COMPREHENSIVE CARE CLINIC: DIABETES: Diabetes-related Stress and Depression

Patients with diabetes, as well as other people withchronic diseases, commonly experience long-termstress or depression. It often is a direct result of the diseaseitself, because of all the emotional ups and downspatients experience during chronic management. For example,patients with diabetes often worry about lasting complicationsof the disease, how to manage the cost of the disease,and how it will affect their families or their jobs.

As many as 1 in every 3 persons with diabetes suffers fromdepression. The disease itself can be overwhelming andoften leaves a patient wondering, "Why me?" Identifyingthese patients and helping them with tips to manage stressand depression effectively can have a positive impact, notonly on their emotional well-being, but on their long-termclinical outcomes as well.

Sources of stress can be physical or mental. Examples ofphysical stresses include infections, trauma, injuries, or sickness.Mental stresses include relationship difficulties, financialconcerns, and pressure from a stressful job. Physiologically,the body responds to stressors by secreting the counter-regulatoryhormones such as epinephrine, cortisol, and glucagon.These hormones, although helpful in some circumstances,certainly can add to the complications of a diabetic patient.Their effects include increased heart rate, blood pressure,and glucose levels.

Stress and depression also can affect patients' control oftheir diabetes in indirect ways. For example, these patientsmay have a lack of concern for taking care of themselves.They often do not sleep well, or they sleep too much and arenot as attentive to their basic daily needs as they should be.They also often are unconcerned about daily diabetic requirements,such as eating properly, taking the proper medications,or performing regular self-monitoring of blood glucose.

Recognizing the Signs

For pharmacists, recognizing the signs and symptoms ofdepression can be the first step in assisting these patients tofind help. Pharmacists can generate conversations that identifypatients' specific issues: Are they losing interest in theirusual activities? Are they experiencing any changes inweight? Are they having trouble sleeping?

Most patients will not seek help or make direct statements,such as "I'm feeling very down and depressed." Yet,paying attention to their usual habits and personalities andnoticing any changes can be the first step. For example, thepharmacist should notice when a patient who has not beenknown to seek medications for insomnia is asking about thebest OTC product to help him or her sleep. The pharmacistalso should take note of a patient recently diagnosed withdiabetes who is asking about alternative therapies to helphim or her feel better or have more energy.

Getting Help for Patients

One of the simplest yet most effective interventions is tohelp these patients understand that what they are experiencingis normal and that successful treatments are available.Depression and stress can be treated effectively with psychotherapy(counseling) and/or medication therapy. Most ofthe time, health insurance plans will cover counseling fordiabetes-related depression. For patients without insurance,there may be local health clinics that will offer counselingservices at a reduced fee or on sliding-scale payment options.Local diabetes education centers also traditionally have supportpersonnel to assist with patient counseling. Counselorsoften can teach patients various relaxation techniques.

Patients who lack the basic information or skills needed tomanage their disease will feel more stressed or depressed, simplybecause they feel overwhelmed. Support from family andfriends is important, but sometimes the support of otherpatients experiencing the same illness or problems can bemore therapeutic for a patient. Many communities have wellnesscenters that offer diabetes support groups. For patients tofeel that they are not alone and to be able to express the fearsand difficulties, as well as successes, associated with their diseasecan have a positive impact on their mental and physicalwell-being. Diabetes centers also generally offer group or individualeducation classes.

For patients who are medically cleared by their physician,suggesting a regular exercise regimen can be helpful, notonly for long-term stress management, but also for improvingglycemic and cardiovascular outcomes. Patients shouldbe encouraged to start a physical activity program slowly.

Dr. Brian is a clinical specialist with Cornerstone Health Care, HighPoint, NC.

For a list of suggested reading, send a stamped,self-addressed envelope to: References Department,Attn. A. Stahl, Pharmacy Times, 241 Forsgate Drive,Jamesburg, NJ 08831; or send an e-mailrequest to: astahl@ascendmedia.com.