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[IP] Another study by Dr. Lustman concerning diabets, depression and drugs to treat

Treating Depression in Diabetics
Helps Control Blood Sugar

by Jim Dryden 
Washington University
School of Medicine in St. Louis
Jim Dryden

For patients with diabetes, the goal is tight control. The Diabetes Control 
and Complications Trial, the landmark diabetes study completed four years ago, 
concluded unequivocally that keeping a close reign on blood sugar can prevent 
or delay the kidney, eye and nerve complications that affect patients with 
diabetes. But for some with the disease, that goal is nearly impossible. 
Diabetics with depression have a very difficult time managing their blood 
sugar levels.

Now, investigators at Washington University School of Medicine in St. Louis 
have found that treating clinical depression can help diabetic patients better 
control their blood sugar levels. Reporting in the May 22, 1997, issue of 
Psychosomatic Medicine, the researchers say the anti-depressant drug 
nortriptyline helps patients control their blood glucose, even though the drug 
itself tends to raise blood glucose levels. In depressed diabetics, treating 
depression more than made up for those increases in blood sugar. 
"The drug had two opposing effects," explains Patrick J. Lustman, Ph.D., 
principal investigator and associate professor of psychiatry. "It improved 
depression significantly, but it worsened glucose control in patients who were 
not depressed. Yet, even in the face of this opposing effect, we found that as 
depression improved, glucose control did too."

While depression affects about 5 percent of the general population at a given 
time, the rate is between 15 and 20 percent in patients with diabetes. 
Lustman and colleagues studied 68 patients with diabetes. All had poor glucose 
control. Twenty-eight of them also were clinically depressed.

Study participants were divided into four groups. Half of the patients with 
depression received the drug nortriptyline, a tricyclic anti-depressant. The 
rest received an inactive substance. Patients who were not depressed also were 
divided into nortriptyline and placebo groups. Then the patients were followed 
for eight weeks. 
This was the first placebo-controlled study to establish that it is possible 
to treat depression in diabetic patients. "The drug therapy helped bring 
almost 60 percent of the depressed patients into remission," Lustman says. The 
study was supported by a grant from the National Institute of Diabetes and 
Digestive and Kidney Diseases of the National Institutes of Health, and in 
part by the Sandoz Corp., which provided the nortriptyline.

Better Compliance
Depression has a negative influence on quality of life for anyone, but it can 
cause additional problems for patients with diabetes because it is closely 
associated with poor glucose control. Depression also is linked to poor 
compliance with diabetes treatment.

"There are several theories about why depression has such a negative effect on 
patients with diabetes," Lustman says. "Depressed patients may not comply with 
their treatment regimens, or perhaps depression may cause changes in 
neuroendocrine function, making blood sugar especially difficult to control." 
Because depression makes it hard for a person to get anything done, it makes 
sense that the disorder might interfere with measuring blood glucose levels 
and exercising, watching one's diet or taking insulin. Therefore, treating 
depression could enable a diabetic patient to better manage diabetes. But 
Lustman says the study showed that better compliance alone did not explain the 
better blood sugar control.

The researchers used electronic monitoring devices to determine whether the 
subjects took their medication. And they used memory glucometers to 
automatically record the dates and times that patients tested their blood 
glucose levels. They found that all of the participants followed their 
prescribed treatment regimens with little fluctuation during the eight weeks 
of the study.

Meaningful Improvement
In patients who were depressed and who were given nortriptyline, blood glucose 
levels improved along with psychiatric health. "Each one-point drop in the 
index that we use to measure depression correlated with a small reduction in 
blood sugar levels," Lustman says.

He says the new study demonstrates that improvement in depression can 
translate into a clinically meaningful improvement in glucose control. 
"Though the point-by-point change is small, the benefits could be substantial 
because many depressed patients drop more than 20 points in their depression 
index with effective treatment," he explains.

Because the drug was administered to diabetic patients who were not depressed, 
it was possible to measure the direct effects of nortriptyline on glucose 
regulation. "We found that taking nortriptyline increased glucose levels in 
patients who took the drug but were not depressed," Lustman explains. 
Other anti-depressants or non-drug interventions such as cognitive 
psychotherapy that do not have this opposing effect on glucose control may be 
more effective in diabetes management. Currently, Lustman is studying other 
treatment methods to see whether he can improve on his recent results.

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