Patients with diabetes, as well as other people with chronic diseases, commonly experience long-term stress or depression. It often is a direct result of the disease itself, because of all the emotional ups and downs patients experience during chronic management. For example, patients with diabetes often worry about lasting complications of 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 from depression. The disease itself can be overwhelming and often leaves a patient wondering, "Why me?" Identifying these patients and helping them with tips to manage stress and depression effectively can have a positive impact, not only on their emotional well-being, but on their long-term clinical outcomes as well.
Sources of stress can be physical or mental. Examples of physical stresses include infections, trauma, injuries, or sickness. Mental stresses include relationship difficulties, financial concerns, and pressure from a stressful job. Physiologically, the body responds to stressors by secreting the counter-regulatory hormones 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 of their diabetes in indirect ways. For example, these patients may have a lack of concern for taking care of themselves. They often do not sleep well, or they sleep too much and are not 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 of depression can be the first step in assisting these patients to find help. Pharmacists can generate conversations that identify patients' specific issues: Are they losing interest in their usual activities? Are they experiencing any changes in weight? 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 and noticing any changes can be the first step. For example, the pharmacist should notice when a patient who has not been known to seek medications for insomnia is asking about the best OTC product to help him or her sleep. The pharmacist also should take note of a patient recently diagnosed with diabetes who is asking about alternative therapies to help him or her feel better or have more energy.
Getting Help for Patients
One of the simplest yet most effective interventions is to help these patients understand that what they are experiencing is normal and that successful treatments are available. Depression and stress can be treated effectively with psychotherapy (counseling) and/or medication therapy. Most of the time, health insurance plans will cover counseling for diabetes-related depression. For patients without insurance, there may be local health clinics that will offer counseling services at a reduced fee or on sliding-scale payment options. Local diabetes education centers also traditionally have support personnel to assist with patient counseling. Counselors often can teach patients various relaxation techniques.
Patients who lack the basic information or skills needed to manage their disease will feel more stressed or depressed, simply because they feel overwhelmed. Support from family and friends is important, but sometimes the support of other patients experiencing the same illness or problems can be more therapeutic for a patient. Many communities have wellness centers that offer diabetes support groups. For patients to feel that they are not alone and to be able to express the fears and difficulties, as well as successes, associated with their disease can have a positive impact on their mental and physical well-being. Diabetes centers also generally offer group or individual education classes.
For patients who are medically cleared by their physician, suggesting a regular exercise regimen can be helpful, not only for long-term stress management, but also for improving glycemic and cardiovascular outcomes. Patients should be encouraged to start a physical activity program slowly.
Dr. Brian is a clinical specialist with Cornerstone Health Care, High Point, NC.
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