Thursday, May 24, 2012

May Commemorates Many Things; Mental Health Is One PWDs Should Be Aware Of

The month of May commemorates many things, including Memorial Day in the U.S., which is a Federally-observed, national holiday on the last Monday of May meant to honor all Americans who have died in all wars. In practice, however, Memorial Day weekend, which amounts to a three-day weekend for most people, is effectively the kickoff to the summer season (another three-day weekend, Labor Day, marks the unofficial end, incidentally). Typically, colleges and universities are already finished by Memorial Day, and most public (and private) grade schools finish in the weeks that follow (often contingent upon completion of a certain number of days, which may be impacted by "snow days" in which school is called off for inclement weather, typically during winter months).

May also happens to be "Arthritis Awareness Month", although for those in the diabetes community who weren't already aware of it, there are several different forms of arthritis, including a far more prevalent form of arthritis known as osteoarthritis (or "OA"), which is degenerative joint disease that people are more prone to developing as they age, and then there's a less common, autoimmune variety known as Rheumatoid Arthritis (or "RA") which is, in a number of ways, a very different illness. Yet when people hear the word "arthritis", they automatically presume it's all the same (meaning OA like their grandmother had) and they also tend to think they know far more about it than they actually do!

Hmmmmm, that really SHOULD sound familiar since when most people hear the word "diabetes" they automatically presume it's one single illness (it isn't) caused by the same thing, and treated and dealt with the same way in all cases -- of course, nothing could be further from the truth! Those who are more familiar with diabetes know there's a less common form known as type 1 caused by an autoimmune response, and no amount of diet or exercise can prevent that form from occurring or cause it to go into remission. Hence, I have been blog and Twitter "lurking" about the issues impacting the RA community for the past year (on Twitter, you can use the #RA or #rheum hashtag designations), and while some of their issues are surprisingly similar (who doesn't complain about their insurance company?) others are very different from those of people with diabetes (or PWDs, as editors and others should know that the term "diabetic" is really an adjective, but has fallen out of favor among doctors when used as a noun -- and with good reason -- because it's quite inappropriate to name an entire group of people after their diseases, especially when the same is NOT typically done for people other types of illnesses).

May Is Mental Health Month

Without digressing too far from the point of today's post, aside from Arthritis Awareness Month, the month of May also happens to be "Mental Health Month", which began in 1949 to raise awareness of mental health conditions and mental wellness for all. When I first read about it, I was dismissive, as I'm fortunate not to be impacted by mental health issues personally (knock on wood!). But consistent with the theme of Mental Health Month, this year (in 2012), the Diabetes Advocates [] (or "DA") of which, I've been a proud member for the last few years, wants to use this opportunity to call attention to the mental health issues faced by people with diabetes. People with diabetes should be aware of the connection between mental health and diabetes care, but beyond that, they should know how to get assistance if you suspect you might be impacted. The American Diabetes Association has a page dedicated to the issue of depression with diabetes HERE.

More than a few studies have shown a signficantly higher incidence of clinical depression in people with diabetes, albeit there is little solid evidence of a causal relationship between type 1 diabetes and clinical depression. Said another way, PWDs are more likely to become clinically depressed, which adversely impacts both their mental state of mind, and in turn, glycemic management. It's a lot tougher to manage diabetes effectively if one is battling a mental health issue like depression, but more importantly, challenges in managing diabetes can also impact one's depression and mental health.

One of my favorite posts on the subject was written by my friend Deb Butterfield, who passed away last autumn (I wrote a post about her passing HERE). Her 1998 post was actually a compelling critique of the DCCT and the NIH/NIDDK's subsequent plans to use the results of that particular study for things like using "behavioral theories and strategies to maximize diabetes self-management" and "to study interventions to decrease psychiatric and social co-morbidities in individuals with diabetes (for example, depression, eating disorders, and family dysfunction)" rather than putting more funds into things like cure-related research. I believe her argument was compelling when Deb wrote (see her eloquent article HERE):

"Perhaps the best test of these 'behavioral theories and strategies' would be to follow 1,441 non-diabetic people [Note: Notice how she used diabetic as an adjective, not a noun!] over a period of 10 years as they try to comply with the regimen of injections, restrictions and uncertainty that is expected of the diabetic population. The conclusion would, I'm sure, be that the regimen itself is unreasonable and that the co-morbidities of depression, eating disorders and family dysfunction are, after all, only human. The disparity between the findings of the DCCT and the continued escalation of secondary complications points to one undeniable truth--only a cure for diabetes can have any significant impact on the human toll the disease extacts."

Ignoring the cure comment for a just second, note how she implied that depression, eating disorders and family dysfunction were entirely human responses to living with a chronic disease like diabetes. Still, it is important to note that depression is nothing to dismiss casually -- it can impact EVERYTHING in a person's life. Now, I have no personal experience with clinical depression myself, but over the years, I've met a fair number of people who have diabetes and clinical depression, and most of them say one cannot effectively deal with diabetes until they've addressed depression, and that comes with people who know first-hand. A number of my fellow diabetes blogger peers have written on issues related to depression and you might consider having a look at some of their posts, catch a few of them (not nearly everything written on this topic): us.html

Mental Health Issues Can Impact EVERYTHING Else!!

For some, there is the feeling of "Why Bother?" or that they somehow deserve these health problems. Let me set the record straight: no one "deserves" diabetes, and depression can make glycemic control look like a cruel joke, quite frankly, even though better glycemic management can certainly help improve one's mental state of mind.

My Perspective: Mental Health is Priority #1, Glycemic Control Can Be Priority #2

Aside from periodic diabetes burnout, which impacts nearly ANYONE with any type of chronic medical condition from time-to-time, there have been advances in mental healthcare in recent years, and treating depression can be done effectively with proper medical attention. But I believe anyone who prescribes glycemic management ahead of treating clinical depression really ought to have their own heads examined! 

Seriously, mountains of data show that people can live with elevated blood sugar levels for a very long time (even though it can be damaging in the long-term), but from my perspective, I think addressing the mental health issues should take top priority. Think about it this way: when a person with diabetes experiences hypoglycemia, the brain isn't getting enough fuel (in the form of glucose) to function properly.  That needs to be treated before you can do ANYTHING else!  The same applies to mental health: if you're battling depression, you cannot be expected to make appropriate decisions about caring for another disease like diabetes. Take care of the brain, first, people!

After all, one can make much better self-care decisions only once issues like clinical depression is effectively addressed. Sadly, too many doctors (who seldom have much recent training in mental health), fail to acknowledge this, and often sound like broken records when they start fixating on glycemic control without considering that something else like mental health might be a very legitimate health obstacle to addressing glycemic control.

Now, let me be very clear: I am not a medical doctor, the above is my personal perspective only. As always, you should seek treatment from qualified, licensed medical doctors in both mental health as well as in diabetes care (endocrinology) -- and my personal preference would be to get that from specialists who work with either mental health, or diabetes care ALL the time because the liklihood of them being aware of the latest advances is quite good.

Don't misunderstand: I think general practitioners (family doctors) can be tremendously wonderful resources (I had a really awesome family doctor when I lived outside of Philly, and felt no need to see an endocrinologist under his care), and some are even pretty up-to-date on one or the other (or both!), but many others have not had recent continuing medical education (CME) training on mental health as well as all forms of diabetes care. And, let's face it: recent training on the latest oral diabetes drug won't help much if you have autoimmune type 1 diabetes and rely on insulin alone, yet their last CME credits related to insulin were more a decade ago! Medicine is constantly evolving, and your doctors should be aware of the latest for both!

All of this is to say that depression and diabetes never a fun combination, but realize that you are entitled to and DESERVE treatment for both.  If you think you may be depressed, and I will probably get criticized for this, I suggest let the diabetes care wait a while until you get the depression effectively treated.  Also, even if you suspect depression, have it checked out -- if its NOT depression, great, but if it is, you've made a huge step in addressing the issue already!  The key is finding the right psychiatric doctor, and realize that like endocrinologists, there is considerable diversity among them.  You may like one better than another, so you can indeed shop around for the right mental health doctor, too.  But the co-morbidity of depression and diabetes is a challenging combo, but there IS help and treatment out there for both.  Remember: you DESERVE the best care available!


Mike Hoskins said...

Greta post, Scott. I appreciate you highlighting the arthritis awareness this month. And for pointing us to Deb's blog on the depression issue. Lots to read, but great information. Thanks for sharing all this.

Jenny said...


Sadly, too much "treatment" for diabetes involves giving people drugs that are well known for increasing insulin resistance and obesity in once normal people and for causing diabetes in people who otherwise would not have had it.

For years the drug companies said that the diabetes preceded the depression suggesting it caused it. This turned out not to hold up in epidemiological studies not funded by drug companies.

Treating depression with therapy is as effective or more effective than treating it with pharmaceutical drugs that remodel the brain in a way that is functionally addictive, though the drug companies have weaseled out of calling it that, too. Getting off these drugs can be as tough as quitting smoking.

For PWD therapy may be even more helpful because it involves talking with another human being and experiencing the rare gift of being understood.

PWD should also be very aware that the atypical antipsychotics which TV ads are urging on people with garden variety diabetes (Zypreza was the first, the newer one is Abilify) are incontrovertibly linked to causing permanent diabetes in people who started off with no sign of it. They also cause massive weight gain.

The drug companies have turned "Mental health screenings" which they sponsor at times like this into harvesting operations for new drug consumers.

Finding an empathic, wise person to help you get perspective, and learning to change the things in your life that you can change will do for more in the long term to defeat depression than any drug.

This isn't theory for me. I was someone who lived with depression in my teens and 20s and I've done just what I describe above, with lasting and very gratifying results.

Scott S said...


Here is an unfortunate example where far too many doctors take the "easy way out" rather than doing what's right for their patients. Drug treatments tend to be something doctors who are unqualified to treat clinical depression themselves tend to do because it involves almost no work for them, but often with adverse effects for their patients. What ever happened to referrals to qualified psych. doctors? Sadly, that seems to be regularly dismissed in favor of drugs by many doctors.

Thank you for calling attention to these issues in your comments. I think individuals should be skeptical of another drug plan, and perhaps ask for non-pharmacological treatments before accepting drug treatments. Unfortunately, with mass-advertising of drugs in this country, we have come to accept routine drugs as a standard of care rather than the exception.

Again, thanks for your well-informed comments!