Diabetes and Depression: Challenges and Some Opportunities
We invited our experts for this Diabetes Spectrum From Research to Practice section (Joe Solowiejczyk, MSW, RN, CDE; Mary de Groot, PhD, and her colleagues; Maureen Monaghan, PhD, and her colleagues; and Barbara J. Anderson, PhD) to submit articles about the combined challenges of living with depression and diabetes because of their unique understanding of the interrelations between these two diseases. All of our authors have been dynamically involved in some of the best studies and clinical interventions, enhancing the lives of countless patients and their families. Their work helps us understand the development and treatment of depression as it relates to diabetes.
In their articles published here, these experts have reviewed some of the key issues of dealing with depression for people living with diabetes. They have also highlighted some superb efforts that help patients and their families gain emotional and physical balance in their lives. They focus throughout on the multiple challenges that individuals with diabetes and depression face and on the “feelings” that are interwoven with these challenges. I am thankful that each of these experts and the members of their teams took time from their busy professional lives to share their life-enhancing thoughts and experiences with us.
I must also extend my thanks to Neal Kaufman, MD, the chief executive officer of DPS Health, for sharing with me his broad understanding of behavior change and of supporting positive lifestyle and exercise changes with technology (see related editorial on p. 5). Thanks also go to James Mingle, chief executive officer of MyCareTeam, for sharing his expertise and excitement about building user-friendly, successful, life-enhancing, cost-effective diabetes management software programs. Dr. Kaufman and Mr. Mingle have helped me reach a new level of excitement for enhanced electronic support opportunities that will increasingly assist people who are working hard to balance a life with diabetes.
In this preface, I will focus my thoughts on the impact of depression and diabetes, the changing “support village” for people with diabetes, the emerging new electronic options to enhance the lives of people living with diabetes, and some of the nonmedical interventions for mild depression that are gaining attention.
The overall depression rate in people with chronic illnesses is 20-70% compared to ~ 5% in the general population. The prevalence of depression in people with type 2 diabetes has been estimated to be ~ 25%, and depression can occur in as many as 70% of people with diabetes-related complications.1 The added multiple challenges of dealing with diabetes along with life's many other challenges can be discouraging and even overwhelming to the point of leading to or exaggerating depression. Add to this the lack of physically feeling healthy that typically occurs when diabetes is not well balanced and when a person with diabetes knows that he or she could or should be balancing diabetes better, and we can readily understand how feeling emotionally less well, even being depressed, can occur.
The oft-quoted East African proverb “It takes a village to raise a child” highlights the importance of giving children a network of positive role models and peers to help them grow in a balanced manner, realize all the good that life has to offer, and develop the strength to more safely and fully meet life's challenges. Adults also need this support village to meet life's challenges and to realize a more reasonable balance in their lives and stretch to their full potential. The multiple daily challenges of living with diabetes require a strong support village that strengthens individuals and families in their personal efforts. In 1979, the pediatric diabetes team at Children's Hospital of Philadelphia, Pa., noted that the single most important factor predicting a child and family's success in effectively balancing a life with diabetes was whether the mother of the child with diabetes felt adequately supported (L. Baker, J. Solowiejczyk, unpublished observations).
Key elements of this support village have been changing in significant ways during the past 30 years. This spring, for the first time in U.S. history, there will be more women than men working in full-time jobs.2 With more traditional nuclear families (both mother and father living in the home) declining to ~ 50% of all families in the United States and in much of the world, with both adults in intact families more often working full-time, and with more childless adults living alone, many people no longer have adequate access to person-to-person support and reinforcement for the daily challenges of life.
Approximately 8% of all adults in the United States now have diabetes,3 and the Centers for Disease Control and Prevention and the American Diabetes Association commonly quote estimates that one out of three children born in 2000 is at risk for developing diabetes during their lifetime. This alarming growth in the number of adults and children with diabetes is occurring at the same time that the number of diabetes specialists continues to decline. Now consider the increasing documentation requirements facing the majority of diabetes health care providers, many of whom have not effectively moved to efficient electronic records and diabetes management tools. It is clear to see some of the key reasons why professionals' time with patients continues to decline.
Understanding that the support village is vital to ensuring that people with diabetes can achieve balance in their lives, we must continue to develop and maximize our positive impact when we are able to connect with our patients. Recognizing these challenges to secure enough time with patients and their family members, we must continue to develop and share successful counseling interventions and support programs that are shown to minimize or ease depression.
The newer education and village support opportunities that can help patients and practitioners most effectively use their time include electronic tools such as the Internet, Web-based software, cell phones, texting, Skype, and maybe even some Twitter and Facebook efforts. These newer media are getting the world more connected and expanding the support village for people with diabetes throughout the world.
Some diabetes management software programs have resulted in important A1C improvements, and often users (both consumers and professionals) report that their time is used more efficiently, that safety is increased, and that the right software is cost-saving in both the short and long terms. These tools allow patients and professionals to use their time more effectively, improve health, and participate in discussions that are more focused on action than on data collection. More information can be found at www.mycareteam.com and www.mycareconnect.com.
The most successful diabetes software program has shown A1C reductions of 1.9 to > 2.5% in studies run by independent groups.4 As was powerfully demonstrated in the Diabetes Control and Complications Trial in 19935 and the U.K. Prospective Diabetes Study in 1998,6 improvement in A1C levels can significantly reduce the costs of living with diabetes in terms of long-term physical and emotional complications and financial burden.
As we consider diabetes management software programs, it is important to encourage the use of software that has been tested and has realized statistically significant, positive results in well-run studies by independent researchers. Diabetes management software programs should also be compliant with the Health Insurance Portability and Accountability Act. They should have Food and Drug Administration clearance under Section 510k of the Food, Drug, and Cosmetic Act. And finally, Web sites for electronic interventions should be secure, with 128-bit encryption and secure socket layer certificates, both of which are measures to ensure privacy and the safe sharing of information over the Internet. In reviewing these programs, it is important to note that programs that have brought about sustained improvements in A1C and seem to have garnered the most positive support from users all include a social network or social support component.
We also see in the literature solid evidence that regular exercise is associated with therapeutic effects in psychiatric patients suffering from depression and possibly other disorders.7 Exercise has been referred to as the best kept secret in preventive medicine. Regular exercise provides essential protection against many of the diseases that plague us, including cardiovascular disease, hypertension, diabetes, obesity, osteoporosis, depression, breast cancer, and dementia (memory loss).8 Given these extensive potential health benefits, it is clear that regular moderate exercise such as walking or swimming is one of the best emotional and physical health enhancers that we can recommend and prescribe. Dr. Elliott Joslin used to write on a prescription pad the recommendation that his patients buy a dog. He did this because he knew that dogs can be wonderful companions, and their owners feel compelled to take them out for regular walks.
A recent study published in the Archives of General Psychiatry9 followed more than 10,000 people and found that people who most closely followed the Mediterranean-style diet had a 30% lower risk of depression than those whose diets had only a few elements of the Mediterranean diet pattern.
The late motivational speaker and author Leo Buscaglia is often quoted as saying that, “Too often, we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” That touch, that listening ear is increasingly occurring via texting on cell phones and through social interaction initiatives on our computers, netbooks, and Blackberries.
Yes, the support village has been changing dramatically for many people throughout the world, especially during the past generation. The life-enhancing power of positively connecting with people remains paramount to helping ensure that people realize the fullest emotional, physical, and spiritual balance in life. The support village now includes software, text messaging, and other new opportunities to encourage and positively support people facing the challenges of diabetes. We need to learn more about, refine, enhance, and adopt new tools to maximize opportunities to reach and dynamically support our patients and their families as they strive to truly realize the fullest of lives.
Even when our patients learn about and understand their diabetes and work very hard to balance their blood glucose levels, blood glucose results do not always clearly tell them that they have been successful. Living successfully with diabetes requires a deeper level of inner strength and patience. Our patients should be congratulated for all of their efforts focused on balancing the added challenges that diabetes presents, even when their blood glucose results do not indicate that everything is so balanced.
Another relevant insight that I believe captures our patients' lives with diabetes comes from Mary Anne Radmacher, who is often quoted as saying, “Courage does not always roar. Sometimes courage is a quiet voice at the end of the day saying, ‘I will try again tomorrow.’” Controlling blood glucose levels in a life with diabetes is a dynamic challenge that includes both similarities day to day and frequent surprises. The challenges are constant, at times overwhelming, tedious, and frequently repetitive. These challenges are an aspect of life our patients would understandably like to be without.
Thank you all for your patience, insights, passion, and determination to enhance the diabetes management and lives of your patients. Congratulate your patients on their attempts, determination, and tenacity to work with the challenges that arise today and for their willingness to try again tomorrow.
- American Diabetes Association(R) Inc., 2010