emotional health

Diabetes and Depression

What is depression?

People who have diabetes sometimes ask if it can make you depressed. Since first being diagnosed they had noticed that they had become irritable and didn’t seem to be able to enjoy life as much.

Although these are typical signs of depression, they are often only a passing phase. A sadness that passes after a few days is not depression, but a normal emotional reaction to the demands of the illness. Only when someone has been constantly in this mood for two weeks and when nothing can cheer him up would we speak of depression.

Depression means that a person feels different, he thinks only in a negative fashion, is lacking in energy and feels unable to manage things, independent of what happens around him. He has low self-esteem. He experiences everything around him, including friends and family, as negative, the future appears dark. He is unable to enjoy things; he worries a lot and finds it difficult to make decisions. Some people become nervous, irritable or even aggressive. It’s as though all hope of your life or your mood improving is lost. It is this internal change that causes a lot of the suffering. Five percent of those living in industrial nations suffer from depression that warrants treatment. Seventh people suffer from depression at some time in their lives.

Who gets depression?

Although everyone can get depression, it is most common among people who have long had problems –mostly since childhood– in dealing with stressful demands and conflicts. They have difficulty solving problems or resolving situations in a helpful way. They take things very seriously, can hardly stand strong feelings (sadness, pain, loss) and tend to escape into activity, without learning to deal with their feelings. They have a poor view of their abilities to cope with difficult situations and little self-confidence. Thus change of any kind can be experienced as a great threat.

It is generally assumed that depression is largely due to hereditary factors: the relatives of people with depression are more likely to have depression themselves as the relatives of those who do not. Growing up with a depressed parent can increase the likelihood of learning depressed patterns of thought. The partners of depressed people may often become "co-depressed". They assume the role of the "strong one" in the family, who supports the depressed partner. This just makes the problem worse.

It is easy to see how the diagnosis of diabetes could mean the final straw to such a person: the demands of the illness are too much for him and he reacts with clinical depression. As a result he is very often unable to deal well with therapy: the HbA1c values are too high, quality of life takes a nosedive.

Whatever was just about managed so far, suddenly seems an insurmountable burden. This doesn't mean that the diabetes is the cause of the depression, but that it helped it to break out. About half of those who react with depression to diabetes had already shown some depression in answer to stress in the past. Many had previously been treated with psychotherapy.

Women suffer from depression twice as much as men. Why is this? Women are more susceptible to depression at certain times: during menstruation, after a birth. The numerous demands of career, housework and children are too much for some women: some withdraw socially, making themselves dependent on their husbands, while the men concentrate on their careers. Women also tend to talk about their feelings more, their fears and moods. It is possible that this is one of the reasons why their depression is more easily recognized. Men who are depressed may react with irritation, loss of libido and increased alcohol consumption – all symptoms that are usually labeled "stress", but are more likely to be due to depression which could easily be overlooked.

Diabetes and depression

Recent research has shown that people with diabetes suffer twice as much from depression as people of the same age (depression did not always manifest after diagnosis!) Some think that there is a common hereditary basis for diabetes and depression, which would explain the fact that they appear so often together. However it is also possible that depression occurs just as frequently with other chronic illnesses – so far this question has not been fully researched.

What are the signs of depression?

• a feeling of inner emptiness, lack of confidence and hopelessness
• lack of energy: everything seems an effort
• worrying about things without being able to make a decision
• poor concentration
• feelings of low self-esteem and guilt
• loss of interest in and enjoyment of pleasant activities - unmoving facial expression, low voice
• subdued feelings, numbness
• sleeping difficulties
• lack of appetite
• no interest in sex
• physical complaints (pains, overly sensitive reactions)
• suicidal thoughts

There are different forms of depression according to severity:

Mild depressions show only a few of these symptoms, which appear in a light form so that they are often overlooked. They occur typically as a reaction to a new and severe source of stress.
Moderate depressions may occur without a recognizable cause. The symptoms are more severe, the ability to manage daily life is reduced.
Severe depressions affect all aspects of a person. He becomes apathetic and completely lacking in energy and motivation. He withdraws completely, becomes ill, inflexible/rigid and sometimes confused. Without treatment these people are often unable to work for long periods of time. Such extreme forms are rare.

Many types of depression occur in phases (episodes), after which the mood lifts. The episodes may occur again and again. With another type of depression, people suffer from depressed mood for years, but the symptoms are less severe (Dysthymia).

Depression occurs mainly in adults over 20 years of age. Prior to this age, depression is rare. From 45 onwards there is an increase in the frequency of depressions related to the changes associated with aging (death of a partner, separation, physical illness). The suicide rate of those over 55 is three times as high as among younger people with depression. The rate of depression is the same in persons with type 1 as in type 2 diabetes of the same age. But since the rate of depression increases with age, it is actually higher in persons with type 2 diabetes.

Therapy

Depression has a tendency to worsen without treatment and people with depression need professional help. Pulling yourself together without outside support very rarely works. Family members are also often over faced with the task and eventually give up, saying they can’t stand it any more. Often the depressed person won’t accept help. In this case it may have to be explained patiently, if necessary repeatedly, that there is help and that it is essential with this illness if there is to be any improvement. Often depression is overlooked in people with diabetes, because it is often assumed that it is a normal reaction to the demands of the illness. It is, however, a second, different illness, that the majority of people with diabetes never get.

Psychiatrists and psychologists are able to ascertain whether it is a depression warranting treatment. Treatment consists of medication (usually anti-depressants) and/or psychotherapy. Success rates are good and much suffering and many cases of suicide can be thus avoided. Very often psychotherapy is sufficient with the less severe forms of depression. With the more severe forms, psychotherapy must be combined with medication, as the depressed person is unable to think and function clearly.

Professional help is also particularly important because relatives usually instinctively do the wrong thing when dealing with mental illness: they either do everything for the depressed partner or tell him to pull himself together; they try to cheer him up and take his mind off things by organizing enjoyable activities; they show no understanding for his very negative feelings; they comfort him and tell him things aren’t so bad. All these attempts at help simply backfire and make the depression worse: being forced to take part in activities that you once enjoyed, for example, reinforces your awareness of your inability to feel pleasure; being relieved of the normal pressures of daily life can make you feel useless; being told that things are fine when they patently are not, can make you feel misunderstood and isolated.

A good psychotherapist is careful to avoid these pitfalls. He works at gradually giving the depressed person his sense of independence back. He helps him to recognize areas where he still functions well. He doesn’t relieve him of responsibility and he doesn’t over face him. Instead he asks him patiently, what he can decide and what he can do. He takes the symptoms seriously and doesn’t try to talk him out of them. He helps him to understand his situation better and to recognize how he has come to a dead-end. He has faith in his ability to find his own solutions. He knows that the depression doesn’t go away just because the symptoms abate – a lack of symptoms can even be a danger sign (suicide) if the sense of hopelessness hasn’t improved.

The important bits

•  Depression occurs in people with diabetes more frequently than in other people.
Untreated, depression tends to worsen and should therefore be treated early on.
Self-help and help from relatives is not sufficient and can in fact worsen the depression.
Depression can be treated with psychotherapy and medication.
When depression is improved, parallel improvements in diabetes therapy can be more easily implemented.
Axel Hirsch and Susan Woods
Department of Diabetes and Metabolic Diseases
Bethanien-Hospital Hamburg, Germany
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