Treatment of Depression in Patients With Diabetes Mellitus

BACKGROUND: Depression occurs frequently in patients with diabetes mellitus. Little has been published on the epidemiology, biochemistry, and treatment of depression in diabetic patients. METHOD: We searched MEDLINE for literature from January 1966 to July 1993 and cross-referenced the terms diabetes, glucose, hyperglycemia, or hypoglycemia, with each of the following: antidepressants, monoamine oxidase inhibitors, tricyclic antidepressants, fluoxetine, paroxetine, sertraline, and bupropion. The results reviewed were 20 papers on epidemiology, 15 papers on neurochemicals and glucose control, and 28 papers on antidepressants and factors of importance to diabetics. Additional papers were selected from the reference lists of the retrieved articles. RESULTS: The prevalence of depression in diabetics varies from 8.5% to 27.3%. Severity of depression correlates strongly with many symptoms of diabetes mellitus. The hydrazine monoamine oxidase inhibitors (MAOIs), e.g., phenelzine, potentiate animal models of hypoglycemia due to direct influence on gluconeogenesis secondary to the hydrazine structure, not to MAOI considerations. Dopamine and norepinephrine influences in these models appear to be hyperglycemic. Serotonergic influences, in the presence of MAOIs, which decrease serotonin metabolism, are in contrast hypoglycemic. Clinically, MAOI use is limited by the possible severity of the induced hypoglycemia, induced weight gain, and required diets. The tricyclic antidepressants may lead to hyperglycemia, to an increase in carbohydrate craving (from 86% to 200%), and impaired memory. Serotonin selective reuptake inhibitors (SSRIs) may be hypoglycemic (causing as much as a 30% decrease in fasting plasma glucose) and anorectic (causing an approximately 2-lb decrease), while possibly improving alertness. CONCLUSION: Depression is frequent among diabetic patients and impairs diabetic management. To maximize response of both depression and diabetic disorder, one should consider the SSRIs in preference over the TCAs.