As a scientific researcher trained in the art of objective analysis it is appalling to find the lack of discipline in some of the “opinion” papers reviewed for this article. In one paper, the authors openly state that there is a “problem with our data”, that defining brittle diabetes is difficult and necessarily “somewhat subjective” , and that the data obtained on perceived causes of brittleness “is of course unsubstantiated and speculative”. Why was this paper ever accepted for publication?
What is even more disturbing is that this paper is repeatedly cited by those who hold to the concept that behavioral attitudes lead to patient non-compliance which, in their thinking, accounts for the brittle condition - a rapid uncontrolled shifting, up and down, in blood glucose levels.
This 1996 paper was written in an era when the relationship between depression and diabetes, particularly brittle diabetes, was viewed as unidirectional, and little if anything was understood about potential cause(s) of brittleness. Over the last decade, research into the relationship between diabetes and depression has begun to provide better insight into what most researchers today see as a strong association between these two chronic illnesses. According to Nebergall , the term association “means only that far more of the factors were found together than could be explained by random happenstance. It doesn’t mean you’re nuts”.
In BDF's opinion, the evidence is inadequate to accept or reject a causal relationship and prefers the use of association although the term “causal” is commonly employed in the literature. If you accept the medical definition for complication then both these chronic diseases can serve as a complication of the other.
In a decade long study of 65,000+ women ages 50 to 75, Harvard researchers found that those with diabetes had a 29% higher risk of developing depressive symptoms compared to those without diabetes. But, in the case of those diabetic women using insulin, the risk of developing depression increased to 53%. If the increase is a function of diabetic severity (glucose instability), would that number have been higher had brittle diabetics been identified as a distinct group in this survey?
Conversely, those exhibiting initial signs of depression were 17% more likely to develop diabetes than those in the non-depressed control group. This risk factor for diabetes increased to 25% for those being treated with anti-depressants. To account for this, scientists suggest that there is a rise in levels of stress hormones which may interfere with glucose metabolism, increase insulin resistance, and cause an increase in stomach fat - all considered risk factors for the development of diabetes.
Each of these chronic disorders apparently serves as a risk factor for the other. Evidence suggests that if you resolve one condition an improvement tends to be seen in the other, and researchers are presently trying to sort out the associative relationship.
Evidence is mounting that those with diabetes are anywhere from two to four times likely to suffer depression than non- diabetic control populations and generally women are found to be at greater risk than men. As glucose instability increases, depression appears to increase as well. For example, in a Brazilian research study , 42% of diabetics whose HbA1c was >9% were found to exhibit symptoms of depression, twice the number of those whose HbA1c was <9%.
The HbA1c represents the average plasma glucose concentration over a three month period with 6.5% recommended by The American College of Endocrinology as a healthy target level.
Brittle type1 diabetes is considered to be the most severe form of type1. Episodes of hypoglycemia and/ or hyperglycemia are known to cause a disruption in the bodies metabolic processes while at the same time placing undue stress on the diabetic. For the brittle diabetic this is a vicious cycle that repeats itself on a daily basis leading to a disruption in normal daily living and often times, trips to the emergency room. This in turn can lead to a depressive state.
Likewise, the complications normally associated with diabetes, neuropathy, nephropathy, retinopathy etc. may worsen the symptoms of depression which in turn compounds the problem with managing diabetes.
Logic suggests that this associative relationship between diabetes and depression will continue to result in this vicious cycle if physicians fail to recognize bi-directionality, fail to look for signs of depression in their diabetic patients or vice versa, and when observed, fail to treat both simultaneously with medication and, when necessary, psychotherapy.
We sometimes lose track of the fact that medicine, while an honorable profession is also a business and physicians must streamline their operations, to make them efficient and cost effective. Unfortunately, within the established government care programs that physicians must now operate, the likelihood that time will be taken to entertain screening for associative relationships is slim especially if, out of bottom line necessity, physicians need to have one eye on the clock and one foot out the door.
G.V. Gill, S. Lucas and L.A. Kent. Prevalence and Characteristics of Brittle Diabetes in Britain . 1996. QJM (1996) 89 (11): 839-84
Peter J. Nebergall Depression and Diabetes. http:// nfb.org/Images/nfb/publications/vod/ vsum007.htm
An Pan, PhD; Michel Lucas, PhD; Qi Sun, ScD; Rob M. van Dam, PhD; Oscar H. Franco, MD, DSc, PhD; JoAnn E. Manson, MD, DrPH; Walter C. Willett, MD, DrPH; Alberto Ascherio, MD, DrPH; Frank B. Hu, MD, PhD . 2010. Bidirectional Association between Depression and Type2 Diabetes Mellitus in Women. Arch Intern Med. 2010;170(21):1884-1891. .
Diabetes – Stress, Anxiety and Depression cited in regarding a Brazilian research paper presented at the America Diabetes Association 1998 Conference