Sugar, sadness and strategising a way forward.

When one considers the fast paced, high stress lifestyles we endure, one can only marvel at the fact that we find the strength to soldier on. Then we add fuel and living costs, environmental factors like load shedding, water issues, political instability and likely this strength will wane. In practice, I often meet overwhelmed and ‘sad’ clients and I am forced to acknowledge how much more stress is added on by medical conditions such as diabetes mellitus (‘diabetes’). I thus decided it was time to discuss depression and diabetes as these two conditions symbiotically feed off each other to negatively impact the lives our clients.

^‍Diabetes is a global pandemic which is insidiously infiltrating our population with no fanfare. The International Diabetes Federation (IDF) estimates that around 537 million people are living with diabetes worldwide, with about 4.2 million of those individuals in South Africa.¹ The cost of managing diabetes and its potential complications is a financial burden which cost South Africa around 2.7 billion rand to manage in 2018.² This estimate is expected to increase by 2030 to 35.1 billion rand of which 49% will be used to treated complications. It is therefore imperative that we optimise early glycaemic management in our clients - this can only be achieved by addressing the biopsychosocial as well as the physical aspects of management.

^‍Depression is more common than we suspect with a lifetime prevalence of 11% and 15% in low and high-income populations respectively.³ Depression is a mood disorder, but it affects more than just mood. Cognition and behaviours are also influenced by depression. The rates of depression in people with type 1 diabetes may be more than three times the rate in people who do not have diabetes. Similarly, the rate in people with type 2 diabetes is also almost twice that in people who do not have diabetes.⁴ Conversely, depression may increase the rate of type 2 diabetes by almost 60%.^5,6
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Stress in both diabetes and depression is not likely to be the most obvious cause. There is probably a strong biological relationship between these two conditions.⁷ An early adverse life event may activate the inflammatory cascade leading to cytokine production which could increase the risk of type 2 diabetes and lay the groundwork for depression. Further, the hypothalamic-pituitary-adrenal (HPA) axis may also be activated and worsen endothelial dysfunction. Chronic hypercortisolaemia and sympathetic nervous system activation promotes insulin resistance, visceral adiposity and type 2 diabetes. Chronic stress may also lead to depression and food cravings.

Increased risk of diabetes in people who are depressed

In addition to above mechanisms, the use of multiple antidepressants is associated with increased HbA1c levels in people with diabetes, according to one report.⁸ This should not be a deterrent to early treatment of depression as treating depression will reduce the activation of the sympathetic nervous system. In fact, the selective serotonin reuptake inhibitor (SSRI) class of antidepressants has shown to improve glycaemia in type 2 diabetes.⁹

Depression risk in people with diabetes

‍The mere psychological burden of a chronic health condition like diabetes and its associated self-management burdens may trigger anxiety and depression. Depression may also have a higher prevalence due to poor lifestyle choices like physical inactivity and unhealthy eating patterns. Further, severe hypoglycaemia is associated with the severity of depressive symptoms independent of complications, general glycaemic control and use of insulin.¹⁰ Diabetes may be associated with structural changes in the brain including cerebral atrophy, and depression has also been associated with neurodegenerative changes in the brain. Therefore, brain changes seen with type 2 diabetes may be a fertile ground for depression to develop.
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^‍The aim of this blog is to emphasize that it is NOT a coincidence that we seem to be finding an increase in depression in our clients with diabetes. There is such a strong link between these two conditions that it is essential we ask our clients about depressive symptoms. Depression may be a major obstacle in achieving optimal risk factor management in our clients. We need to identify those at risk and ensure a multidisciplinary approach in facilitating the management of these individuals. The psychologist and psychiatrist need to be involved timeously.

I personally have seen the change glycaemic management once individuals have been managed as a whole being. The reward of improvements in glycaemia and other risk factors is worth the extra time and energy it takes to delve into a client’s feelings and stressors. Then the choice of the correct antidepressant can further positively impact the biopsychosocial outcomes of our clients.

References^‍

1. International Diabetes Federation (2021) IDF Diabetes Atlas, 10th edn. Brussels, Belgium. Available at: https://www.diabetesatlas.org
2. Erzse A, Stacey N, Chola L, Tugendhaft A, Freeman M, Hofman K (2019). The direct medical cost of type 2 diabetes mellitus in South Africa: a cost of illness study. Glob Health Action. 12(1):1636611.
3. Bădescu SV, Tătaru C, Kobylinska L, Georgescu EL, Zahiu DM, Zăgrean AM, Zăgrean L (2016). The association between Diabetes mellitus and Depression. J Med Life; Apr-Jun;9(2):120-5.
4. Roy T, Lloyd CE (2012). Epidemiologyof depression and diabetes: a systematic review. J Affect Disord; 142Suppl; S8 -21.
5. Mezuk V, Eaton WW, Albrecht S, Golden SH (2008). Depression and type 2 diabetes over a lifespan: a meta-analysis. Diabetes Care; 31: 2383-2390.
6. Rubin RR et al. (2008). Elevated depression symptoms, antidepressant medicine use and risk of developing diabetes during the diabetes prevention program. Diabetes Care; 31: 420-426.
7. Norman Sartorius (2018) Depression and diabetes, Dialogues in Clinical Neuroscience, 20:1, 47-52
8. Kammer JR, Hosler AS, Leckman-WestinbE, DiRienzo G, Osborn CY (2015). The association between antidepressant use and glycaemic control in the Southern Community Cohort Study. J Diabetes Complications. 30(2), 242–247.
   https://doi.org/10.1016/j.jdiacomp.2015.10.017
9. Deuschle M (2013) Effects of antidepressants on glucose metabolism and diabetes mellitus type 2 in adults. Curr opin Psychiatry; 26: 60-65.
10. Kikuchi et al. (2015). Association of severe hypoglycaemia with depressive symptoms in patients with type 2 diabetes, the Fukuoka Diabetes Registry. BMJ Open Diabetes res Care.