DIABETES AND DEPRESSION  

Diabetes and Depression – both are very common diseases mainly to the people of middle class society. Diabetes people are more at risk of developing depression. This disease can be exhausting and overwhelming.

As a result, diabetes can cause a feeling of low. We know that feeling low or sad from time to time is natural. It’s a normal part of life. But during diabetes, if you have long periods of sadness, anxiety and hopelessness, – this could mean you have depression.

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TABLE OF CONTENT: DIABETES AND DEPRESSION :

  1. INTRODUCTION
  2. WHY ARE DEPRESSIONS  IN PREDIABETES AND DISBETES
  3. WHO ARE MORE DEPRESSED IN VARIOUS TYPES OF DEPRESSION? 
  4. CAN DEPRESSION INCREASE THE RISK OF TYPE 2 DIABETES? 
  5.  SYMPTOMS OF DEPRESSION IN DIABETES 
  6. SOME COMMON SYMPTOMS 
  7. RISK FACTORS 
  8. WHAT CAUSES DEPRESSION IN PEOPLE WITH DIABETES? 
  9. WHEN YOU SHOULD TAKE HELP OF A DOCTOR? 
  10. MOVE MORE 
  11. DIABETES, DEPRESSION AND INDIA 
  12. CONCLUSION

There is evidence that the prevalence of depression is moderately increased in pre – diabetes patients and undiagnosed diabetic patients. Besides, it markedly increased in the previously diagnosed diabetic patients compared to normal glucose metabolism individuals.

The prevalence rates of depression could be up to three times higher in patients with type 1 diabetes and twice as high in people with type 2 diabetes compared with the general population worldwide.

Anxiety appears in 40% of the patients with type 1 or 2 diabetes. The presence of depression and anxiety in diabetic patients worsens the prognosis of diabetes. It increases non-compliance to medical treatment. Therefore, decreases the quality of life and increases mortality.

On the other hand, depression may increase the risk of developing type 2 diabetes with 60%.

Read More:Are You Diagnosed With Prediabetes?/https://kalpatarurudra.org

So, it seems that there is a bidirectional association between diabetes and depression. It’s a complex relation that might share biological mechanisms, whose understanding could provide a better treatment. And improve the outcomes for these pathologies .

The purpose of this review was to show the connections between depression and diabetes. And also to point out the importance of identifying depression in diabetic patients and the possible ways to address both diseases.

    As the prevalence of depression among patients with type 2 diabetes mellitus is high, so endocrinologists should be made aware of the increased risk of depression in this patient population and screening individuals for relevant risk factors. 

However, depression is one of the most common mental health disorders. It’s a lifetime prevalence estimated at approximately 20% of the worldwide population.

According to the World Health Organisation (WHO), the global prevalence of depression is about 5%, second only to cardiovascular diseases as the leading cause of functional impairment in patients by the year 2020.

 Any individual can suffer from depression. However, the risk is higher among those with type 2 diabetes mellitus than in the general population. Previous studies have shown that the prevalence of depression was two-fold higher in diabetic patients versus the general population. 

In 2018, Khaledi, Haghighatdoost, Feizi, Aminorroaya  conducted a meta-analysis of 248 studies around the world (n= 83,020,812 study participants) and showed that the prevalence of depression in those affected by type 2 diabetes mellitus was 28%. 

So, this rate was much higher than the 5% reported for the general population by WHO. Alajmani, Alkaabi, Alhosaniet al studied 559 type 2 diabetes mellitus patients in Dubai, United Arab Emirates (UAE). They used the Beck Depression Inventory (BDI) and found that the rate of depression in these patients was 17%.

                 In Vietnam, the prevalence of depression was reported to be 25.6% in a study. Dang, a scientist conducted it. They have taken 606 diabetic patients at the centre of Endocrinology (Quang Ngai province) using the PHQ-9 score of 9 as a cutoff. 

The combination of depression and diabetes is an important and complicated public health issue. The causal relationship between depression and diabetes is not well understood. 

DIABETES AND DEPRESSION :

Depression is not only a cause but also a result of hyperglycaemia. Diabetes is a chronic condition with a strict treatment regimen that typically includes adherence to medication, diet, and physical activity. Moreover, diabetes can also lead to many complications including macro- and micro-vascular diseases, neuropathy, and nephropathy. 

Diabetes is one of the most common causes of economic burden, co-morbidity and an increase in mortality in the world. Hence, these factors become a psychological burden for patients. And can lead them down a path towards depression. 

   Furthermore, depressed patients with type 2 diabetes mellitus have worse adherence to dietary, medication, physical inactivity. As a result,, they have metabolic and glucose control problems. It can exacerbate diabetic complications resulting in disease severity and increasing healthcare expenditures. And even lowers patients’ quality of life. 

There have been several studies on depression in type 2 diabetes mellitus but reported that the associated factors with depression in type 2 diabetes mellitus were uncertain and different among studies.

   In 2015, two different reviews  indicated three possible directions for the association of diabetes and depression: both diseases might have a common aetiology, diabetes increasing the prevalence of risk for future depression; depression increasing the prevalence of risk for future diabetes.

Depression is a serious mental health condition . It can affect anyone, regardless of culture, background and family history. It causes you to feel bad about yourself, your life and your relationships.

If you experience one or more of these symptoms for longer than two weeks, then talk to your healthcare professional. Depression can affect diabetes. A few symptoms of depression can have a direct impact on your diabetes management, such as:

Not wanting to do anything or see anyone. You might not manage your diabetes properly. This may mean not taking your medication or testing your blood sugars, missing your doctor appointments or ignoring other health problems. All of these could lead to complications.

  1.    Feeling down often and for long periods.
  2. Waking up a lot at night, or not being able to get out of bed.
  3. Feeling exhausted more often than not.
  4. This could stop you from exercising, which can help your diabetes management.
  1.   Overeating, which might make your blood sugars rise.
  2. Not eating enough, which might lead to a hypo if you take insulin or other medication that has hypos as a side effect.
  1. Feeling bad about yourself and worrying that you’ve let friends and family down.
  2. Being easily distracted and struggling to concentrate.
  1. Feeling restless and jittery.
  2. Moving slowly and not wanting to speak.
  3. Thinking that things would be better if you were dead or having suicidal thoughts. 

Depression can also make you self-destructive, and if you feel like you’d be better off dead, then you might stop taking care of yourself.

Though feeling low is unpleasant, if it doesn’t last very long then try not to worry about it. Everybody gets sad every now and then.

But if you have any of these symptoms for two weeks or more, you should talk to your physician or another healthcare professional. They will be able to do an assessment with you, and recommend what to do next.

SOME COMMON SYMPTOMS INCLUDE : DIABETES AND DEPRESSION

  • No longer finding pleasure in activities that you once enjoyed
  • experiencing insomnia or sleeping too much
  • loss of appetite or binge eating
  • inability to concentrate
  • feeling lethargic
  • feeling anxious or nervous all the time
  • feeling isolated and alone
  • feeling sadness in the morning
  • feeling that you “never do anything right”
  • having suicidal thoughts harming yourself

  • Poor diabetes management can also prompt symptoms similar to those of depression. For example, if your blood sugar is too high or too low, you may experience increased feelings of anxiety, restlessness, or low energy
  • Low blood sugar levels can also cause you to feel shaky and sweaty, which are symptoms similar to anxiety.

The rigours of managing diabetes can be stressful and lead to symptoms of depression.

Diabetes can cause complications and health problems that may worsen symptoms of depression.

RISK FACTORS :

Depression can lead to poor lifestyle decisions, such as unhealthy eating, less exercise, smoking and weight gain — all of which are risk factors for diabetes.

Depression affects your ability to perform tasks, communicate and think clearly. This can interfere with your ability to successfully manage diabetes.

If you’re experiencing symptoms of depression, you should consult a doctor. They can help you determine if depression is causing your symptoms and make a diagnosis, if needed. They can also work with you to develop a treatment plan that best suits your needs.

  • WHAT CAUSES DEPRESSION IN PEOPLE WITH DIABETES?

It’s possible that the demands of managing a chronic disease such as type 2 diabetes can lead to depression. This may ultimately result in difficulty managing the disease.

It seems likely that both diseases are caused and affected by the same risk factors. They include:

  • family history of either condition
  • obesity
  • hypertension
  • inactivity
  • coronary artery disease
  • Poor economic conditions
  • Unemployment. 

        Katon, Pedersen, Ribeet al11 studied on 2,454,532 patients with type 2 diabetes mellitus and follow up in many years, the results showed that the rate of depression was higher in people under 65 years compared with people from and above 65 years.

     In another study, Tran  also found that younger age (under 60 years) is predictor of depression in type 2 diabetes mellitus patients. However, in a meta-analysis study, Roy, Lloyd  reported that the association between age and depression with type 2 diabetes mellitus was uncertain. 

Several studies revealed that depression occurred more often in patients under 60 years but others showed an inverse relationship. Younger age, which was one of the predictors of depression in type 2 diabetes mellitus, could be explained by the fact that younger people are less experienced when coping with difficult situations, have more negative influences in many dimensions of their daily life including marital status, working and social functions. These factors could all lead to depression. 

    Unemployment is also a risk factor of depression in several studies. Unemployment was attributed to depression by causing poor economic status, lowering self-esteem. However, we found that patients with an unstable job had a higher rate of depression than those with unemployment (34.5% vs 17.7%, p<0.05) in single-variate analysis.

Some scientists conducted a  study in diabetic inpatients so the patients with unstable jobs, were likely to lose their jobs during hospitalization, making it difficult for them to find work again after discharge.

      Besides, those were often combined with poor economic status in  study. These would result in them more likely to succumb to depression. Correlation of having stressful events during the past year with depression in patients with type 2 diabetes mellitus was also found in this  study (OR=11.18, 95% CI: 2.18–57.33, p<0.01).

      Stressful events could provoke and cause relapses of depression in both the general and diabetic population. Lee, Brazeal, Choiet Al  studied 421 patients with type 2 diabetes mellitus and revealed that the patients with stressful events had higher prevalence of depression than those who had no stressful events.

Besides, it is known that type 2 diabetes mellitus is chronic condition and last for a lifetime so if the younger people get disease the longer duration of illness and the more complications they have in their life. This thought would lead younger people to depression.

Evidence from other study points to poor economic status as significant predictors of depression in both the general population and diabetic patients. In univariate analysis in our study, depression was significantly associated with poor economic status. 

However, it may be that your depression is making it more difficult for you to manage your diabetes physically as well as mentally and emotionally.

Depression can affect all levels of self-care. Diet, exercise, and other lifestyle choices may be negatively impacted if you’re experiencing depression. In turn, this can lead to poor blood sugar control.

DIAGNOSIS OF DEPRESSION IN PEOPLE WITH DIABETES :

If you’re experiencing symptoms of depression, you should immediately take the advice of a Doctor or a psychiatrist. They can determine whether your symptoms are the result of poor diabetes management, depression, or tied to another health concern.

To make a diagnosis, your doctor will first assess your medical profile and ask about any family history of depression.

Your doctor will then conduct a psychological evaluation to learn more about your symptoms, thoughts, behaviours, and other related factors.

They may also perform a physical exam. In some cases, your doctor may do a blood test to rule out other underlying medical concerns, such as problems with your thyroid.

HOW TO TREAT DEPRESSION? 

Depression is typically treated through a combination of medication and therapy. Certain lifestyle changes may also help relieve your symptoms and promote overall wellness.

Medication

There are many types of antidepressant medications. Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) medications are most commonly prescribed. These medications can help relieve symptoms of depression or anxiety.

If your symptoms don’t improve or worsen, your doctor may recommend a different anti-medication or a combination plan.

Important to know that under-diagnosed depression can cause weight gain or weight loss, and some medications may have more severe side effects. Be sure to discuss the potential side effects of any medication your doctor recommends.

Psychotherapy

Also known as talk therapy, psychotherapy can be effective for managing or reducing your symptoms of depression. There are several forms of psychotherapy available, including cognitive behavioural therapy and interpersonal therapy. Your doctor can work with you. He will decide the option best suits your needs.

Overall, the goal of psychotherapy is to:

•recognise potential triggers

identify and replace unhealthy behaviours

develop a positive relationship with yourself and with others

promote healthy problem-solving skills

If your depression is severe, your doctor may recommend that you participate in an outpatient treatment program until your symptoms improve.

YOUR LIFESTYLE MAY CAUSE, SO CHANGE IT : 

Regular exercise can help relieve your symptoms by boosting the “feel good” chemicals in your brain. These include serotonin and endorphins. Additionally, this activity triggers the growth of new brain cells in the same manner as antidepressant medications.

Physical activity can also assist in diabetes management by raising metabolism, managing blood sugar levels, and increasing your energy and stamina.

Other lifestyle changes include:

eating a balanced diet

maintaining a regular sleep schedule

working to reduce or better manage stressors

seeking support from family and friends.

Both diabetes and depression reduce the quality of life for an individual, but together they have a more negative impact . Due to the negative effects on health, the rise in complications, both diseases should be recognised in an individual and treated simultaneously, to reduce depression and better control diabetes.

However, depression remains underdiagnosed and untreated in diabetic patients. Increased awareness for depression in diabetes might improve the outcomes and a first step would be a simple method for screening depression to be used on regular diabetic follow-ups.

WHEN YOU SHOULD TAKE THE HELP OF A DOCTOR :

There are different ways that people deal with depression. Your doctor may advise you to talk to a professional, recommend medication or point you towards Cognitive Behavioural Therapy. You can decide the best steps together.

 When depression is diagnosed in a diabetic patient, the common sense would be to treat both diseases at the same time. Petrak et al. recommended treating depression as a priority, as the response to medication is usually seen within 2-4 weeks for antidepressants, while the improvement in the glycemic control and levels of HbA1C needs several months to settle [55]. Moreover, Petrak et al. suggested that patients having a better mood might follow their diabetic treatment better [55]. They also proposed a model for treating depression and diabetes, stepped according to the degree of depression [55].

TALK TO FRIENDS, FAMILY OR PEERS: 

Sometimes talking to those who know you best can really help. We know that these conversations can be difficult to have, so we have put together some tips to help you talk about your diabetes.

And remember, you are not alone. Lots of people are going through something similar. You can talk to other people living with diabetes through our online support forums.

FOOD CAN CHANGE YOUR MOOD:  

Food can be a huge part of your life. Having diabetes can turn something you used to enjoy into something that is stressful. But food can be a great way of lifting your mood. Have a look at our food and mood advice for more information about eating for a healthy body and healthy mind.

DO NOT STAY LYING OR SITTING : SO MOVE MORE 

Exercising is an important part of how you manage diabetes. It has loads of positive benefits, such as managing your weight, lowering your blood sugar levels and helping the body use insulin more effectively. It can also really help with your mood.

It can be really difficult to motivate yourself. Having depression can mean the last thing you want to do is get up and move more. But the benefits can be remarkable.

When you’re active, your body releases endorphins, which is a chemical that makes you feel good. Exercising to improve your mood can really help you feel better, and could help you manage your diabetes as well.

DIABETES, DEPRESSION AND INDIA: 

Journal of The Association of Physicians of India ■ Vol. 65 ■ August 2017   

          An estimated 50.8 million people suffer from major depression. The prevalence of depression is steadily increasing and is expected to move to 1st place concerning the global burden of disease by 2030 as predicted by the World Health Organisation. Indian studies: The prevalence of depression is high, both in urban and rural India.

         In a cross-cultural study conducted by WHO at 14 sites, the most common diagnosis in primary care settings was depression.  Earlier Indian studies have reported prevalence of depression varying from 21-83% in primary care settings.

            However as these are all clinic based studies, they are subject to various degrees of referral bias. A study conducted in Goa on postnatal depression in India has shown that the prevalence of depression was 23%, economic deprivation and poor marital relationships were the important risk factors for the occurrence and chronic nature of depression.

          The prevalence of depression in Dharwad district, Karnataka was reported to be high at 29.3%14 while in a rural population of Ahmednagar, Maharashtra, it was even higher – 31.4%. 

       The prevalence of depression was high (39.0%) among the elderly in Surat city and it was observed that several important socio-demographic variables had shown a significant association with depression in the elderly.

       A large population-based study which involved 26,001 subjects in urban South Indians called the “Chennai Urban Rural Epidemiology Study (CURES) “also looked at the prevalence of depression in Chennai city in South India. The study showed that the overall prevalence of depression in Chennai was 15.1%.

                    Female gender, age, low socio-economic status, lack of education and marital factors were associated with depression in this population. Studies done in an elderly community in Vellore, South India reported that the prevalence of depression was 12.7%.

        Such wide variations in prevalence of depression could be attributed to the different methods of assessing depression and the different populations studied.There are many studies which have looked at the association of depression with the socio-economic status.

       A study by Shidhaye19 done on 5703 women with mental disorders showed that socio-economic factors were independently associated with common mental disorders.  

    Nair et al  studied the prevalence of depression aiming geriatric subjects in Raichur and found that prevalence of depression was very high.Moreover it was associated with substance abuse, unemployment, disrupted mental status, illiteracy and lower . 

Table 1:  Studies on prevalence of depression in population based studies – International studiesAuthor / Year Place Total subjects:  Age : (years): Diagnostic riteria : Population Method of urvey. Prevalence of depression (%)Ovuga et al,  2005. 

     Adjumani and Bugiri [Uganda]939 , 13 item Beck Depression Inventory (BDI): Rural population : Structured interview.  Vasiliadis  et al, 2007 , Canada and USA, 5055,183>18 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 

    Diagnostic and statistical Manual of Mental Disorders (DSM-IV). Telephone survey 8.28.7.  DM Ndetri,  et al, 2009. Kenya 2770 >18 BDI In and out patient population, Interviews 41%. 

     Pouwer et al, 2010. Netherlands 772 29-74 CIDI and CESD-16 , Out patient population, Self-report:  measures of depression and a diagnostic interview: 32.9% Dirmaier et al, 2010.  Germany 866 57-77 DSQ score Primary care center Standardized assessment, including questionnaires for patients and the physician and diagnostic screening measures MDE-11, 8%Minor-20,7% Agbir et al,  2010 . Nigeria 160 20-99 Structured Clinical Interview for DSM-IV axis I disorder (SCID). Hamilton Rating Scale for Depression (HDRS) Out patient population  Interview by psychiatrist 19.4%. Yu et al, 2010 China 100 49±11 Self-Rating Depression Scale (SDS). Out patient population, Self- reported 28%. Trento et al,  2011, Italy 459 40-80, Zung self-rating depression scale. Out patient population, Self-reported Questionnaire, 14.1%. Tovilla – Zarate et al, 2012, Mexico : 458 18-80 Hamilton Rating Scale of depression (HAM-D),  Out patient population,   Interview by psychologist / nurse : 48.3%. 

Journal of The Association of Physicians of India ■ Vol. 65 ■ August 201762 •Table 2 :

 Studies on prevalence of depression in population based studies – National studies  Author / Year, Place,  subjects, Age (yrs) Population, Method of Survey : 

Prevalence of depression : Biswas et al,  2009  Vellore 204 > 60 (CIS-R), a Revised Clinical Interview Schedule  Elderly population Door to door survey 31.5; Poongothai  et al, 2009 Chennai 25,455 > 20, Patient Health : Questionnaire (PHQ-12 item), Representative sample of chennai city , Interview – Door to Door survey 15.1Joseph et al, 2013.  Karnataka 230 PHQ – 9 Clinic population Interview based 45.2 Jain et al, 2015 Jaipur 100/100 18-70 PHQ – 9 Clinic population, Self-reported. Kulkarni et al, 2014 Karnataka 100 25-65 PHQ – 9 Clinic population Interview based 29.1Sengupta et al, 2015Punjab 290 60->80 Geriatric Depression Scale (GDS short version)Cross sectional study Interview method – semi-structured questionnaire : Urban –10.1Rural – 7.3 economic status.

  Neelanjana Paul of Kolkata did a study in this respect and found that the depressed subjects were significantly older, had less education, belonged to lower socioeconomic status. Besides, they possessed greater cognitive impairment and disability. Education was found to have a protective role.

    It can be seen that the estimates on prevalence of depression vary widely in different populations. This could be attributed to different ethnicity and demography of the study populations and /or different diagnostic criteria and study instruments employed.

  We have to see the prevalence of depression in special populations i.e. elderly, adolescence and women in India. It is interesting to note that the prevalence of depression in elderly in Chennai is higher in both urban and rural compared to Kerala and Punjab. Also it is found that the prevalence is higher in rural areas compared to urban areas of Tamil Nadu.

As early as 17th century, scientists observed that there is a connection between depression and type 2 diabetes. Today, depression and type 2 diabetes have become a great global challenge. 

         Prevalence of Depression and Diabetes :   

        Several studies have shown that depression is associated with type 2 diabetes. However the direction of the relationship is unclear. In addition to depression being a consequence of type 2 diabetes, depression may also be a risk factor, or a triggering factor, for the onset of type 2 diabetes. 

     Thus there appears to be a bidirectional relationship between type 2 diabetes and depression. Golden and his colleagues confirmed by a recent study that they found that diabetic individuals without depressive symptoms at baseline had higher odds of developing depressive symptoms during the follow-up period. 

     There are some studies on prevalence of depression in special population in India. First of all, Patel et al Women Clinic population Goa, 2002, secondly, Pillai et al Adolescents Rural population (school children)Goa 0.5 2008; and Nair et al Adolescents Rural population (school children)Kerala 11.2 (school dropouts)3 (school going), 2009; Barua et al Elderly Rural population Karnataka 21.7 2010; David et al Adolescents Clinic population (medical students)Hyderabad 11.7 ,2012; Balaji et al Elderly Urban and rural slum, Chennai Urban – 41Rural – 46, (2013 Sengupta). 

Journal of The Association of Physicians of India ■ Vol. 65 ■ August 2017 , 63 outpatients with a prevalence rate of 13%.   In Jamaica, Wilks et al found that diabetes mellitus was more prevalent among those with symptoms of depression.

  A Trinidad study reported a prevalence of 17.9% among subjects with type 2 diabetes. There is  a study done in Nigeria. They reported that the prevalence of depression among T2DM was 30% while in Bangladesh, the prevalence of depression is 34% . 

The World Health Study reported that the prevalence of depression in diabetes was 2% in adults aged 18 years and above, in 60 different countries over the period of one year. 

 Studies by de Groot et Al  showed that depression was significantly associated with a wide range of diabetes complications. 

The overall prevalence of depression in diabetes vary from 8.5% to 27.3%. Indian studies Madhu et al reported the prevalence of depression to be 49% amongst subjects with diabetes in Trivandrum, India. 

       The predictors of depression were found to be female gender, elevated fasting blood sugar level, physical disability and lack of physician’s advice regarding lifestyle modifications.

      Ranjan Das et al showed that in West Bengal, the prevalence of depression was 46.2% and reported that the presence of depression in type 2 diabetes further deteriorates the quality of life of the patients. Therefore, it is reasonable to assume that treating depression would have a beneficial effect on the quality of life. 

Naseer Ali et Al  found the prevalence of depression was 27.0% amongst diabetic subjects and 11.1% amongst healthy controls, in New Delhi. 

        Siddiqui et Al found that there is a higher prevalence of depression in patients with type 2 diabetes was almost twice as high compared to those without diabetes (35.4% vs 20%; p=0.006) in Delhi. 

       He suggested that assessment of depression should be performed as part of the routine practice in India as persons with type 2 diabetes are at higher risk of developing depression.

      In the CURES study, 25,286 subjects in whom fasting capillary glucose estimation was available. They were assessed for depression, using a self-reported and previously validated instrument. Depression was studied about the different stages of glucose intolerance.

      It can be seen that the prevalence of depression was highest among known diabetic subjects (30.2%) followed by the newly diagnosed diabetes (19.7%). It impaired fasting glucose (15.5%) and was lowest among normal fasting glucose subjects (13.8%) and the trend was significant (p<0.001). 

         Thus it is clear that the prevalence of depression increases with greater degrees of glucose intolerance. According to the National Institute of Mental Health, depression has a more serious progression in persons with diabetes.

Besides, it is linked to a higher rate of depression relapse and is associated with more diabetes-related medical complications. Therefore, it engenders higher healthcare costs than depression in persons without diabetes.

   Prevalence of Depression in Diabetic complications : 

       Earlier studies have examined the association of depression with micro- and macro vascular complications of diabetes. As a result, there is evidence to suggest that the long-term complications of diabetes are associated with depressive symptoms. 

           The majority of studies on the association between depression and diabetic complications have been cross sectional. However, prospective studies have shown that depression is associated with a higher and more rapid incidence of diabetic complications.

             The prevalence of depression was significantly higher among diabetic subjects with DR (35.0% vs 21.1%, p<0.001), neuropathy (28.4% vs15.9%, p=0.023), nephropathy (35.6% vs 24.5%, p=0.04) and PVD (48.0% vs 27.4%, p<0.001) as compared to subjects without these complications.

        The CURES study demonstrated that all the microvascular complications and macro vascular complications are associated with depression even after adjusting for confounding factors. The CURES study also found that the risk of depression was significantly higher in those on insulin (OR: 1.9, p=0.037) compared to diet only group while the odds

CONCLUSION: 

Journal of The Association of Physicians of India ■ Vol. 65 ■ August 2017, the ratio for depression in subjects treated with OHA was 1.3 (p=0.210) compared to those who were on diet only regimen.

     This is understandable as taking insulin is associated with depression in some people. Alternatively, those treated with insulin may be more symptomatic because of more severe disease or may have one or more complications. Therefore, many physicians put them on insulin in the first place.

     Studies have shown a significant relationship between depression and poor adherence to self-management guidelines. So it is sure that patients with depression are the chances to have a higher rate of diabetes complications. 

    People with diabetes, therefore, need to successfully manage their disease to avoid complications. Epidemiologic evidence of an association between atherosclerosis and depression in the general population is lacking and most earlier studies have been performed in patients with pre-existing vascular.

      After all,  these studies show a high risk of co-morbidity depression on survival after a cardiovascular event. There are only a few studies that have looked at the association between depressive disorders and atherosclerosis. 

        The CURES Study looked at the relationship between two measures of atherosclerosis, structural and functional (augmentation index) and depressive disorders in an urban south Indian population.

          Moreover, the prevalence of depression in subjects with normal IMT (<1.0 mm) was 16.2% compared to 30.4% in subjects with increased IMT (≥ 1.0 mm, p=0.013). This study shows that depression is associated with IMT, a population with a high prevalence of premature CAD. Mainly, It’s an early atherosclerotic marker in Asian Indians.

       Depression and diabetes are both chronic and complex disorders. Hence there is a need to find solutions and step towards clinical- and self-care for these conditions. 

              Both behavioural activation and motivation are critical for adherence to management plans in both conditions. Unfortunately, major barriers like stigma at the patient level, as well as clinical inertia hamper to intensify treatment by the provider. 

    So, patients and care providers should interact with each other to address the co-existing depression and diabetes. I think it is the need of the hour. It is a Integrating Depression with Diabetes Care.

       As diabetes and depression are both common conditions, it is important to assess depression in patients with diabetes and associated complications. Why? Because they are particularly vulnerable to further deterioration. 

           Vikram Patel suggested evidence-based treatments such as antidepressants along with psychotherapy. Both are effective in managing depression.

The delivery of these treatments should ideally be carried out through the integration of depression programs into existing health services or community settings. It will be with task-shifting to non – specialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers. 

         This was well demonstrated by the chronic care model developed by Katon et Al called TEAM care. Significant improvement in depression and glycemic control was observed in the group where intervention was provided by non – specialists compared to the usual care. 

       There is currently a study ongoing in India at 4 centres called the “INDEPENDENT Study. The research is looking at intervention in subjects with depressive symptoms, seen at 4 diabetes centres in India. 

         A study by Lydia et Al demonstrated the feasibility of implementing a collaborative care program for poorly-controlled type 2 diabetes and complex behavioural health disorders in an urban primary care clinic. 

           They showed that the integration of behavioural healthcare into chronic care management of patients with diabetes is a promising strategy to improve outcomes among the high-risk population.

The study showed that there was a mean decrease in HbA1c of 0.9 (10.6 to 9.4) among those referred to the collaborative care team, compared to a mean decrease of 0.2 (9.4 to 9.2) among those not referred.

       This was a significantly greater percent change in HbA1c (p=0.008).The demand for chronic care for both diabetes and depression is high as their interactions produce biological, social, and economic confluence among populations. 

          Adopting a syndromic framework in recognising, evaluating and implementing integrated health programmes appears to be the way forward as emphasised in a recent Lancet review. 

      The rationale for integrating treatment for depression and diabetes is that people with diabetes will comply with their treatment plan better if they get treatment for depressive symptoms . 

      Treatment of depression could be a pre-requisite for good diabetes self management.  Hence it is important that physicians dealing with diabetes are also

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