Diabetes and Depression

November 20, 2015 Dr. Michele R Guzmán and Kendal Tolle, LMSW

November is National Diabetes Month and is intended to increase awareness of the disease and its effects on millions of people in the U.S. Approximately 26 million children and adults in the U.S. have Type I or Type II diabetes, with most having Type II.¹ In addition to not being aware of the prevalence of the disease, many people may not realize that depression frequently co-occurs with diabetes, most frequently with Type II.² One out of every four people with Type II diabetes has clinically significant depression, with the prevalence of depression being double in people with Type II diabetes in comparison to the general population.³

Unfortunately, fewer than 25% of individuals with diabetes and depression receive adequate treatment.4 Untreated and poorly managed diabetes can lead to serious consequences. When patients with diabetes are also experiencing depression, physicians may have concerns that they may not take the correct dosage of medications or monitor blood sugar levels appropriately. This can lead to overall poor management of diabetes and result in serious health conditions (heart disease, blindness, amputations).5 Major depression also has adverse effects on diabetes outcomes, resulting in poorer quality of life and lowered self-care.6

There is a high prevalence of comorbid diabetes and depression in the Latino population, especially among low-income Latinos.7

Among Latinos, Mexican Americans experience higher rates of depression than other groups, and are further susceptible to comorbid diabetes and depression.8 Studies of Hispanic culture and health show some Hispanic individuals seek medical care from traditional healers or use home remedies and over-the-counter medications, often due to financial and cultural/linguistic barriers. Stigma associated with mental illness and depression may affect whether or not individuals choose to seek treatment for comorbid diabetes/depression.9

What do we know about how to best help individuals with co-occurring depression and diabetes?

Research tells us that Latinos with Type II diabetes experiencing depressive symptoms “may derive the greatest benefits from diabetes self-management interventions.”10 These types of educational programs provide people with skills that they can incorporate into their everyday lives. It almost goes without saying that improved eating habits support diabetes management, but a healthy dietary pattern has also been associated with a reduced likelihood of depressive symptoms, especially with Type II diabetes; healthy diet has been associated with a reduced likelihood of depression/depressive symptoms for those both with and without diabetes.11

In addition to self-care, there are models of care and approaches that physicians can take that result in better outcomes for individuals with these co-occurring conditions. First of all, early detection is key. It is recommended that primary care physicians screen for depression in diabetic patients.12 Besides screening, depression treatment provided by primary care providers has been shown to be effective for low-income, racial and ethnic minority populations.13 However, it should be noted that medication-only may not be the best route for all individuals with these co-occurring conditions. Counseling may provide the opportunity to not only address the symptoms and underlying issues related the depression, but also allow for conversations about changing behavior and lifestyle to better manage diabetes.

Integrated health care efforts, models in which behavioral and primary health care are not only co-located, but closely coordinated, are particularly well-suited to treating co-occurring diabetes and depression. The Diabetes-Depression Care-Management Adoption Trial conducted in Los Angeles explored the impact of the collaborative depression care model, which incorporates evidence-based diabetes care management components and utilizes structured tools such as patient education, care coordination, depression screening, electronic disease registry, and integrated clinical decision support systems. The model also includes integrated team-based care, an intensive care model with strict guidelines for follow-up and monitoring of diabetes symptoms and comorbid risks, such as depression. The quasi-experimental trial found that the implementation of collaborative depression care in a diabetes disease management program effectively improved depression outcomes along with patient satisfaction, specifically in safety-net care systems.14 An evaluation of integrated care programs in Texas utilizing the collaborative care model for the treatment of depression and anxiety found the odds of improvement for patients with depression were 54 percent higher among patients who preferred Spanish, compared to patients who preferred English, demonstrating that for this subset of Latinos, this type of coordinated care may be especially effective.15

The Meadows Mental Health Policy Institute (MMHPI) is a non-profit organization established in 2013 to provide policy research and development to improve mental health services in Texas. It analyzes and evaluates public policy through evidence-based research and data-driven assessment of outcomes. The mission of the institute is to support the implementation of policies and programs that help Texans obtain effective, efficient mental health care when and where they need it.

1Semenkovich, K., Brown, M., Svrakic, D., & Lustman, P. (2015). Depression in Type 2 Diabetes Mellitus: Prevalence, Impact, and Treatment. Drugs, 75(6), 577-587.
2Dipnall, J., Pasco, J., Meyer, D., Berk, M., Williams, L., Dodd, S., & Jacka, F. (2015). The Association between Dietary Patterns, Diabetes and Depression. Journal of Affective Disorders, 174, 215-224.
3Semenkovich, K et. Al, “Depression in Type 2 Diabetes Mellitus” (see footnote 1)
4Colon, E., Giachello, A., McIver, L., Pacheco, G., & Vela, L. (2013). Diabetes and Depression in the Hispanic/Latino Community. Clinical Diabetes, 31(1), 43-45.
5CDC Explores the Relationship Between Diabetes and Depression. (2009, November 1). Retrieved from http://www.usmedicine.com/2009-issues/november-2009/cdc-explores-the-relationship-between-diabetes-and-depression/
6Ciechanowski, P.S. Katon, W.J., & Russo, J.E. (2000). Impact of depressive symptoms on adherence, function, and costs. JAMA Internal Medicine, 160(21).
7Wu, B., Jin, H., Vidyanti, I., Lee, P., Ell, K., & Wu, S. (2014). Collaborative Depression Care Among latino Patients in Diabetes Disease Management, Los Angeles, 2011-2013. Preventing Chronic Disease, 11.
8Nedungadi, T., Johnson, L., Edwards, M., Barber, R., Hall, J., D’Agostino, D., . . . O’Bryant, S. (2015). Comorbid Diabetes and Depression Impacts Diabetic, Cognitive and Affective Outcomes among Mexican Americans. The Journal of the Federation of American Societies for Experimental Biology, 29(1).
9Colon, E. et. al, “Diabetes and Depression in the Hispanic/Latino Community” (see footnote 4)
10Wang, M., Lemon, S., Whited, M., & Rosal, M. (2014). Who Benefits from Diabetes Self-Management Interventions? The Influence of Depression in the Latinos en Control Trial. Annals of Behavioral Medicine, 48(2), 256-264.
11Dipnall, J. et. al, “The Association between Dietary Patterns, Diabetes and Depression” (see footnote 2)
12CDC Explores the Relationship Between Diabetes and Depression (see footnote 5)
13Wu, B., Jin, H., Vidyanti, I., Lee, P., Ell, K., & Wu, S. (2014). Collaborative Depression Care Among latino Patients in Diabetes Disease Management, Los Angeles, 2011-2013. Preventing Chronic Disease, 11.
15An Evaluation of the Collaborative Care Model of Integrated Health Care in Texas: An Executive Summary. (n.d.). Retrieved from http://www.hogg.utexas.edu/uploads/documents/CollaborativeCareModel_EvaluationReport1.pdf