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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
School of Medicine in St. Louis
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
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.
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.
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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