DEPRESSION AND DIABETES

A synopsis based on the WPA volume Depression and Diabetes

(Katon W, Maj M, Sartorius N, eds. Chichester: Wiley, 2010)

Epidemiology of depression and diabetes

In people with diabetes, the prevalence of clinically relevant
depressive symptoms is 31% and that of major depression
is 11% (Anderson et al., 2001).
People with depressive disorders have a 65% increased
risk of developing diabetes (Campayo et al., 2010).
The prognosis of both diabetes and depression (in terms of
complications, treatment resistance and mortality) is worse
when the two diseases are comorbid than when they occur
separately.
From Lloyd CE et al. The epidemiology of depression and diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley,
2010.

People with both depression and diabetes have a greater decrement in self-reported health than
those with depression and any other chronic disease (Moussavi et al., Lancet 2007;370:851-858).
From Lloyd CE et al. The epidemiology of depression and diabetes. In: Depression and Diabetes.
Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Health care utilization is significantly higher among depressed compared with non-depressed diabetes patients
(US 1996 data). From Egede LE. Medical costs of depression and diabetes. In: Depression and Diabetes. Katon
W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Health care expenditures are significantly higher in depressed than in non-depressed diabetes patients (US
1996 data). From Egede LE. Medical costs of depression and diabetes. In: Depression and Diabetes. Katon W,
Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Depression and diabetes complications

A prospective association has been documented between prior
depressive symptoms and the onset of coronary artery disease
in people with diabetes (Orchard et al., 2003).
A prospective association has been found between depression
and the onset of retinopathy in children with diabetes (Kovacs et
al., 1995).
Depressive symptoms are more common in diabetes patients
with macro- and micro-vascular problems, such as erectile
dysfunction and diabetic foot disease, although the causal
direction of the relationship is unclear (Thomas et al., 2004).
From Lloyd CE et al. The epidemiology of depression and diabetes. In: Depression and
Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Diabetic population

Non-diabetic population

Survival functions in a diabetic population stratified by Centers for Epidemiologic Survival

Studies functions in a nondiabetic population stratified by Centers for Epidemiologic Studies
Depression (CES-D) Scale score, NHANES I Epidemiologic Follow-up Study, 1982-1992
Depression (CES-D) Scale score, NHANES I Epidemiologic Follow-up Study, 1982-1992

Zhang, X. et al. Am. J. Epidemiol. 2005 161:652-660; doi:10.1093/aje/kwi089

ght restrictions may apply.

Zhang, X. et al. Am. J. Epidemiol. 2005 161:652-660; doi:10.1093/aje/kwi089

Copyright restrictions may apply.

A strong association has been found between depressive symptoms (as assessed by the Center
for Epidemiological Studies - Depression Scale, CES-D) and increased mortality in people with
diabetes, but not in those without diabetes, after adjusting for socio-demographic and lifestyle
factors (Zhang et al., Am. J. Epidemiol. 2005;161:652-660). From Lloyd CE et al. The epidemiology
of depression and diabetes. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.

The depression-diabetes link: behavioural factors

Depression is associated with reduced physical activity, which
increases the risk for obesity and consequently for type 2
diabetes.
Depression is associated with poor diabetes self-care
(including oral medication taking, dietary modifications,
exercising and monitoring of blood glucose).
Emotional problems related to diabetes may lead to the
development of depression.
From Lloyd CE et al. The epidemiology of depression and diabetes. In: Depression
and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

The depression-diabetes link: biological factors

Depression is a phenotype for a range of stress-related
disorders which lead to an activation of the hypothalamicpituitary-adrenal axis, a dysregulation of the autonomic nervous
system and a release of pro-inflammatory cytokines, ultimately
resulting in insulin resistance.
Metabolic programming at the genetic level and undernutrition
(in utero and childhood) may predispose to both diabetes and
depression.
From Ismail K. Unravelling the pathogenesis of the depression-diabetes link. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Practical problems arising from depression-diabetes comorbidity - I

Problem

Depression and diabetes symptoms overlap

Depression symptoms mimic diabetes

Impact

Patient and clinician may be unaware of depression, and may

primarily attribute changed status to worsening diabetes self-care

symptoms

Depression may be associated with onset or

amplification of physical symptoms

Depression is commonly associated with

difficulties with diabetes self-management and
treatment adherence

Patient may not sense he/she is fully understood or supported by

his/her clinician during health care visits when physical or lab
results do not correspond to subjective complaints

Patient may feel resigned about the ability to make changes, e.g. I
know what I am supposed to do and what I am not supposed to do,
but I still do the wrong things and I dont know why!
Clinician may feel discouraged about the ability of the patient to
make relevant changes in his/her care

From Hellman R, Ciechanowski P. Diabetes and depression: management in ordinary clinical

conditions. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley,
2010.

Practical problems arising from depression-diabetes comorbidity - II

Problem

Individuals with depression may attempt to regulate

emotions with food or substances

Stressors that interfere with self-management

strategies and worsen diabetes status may also
precipitate or exacerbate depression

Depression may reduce the ability of affected

individuals to trust others or to be satisfied with health
care
Depression is commonly associated with changes in
health care seeking patterns and follow-through with
appointments

Impact

A clinician not understanding the underlying depressive

symptoms and patients desperation to regulate emotional pain
may come across as judgmental because of the stigma and
associated response to these behaviors

Patient and clinician may attribute poor diabetes outcomes to a

decrease in self-management because of a busy lifestyle but
may not appreciate the insidious development of depression and
its consequences

Patient may be reluctant to make appointments, show up for

appointments, seek support of health care providers or
collaborate with health care providers during appointments

From Hellman R, Ciechanowski P. Diabetes and depression: management in ordinary clinical

conditions. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley,
2010.

Practical problems arising from depression-diabetes comorbidity - III

Problem

Depression may be associated with

poor blood glucose control irrespective
of behavioral actions

Depression is commonly associated

with difficulty organizing tasks

Impact

This may lead to hopelessness, guilt, loss of empowerment, or a decreased

sense of control of illness and may influence the motivation of the patient to
engage in further clinical treatment recommendations
Unsuspecting clinicians may unwittingly blame the patient for a situation the
patient now has little control over

What might have been easily understood in the past may need to be written,
repeated and checked for comprehension while the patient is depressed

Depression leads to a more pessimistic Clinicians may need to help depressed patients break down tasks into
view of the future

Depression is commonly associated

with anxiety

manageable action steps that may have shorter-term pay-off (e.g., reduction of
physical symptoms)

Clinicians need to consider presence of anxiety which heightens a patients

uncertainty around decision-making and increases a general sense of dread
about the likelihood of success

From Hellman R, Ciechanowski P. Diabetes and depression: management in ordinary clinical

conditions. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley,
2010.

Efficacy trials of psychotherapies for depression in diabetes

Study

Interventions

Outcome

Lustman et al., 1998

Cognitive-behavioural therapy (CBT) plus diabetes

education vs. diabetes education alone

Improvement in depression as well as

glycemic control in CBT vs. control group

Huang et al., 2002

Antidiabetics + diabetic education + psychological

treatment + relaxation and music treatment vs.
antidiabetics only

Improvement in depression as well as

glycemic control in treatment vs. control group

Li et al., 2003

Antidiabetics + diabetic education + psychological

treatment vs. antidiabetics only

Improvement in depression as well as

glycemic control in treatment vs. control group

Lu et al., 2005

Diabetes and cerebrovascular accident education +

electromyographic treatment + psychological treatment
vs. usual care

Improvement in depression as well as

glycemic control in treatment vs. control group

Simson et al., 2008

Individual supportive psychotherapy vs. usual care

Improvement in depression as well as

glycemic control in supportive psychotherapy
vs. control group

From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Efficacy trials of medications for depression in diabetes

Study

Interventions

Outcome

Lustman et al., 1997

Glucometertraining + nortriptyline vs. placebo

Improvement in depression but not in glycemic control

with nortryptiline vs. placebo

Lustman et al., 2000

Fluoxetine vs. placebo

Improvement in depression but not in glycemic control

with fluoxetine vs. placebo

Paile-Hyvrinen et al., 2003 Paroxetine vs. placebo

After initial improvement in paroxetine group at 3

months, no significant improvement for both outcomes
at the end of follow-up

Xue et al., 2004

Paroxetine vs. placebo

Improvement in depression but not in glycemic control

with paroxetine vs. placebo

Glseren et al., 2005

Fluoxetine vs. paroxetine

Both groups improved significantly in depression but

not in glycemic control

Paile-Hyvrinen et al., 2007 Paroxetine vs. placebo

No significant improvement in depressive outcomes and

glycemic control

From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Depression care in patients with diabetes: Step 1

Screen for:

Depression with the Patient Health Questionnaire - 9 (PHQ-9)

Helplessness/giving up or sense of being overwhelmed about disease self-management
Comorbid panic attacks and post-traumatic stress disorder
Inability to differentiate anxiety symptoms from diabetes symptoms (e.g., hypoglycemia)

Associated eating concerns

Emotional eating in response to sadness/loneliness/anger
Binge eating/purging
Night eating

From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Depression care in patients with diabetes: Step 2

Improve self-management:

Explore loss of control of disease self-management

Explore understanding of bidirectional link between stress and suboptimal disease selfmanagement and outcomes

Define depression and how it overlaps with and is distinct from stress
Review symptoms of depression and how these symptoms overlap with or mimic diabetes
symptoms

Discuss depression-related medical symptom amplification

Break down tasks in self-management of diabetes, depression, other illnesses

Help patient prioritize order of importance of specific tasks

From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Depression care in patients with diabetes: Step 3

Support:

Consider adjunctive brief psychotherapy for:

emotional eating (cognitive-behavioural therapy)
breaking down problems (problem-solving therapy)
improving treatment adherence (motivational interviewing)

From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

Depression care in patients with diabetes: Step 4

Consider medication:

Comorbid depression and anxiety: SSRI or SNRI

Sexual dysfunction: use bupropion or, if already responding to SSRI, add buspirone
Significant neuropathy: choose bupropion, venlafaxine or duloxetine due to effectiveness
in treating neuropathic pain

From Katon W, van der Felz-Cornelis C. Treatment of depression in patients with diabetes. In:
Depression and Diabetes. Katon W, Maj M, Sartorius N (eds). Chichester: Wiley, 2010.

$25.000

Savings

Intervention

$5.000

Usual Care

$10.000

Savings

$15.000

Intervention

Total Medical
Costs Over a 2Year Period

Usual Care

$20.000

$0

Katon et al., 2006

Simon et al., 2007

Enhanced treatment of depression in patients with diabetes is associated with lower health care
costs over a 2-year period. From Katon W, van der Felz-Cornelis C. Treatment of depression in
patients with diabetes. In: Depression and Diabetes. Katon W, Maj M, Sartorius N (eds).
Chichester: Wiley, 2010.

Acknowledgements

This synopsis is part of the WPA programme aiming to raise the

awareness of the prevalence and prognostic implications of depression
in persons with physical diseases. The support to the programme of the
Lugli Foundation, the Italian Society of Biological Psychiatry, Eli-Lilly and
Bristol-Myers Squibb is gratefully acknowledged. The WPA is grateful to

Dr. Andrea Fiorillo, Naples, Italy for his help in the preparation of this
synopsis.