Vous êtes sur la page 1sur 4

26

Journal of the association of physicians of india december 2013 VOL. 61

Original Article

Depression and Diabetes : Impact of Anti-


Depressant Medications on Glycaemic Control
HS Dhavale*, Vijay Panikkar**, Bindoo S Jadhav***, Mangesh Ghulghule****,
Adita Dagaria ****

Abtract
Introduction : One of the consistent findings among various studies on diabetes has been the prevalence
of depression with or without comorbid anxiety among patients of Diabetes Mellitus. Also, numerous
other studies have pointed to the negative bearing of the same on blood sugar levels among patients.
However there is a lack of data on the outcome of treatment with anti-depressants on the blood glucose
level. Considering the ever increasing population of diabetics in our country and the significant causal
relationship established by current literature, this study was undertaken.
Aims and Objectives : To study prevalence of depression and anxiety in patients of Type 2 Diabetes
Mellitus with an increase in blood glucose levels.
To study the socio-demographic profile and role of stressors in patients of Type 2 Diabetes Mellitus.
To study the effects of management of depression and anxiety on blood glucose levels in patients of
Type 2 Diabetes Mellitus.
Material and Methods : Sample Size : 100
Consecutive 100 patients diagnosed with Type 2 Diabetes Mellitus(DM) fulfilling the inclusion and
exclusion criteria were included in the study. Ethics committee approval was taken for the study. The socio-
demographic details of the patients were collected using a specially designed semi-structured proforma.
Patients were evaluated for psychiatric disorders using DSM IV TR criteria for diagnosis and Montgomery
Asberg Depression Rating Scale (MADRS) and Hamilton Anxiety Rating Scale(HAM-A) were used thereafter
to assess the severity of depression and anxiety, respectively. Patients detected with depression and / or
anxiety were started on T. Escitalopram (10 mg); keeping the management of DM unchanged. Patients
were reviewed after 6 weeks from date of initial assessment and blood glucose levels were repeated. Data
thus collected was analysed using SPSS Software.
Results : The prevalence of depression with/without anxiety in the study was 39%. Among depressed
patients stressors were found in 84% of patients with social and interpersonal stressors as the more
prevalent types. The socio-economic profile showed a female preponderance, lower to middle socio-
economic and educational status and majority were married. 47% of the patients started on T. Escitalopram
showed lower fasting and post-lunch blood sugar values on follow up, which was clinically and statistically
significant.

Professor and Head, Dept. of


Introduction
*

Psychiatry, **Professor, Dept. of

D
Medicine, ***Associate Professor,
iabetes Mellitus (DM) is one of the most common chronic medical diseases
Dept. of Psychiatry, ****Resident,
Dept. of Psychiatry, K.J. Somaiya worldwide with an estimated prevalence of detected DM being 3 to 4% in the
Medical College and Research general population. 1 One of the consistent findings among various studies on diabetes
Centre, Everard Nagar, Sion, has been the high prevalence of depression with or without comorbid anxiety among
Mumbai-400 022 patients of DM. 2-5 Major depression is associated with increased medical utilisation
Received: 23.08.2011;
and costs, higher symptom burden, increased functional impairment including poor
Accepted: 12.06.2013

896 JAPI december 2013 VOL. 61


Journal of the association of physicians of india december 2013 VOL. 61 27

Table 1 : Prevalence of depression with / without anxiety. 40 35.9


35
Sample size 100 30
Depression with Anxiety 21 25 20.5 17.9
20
12.8
Depression without Anxiety 18 15
7.7
10 5.1
Absent 61 5
0

Table 2 : Socio-Demographic Profile

nt
l

al

l
ia
ca

na
l
na
ci

e
nc
si

bs
io
So

o
y

na

at

A
Patients with Patients Without

rs
Ph

up
Fi
e
rp

cc
Depression Depression

te

O
In
Age (Years) :
18-30 -- -- Fig. 1 : Prevalence of Type of Stressors among depressed
31-45 7 9 patients (%)
46-60 27 34
this context is Selective Serotonin Re-uptake Inhibitors
> 60 5 18
Sex :
(SSRI), such as fluoxetine, sertraline and escitalopram.
Male 15 34
They have been shown to improve both dietary
Female 24 27
compliance and HbA1c levels in addition to reduction
Education
in severity of depression and anxiety.
Illiterate 3 2 The role of stress as one of the most common
Primary 2 7 aetiological factors for both depression and diabetes
Secondary 17 18 has been well established. 10-14 Stress may lead to
Graduate 12 28 deterioration of glycaemic control via its effects on
Post-graduate 5 6 the neuroendocrine system wherein the psychological
Occupation reaction to stressors leads to the activation of the
Self-Employed 16 18 hypothalamo-pituitary-adrenal (HPA) axis, leading in
Service 5 13 turn to various endocrine abnormalities, such as high
Housewife 16 20 cortisol and low sex steroid levels, that antagonise the
Retired / Others 2 10 actions of insulin, or it may impact more indirectly
Marital Status via changes in health behaviours, such as regimen
Single -- 1 adherence, smoking, or drinking practices. At the
Married 37 57 same time, an increase in visceral adiposity (increased
Widow/ Widower 2 2 girth) is seen, which plays an important role in
Annual Gross Income (lac) diabetes by contributing to insulin resistance.
< 1.5 21 21 Considering the ever increasing population of
1.5-5 8 28 diabetics in our country and the significant causal
>5 10 12 relationship of depression and glycaemic control
established by current literature, this study was
self care, non compliance to treatment and other undertaken.
decrements in quality of life, and increased rates of
mortality. 6,18 Identification and effective treatment of Aims and Objectives
comorbid depression is thus an essential component
of high quality clinical care of patients with chronic 1. To study prevalence of depression and anxiety
medical illness like DM in the specialty medical in patients of Type 2 Diabetes Mellitus with an
setting. increase in blood glucose levels.

Patients with depression have been shown to 2. To study the socio-demographic profile and
exhibit insulin resistance and decreased glucose role of stressors in patients of Type 2 Diabetes
tolerance, and conversely increases in serotonergic Mellitus.
function results in increased sensitivity to insulin and 3. To study the effects of anti- depressant medication
reduces plasma glucose levels. 7-9 Recent studies have on blood glucose levels in patients of Type 2
shown that short-term administration of Tricyclic Diabetes Mellitus.
antidepressants (TCA) such as nortryptiline and
imipramine may lead to reduced fasting blood glucose, Inclusion Criteria
while longer use increases baseline values due to their
1. Patients more than 18 years of age.
catecholamine profile. Thus they successfully treat
depression but also lead to deterioration in glucose 2. Patients diagnosed with Type 2 Diabetes Mellitus,
control. The other class of antidepressants studied in compliant on treatment and on regular follow up
with diabetologist.

JAPI december 2013 VOL. 61 897


28 Journal of the association of physicians of india december 2013 VOL. 61

Table 3 : Mean fasting blood sugar (FBS) and post-lunch blood profiles of patients with / without depression. Among
sugar (PLBS) levels depressed patients - 27(69%) were in the age group
Baseline Follow Up T value P value 46-60. There was a female preponderance with 24
FBS 179.44 153.42 2.27 0.029* (61%) patients being female. Majority among these
PLBS 251.39 197.47 3.08 0.004* patients- 37 (94%) were married. Almost half the
*
p < 0.05 patients 17(44%) had secondary education, whereas
12 (30%) were graduates. 16 patients (40%) were
3. Patients with spikes or increase in the blood housewives and 21(54%) reported annual gross
glucose levels from previously maintained incomes lower than 1.5 lac per annum. This data is in
baseline within last three months line with most major epidemiological studies which
report higher prevalence rates for depression among
Exclusion Criteria females and older age groups. 3-5
The prevalence of stressors among depressed
1. Patients having history of prior psychiatric
patients was 84% (33) and as seen in Figure 1, among
illness and / or prior treatment with psychiatric
stressors, the highest prevalence was reported for
medicines.
interpersonal stress (35.9%) and the least reported
2. Patients with a current diagnosis on Axis 1 of DSM single major stressor was physical stress (5.1%).
IV-TR other than depression and anxiety.
36 patients with depression with / without anxiety
3. Patients with Type 1 Diabetes Mellitus. were started on T. Escitalopram (10 mg) and in 17
(47%) patients, reduction in mean glucose levels
Material and Methods was seen as compared to their baseline values. 16
Sample Size : 100 (44.44%) patients reported no significant change in
blood sugar levels whereas an increase was seen in 3
Consecutive 100 patients diagnosed with Type
(8.33%) patients.
2 Diabetes Mellitus (DM) fulfilling the inclusion
and exclusion criteria were included in the study. As seen in Table 3, there was reduction of mean
Ethics committee approval was taken for the study. fasting blood sugar (FBS) levels from baseline value of
The socio-demographic details of the patients were 179.44 mg/dl to follow-up value of 153.42 mg/dl. This
collected using a specially designed semi-structured difference was found to be statistically significant [t =
proforma. 2.27, p = 0.029]. Also, the results show the mean follow
up post lunch blood sugar (PLBS) levels(197.47 mg/dl)
Patients were evaluated for psychiatric disorders
were lower than the mean baseline values (251.39 mg/
using DSM IV TR criteria for diagnosis and Montgomery
dl) and this difference was also found to be statistically
Asberg Depression Rating Scale (MADRS) and
significant [t = 3.08, p = 0.004]. A study by Lustman
H a m i l t o n A n x i e t y R a t i n g S c a l e ( H A M - A) we r e
et al in 1997 16 had reported a positive correlation
used thereafter to assess the severity of depression
of treatment-type independent improvement in
and anxiety, respectively. Patients detected with
depression with glycaemic control. The same study
depression and / or anxiety were started on T.
had also reported long term use of Nortryptiline
Escitalopram (10 mg); keeping the management of
to be associated with hyperglycaemia among these
DM unchanged. Patients were reviewed after 6 weeks
patients. Lin et al in 2006 17 also reported negative or
from date of initial assessment and blood glucose
no benefit with Nortryptiline. A study by Klouse et
levels were repeated. Data thus collected was analysed
al in 2006 19 had reported significant improvement in
using SPSS software.
glycaemic control with use of Sertraline. The study
Results and Discussion further demonstrated superior efficacy of Selective
Serotonin Re-uptake Inhibitors (SSRIs) such as
A total of 100 patients diagnosed with Type 2 fluoxetine, sertraline and escitalopram, as a class of
Diabetes Mellitus were studied and as seen in Table anti-depressant medicine over tricyclics, as reported
1, the prevalence of depression with / without anxiety by other studies as well. 15,23 Few specific features of
among them was 39%. A large meta-analytic study by escitalopram make it a promising medication for
Anderson et al 2 reported prevalence rate of comorbid use in diabetes. These include i) a benign side effect
depression with diabetes between 18 30 % across profile, even among SSRIs; ii) high tolerance in
different clinical settings, which were lower than the elderly patients; iii) rapid action with efficacy often
findings in our study. Current estimates of lifetime demonstrated in as little as 1-2 weeks, which in turn
prevalence of depression in general population across could help improve compliance and iv) its efficacy for
cultures range from 4-19%. 3-5 treatment of anxiety, which co-occurs frequently with
Table 2 shows the comparison of socio-demographic depression as well as diabetes. 22 Hence it was chosen
as the antidepressant medication for this study.

898 JAPI december 2013 VOL. 61


Journal of the association of physicians of india december 2013 VOL. 61 29

Conclusions 7. Lustman PJ, Griffith LS, Clouse RE, et al: Psychiatric illness in diabetes:
Relationship to symptoms and glucose control. J Nerv Ment Dis
1986;174:736-742.
1. Prevalence of depression among patients of Type
2 Diabetes Mellitus was 39%. 8. Rosenthal MJ, Fajardo M, Gilmore S, Morley JE, Naliboff BD.
Hospitalization and mortality of diabetes in older adults: a 3-year
2. The patients socio-demographic profile indicated prospective study. Diabetes Care 1998;21:231-235.
a female preponderance, majority being married 9. Gross et al., Depression and Glycemic Control in Hispanic Diabetics.
and belonging to middle to lower educational and J Gen Intern Med 2005;20:460466.
income levels. 10. Richard S. Surwit, Mark S Schneider. Role of Stress in the Etiology and
3. Stressors were present in a significant majority of Treatment of Diabetes Mellitus. Psychosomatic Medicine 1993;55:380-
affected patients(84%). 393.
11. Alessandro Bartolomucci, Rosario Leopardi. Stress and Depression.
4. 47% of the patients started on the anti-depressant
Preclinical Research and Clinical Implications 2009;4:e4265.Plos one.
escitalopram showed a reduction in the blood
12. Analava Mitra. Diabetes and Stress: A Review. Ethno-Med., 2(2):
sugar levels from their baseline values, which was 131-135 (2010381)
clinically and statistically significant.
13. Vadde, Ramakrishna, Rama Jailkhani. 2007.Evaluation of Oxidative
Stress In Insulin Dependent Diabetes Mellitus (IDDM) Patients.
Implications Diagnostic Pathology, Doi:10.1186/1746-1596-2-22.

The study underscores the need for screening 14. National Diabetes Data Group: Diabetes in America, Bethesda, U.S.
Department of Health and Human Services Publication 1985;85-
and treatment of depression and anxiety in patients
1468.
of diabetes. Positive response to anti-depressant
15. Kaplan Sm, Mass Jw, Pixley Jm, et al: Use of Imipramine In Diabetics:
therapy indicated a favourable overall outcome in
Effects On Glycosuria and Blood Sugar Levels. Jama 1960;174:511-
the management of a chronic illness such as diabetes 517.
and raises the chances of holistic therapy for similar
16. Clouse RE,Lustman PJ, Griffith LS, Freedland KE, et al: Effects of
ailments. nortriptyline on depression and glucose regulation in diabetes:
The high prevalence of stressors has important results of a double-blind, placebo controlled trial. Psychosom Med
1997;59:241250.
implications for lifestyle changes, coping strategies
and long-term management for reduction in stress 17. Elizabeth H. B. Lin, MD, MPH,Wayne Katon, MD,et al. Effects of
Enhanced Depression Treatment on Diabetes Self-Care. Annals of
levels.
Family Medicine 2006.

References 18. Ciechanowski PS, Katon WJ, Russo JE. Depression and Diabetes:
Impact of Depressive Symptoms on Adherence, Function and Costs.
1. Amos A, Mcarthy D. The Rising global burden of diabetes and its Arch Intern Med 2000;160: 32783285.
complications: Estimates and Projections to the year 2010. Diabetic 19. Patrick J Lustman, Ray E Clouse, Billy D Nix, et al. Sertraline for
Medicine 1997;14:S7-85. Prevention of Depression Recurrence in Diabetes Mellitus. Arch Gen
2. Ryan J Anderson, Ba Kenneth E Freedland, Ray E Clouse, Patrick J Psychiatry 2006;63:521-529.
Lustman. The Prevalence of Comorbid Depression in Adults with 20. Lustman PJ, Freedland KE, Griffith LS, Clouse RE. Fluoxetine for
Diabetes - A meta-analysis. Diabetes Care 2001;24:10691078. depression in diabetes: a randomized, double-blind, placebo-
3. Andrade L, Caraveo-A.. Epidemiology of major depressive controlled trial. Diabetes Care 2000;23:618-623
episodes: Results from the International Consortium of Psychiatric 21. Bussing, R. (2006). Choosing the Best SSRI.Psych Central
Epidemiology (ICPE) Surveys.Int J Methods Psychiatr Res 2003;12:3
22. Cipriani A, Santilli C, Furukawa TA, et al. Escitalopram versus other
21.
antidepressive agents for depression. Cochrane Database of
4. Kessler RC, Berglund P, Demler O. The epidemiology of major Systematic Reviews 2009, Issue 2. Art. No.: CD006532.
depressive disorder: Results from the National Comorbidity Survey
23. Diabetes Control and Complications Trial Research Group. The
Replication (NCS-R).JAMA 2003;289:3095105.
effect of intensive treatment of diabetes on the development
5. Leonard E. Egede, Charles Ellis - Diabetes and depression: Global and progression of long-term complications in insulin-dependent
perspectives : diabetes research and clinical practice 2010;87: diabetes mellitus. N Engl J Med 1993;329:977-985.
302312.
6. Katon.W, Paul Ciechanowski - The Impact of Major Depression in
Patients With Chronic Medical Illness : Journal of Psychosomatic
Research 2002; 53:859863.

JAPI december 2013 VOL. 61 899