Health for life

People with diabetes experience depression more often than people without diabetes.

Does having diabetes raise your risk of developing depression? Or is it the other way around ... Does experiencing depression raise your risk of developing diabetes?

No definitive answer to that question exists. In fact, the two may be inextricably intertwined. That did not deter a group of Johns Hopkins researchers from seeking to tease the two conditions apart. Their findings were reported in the June 18 issue of JAMA:

Examining A Bidirectional Association Between Depressive Symptoms And Diabetes

The study had two parts. The cohort used was the Multi-Ethnic Study of Atherosclerosis (MESA study), a group of US adults followed for about 3 years.

The first part involved 5201 participants without diabetes. Their findings:

"The crude incidence of type 2 diabetes over 3.2 years was 22.0 per 1000-person years for those with elevated depressive symptoms and 16.6 per 1000 person-years for those without elevated depressive symptoms."

So, there was a small increase in risk for diabetes in individuals experiencing depression. This difference, however, was partially lessened when lifestyle factors (smoking history, caloric intake, alcohol use, physical activity level) were considered. It is possible that the same lifestyle factors that put someone at risk for depression (physical inactivity, higher caloric intake with weight gain), also increase their risk for diabetes.

The second part involved 4847 participants without depressive symptoms. Their findings:

"Individuals with untreated type 2 diabetes were not at increased risk of developing elevated depressive symptoms, those with treated type 2 diabetes were at increased risk of developing elevated depressive symptoms. ... Treated type 2 diabetes was associated with a 52% higher odds of developing elevated depressive symptoms."

That last finding, where untreated patients did not experience depression but treated patients did, led the authors to conclude:

"Clinicians should be aware of increased risk of elevated depressive symptoms in individuals with treated type 2 diabetes and consider routine screening for depressive symptoms among these patients."

What is it about treatment for diabetes that raises risk for depression?

The authors speculate that psychological stress associated with diabetes management may contribute. Also, if youre being treated, youre likely to have a number of complications which by themselves could increase the risk for depression.

When depression occurs along with diabetes, it can hasten death. If you treat the depression, can you forestall that earlier death?

Thats what researchers publishing in this months issue of Diabetes Care asked. They analyzed data on 584 participants of the PROSPECT Trial (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) and found:

"Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices."

The risk for death was reduced by about 50% over a 5-year period for patients with diabetes whose depression was being treated.

The authors concluded:

"These results should propel the development and dissemination of models of care that better integrate depression management for individuals with diabetes."

________For the study:
Diabetes, Depression, and Death; A randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT)

Exercise may benefit people suffering from depression, according to an updated systematic review published in The Cochrane Library. The authors of the review found evidence to suggest that exercise reduces symptoms of depression, although they say more high quality trials are needed.

Worldwide, more than 120 million people suffer from depression. Antidepressants and psychological therapies are recommended as effective treatments for depression. However, antidepressants have side-effects and some people per not to receive, or may not have access to, psychological therapies. Physical exercise is also used as a treatment for depression. There are a number of reasons why it might work such as changing hormone levels that affect mood or providing a distraction from negative thoughts.

The previous version of the Cochrane review found only limited evidence of benefit for exercise in depression. However, more trials have now been completed, leading researchers to carry out a further update. Altogether, they reviewed the results of 39 trials involving 2,326 people diagnosed with depression. The severity of patients symptoms was assessed using standard scales of depression.

In 35 trials comparing exercise with control treatments or no treatment, the researchers saw moderate benefits of exercise for treating depression. Exercise was as effective as psychological therapy or taking antidepressants, although these findings were based on only a few, small, low quality trials.

"Our review suggested that exercise might have a moderate effect on depression," said one of the authors of the review, Gillian Mead of the Centre for Clinical Brain Sciences at the University of Edinburgh in Edinburgh, UK. "We cant tell from currently available evidence which kinds of exercise regimes are most effective or whether the benefits continue after a patient stops their exercise programme."

Conducting high quality trials involving exercise can be problematic. For example, it is difficult to conceal which patients have been allocated to treatment groups, and which have been allocated to control or no treatment groups. Theore, the researchers carried out a separate analysis focussing on the high quality trials. In these six trials, the effect of exercise was weaker.

"When we looked only at those trials that we considered to be high quality, the effect of exercise on depression was small and not statistically significant," said Mead. "The evidence base would be strengthened by further large-scale, high quality studies."

My previous post, "Treat The Depression, Extend Life", discussed how treating depression could reduce the risk of dying in patients with diabetes. I was curious about what constituted "depression care management". What was the specific treatment?

The intervention which sought to decrease depressive symptoms was spelled out in the 2004 JAMA study below, also known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial):

Reducing Suicidal Ideation And Depressive Symptoms In Depressed Older Primary Care Patients

The treatment guidelines consisted of:

1. Formal screening using established depression scales.
   
2. ".. a first-line trial of a selective serotonin reuptake inhibitor (SSRI). The protocol specified citalopram because it is equally efficacious with other antidepressants, has limited drug interactions, low potential for central nervous system activation, and an insignificant withdrawal syndrome."
   
3. "When a patient declined medication therapy, the physician could recommend interpersonal psychotherapy."
   
4. "The depression care manager interacted with patients in person or by telephone at scheduled intervals, or when clinically necessary, to monitor depressive symptoms, medication adverse effects, and treatment adherence."

Citalopram is marketed under the brand name Celexa.

So, to achieve the benefits seen in both this study (which found that symptoms of depression and suicidal ideation could be decreased), and the previously posted study (which found that diabetes patients lives could be extended), an intervention involving formal depression screening in the primary care setting, deployment of medication and/or psychotherapy, and regular follow-up - both scheduled and as-needed - by trained clinicians would have to be implemented.

Its also important to note that:

"Research funds covered the cost of interpersonal psychotherapy and citalopram."

So, cost and insurance coverage are also considerations.________

Omega-3 fats are part of our nutritional heritage and are shown to play a crucial role in the prevention and treatment of debilitating conditions such as clinical depression throughout all phases of life and especially in the elderly. Neural cellular walls are largely constructed of Omega-3 fats, specifically the DHA long-chain component that determines how nutrients transport across cell membranes, electrical conductivity and the activity of critical neurotransmitters in cellular communications.

In the same way that a little wine may be good for the heart, it might also help avoid depression, a Spanish study suggests.

So while drinking a lot of wine or other alcohol may be a sign of depression or other mental health problems, alcohol in moderation may benefit mental health, the study authors contend.

"One drink a day, preferentially wine, may help prevent depression," said lead researcher Dr. Miguel Martinez-Gonzalez, chair of the department of preventive medicine and public health at the University of Navarra, in Pamplona.

But several mental health experts not involved with the study had reservations about the findings. And the research only found an association between moderate drinking and emotional well-being; it didnt prove cause-and-effect.

Martinez-Gonzalez said he thinks the apparent benefit of wine in preventing depression may work the same way that moderate drinking helps prevent heart disease.

"Depression and heart disease seem to share some common mechanisms because they share many similar protective factors and risk factors," he said. However, he added that depression prevention is not a reason to start drinking.

"If you are not a drinker, please dont start drinking," he said. "If you drink alcohol, please keep it in the range of one or less drinks a day and consider drinking wine instead of other alcoholic beverages."

The report was published Aug. 30 in the online journal BMC Medicine.

Tony Tang, an adjunct psychology professor at Northwestern University, in Evanston, Ill., said the new research "is consistent with other studies suggesting modest health benefits of very modest drinking."

But, Tang said other factors may be at work in the potential connection between wine and depression. He noted that compared to nondrinkers, those in the Spanish study who drank a moderate amount of wine were more likely to be married men who were also physically active.

Being single or divorced, living alone and being sedentary "are well-established risk factors of depression. Thus, perhaps the correlation between modest drinking and depression is a coincidence caused by these other known factors," he said.

"An adequate social life is the most important factor we know that protects people from depression," Tang said. "Perhaps not drinking is a sign of serious social isolation in Spain while drinking a glass of wine a day is simply a sign of having a normal social life."

For the study, researchers followed more than 5,500 light-to-moderate drinkers for up to seven years. All the participants were part of a large Spanish study on nutrition and cardiovascular health, and were between 55 and 80 years old.

None of the individuals had suffered from depression or had alcohol-related problems at the start of the study. Over seven years, with medical exams, interviews with dietitians and questionnaires, the researchers kept tabs on participants mental health and lifestyle.

Wine was the most popular drink and participants who drank two to seven glasses a week were the least likely to suffer from depression, compared to nondrinkers.

These findings remained significant even after the researchers took factors such as smoking, diet and marriage into account.

Eva Redei, a distinguished professor in the department of psychiatry and behavioral sciences at the Feinberg School of Medicine at Northwestern University, in Chicago, also expressed doubts about the direct effect of wine on depression.

"Considering the increase of major depression in the age group examined in this study, the finding of protective effects of moderate alcohol consumption is intriguing," she said.

However, it raises more questions than answers. "Is moderate wine consumption related to increased socialization, decreased cardiovascular events, or as it seems, increased activity? These questions are not answered by this study, but the findings are definitely worth noticing," Redei said.

"Is it possible that in vino veritas [in wine theres truth] reflects a bigger truth?" she asked.

A healthy diet may reduce the risk of severe depression, according to a prospective follow-up study of more than 2,000 men conducted at the University of Eastern Finland. In addition, weight loss in the context of a lifestyle intervention was associated with a reduction in depressive symptoms.

"The study reinforces the hypothesis that a healthy diet has potential not only in the warding off of depression, but also in its prevention," says Ms Anu Ruusunen, MSc, who presented the results in her doctoral thesis in the field of nutritional epidemiology.

Depressed individuals often have a poor quality of diet and decreased intake of nutrients. However, it has been unclear whether the diet and the intake of foods and nutrients are associated with the risk of depression in healthy individuals.

Those following a healthy diet are less at risk

A healthy diet characterized by vegetables, fruits, berries, whole-grains, poultry, fish and low-fat cheese was associated with a lower prevalence of depressive symptoms and a lower risk of depression during the follow-up period.

Increased intake of folate was also associated with a decreased risk of depression. Vegetables, fruits, berries, whole-grains, meat and liver are the most important dietary sources of folate. In addition, increased coffee consumption was non-linearly associated with a decreased risk of depression.

In addition, participation in a three-year lifestyle intervention study improved depression scores with no specific group effect. Furthermore, a reduction in the body weight was associated with a greater reduction in depressive symptoms.

Junk food, sugar and processed meats may increase depressive symptoms

Adherence to an unhealthy diet characterized by a high consumption of sausages, processed meats, sugar-containing desserts and snacks, sugary drinks, manufactured foods, French rolls and baked or processed potatoes was associated with an increased prevalence of elevated depressive symptoms.

Contrary to some earlier observations, vitamin B12 intake, serum concentrations of n-3 PUFAs, serum ratio of n-6 to n-3 PUFAs, tea drinking and total caffeine intake were not related to the risk of depression in this study.

The study was based on the population-based Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Study. The participants, over 2,000 middle-aged or older Finnish men were followed-up for an average of 13󈞀 years. Their diet was measured by food records and food frequency questionnaires, and information on cases of depression was obtained from the National Hospital Discharge Register. The effects of the three-year lifestyle intervention on depressive symptoms were investigated in the Finnish Diabetes Prevention Study (DPS) with 140 middle-aged men and women randomized to intervention and control groups.

Depression is one of the leading health challenges in the world and its effects on public health, economics and quality of life are enormous. Not only treatment of depression, but also prevention of depression needs new approaches. Diet and other lifestyle factors may be one possibility.

The original articles were published in Psychotherapy and Psychosomatics, European Journal of Nutrition, Public Health Nutrition and Diabetic Medicine. One submitted article was also presented.