Depression and suicide in patients with diabetes

Diabetes is associated with psychiatric disorders including depression and suicidal behavior.¹- ³ The relationship between depression and diabetes has been recognized many years ago.³ A recent meta-analysis of 44 studies suggests that the prevalence of depression was significantly greater in individuals with type 1 or type 2 diabetes in comparison to people without diabetes.²

Studies indicate a bidirectional relationship between diabetes and depression: individuals with diabetes are more likely to have comorbid depression and patients with depression are at increased risk to have comorbid diabetes.¹ Probably, diabetes and depression share some underlying biological mechanisms, such as hypothalamic-pituitary-adrenal axis abnormalities and inflammation.⁴

Comorbidity of diabetes with depression is associated with a reduced quality of life, insufficient self-care, a sedentary lifestyle, and significant medical issues including poor glycemic control, poor adherence to treatment of diabetes, greater rates of cardiovascular events and cardiac mortality.²,⁴ It has been observed that acute hyperglycemia leads to changes in mood, including heightened irritability and feelings of reduced wellbeing.⁵

Considerable evidence suggests that diabetes is associated with suicide ideation, attempts, and deaths.¹ Studies indicate that diabetes increases the risk of suicide death 1.6-3.6 times in comparison to the general population.¹,⁶ For example, an epidemiological study in Sweden showed that patients with diabetes were 3.4 times more likely to die by suicide in comparison to the general population.⁶ Some observations suggest that suicide is more frequent among individuals with type 1 diabetes in comparison to patients with type 2 diabetes.⁷

It should be noted that many individuals with diabetes have access to insulin, tricyclic antidepressants, opioids, or other drugs that are deadly at high doses. Lethal insulin overdoses are frequently suicides.⁶

It has been observed that psychological adjustment to diabetes and metabolic control in patients with type 2 diabetes are influenced by affective temperaments.⁸ Affective temperaments may also contribute to the pathophysiology of suicidality in patients with diabetes.⁹

Mental health, primary care, and internal medicine clinicians should screen individuals with diabetes, especially patients with poorly controlled diabetes, for depression and suicidal ideation. Individuals with depression and/or suicidal ideation who do not receive psychiatric treatment need to be referred to mental health clinicians. Acutely suicidal patients need to be referred to emergency psychiatric services.

It is necessary to educate primary care and internal medicine physicians on how to assess patients for depression and suicidality. The knowledge and skills needed to make such assessments should be taught in medical schools and postgraduate medical education programs. It should be noted that even well-trained medical professionals sometimes have difficulties assessing patients for suicidality.

Patients with diabetes are a psychologically vulnerable population. Depression and suicidal behavior in individuals with diabetes are an underappreciated and understudied issue that needs more attention from clinicians, researchers, and public health leaders. The effect of anti-hyperglycemic medications on mood and behavior needs to be comprehensively investigated. It is to be hoped that this note as well as other publications related to psychological issues and suicide in diabetes will help individuals with diabetes to receive more and better care.

References

• ¹
  Sher L. Suicide in diabetes: an important but underappreciated problem. Mol Psychiatry. 2022 Apr 22. Epub ahead of print.
• ²
  Farooqi A, Gillies C, Sathanapally H, Abner S, Seidu S, Davies MJ, et al. A systematic review and meta-analysis to compare the prevalence of depression between people with and without type 1 and type 2 diabetes. Prim Care Diabetes. 2022;16:1-10.
• ³
  Rihmer Z, Arató M. Depression and diabetes mellitus. A study of the relationship between serum cortisol and blood sugar levels in patients with endogenous depression. Neuropsychobiology. 1982;8:315-8.
• ⁴
  Holt RI, Groot M, Golden SH. Diabetes and depression. Curr Diab Rep. 2014;14:491.
• ⁵
  Sommerfield AJ,Deary IJ,Frier BM. Acute hyperglycemia alters mood state and impairs cognitive performance in people with type 2 diabetes. Diabetes Care.2004;27:2335-40.
• ⁶
  Webb RT, Lichtenstein P, Dahlin M, Kapur N, Ludvigsson JF, Runeson B. Unnatural deaths in a national cohort of people diagnosed with diabetes. Diabetes Care. 2014;37:2276-83.
• ⁷
  Wang B, An X, Shi X, Zhang JA. Management of endocrine disease: suicide risk in patients with diabetes: a systematic review and meta-analysis. Eur J Endocrinol. 2017;177:R169-81.
• ⁸
  Gois C, Barbosa A, Ferro A, Santos AL, Sousa F, Akiskal H, et al. The role of affective temperaments in metabolic control in patients with type 2 diabetes. J Affect Disord. 2011;134:52-8.
• ⁹
  Baldessarini RJ, Innamorati M, Erbuto D, Serafini G, Fiorillo A, Amore M, et al. Differential associations of affective temperaments and diagnosis of major affective disorders with suicidal behavior. J Affect Disord. 2017;210:19-21.

Publication Dates

• Publication in this collection
  29 Aug 2022
• Date of issue
  Jan-Feb 2023