Review Article<Depression in diabetic patients: The relationship between mood and glycemic control
Introduction
Diabetes mellitus is a chronic disease resulting from defects in insulin secretion, insulin action, or both. It currently affects approximately 17 million people, or 6.2% of the population of the United States; this figure is expected to rise to 9% by 2025 (American Diabetes Association, 2003). Long-term macrovascular, neurological, and microvascular complications, such as retinopathy, nephropathy, and neuropathy, are significant causes of morbidity and mortality in patients with diabetes. More recently, major depression also has been shown to be a common comorbidity, affecting more than one quarter of the diabetic population Anderson et al., 2001, Egede et al., 2002, Gavard et al., 1993, Goodnick et al., 1995. Growing evidence from clinical studies indicates that diabetic patients with major depression demonstrate poor adherence to antidiabetic regimens, have poor glycemic control, and are at increased risk for retinopathy (Kovacs, Mukerji, Drash, & Iyengar, 1995) and macrovascular complications (Lloyd, Matthews, Wing, & Orchard, 1992).
This article reviews diabetes-associated depression and its relationship to glycemic control. It describes approaches for the detection and management of depression, including the use of antidepressant therapies and their effects on glycemic control. Also reviewed are data showing the positive effects that good metabolic control has on psychological well-being and outcomes of the treatment of depression in diabetic patients.
Section snippets
Depression in diabetes
The prevalence of symptomatic major depression in the general adult population is 3% to 4%, a figure that is on the rise (Gavard et al., 1993). Diabetes has been reported to at least double the risk of comorbid depression, with the point prevalence approximating 11% in the diabetic population Anderson et al., 2001, Egede et al., 2002, Goodnick et al., 1995. A recent meta-analysis suggests that the prevalence increases to 28.5% when diabetic patients with previous histories of depression are
Major depressive disorder as a risk factor for type 2 diabetes
Major depressive disorder is a multidimensional phenomenon involving the interaction of biological and psychosocial factors that may increase the probability of developing type 2 diabetes (Talbot & Nouwen, 2000). Longitudinal studies have confirmed that MDD poses this risk (Talbot & Nouwen, 2000). Although depression typically follows the diagnosis of type 1 diabetes, the depression-related mechanisms contributing to the development of type 2 diabetes may be equally detrimental in type 1
Management of concomitant depression in diabetes
Concomitant depression occurring in diabetic patients follows a chronic and severe course compared with depressed individuals without diabetes (Lustman, Griffith, Gavard, & Clouse, 1992). An episode of depression typically lasts for 6 to 9 months but may last for up to 2 years. Most patients experience recovery (Keller, Shapiro, Lavori, & Wolfe, 1982a) or enter remission from an initial episode of major depression (Mueller & Leon, 1996). Unfortunately, patients that recover from an initial
Treatment algorithm for comorbid depression and type 2 diabetes
Because of the particular importance of depression to the onset and course of type 2 diabetes, an algorithm incorporating the management of both seems relevant but was not discovered in the literature review. Based on available information regarding the bidirectional interaction of these disorders, a prototypical management strategy is presented in Fig. 3. This combined management approach includes one commonly utilized algorithm for treating type 2 diabetes (Texas Diabetes Council, 2003)
Conclusions
The appropriate management of any chronic medical illness, including diabetes, should include the identification and treatment of comorbid depression. This approach considers the major effects of affective illness on symptom burden, functional impairment, quality of life, and self-management of the primary disease. Among patients with diabetes, more than one quarter has depression at a clinically significant level. Despite this, depression is recognized and treated in only about one third of
Acknowledgements
This work was supported in part by grants DK36452, DK53060, and DK59364 from the National Institutes of Health.
References (79)
- et al.
The course of major depression in diabetes
General Hospital Psychiatry
(1997) - et al.
Nonpsychiatric physicians' identification and treatment of depression in patients with diabetes
Comprehensive Psychiatry
(1987) - et al.
Stress and diabetic control
Lancet
(1983) Enhancing central and peripheral insulin activity as a strategy for the treatment of endogenous depression—An adjuvant role for chromium picolinate?
Medical Hypotheses
(1994)- et al.
Recovery, chronicity, and levels of psychopathology in major depression
Psychiatric Clinics of North America
(1996) - et al.
Relative insulin insensitivity and cortisol secretion in depressed patients
Psychiatry Research
(1981) - et al.
Insulin resistance in patients with depression and its changes during clinical course of depression: minimal model analysis
Metabolism
(2000) - et al.
Insulin improves well-being for selected elderly type 2 diabetic subjects
Diabetes Research and Clinical Practice
(2002) Economic costs of diabetes in the U.S. in 2002
Diabetes Care
(2003)- American Diabetes Association. (2003). Facts and figures. Available at: http://www.diabetes.org/info/facts/facts.jsp....
The prevalence of comorbid depression in adults with diabetes: a meta-analysis
Diabetes Care
An inventory for measuring depression
Archives of General Psychiatry
Relapse after recovery from unipolar depression: a critical review
Psychological Bulletin
Treatment satisfaction and psychological well-being in patients with type 1 diabetes, treated with a new long-acting insulin, insulin glargine (Abstract 1547)
Diabetes
Symptoms of depression as a risk factor for incident diabetes: findings from the National Health and Nutrition Examination Epidemiologic Follow-up Study, 1971–1992
American Journal of Epidemiology
Depression and diabetes: impact of depressive symptoms on adherence, function, and costs
Archives of Internal Medicine
Early detection of depression using the Zung Self-Rating Depression Scale
Puerto Rico Health Sciences Journal
Screening for depression in adults (letter)
Annals of Internal Medicine
Screening for depression in adults (letter)
Annals of Internal Medicine
Association of depression and diabetes complications: a meta-analysis
Psychosomatic Medicine
Medications versus cognitive behavior therapy for severely depressed outpatients: mega-analysis of four randomized comparisons
American Journal of Psychiatry
Depression and risk for onset of type II diabetes. A prospective population-based study
Diabetes Care
Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes
Diabetes Care
National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments
Archives of General Psychiatry
Contributors to depression in Latino and European-American patients with type 2 diabetes
Diabetes Care
Three-year outcomes for maintenance therapies in recurrent depression
Archives of General Psychiatry
Depressive symptoms and metabolic control in African-Americans with type 2 diabetes
Diabetes Care
Prevalence of depression in adults with diabetes: an epidemiological evaluation
Diabetes Care
Mood changes associated with blood glucose fluctuations in insulin-dependent diabetes mellitus
Health Psychology
Use of antidepressants in treatment of comorbid diabetes mellitus and depression as well as in diabetic neuropathy
Annals of Clinical Psychiatry
Treatment of depression in patients with diabetes mellitus
Journal of Clinical Psychiatry
A rating scale for depression
Journal of Neurology, Neurosurgery, and Psychiatry
Depression in subjects with type 2 diabetes: predictive factors and relation to quality life
Diabetes Care
Depressive symptoms and occurrence of type 2 diabetes among Japanese men
Diabetes Care
Recovery in major depressive disorder: analysis with the life table and regression models
Archives of General Psychiatry
Relapse in major depressive disorder: analysis with the life table
Archives of General Psychiatry
Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey
Archives of General Psychiatry
Biomedical and psychiatric risk factors for retinopathy among children with IDDM
Diabetes Care
Major depressive disorder in youths with IDDM: a controlled prospective study of course and outcome
Diabetes Care
Cited by (490)
Association between antidepressants and the risk of diabetic foot ulcers and amputation in antidepressant-naïve type 2 diabetes mellitus patients: A nested case-control study
2024, Diabetes Research and Clinical PracticeImpact of nonalcoholic fatty liver disease-related metabolic state on depression
2023, Neurochemistry InternationalHigher levels of peripheral blood glucose in the acute stage of stroke increase the risk of post-stroke depression: A systematic review and meta-analysis
2022, Neuroscience and Biobehavioral ReviewsThe prevalence and characteristics of alexithymia in patients with type 2 diabetes mellitus: A systematic review and meta-analysis
2022, Journal of Psychosomatic Research