of treating a chronic disease. Furthermore, the physical effects of increasing blood glucose levels may worsen the depressive symptoms.

What is the effect of depression on diabetes outcomes? There is overwhelming evidence that depression is associated with poor sugar control. There are multiple studies that illustrate its link with increased risk of diabetic complications like retinopathy, nephropathy, neuropathy, macrovascular complications and sexual dysfunction. There is also proof that depression increases the risk of death in diabetic individuals.

Several researches have confirmed that depression negatively affects selfcare behaviors essential for good glucose control including diet, physical activity, compliance with medications and self monitoring of blood glucose. It is also significantly associated with missed medical appointments, decreased work productivity and decreased quality of life in adults with diabetes.

Symptoms of Depression
Symptoms of depression may include the following. Keep in mind that these symptoms and their severity can vary from person to person.

• Sleep
  • Difficulty falling asleep (insomnia)
  • Waking up at night and not being able to go back to sleep
  • Excessive sleep or sleepiness
• Feelings
  • Sadness that does not go away
  • Anxiety or nervousness after a day or two
  • Irritability
  • Sadness that is worst in the morning
  • Overwhelming guilt
• Thoughts
  • Inability to concentrate, remember, or make decisions
  • Suicidal thoughts or attempts
  • Loss of interest in previously fun activities, including sex
• Body
  • Increase or decrease in appetite
  • Aches, pains, and digestive disturbances that don’t respond to treatment
  • Slowed speech or body movements
  • Crying for no apparent reason

Treatment
Before starting treatment, it is imperative that additional history, complete physical examination, and appropriate diagnostic tests be done. The history should include prior episodes of depression and suicidal ideations, response to previous treatments, current life stressors, family history of emotional disorders, present medications and use of illicit substance. Physical examination and initial diagnostics are performed to rule out coexisting medical conditions like thyroid disease, hypertension and cardiac disease that may influence choice of therapy.

There are several types of antidepressants, and it may take trial and error to find the one that works best for any particular patient. Only 6 out of 10 people will feel better with their first antidepressant.

Newer pharmacotherapies such as the selective serotonin reuptake inhibitors (SSRI), serotonin norepinephrine reuptake inhibitors (SNRI), and bupropion are easier to dose, better tolerated by patients, and have fewer side effects and drug-drug interactions than the older agents such as the tricyclic antidepressants or monoamine oxidase inhibitors. MAOls require significant dietary restrictions, have major drug-drug interactions and should probably be avoided in individuals with diabetes. Different people can have a variety of responses to each antidepressant, so it is difficult to predict how any particular medication will affect a person. A 2009 review in Current Opinion in Psychiatry found no evidence that any single treatment for depression leads to consistently better outcomes than any other in people with diabetes.

According to the Agency for Healthcare Research and Quality, the most common side effects of antidepressants are constipation, daytime sleepiness, diarrhea, dizziness, dry mouth, headache, nausea, sexual problems, shakiness, trouble sleeping, and weight gain. Side effects can go away within a few weeks or remain until the medication is discontinued. However, some medications are more likely to cause certain side effects than others. Since weight is a particularly important factor for people with type 2 diabetes, antidepressants that are less likely to cause weight gain may be the more popular choice.

Another important factor to consider is drug interactions. Doctors, psychiatrists, and pharmacists need to be in close contact so that treatments don’t collide and create a dangerous health situation for a patient. Furthermore, patients must be up front about any medications and supplements they are taking, including herbal substances.

Something that people with diabetes, or anyone, can do to help themselves cope with depression is exercise. Many studies link physical activity to improved mood. And, of course, not only can exercise boost spirits, but it can also improve health in other ways.

A common thought in treating depressed diabetics is that once depression goes into remission, the glucose control would improve. Several studies have proven this to be untrue. Healthcare providers should not just focus on treatment of depression to the extent that good glycemic control is lacking. The goal should always be to reach remission of depression while maintaining optimal glycemic control. This may require combining pharmacotherapy, psychotherapy and aggressive diabetes self-care and treatment.

Depression can make life with diabetes a dreadful experience. Scientists are continuously studying the link between these two diseases. There is therefore reason for hope. Help is within reach. Treatment for depression is just as effective in people with diabetes as in those without. Finding the right combination of therapy, medications and exercise to fight depression is not always easy or fast. In most cases though, a solution is out there that will help make each day a bit more delightful and happy.

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