Review Article<
Depression in diabetic patients: The relationship between mood and glycemic control

https://doi.org/10.1016/j.jdiacomp.2004.01.002Get rights and content

Abstract

Problem

Evidence from prospective and cross-sectional studies demonstrates that the presence of diabetes doubles the risk of comorbid depression. This commonly overlooked comorbidity affects more than one quarter of the diabetic population, making its recognition and treatment in diabetic patients clinically relevant.

Methods

PubMed, PsycINFO, and MEDLINE databases were searched (search words: diabetes, depression, metabolic control, hyperglycemia, hypoglycemia) for articles that evaluated outcomes, relationships, and/or management of comorbid depression and diabetes published between 1980 and 2002. This review represents a synthesis of the findings including treatment recommendations.

Results

Concurrent depression is associated with a decrease in metabolic control, poor adherence to medication and diet regimens, a reduction in quality of life, and an increase in health care expenditures. In turn, poor metabolic control may exacerbate depression and diminish response to antidepressant regimens. Psychotherapy and pharmacotherapy are effective in the presence of diabetes; both cognitive behavior therapy and selective serotonin reuptake inhibitors are weight neutral and have been associated with glycemic improvement in some studies.

Conclusion

Depression is common in both type 1 and type 2 diabetes and has significant effects on the course and outcome of this medical illness. Conventional antidepressant management strategies are effective and the regimen should be tailored to the individual patient. Enhanced efforts toward good glycemic control may also contribute to improvements in mood and perceptions of well-being.

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.

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