Black Salmon – Shutterstock
Medically reviewed by Anna Goldman, MD.
Mental health challenges are a natural consequence of living with diabetes, a condition that seems to intrude on everything we do. Life with diabetes is not easy — we have to keep our condition at the front of our minds every time we eat and exercise — and the stress adds up quickly.
People with diabetes are much more likely to experience depression, a diagnosable medical condition that should be addressed by a doctor. Many others will experience diabetes distress, a term used to define the persistent feelings of frustration and helplessness that lead to burnout and glucose management frustrations.
Each of these conditions can create a vicious cycle. If you’re not in the best state of mind, you can’t manage your blood sugar optimally — which may only make your depression or distress even worse.
Depression and diabetes distress are not quite the same thing, but they’re two important conditions that are too often overlooked. This article will outline the differences and explain what to look for.
Diabetes and Depression
Depression is not just a vague feeling of sadness or gloom, it is considered a diagnosable condition that deserves professional treatment.
The official definition of depression (also known as major depressive disorder or clinical depression) is set forth in the Diagnostic and Statistical Manual of Mental Disorders. The latest version of this authoritative book is known as the DSM-5. To be diagnosed with depression, a person must exhibit five or more depressive symptoms. These include major issues such as:
- Loss of pleasure in most activities
- Significant unintentional weight loss or gain
- Unhealthy sleep patterns
- Persistent fatigue
- Sense of worthlessness or guilt
- Suicidal ideation
According to the American Psychiatric Association, almost 7 percent of Americans experience depression in any given year, and about 17 percent will experience it at some point in their lifetime. But those numbers are substantially higher in people with diabetes.
Studies show that depression is “more than three times higher in people with type 1 diabetes … and nearly twice as high in people with type 2 diabetes.” Related conditions, such as anxiety, stress, and eating disorders are also more common.
It may seem obvious that diabetes might cause depression — why wouldn’t an inescapable health condition make you feel bad? — but it’s more complicated than that. There are surprising connections between the brain and the metabolism, and researchers suspect that depression may actually help cause type 2 diabetes development and progression in the first place. Loneliness, for example, provokes the release of cortisol, which raises blood sugar levels. And studies suggest that adults in a marriage or those who spend more time with friends enjoy direct metabolic benefits.
Of course, for some people, diabetes and depression may have no apparent connection.
Diabetes Distress and Burnout
Diabetes distress is a less famous condition, but one that most people with diabetes will be able to recognize very easily. Diabetes distress is an emotional reaction to diabetes, the effect of all the fears, worries, and burdens that this disease entails. This is a natural reaction to the stress of daily life with diabetes — managing blood sugar levels, medication, medical devices, and the million other ways it impacts all the little decisions we make.
It is exceptionally common. Separate studies reported that as many as 36 percent of people with type 1 and type 2 diabetes have diabetes-related distress.
Unlike depression, diabetes distress is not well-defined as a clinical diagnosis, and it is not generally treated with medication. Nevertheless, diabetes distress deserves treatment! This snowballing feeling of frustration and pointlessness leads straight to burnout.
The US Centers for Disease Control and Prevention (CDC) explains that diabetes burnout is when you “slip into unhealthy habits, stop monitoring your blood sugar, even skip doctor’s appointments.” Burnout can send your blood sugar skyrocketing and is very bad for long-term health. In the worst cases, neglect or carelessness related to burnout can result in severe hypoglycemia or hyperglycemia, which can lead to terrible outcomes like diabetic ketoacidosis (DKA).
Which Is It? Depression vs. Diabetes Distress
It can be difficult to say where diabetes distress ends and where depression begins. Kathryn Evans Kreider, DNP, wrote an article for Diabetes Therapy discussing the way these two conditions do and do not overlap. Dr. Kreider is a clinical professor at Duke University’s School of Nursing.
- Depression and distress may have similar symptoms, but depression is typically more severe. For example, people with diabetes distress feel unmotivated or overwhelmed, but those feelings may be less intense and debilitating than the loss of pleasure characteristic of major depressive disorder.
- Some distress symptoms may really be consequences of diabetes. For example, a lack of sleep that is caused by repeated overnight hypoglycemia events is not the same as insomnia caused by major depressive disorder. Fatigue may be a consequence of hyperglycemia rather than depression.
- Diabetes distress symptoms may likewise be caused or exacerbated by conditions common in diabetes, such as thyroid disorders, sleep apnea, or vitamin deficiencies.
- Depression may have more severe physical effects, such as psychomotor retardation, the slowing of mental and physical functions, including eye movements and facial expressions.
Nevertheless, there is also plenty of overlap. Both conditions, for example, may involve a diminished ability to concentrate, and it’s not easy to say exactly how severe this effect needs to be to qualify as a symptom of depression. And it can be difficult to tease out cause and effect. A patient’s level of diabetes distress, independent risk factors for depression, and glycemic control are all intimately connected.
There are a number of online screening tools and questionnaires available to see if you might have diabetes distress or depression. But diagnosing diabetes distress and depression is the job of a medical professional.
If you are experiencing any of the symptoms discussed above, you should share your concerns with your clinician, preferably the doctor or endocrinologist who helps care for your diabetes, as soon as you can. Even your family doctor may be comfortable screening you for depression.
Both depression and diabetes distress can have a direct impact on your ability to manage your condition well.
Mental Health Resources for People with Diabetes
Diabetes Daily curates a collection of mental health resources for people with diabetes. Ideally, your diabetes clinician will be able to connect you with exactly the mental health help that you need, but not everyone is so lucky to have access to such optimal care.
The American Diabetes Association operates a Mental Health Provider Referral Directory, which will help American patients find mental health providers who have expertise in the unique issues related to diabetes.
Clinical depression should receive professional attention. For those with diabetes distress, it may be more difficult to find professional help (or to convince your insurer to pay for it). But there are many other resources out there that could help you get back on track:
- Several national organizations organize meet-ups and support groups
- Online therapy can offer less expensive access to experts who really understand diabetes
- The diabetes online community, including the Diabetes Daily forum, is an amazing place to find advice and wisdom from people who have been through it all
Prevention & Treatment
There’s no easy way to prevent mental health issues. Some variables will always be out of our control — from genetics to geopolitics. The Cleveland Clinic recommends three steps for warding off depression:
- Maintaining a healthy sleep routine.
- Managing stress with healthy coping mechanisms.
- Practicing regular self-care activities such as exercise, meditation and yoga.
For people with diabetes, proper self-care undoubtedly also entails good blood sugar management, as well. It may be worth looking into new technology that could help ease your glucose management burden, particularly continuous glucose monitors (CGMs), insulin pumps, or artificial pancreas (“looping”) systems.
There are many treatments available to improve the symptoms of diabetes distress and depression. These may include talk therapy, lifestyle changes, medication, as well as optimizing glycemic management and managing any other health conditions.
The treatment of clinical depression is far too large a subject to tackle here. It is important to talk to your healthcare provider about your specific situation and work together to develop the most reasonable plan of care for yourself or your loved one. It is worth noting, however, that several common antidepressant medications can have an impact on blood sugar levels.
If you are experiencing diabetes distress and seem to be spiraling towards burnout, the CDC offers ideas on how to get back on track, including:
- Take your feelings seriously
- If your diabetes medication and equipment is too expensive, ask your doctor and pharmacist about affordability programs
- Ask friends and family for help with your condition
- Find support from other people with diabetes
- Set small, manageable goals for improving your self-care
Conclusion
Diabetes affects not just our bodies but our minds, and the stress of blood sugar management can get to anybody. These mental health conditions can have bad consequences if they prevent you from managing your diabetes to the best of your ability.
Diabetes distress and depression are serious conditions that deserve the attention of your medical health team. If you feel that frustration, malaise, or sadness are having a material impact on your health, please speak to your clinician. It may take hard work and comprehensive support to get you back on track to thriving with diabetes.