Lead study author Lawrence Fisher, Ph.D., ABPP, a professor of family and community medicine at the University of California, San Francisco who recently presented the study at the American Diabetes Association’s (ADA) 74th Scientific Sessions, said in a press statement, “Because depression is measured with scales that are symptom-based and not tied to cause, in many cases these symptoms may actually reflect the distress people are having about their diabetes, and not a clinical diagnosis of depression.” Interventions can significantly reduce these patients’ depression symptoms, according to Fisher.
The researchers developed measures of diabetes-specific distress that reflect whether a person is worried about a variety of problems associated with their diabetes, such as hypoglycemia. They also asked patients to fill out a questionnaire to measure their depressive symptoms. Those who reported high levels of distress and high levels of depressive symptoms were assigned one of three interventions, all of which were designed to reduce the distress associated with managing diabetes, rather than symptoms of depression.
Interventions Can Help
One group participated in an online diabetes self-management program. A second group participated in the online program and received individual assistance to solve issues related to their diabetes distress. A third was provided with personalized health risk information and received educational material in the mail. All participants also received personal phone calls.
All three interventions significantly reduced distress, as well as depressive symptoms, over a 12-month period, and patients maintained those reductions over the course of the study.
Overall, 84 percent of those whose depression scores indicated moderate to severe depression reduced their depression to below moderate levels after the interventions, Fisher said. Reductions were evenly distributed across all three groups. “What’s important about this,” said Fisher, “is that many of the depressive symptoms reported by people with type 2 diabetes are really related to their diabetes, and don’t have to be considered psychopathology. So they can be addressed as part of the spectrum of the experience of diabetes and dealt with by their diabetes care team."
Dr. Xavier Jimenez, a psychiatrist at the Center for Brain Health at the Cleveland Clinic, told Healthline, “There are a huge number of people who do not meet the criteria for clinical depression and yet have diabetes distress. It is common. It is not full-blown depression, but it is still impacting the patient.”
Noting that these feelings of distress are often seen in newly diagnosed diabetes patients because of the huge adjustment involved, Jimenez said, “We also see it sometimes years later when the consequences of diabetes catch up. Many people who have diabetes for many years may develop renal disease and neuropathy issues, and they tend to present with significant depression.”
Lifestyle Changes Are Key
Pointing out that diabetes distress is more common in men early in their disease because of the dramatic change diabetes represents in their lifestyle, Jimenez said that when the disease advances and complications occur, the distress is seen equally in men and women.
Jimenez emphasized that simple lifestyle changes, such as increasing exercise and trying relaxation techniques, can also help patients. “Patients may develop frequent urination, pain, and changes in sleep. You need to feel refreshed in terms of making sure you are getting enough sleep,” said Jimenez. He suggested that patients keep their bedrooms dark, cool, and free from sound, and that they don’t drink caffeine before going to bed.
Jimenez said that a diabetes diagnosis can be a “big shocker for [patients]. It’s a life altering condition. They should talk with diabetes educators, peers, people or family members who have had diabetes, and find a support group. Being alone in the process can be particularly difficult, and it puts people at risk of actual clinical depression.”
“If I find someone after numerous changes feeling overwhelmed, it may be time to explore anti-depressant medication,” Jimenez added.
Depression and Mortality Risk
A second, unrelated study, also presented at the ADA conference analyzed data from a cohort of people with type 1 diabetes in the Pittsburgh area, and found that those who exhibit the highest level of depressive symptoms are the most likely to die early.
In this study, the Beck Depression Inventory was used to measure depressive symptoms such as low mood, loss of interest in activities, loss of appetite, feelings of worthlessness, and suicidal tendencies. Participants in the study had been diagnosed with diabetes as children between 1950 and 1980 and were first studied in 1986. They are now in their 25th year of follow-up as part of a large, prospective cohort study.
Lead study author Cassie Fickley said in a press statement, “For every one-point increase on the Beck Depression Inventory scale, participants showed a four percent increase in risk for mortality—after controlling for other factors that might increase the risk of death.”
Addressing Patient Fears
Jerry Meece, R.Ph., CDE, and owner of Clinical Services at Plaza Pharmacy and Wellness Center in Gainesville, Tx., who has incorporated diabetes care into his pharmacy practice, told Healthline, “When a person is diagnosed with a disease they will have to deal with 24/7, it’s easy to understand why they would be distressed. They are pricking their finger and injecting four times a day. They've heard every bad thing and have seen the side effects of a relative not managing it well. It wouldn't be natural if they weren't distressed or depressed."
Diabetes educators and other healthcare professionals can help patients by asking them motivational questions, he added. “Instead of a checklist, professionals have to take a minute and ask, what drives you crazy about your diabetes? It may be something that is not on our list. They may worry they are going to go blind, or lose their foot like their uncle did," Meece said. "There are studies that say if you keep your A1C down to close to seven [percent], you can reduce the risk of these things happening. There is something you can do about your diabetes.”
It is also important for diabetes educators and other clinicians to learn how to use basic screening tools to help determine if a patient has depression, and when to refer patients to mental health professionals. “That’s not being done enough,” he said.
Diabetes patients may have different stressors at different times, Meece said. "It’s also important to ask patients, What components can we get off your plate? What is your biggest stressor right now? What medication are you taking? Are you having problems?”
Concerns about nutrition, blood glucose levels, exercise, carbohydrate intake, self-injections, and the price of medications are among the worries his patients have. “They ask, how do I do all these things and still have a life? People are overwhelmed when they walk out of the doctor’s office,” said Meece.
Patients can learn how to "work their diabetes around their life. You’ll have a full life, but there are certain things you have to do first. If you want to bike 10 miles, yes you can, but you have to bring a snack," Meece said. "This isn’t your grandma’s diabetes. We know more about diabetes than before. If you keep your blood glucose down, and blood pressure in check, you can live a long and healthy life."