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Impact of Depression on Type II Diabetes Management

Updated: 15 hours ago

By Faith Spivey, PharmD Candidate 2024 and Adenike Atanda, PharmD, BCACP, CDCES, CTTS


Type II diabetes (T2DM) in the United States population has grown rapidly over the past decade and is predicted to substantially increase in the future.(1) Treatment of T2DM may be complex for many patients, especially those who are juggling medications for other disease states. In recent years, it has been found that 20-30% of people with T2DM have been diagnosed with depression.(2) Symptoms of depression can lead to increased hyperglycemia and micro/macrovascular complications in patients with diabetes.(3) With this correlation, the question becomes, how can we best manage patients with depression and type II diabetes?


Diabetes distress is a newer term to describe patients with diabetes who experience emotional stress while managing their diabetes. Diabetes distress has symptoms that are common to major depressive disorder but they are not as severe as depression. Symptoms of diabetes distress can include guilt, stress, and lack of motivation. Patients experiencing diabetes distress are less adherent to their diabetes medication and exhibit poor self-care behaviors. It is estimated that up to 45% of people living with T2DM experience diabetes distress.(4) The American Diabetes Association (ADA) recognizes diabetes distress as negatively impacting patient outcomes and recommends patients to undergo cognitive behavior therapy to help alleviate diabetes distress.(5)


A randomized controlled trial “Moderating the Relationship Between Diabetes Distress and Mastery” analyzed patients who have experienced diabetes distress and their control of diabetes. The trial used the term “mastery” to describe the patient’s perception of their diabetes management. Individuals with a high perception of mastery are more likely to be adherent to their medications. In the small study, they determined that people who had a better mastery of their diabetes were more likely to feel empowered and less likely to experience diabetes distress or depression. There was a significant positive correlation between diabetes distress and depression among the participants.(6)


Another study consisting of 4,117 patients used a Patient Health Questionnaire (PHQ-9) to evaluate depression in patients with T2DM. They saw a correlation between higher depression scores and decreased adherence. Adherence was expanded to include medications and lifestyle modifications, which can both greatly impact the control of diabetes. Comparing patients with diabetes alone to those with diabetes and depression resulted in the latter group having more diabetes related complications, a higher A1c, and a higher body mass index.(7)


Treatment goals for depression are to minimize symptoms of depression and achieve remission. The global goal for patients with T2DM is to lower the HbA1c to the targeted goal. A meta-analysis assessed the effectiveness of using cognitive behavioral therapy to treat patients with depression and T2DM. The analysis concluded that cognitive behavioral therapy had an impact on treating depression symptoms but there was no impact on glycemic control or diabetes distress.(8) Similarly, meta-analyses have evaluated the use of SSRIs (selective serotonin reuptake inhibitors) in the treatment of depression and T2DM. It was found that SSRIs can help improve glycemic control for up to six months but were inconclusive in the impact on glycemic control long-term.(3) The lack of evidence of an effective treatment for the comorbidity of depression and diabetes provides an opportunity for future research.


The studies reviewed support a correlation between depression and lower adherence with diabetes medications. It can be concluded that patients with worse depression have less control over their diabetes. In turn, patients who feel like they have little control over managing their diabetes can further worsen their depression symptoms. Healthcare providers can provide more support to patients with both comorbidities and assist them in having better control by simplifying medication regimens, offering pill packing services or adherence devices and addressing psychosocial factors. Currently, evidence shows SSRIs can be used to improve glycemic control short term, although long-term benefits are unknown. Hopefully, with fewer depressive symptoms, patients will be more adherent to their medications and be able to participate in lifestyle modifications. The relationship between diabetes and depression is complex; and both comorbidities require proper treatment to improve the outcomes of the other.

 

1. Future surge in diabetes could dramatically impact people under 20 in U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2022/p1229-future-diabetes-surge.html#:~:text=Type%201%20diabetes%20remains%20more,type%202%20diabetes)%20by%202060. Published December 29, 2022. Accessed March 31, 2023.

2. Fiore V. The association between diabetes and depression: A very disabling condition. Endocrine. https://pubmed.ncbi.nlm.nih.gov/24927794/. Accessed March 31, 2023.

3. Petrak F, Röhrig B, Ismail K. Depression and Diabetes. [Updated 2018 Jan 14]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK498652/.

4. Kreider KE. Diabetes distress or major depressive disorder? A practical approach to diagnosing and treating psychological comorbidities of diabetes. Diabetes therapy: research, treatment and education of diabetes and related disorders. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5306125/. Published February 2017. Accessed March 31, 2023.

5. ElSayed NA, Aleppo G, Aroda VR, et al. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes—2023. Diabetes Care. 2022;46(Supplement_1):S49-S67. doi:https://doi.org/10.2337/dc23-s004.

6. A, McGuigan K. Moderating the relationship between diabetes distress and mastery: The role of depression and empowerment. Taylor & Francis. https://www.tandfonline.com/doi/full/10.1080/13548506.2021.1894343. Published December 11, 2018. Accessed March 31, 2023.

7. Katon W. Diabetes and poor disease control: Is comorbid depression...: Psychosomatic medicine. Psychosomatic Medicine. https://doi.org/10.1097%2FPSY.0b013e3181bd8f55. Published November 2009. Accessed March 31, 2023.

8. Li C, Xu D, Hu M, Tan Y, Zhang P, Li G, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for patients with diabetes and depression. J Psychosom Res. 2017 Apr;95:44-54.

 

Faith Spivey

PharmD Candidate 2024

HSC College of Pharmacy

Fort Worth, TX






 

Adenike Atanda, PharmD, BCACP, CDCES, CTTS

Assistant Professor of Pharmacotherapy

University of North Texas

Health Science Center College of Pharmacy

Fort Worth, TX

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