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Diabetes and Depression

(Established 13May96; not yet updated.)

Questions answered by Arturo R. Rolla, MD

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I.   Are diabetes and depression related?
II.  What can I do about depression?
III. What about antidepressant medications?
IV.  Will antidepressants affect my libido?
V.   Do oral agents cause depression?
VI.  A list member responds to the thread on depression
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I. Are diabetes and depression related?
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Every time the subject of depression comes up on the list (and it does 
come up quite often), immediately many of the members stand up and tell 
us about their own dealings with this disease and the meds they are 
taking.

Depression is very common in the general population and even more common
among people who have diabetes. Depression is highly variable from 
person to person, and it ranges from very mild to very severe. The main 
risk of depression is suicide. The prevalence of depression in 
industrialized countries is high and getting higher. With the present 
economic crisis, my personal impression is that the prevalence is even 
higher in the general population. Depression is common, period!

Depression is very common among people who have diabetes. We don't know 
if it's related to high blood sugar or other metabolic abnormalities, or 
if it is due to the limitations and health threats that diabetes 
(im)poses. The data we have so far is from comparisons between people 
with diabetes and normal controls. I have not seen any data comparing 
diabetes with other chronic illness, particularly with some painful, 
incapacitating conditions like rheumatoid arthritis, multiple sclerosis, 
etc.

We know a lot about the clinical aspects of depression, but its 
biochemistry is still a big enigma. What we are quite certain of is that 
many depressions are mostly chemical imbalances in the brain, and not 
necessarily due to life events or childhood trauma.  

Depression can be fatal. It kills through suicide. Once you convince 
yourself that nobody is able to understand your problems, that nobody 
can help you and that life is not worth it, you should know you are in 
trouble. When you are that advanced, you need to get outside help. Once 
you start to think about suicide, you should call for help right away.

II. What can I do about depression?
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First, prevent. Like yourself. Exercise a lot. Set reasonable goals for 
your life. Be humble. Exercise some more. Don't take yourself too 
seriously.

If you are already depressed, identify the causes. Laugh at yourself. 
Exercise even more (it's hard to start, but "You can do it"). Fight the 
root and the symptoms. Make an effort to keep going.

If the depression continues, you can do one of two things: a) Talk to a 
shrink. b) Take antidepressants. The batting average is about the same 
for both modalities of treatment. Pills are cheaper, and they seem to be 
be gaining more and more terrain. Freud is losing credibility; molecular 
theories seem to be more prevalent these days.

Finally, talk about your symptoms. Look at them objectively. To do that, 
first vocalize the symptoms. Then listen to your friends, or the members 
of this list. You'll be surprised how many have been or are in your 
situation. 

When you are going down Depression Avenue, try to make a right at 
Acceptance Avenue, and if you can find yourself there, maybe you'll be 
out of it.

Acceptance is an equation where you divide "Accomplishments" by 
"Expectations". If your expectations are always too high, then no degree 
of "Accomplishment" will ever be enough to get you sufficient Acceptance.

Lower the denominator "Expectation" to a human, pragmatic level, and 
you'll see how "Accomplishment" levels appear larger and larger in the 
Acceptance results.

III. What about antidepressant medications?
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Antidepressants are of 3 types:

1) Tricyclic antidepresants: amitryptyline, imipramine, nortriptyline, 
Trazodone, etc. They work mostly by increasing the levels of 
norepinephrine. They give you dry mouth and constipation, and they 
increase your appetite with an unhealthy craving for sweets! For a 
person with DM, they may aggravate symptoms of diabetic neuropathy 
(impotence, postural hypotension, etc.). This is important to know 
because the tricyclics are also used to treat painful diabetic 
neuropathy. On the other hand, they are very effective. In general, it 
takes 5 to 7 days for them to start working.

2) Serotonin antidepressants: They work through a neurotransmitter 
(serotonin), and they work faster (in 3 to 4 days). They decrease your 
appetite. They are very expensive, and they tend to cause more 
nervousness and anxiety, along with insomnia. Prozac is in this group.
For people with diabetes, we tend to use these more frequently than 
tricyclics because the meds in the Prozac family (Zoloft and Paxil 
included) do not increase appetite, do not decrease blood pressure, and 
do not give you cravings for sugar.

3) Monoaminoxidase inhibitotrs: These are for very severe cases that are
resistant to the other antidepressants. They have many side effects. 
Also, they increase your appetite. You cannot eat cheese or drink wine 
with these medications. 

Not every person with depression requires pills. It depends on the 
severity and the type of depression. The less exogenous causes you have 
to be depressed, the more cyclical the pattern, the more "endogenous" or 
"chemical" is your depression, and the higher the chances that you may 
need to take meds.

Meds for depression are not a panacea. You still have to make an effort 
to improve, and they have side effects. 


IV. Will antidepressants affect my libido?
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There is a difference between libido and potency. Libido is the interest 
to do it. Potency is the capacity to do it - mostly ability to obtain an 
erection in males.

Most antidepressants improve libido because depression tends to decrease 
it. So, as you are lifting from the depression, one of the symptoms that 
gets better is the lack of interest in sex. In general, it takes a while 
for libido to go back to normal, and here YMMV (your mileage may vary) 
applies big time. Libido e mobile qual piuma al vento - or better yet, 
in the storm.

Some antidepressants interfere with the potency or the act itself. 
Tricyclic antidepresants have a tendency to worsen neuropathy so, in 
males, they may cause or aggravate or trigger impotence. These people
may have their libido come back, but they find out that there is no 
erection. Occasionally, we have to discontinue these type of medications 
because of this side effect that is much more common in males.

The other type of antidepressants, those that work through the re-uptake 
of serotonin (Prozac, Zoloft and Paxil), also tend to improve libido. 
They work faster in the symptoms of depression. It usually takes them 4 
to 5 days for the patient to start feeling better. Side effects are 
different. They may cause "amphetamine-like" symptoms of irritability, 
nervousness, insomnia, hyperactivity. They do not tend to aggravate the 
impotence caused by neuropathy. On the other hand, they tend to increase 
the time between the beginning of excitement and climax. In other words, 
it tends to delay the appearance of the Big "O". This is more of a 
problem with women, since most men can use a little prolongation in 
their role. The problem ends up then as being a very delayed or 
impossible orgasm in some women.


V.Do oral agents cause depression?
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There is no scientific evidence that oral agents cause or aggravate 
depression. I recently reviewed all the side effects of oral agents and 
did not find any mention of that. I can tell you of many other side 
effects, but depression is not one of them.

VI. A list member responds to the thread on depression
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Thanks to everyone who has contributed thoughts and experiences 
concerning depression. I think it is important to recognize the 
difference between clinical depression and the normal type that everyone 
has from time to time as a result of life.

I find that in my case clinical depression is a bigger concern than the 
DM. When I am not overwhelmed by depression I am able to control my DM 
quite well with attention to diet and exercise and I use much less 
insulin. When I am depressed, I really don't care about anything at all. 
The entire world is grey and I usually get stuck in the "TV Rays" where 
I will watch anything that comes on the screen, though not much 
"registers." It is impossible to "chin up" at those times. I'm barely 
able to manage simple things like taking showers or putting dry food in 
the dogs' bowl. This isn't intended to be sniveling, but to show and 
tell. Unless the depression is horribly bad I can force myself to 
function when I have to, but the effort that takes will then require 
days to recover.

I do believe it is important for those with DM to recognize if they have
clinical depression and get treatment for it. It does not work to 
imagine that one can merely decide to "be happy" when the problem is a 
chemical imbalance in the brain.

I am glad to see this thread has generated a FAQ.

Love,
Lotus --- vwvan82@ptialaska.net

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