Tuesday, March 24, 2009

Depression and diabetes

Dr. Steven Safren

Dr. Steven Safren

You cannot ignore a diagnosis of type 2 diabetes. It can be a matter of life and death. The disease – often diagnosed later in life – happens when the body cannot process sugars from food due to low levels of the hormone insulin.

Living with the disease requires consistent self-care ,including frequent needle pricks for blood-sugar monitoring, a healthy diet, plenty of exercise, foot care and adhering to a medication regimen. It is estimated that 95 percent of diabetes care consists of self-care behaviors. These lifestyle changes can help regulate blood sugar levels and stave off debilitating, and sometimes deadly, complications later in life.

“Patients with diabetes that is not under good control are at risk of blindness, kidney failure, heart attacks, stroke or amputations of the feet or legs,” says Enrico Cagliero, MD, of the Diabetes Unit at Massachusetts General Hospital. “Fortunately, with good control we can prevent most, if not all, these complications.”

Hand in hand

Unfortunately, for approximately one in five patients with the disease, type 2 diabetes goes hand in hand with depression symptoms.

“Having a chronic illness – like diabetes – can be a stressful and difficult challenge for many people,” explains Steven Safren, PhD, ABPP, director of Behavioral Medicine within the Department of Psychiatry at Mass General. “Exposure to chronic stress can increase the likelihood of developing clinical depression.” In fact, he adds the prevalence of clinical depression in patients with a medical illness is usually significantly higher than in the general population.

Safren goes on to say, “What can make it more complicated is that symptoms of depression make it much more difficult for people to adhere to self-care regimens that are required of most chronic illnesses, such as medication, diet and exercise. This can then become a cycle, because if one is not adhering to the necessary self-care behaviors for an illness because of depression, they can feel worse physically, which can then exacerbate certain symptoms of clinical depression, which, in turn, can make it harder to adhere to the self-care regimens.”

The numbers are significant

Considering that 23.6 million people in the United States have diabetes, according to the American Diabetes Association, the numbers of diabetics dealing with depressive symptoms are significant. Studies indicate 15 to 20 percent of diabetes patients are affected by major depression. To put it in perspective, only two to nine percent of the general population suffers from depressive symptoms. In short, a large number of diabetics may not be taking good care of their bodies, causing serious diabetes complications.

Exploring the connection

That is why researchers at Mass General, including Safren and Cagliero, are now exploring the connection between diabetes self-care and depression, and ways to improve self-care by treating depression. While cognitive behavioral therapy (CBT) has shown success in treating people with depression, the effect of CBT on self-care behaviors and depression of those with diabetes is not well known. A clinical trial underway at Mass General will evaluate the efficacy of CBT for medical adherence and depression in people with a depressive mood disorder and type 2 diabetes.

Type 2 diabetics between the ages of 18 and 70 years old with poorly controlled blood sugar and diagnosis of major depression can volunteer for the trial. A caregiver will determine whether volunteers meet all the criteria for the trial. Once accepted, each participant will undergo a psychiatric diagnostic interview, a series of paper questionnaires, neuropsychological testing and blood-sample analysis.

After meeting with a nutritionist and a nurse diabetes educator, each participant will set goals for eating healthfully, physical activity weight and blood sugar levels, and then will be randomly placed in one of two counseling groups.

“Clinical depression is more than just being in a bad mood – it is a distressing and interfering condition on its own, which can lead to difficulties functioning,” says Safren, principal investigator for the study. “We hope to demonstrate that by combining a cognitive behavioral therapy for depression with cognitive-behavioral and lifestyle-management approaches to treating diabetes, that this will help improve depression, adherence and, consequently, diabetes control.”

Cagliero, a coinvestigator in the trial, adds, “Diabetes is a group of diseases that can have very harmful effects on the body – blindness, kidney failure, heart attacks and stroke, to name a few consequences of poor control. We hope to show that these therapies can help keep a patient healthy – physically and mentally – in the long term.”

Learn more about the CBT for Adherence and Depression in Diabetes study at Mass General or visit the National Institutes of Health clinical trials website.

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