Diabetes and depression: a review

Conclusion

The increase in obesity in the Western world has in turn led to a rise in DM. There is also a well-established link between DM and depression. This link is bi-directional, with the presence of one dramatically increasing the likelihood of developing the other. There are many possible explanations for the presence of depression increasing the risk of developing DM, though the most apparent seems to be the presence of worse health behaviours in the depressed, including smoking and lack of exercise. Poor adherence to medical self-care also contributes. Additionally, some classes of anti-depressants have been shown to lead to weight gain and therefore should be avoided in diabetics. This is primarily evident in people between the ages of 20 and 34, and careful consideration should be given to alternative treatments accordingly, for example CBT. Conversely, in diabetics, the burden of having to live with a chronic condition predisposes to depression. Furthermore, both DM and depression increase cortisol levels in the body, increasing inflammatory stress. Because of the overlapping pathogenic mechanisms, the combination of the two diseases increases the risk of death.

People living with the co-morbidity have a 40% greater risk of mortality than patients living with just one of the two. Particular attention should be paid to the elderly age bracket, and depression screening should be performed in this patient group in order to reduce mortality, as there is a 78% greater risk of death in elderly patients with the co-morbidity compared with patients without the co-morbidity. Although importance must be given to treating DM, as it is a persisting chronic illness, treating depression should not be neglected as patients being treated for both depression and DM are less likely to die. Interestingly, adolescent males with type 1 DM are shown to have better health behaviours in order to control their disease. This acts almost as a protective mechanism against depression as the positive attitude towards their health makes them less likely to get depressed.

Antidepressants have been shown to indirectly improve glycaemic control, by directly improving symptoms of depression. A reduction in depressive symptoms enhances patients’ control of their DM and manifests in individuals being more likely to self-manage their condition effectively. A strong correlation has been demonstrated between antidepressants and antipsychotics causing weight gain. These treatments should be carefully prescribed for depression because they are predisposing risk factors in the development of DM. Nortriptyline (TCA), for example, has been shown to directly induce hyperglycaemia. Clinicians should also be wary of prescribing MAOIs for depressed patients suffering from DM, as they increase sensitivity to insulin and have been shown to induce hypoglycaemia.
SSRIs are a better treatment choice for depressed diabetics than the previous mentioned classes of drugs. Primary care workers should also be aware of the increased risk of weight gain associated with 2nd generation anti-psychotics. In particular, commonly prescribed antipsychotics such as olanzapine and clozapine exhibit similar weight gain side effects as many antidepressants.
CBT is the gold standard psychotherapy for depression, with those undergoing CBT being twice as likely to achieve remission. GPs should note that CBT is not successful on all patients, however, and alternatives may be necessary. CBT may also be clinically relevant as preventive intervention, as a method of preventing the deterioration of glycaemic control.
Patients suffering comorbid depression and DM who are treated with a personalised and integrated approach to care exhibit improved clinical outcomes. A collaborative care approach increases remission from depression, and consequently patients achieve improved glycaemic control through better health behaviours.

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