Last week we talked about Celiac Awareness Month. Turns out May is also National Mental Health Awareness Month, so for our ongoing 411 series on diabetes complications, today we’re tackling something that you might not even realize is a complication: depression.
Although not typically listed as a diabetes complication, it is well-documented that depression affects people with diabetes in large numbers. No surprise to us PWDs, considering all the crap we have to deal with: from guilt over blood sugars, to frustrating insurance battles, to the day-in and day-out weight of managing every tiny detail in our lives. We know full well that the hardest part of having diabetes may be the psychological side.
It’s no wonder that the Centers for Disease Control reports that people with diabetes are twice as likely to suffer from depression.
Now, just to clarify: clinical depression is quite different than the “blues” or “diabetes burnout,” in that it is a chemical imbalance in the brain. It does not simply fade away and it’s not just the occasional “I hate diabetes!” outburst. But diabetes burn-out and other mental health issues are just as important to take care of, and burn-out can often be a trigger to more serious distress.
And the connection works both ways.
Some of the common signs of depression are:
- Persistent sad, anxious, or “empty” mood
- Feelings of hopelessness, pessimism
- Feelings of guilt, worthlessness, helplessness
- Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
- Decreased energy, fatigue, being “slowed down”
- Difficulty concentrating, remembering, making decisions
- Insomnia, early-morning awakening, or oversleeping
- Appetite and/or weight changes
- Thoughts of death or suicide, or suicide attempts
- Restlessness, irritability
Whether you think have clinical depression or just going through a rough patch in dealing with the emotions of diabetes (which is as much a roller coaster as our blood sugars!), it is important to seek help as soon as possible. Depression, burn-out, and mental fatigue can have unwanted effects on your health and diabetes management. For example, a study in the Archives of General Psychiatry shows that women with diabetes and depression are at increased risk for cardiovascular disease, which is already one of the most common diabetes complications.
Treatment
Clinical depression is quite treatable if you get the proper help. Although it may be difficult to find a psychiatrist or psychologist who understands diabetes the way you do, it’s still important to get your depression symptoms treated.
Medications, such as tricyclic antidepressants, have been shown to be helpful in treating depression in people with diabetes. But they often have side effects, such as weight gain and nausea, which are clearly undesirable and may impact your diabetes management. Once you start taking an antidepressant, you’ll want to work with both your psychiatrist and your endocrinologist, and not suddenly go off the drug without direction from your doctor, as quitting cold turkey can be very ugly!
Another route that can be effective even without the use of medication is psychotherapy or “talk therapy.” This can often help work out issues regarding stress and guilt that build up over years of dealing with diabetes. It is well-recognized that psychotherapy is an important component of mental health treatment.
Korey Hood, a clinical psychiatrist and type 1 diabetic, tells us that even if you’re unable to find someone who knows about diabetes specifically, you can play educator to your therapist about how diabetes effects your mental state.
“In the process, you’re able to teach [the therapist] about diabetes, and have them increase their appreciation and understanding — and then in turn, they can counsel you on coping strategies for stress and anger or help build your communication skills with your family members,” Korey explains.
Lee Ann Thill, a PWD with type 1, fellow D-blogger, and board certified art therapist in New Jersey, says that therapy has had a profound impact for her in coping with diabetes. “Personally, I value being able to share my feelings about diabetes with the people in my life, but since diabetes is already a burden on them, I try to be careful about how much and when I share. One of the things that I’ve most appreciated about being in therapy is the opportunity to unload the fear and anger I have about diabetes without feeling like I’m upsetting someone I love. Before getting therapy for myself, I underestimated how my feelings about diabetes were contributing to my depression, and I underestimated the value of having a safe, confidential place to share those feelings.”
How to Find a Therapist
The main option for finding a therapist, just like with finding a physician, is to look up those covered under your insurance (assuming you have mental health benefits). Psychology Today and the American Psychological Association both have locator tools to find someone in your area, and you can specify your search to include people who deal with chronic illness, and then cross-check to be sure they’re listed in your network.
Your local diabetes clinic may also have a list of nearby health professionals with whom they have a referral relationship. If you have an open relationship with your endocrinologist (which we hope you do!), talk to him or her about anything you’re struggling with. Depression almost always impacts your diabetes management, and it’s your physician’s duty (and best interest) to help you get the help you need.
If you don’t have insurance coverage for therapy, or if you don’t like anyone in your network, don’t be afraid to expand your search. Many professionals will work within your financial restraints to get you the help you need. Lee Ann recommends just picking up the phone and calling around. It can be difficult to determine areas of specialties from listings, so it’s often easier to determine over the phone whether or not someone is experienced with diabetes. Ask questions about their experience, their credentials, and how they work.
“Having a therapist you like who understands your issues should be a priority when seeking treatment,” Lee Ann says. “Anyone who can’t take the time to help you understand what they do probably isn’t someone you want to see.”
Lee Ann also suggests looking “outside the box” when it comes to mental health professionals: “Family therapists are a great option, especially because diabetes is a family disease. I’m an art therapist, so I encourage people to investigate art, dance/movement or music therapy. In creative arts therapy, you’ll be able to talk about your problems, but you’ll also get to use the arts medium to express your feelings which can facilitate therapeutic progress.”
We also hope you’ve heard of the Behavioral Diabetes Institute, a San Diego-based practice that’s well-known for its team of specialists in diabetes. Although they’re limited in geographic scope, director Dr. Bill Polonsky is a frequent speaker at diabetes events and has written a seminal book on the topic, Diabetes Burn-out: What To Do When You Can’t Take It Anymore.
Other Reading Material
If you can’t get to a therapist right away, there are some other good books that address the emotional issues of diabetes and chronic illness:
* Psyching Out Diabetes – Written by former President of the American Diabetes Association, Dr. Richard Rubin, who’s an expert and principal investigator in several long-term studies of psychosocial and life-style issues with diabetes. Although the book is several years old and some of the technology talk is outdated, dealing with the emotional aspects of diabetes is “evergreen.”
* 101 Tips for Coping with Diabetes – Keeping it in the family, Dr. Stefan Rubin is Dr. Richard Rubin’s son, who has lived with diabetes since 1979. Both Stefan and Richard have spoken at the CWD Friends for Life conferences about living well with diabetes. This book covers tips for handling stress, anger, depression, meal temptation, and more.
* How to Be Sick – Recommended by Psychology Today and the Huffington Post, this Buddhist-infused book on “how to be sick” takes a spiritual approach to living with a chronic illness. While it might not be for everyone, spirituality has been shown to affect people with diabetes in positive ways.
Last word for today:
Depression, like diabetes, is manageable and treatable if you get help, so don’t wait. Whatever you choose to do, just know that you are not alone!
Controlling the blood sugar and achieving average 120-150 mg/dl with A1C below 7.0 should help manage depression. Also we find large number of people deficient in vitamin D3 which is otherwise silent. Make sure the level is checked and deficiency corrected. Otherwise, I think patients with depression should be promptly diagnosed and managed by a professional.
Just tell me how to get rid of the diabetes and the depression will be gone as well.mis
@DrKousa – that’s a bit insulting. You make it sound easy to simply “achieve average 120-150 mg/dl with A1C below 7.0.” Any idea how freakin’ difficult that is for some folks?!
Also, the point is that it’s a vicious cycle: poor BG results lead to depression + depression leads to poor BG results.
Well said, Amy! Thanks! As one who struggles with T1 and depression, the last thing I need a doc to say is: “if you’d keep your blood sugars under perfect control, you’d not be depressed”. I’ll get right on that.
Thank you for your response. I agree with you one hundred percent. On the other hand, depression may cause a person to lose interest and not take care of themselves. Like you said it is a vicious cycle. The good news is that for most people it is not hard to achieve HGB A1C below 7.0. You know something .. there is a good way to do things: Follow a process, due diligence. Have a good doctor and a good dietician, arm yourself with knowledge and education and go about in your business solving the most difficult problems like a breeze. Please do not feel insulted. I learn myself every day and love learning. I face challenges and sometimes I am defeated, but still love facing them and resolving issues. Wish you the very best.
It’s really nice to see someone addressing this issue. I’ve been struggling with depression for about half my life, and although I’m fairly new to diabetes (dx late November 2010), I can definitely see the correlation between mood and control. When my mood is low, I’ll tend to either binge on carb-heavy foods (toast, cake, cookies, and especially pasta) or skip eating altogether until I feel woozy. Not good. I consider myself lucky in that I can keep my depression under control most of the time without medication, but I’m definitely concerned about diabetes burnout.
“for most people it is not hard to achieve HGB A1C below 7.0. ”
Hmmm, so let’s see here…
-Follow a process – check!
-Due diligence – check!
-Good doctor – check!
-Good dietician – check!
-Loves learning – check!
-Education – check check!
-Knowledge – check check check!
-Takes all challenges like a breeze – checkeroo!
Hmmm. Dang, then why was my last A1c above 7.0 then?
Oh, I know what it must be, it must be because…. I have Type 1 Diabetes!!!
Our dear Dr. Kousa, you do not sound to us like a Type 1 Diabetic. If only you knew what it was like. If only you could possibly understand. If only.
Great column! Just wanted to mention that there are lots more antidepressants than the tricyclics, which are really rather old-fashioned. Even the SSRI (Selective Serotonin Reuptake Inhibitors) have been around for quite a while. And there are new ones, like Cymbalta (which is also used for neuropathy), Celexa, Lexapro, and more, which I don’t know the names of. The reason I bring this up is that if one drug doesn’t work, there are MANY others to choose from. Don’t give up if the first one doesn’t work.
As a life-long sufferer of depression, I also heartily agree with your advice about finding a good therapist. The key word here is GOOD. There are a lot of crummy ones out there; I tried 4 of them before I found my current one. He doesn’t know much about diabetes, but he DOES know about feelings, and how to help me express them and get to the root of them.
I do agree with Dr. Kousa that BG control is paramount. I wouldn’t specify a number, but last year, I had a major depression, and started bingeing on carbs, and periodically omitting insulin, and ended up in a coma that almost killed me. What I learned from that experience is that, whatever else I DON’T do, like the dishes, the laundry or the cat boxes, I WILL take care of my diabetes, because once the diabetes is wildly out of control, it’s impossible to take care of any other aspect of your life. If you even have to be hospitalized because you are not taking care of your diabetes, then do it — the alternative REALLY isn’t worth it.
We have found that the don’t do’s have added to depression. Although there are physical reasons for feeling depressed it is important to remember to have fun and live life to the full. Be indulgent at times and remember that you are human and deserve to be happy!
@T1 in Boson – Thank you for that! Clearly, plenty of doctors out there do not have a CLUE what their diabetic patients are dealing with on a day-to-day basis. Ugh!
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Thank you for this post. The co-occurrence of mental health illness with a chronic health condition is profound and has serious consequences. You give great suggestions for type 1′s to seek treatment through therapy and medication. There are several options.
I might add that in addition to depression other mental illnesses pervade those with disabilities including anxiety and eating disorders. The confluence of factors that contribute to each of these mental health illnesses in someone already dealing with a chronic conditions can wreak havoc on one’s ability to care for themselves.
It’s quite a difficult road – being depressed about having diabetes, being anxious about perfect blood sugars and what the doctor will chastise you about or struggling to accept your body with type 1. Unfortunately, there is no “checklist” there is no easy answer. An A1c of 7.0 may be really difficult for some to reach – don’t judge that person because they may have other difficulties they are struggling with. Another person could take another extreme and obsessively attack their diabetes – it also may not be the healthiest way to live even if the numbers are perfect. And then again, having an A1c doesn’t necessarily help depression. Sure, A1c’s have an effect on mood but depression is a serious medical condition that will continue no matter what your A1c is.
Vitamins, supplements, medicines and therapy can be a great help – so find a doctor or therapist you trust. Unfortunately many of our endocrinologists and other doctors don’t address the mental health part of type 1. They focus on the rigidity of numbers to the detriment of deeper issues. So if you are not getting anywhere with your doc, keep asking elsewhere. There is help out there.
To find out more about Mental Health Illnesses, go to:
- National Institute of Mental Health (http://www.nimh.nih.gov/)
- Mental Health America (http://www.mentalhealthamerica.net/)
- American Psychology Association (linked above)
Having depression with diabetes adds to the complexity of the problem. The good news is 1) This can be hard but not impossible. 2) There is plenty of help out there. 3) If you live in the United States, then you are blessed with access to the latest achievements of mankind in the last one million years in terms of medical care and yes this is the best county in the world period and we are blessed to live here amongst the nicest people like yourselves. 4) Never give up. Instead get up and get the help you need and your life will be better and enjoyable again despite diabetes and depression. Depression is a brain drain out of neuro-transmitters that can be replaced with modern medications.
Thanks to every one in this column for their responses.
I meant to mention that we find large number of patients deficient in vitamin D even in the summer months. As you might know, vitamin D deficiency is linked to depression. Normalizing vitamin D level will eliminate depression as a contributory factor in the incidence of depression. It will enhance your mood, give you energy and make depression treatment easier. Other benefits of vitamin D is that it also modulate the immune system, helps you prevent and fight infections ( common colds and UTIs) and helps prevent cancer. Diabetics as you know are immune-compromised and a boost in the immune system is a welcome step.
Thanks for this very informative and important discussion. It’s completely normal to feel down every now and then, but if it persists it’s important to seek help. Very nice post!
HI
Only one organization in the world is dealing with Diabetes and Depression. It is the San Diego based Behaviorial Diabete Institute http://behavioraldiabetesinstitute.org/ . One of thier board members is at UCSF treating patients with depression and diabetes. Check them out for ressources on line and workshops too..
“Depression, like diabetes, is manageable and treatable if you get help, so don’t wait. Whatever you choose to do, just know that you are not alone!”
Great encouragement. There certainly are help out there.
Depression,
Chicken or egg, when too many lows hit the same brain center as booze would, and does. Why do not these Doc’s understand too many lows also contributs to this low depression. Also depression in the DSM is tagged with Major Medical Disease. Personlly having an added tag or lable is more burdensome then understanding, the constant DOING diabetes requires food carb counting, finger sicks, injections, cooking food, running for the glucose tabs, when the lows come.
Or when MD turns face and says all of medical complications are just the diabetic’s bad Karma. A1C 6.1-5.3 five plus years, weight loss 50+ Lbs, till this Karma crap. If MD doesn’t care, or blames paitents for this and other auto immune disease, hard to stay motivated. Harder still when other doc’s close the practice, or wait 6-12 weeks to get into new doc, will this new one be kind, caringing or judemental.