When a diabetic patient is also dealing with depression, there are myriad issues to consider for both the physician and the patient. Everything from diabetes distress and medications to alcohol consumption can affect both conditions.
For people with diabetes, depression acts as a magnifier. It can worsen the pain of diabetes-related neuropathy and wreak havoc on blood glucose by disturbing appetite and sapping the energy required for regular physical activity. Diverse studies such as the Diabetes and Aging Study and the Pittsburgh Epidemiology of Diabetes Complications Study suggest that people with both diabetes and depression have more than twice the risk of early mortality than people who have only diabetes.
According to a May 2013 paper published in SelfCare, roughly 11% of adults with diabetes have major depression, and 31% have clinically relevant depression, harking back to a 2001 study in Diabetes Care. With statistics like that, it’s a given endocrinologists will encounter patients with diabetes who are struggling with depression.
Yet more recent evidence, such as research presented by Lawrence Fisher, PhD, professor of family and community medicine at the University of California–San Francisco at the American Diabetes Association’s 74th Scientific Sessions in June 2014, suggests that depressive symptoms in people with diabetes often point not to clinical depression, but to diabetes distress, a separate, if similar, condition. Whereas depression is overarching, diabetes distress is about the emotional burdens of managing diabetes in particular.
“Over the past few years, we have found that many cases diagnosed as depression really were more specific to how fed up and discouraged people were with their diabetes. Sometimes people were misdiagnosed,” says William H. Polonsky, PhD, CDE, president of the Behavioral Diabetes Institute and associate clinical professor at the University of California, San Diego. “The catch is that if a patient has diabetes distress, giving that person an antidepressant is not going to make it go away.”
Considering the time constraints of an office visit, endocrinologists tend to shy away from discussing their patients’ emotional state, says Jeffrey S. Gonzales, PhD, associate professor in the Department of Medicine and the Department of Epidemiology and Population Health at the Albert Einstein College of Medicine in New York. “Endocrinologists often feel unprepared to deal with the question of depression with diabetes. They can feel like it’s opening a Pandora’s Box, or probing for things they may not have time to respond to.”
Although a diagnosis of depression should come from a mental health professional, endocrinologists are in an excellent position to notice a decline in their patients’ emotional well-being and make a preliminary determination about diabetes distress, he adds. “It’s not that you have to fix the problem in 15 minutes, but to identify it at its most basic level.”
Screening
As with any condition, a patient’s medical history should be the first consideration in determining risk for depression, says Mark Peyrot, PhD, professor and chair of the Department of Sociology at Loyola University Maryland, in Baltimore. “The best place to start is with the idea that depression is a chronic disease like diabetes: If someone has been diagnosed with depression in the past, he or she should be closely monitored on an ongoing basis. It’s a high level of alert.”
Peyrot added that a major downturn in health, such as the development of a diabetes-related complication, is also a warning sign, particularly if there is also a simultaneous loss of diabetes control. “I wouldn’t say that patients with poor blood glucose control are at an exceptionally high risk for depression, but that depression can be one of the reasons why they have poor control.”
Ann Goebel-Fabbri, PhD, assistant professor of psychiatry at Harvard Medical School in Boston, agrees. “The hallmark of depression is lack of motivation and energy, and diabetes management requires both,” she explains. “If a patient is not meeting the optimal glycemic target and the A1c is elevated when it used to be in the healthy range, that could be a red flag.”
The Patient Health Questionnaire 9 offers a quick way to see if a patient is struggling emotionally, says Peyrot. “It’s based on diagnostic criteria for a major depressive disorder. If there is a high symptom count, the patient may qualify for a diagnosis of depression and it would be worth sending the patient to [a mental health professional] who can make that determination.”
But if the results are not clear, endocrinologists should take the time to drill down and assess the patient for diabetes distress, says Polonsky. “Ask them how they feel about their diabetes, and if they can tell you one thing about their diabetes that is driving them crazy. That can give you an immediate sense of how big a problem you’re looking at, and to what degree they are really grappling with diabetes distress,” he says. “People with type 1 may say they feel like they never get a break. People with type 2 may say they are frustrated with trying to lose weight. Both may say they are tired of not reaching their goals despite their best efforts.”
Tools such as the Diabetes Distress Scale 17, developed by Polonsky, Fisher, and their colleagues, contains questions designed to zero in on diabetes distress.
Endocrinologists should also discuss alcohol use, says Joshua J. Neumiller, PharmD, CDE, FASCP, associate professor in the Department of Pharmacotherapy at Washington State University’s College of Pharmacy in Spokane. “People who are depressed may self-medicate with alcohol but often will not share this unless specifically asked,” he says, adding that endocrinologists may find clues in a patient’s glycemic control and could approach the subject that way. “Depending on what a patient drinks and how much, alcoholic beverages can have a considerable impact on glycemia. Alcohol use is also associated with delayed hypoglycemic reactions. This is very much an under-recognized phenomenon and worth looking into.”
Treatment
Basic screening and a few targeted questions can provide a starting point for treatment. If the assessments strongly indicate diabetes distress, the patient may need to go no further than the endocrinologist’s office to address it.
“With diabetes distress, the endocrinologist, diabetes nurse educator, or other clinicians in the endocrinology practice may be best qualified to talk to the patient because treatment will focus on better diabetes management,” says Gonzalez.
However, if screening points to clinical depression, then a referral to a mental health professional is in order. The challenge there is fragmentation in healthcare.
“Even if you’re a very sensitive endocrinologist who knows about depression and wants to get your patient appropriate care, insurance plans may separate mental health benefits from diabetes treatment [in a way that makes teamwork among clinicians difficult],” says Gonzalez. “It’s like chopping people up into different diseases.”
Endocrinologists or their staffs may have to do some legwork to find mental health professionals for appropriate referrals, says Goebel-Fabbri. “Be aware that many mental health providers will not have experience with diabetes, its treatments, and its goals. You may have to search for providers you can imagine your patients working with and keep a list.”
She adds that the dearth of mental health professionals knowledgeable about the finer points of diabetes care may require endocrinologists to be proactive in communicating with counselors. “Information about diabetes should come from the diabetes team,” she says. “It’s unfair to burden the patient with teaching a counselor about it. Physicians and counselors will need to talk to each other.”
— D’Arrigo is a health and science writer based in Holbrook, N.Y., and a regular contributor to
Endocrine News. She wrote about treating diabetes concurrently with cancer in the July issue.
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