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Journal of the association of physicians of india • december 2013 • VOL. 61
Original Article
Depression and Diabetes : Impact of AntiDepressant Medications on Glycaemic Control
HS Dhavale*, Vijay Panikkar**, Bindoo S Jadhav***, Mangesh Ghulghule****,
Adita Dagaria ****
Abtract
Introduction : One of the consistent findings among various studies on diabetes has been the prevalence
of depression with or without comorbid anxiety among patients of Diabetes Mellitus. Also, numerous
other studies have pointed to the negative bearing of the same on blood sugar levels among patients.
However there is a lack of data on the outcome of treatment with anti-depressants on the blood glucose
level. Considering the ever increasing population of diabetics in our country and the significant causal
relationship established by current literature, this study was undertaken.
Aims and Objectives : To study prevalence of depression and anxiety in patients of Type 2 Diabetes
Mellitus with an increase in blood glucose levels.
To study the socio-demographic profile and role of stressors in patients of Type 2 Diabetes Mellitus.
To study the effects of management of depression and anxiety on blood glucose levels in patients of
Type 2 Diabetes Mellitus.
Material and Methods : Sample Size : 100
Consecutive 100 patients diagnosed with Type 2 Diabetes Mellitus(DM) fulfilling the inclusion and
exclusion criteria were included in the study. Ethics committee approval was taken for the study. The sociodemographic details of the patients were collected using a specially designed semi-structured proforma.
Patients were evaluated for psychiatric disorders using DSM IV TR criteria for diagnosis and Montgomery
Asberg Depression Rating Scale (MADRS) and Hamilton Anxiety Rating Scale(HAM-A) were used thereafter
to assess the severity of depression and anxiety, respectively. Patients detected with depression and / or
anxiety were started on T. Escitalopram (10 mg); keeping the management of DM unchanged. Patients
were reviewed after 6 weeks from date of initial assessment and blood glucose levels were repeated. Data
thus collected was analysed using SPSS Software.
Results : The prevalence of depression with/without anxiety in the study was 39%. Among depressed
patients stressors were found in 84% of patients with social and interpersonal stressors as the more
prevalent types. The socio-economic profile showed a female preponderance, lower to middle socioeconomic and educational status and majority were married. 47% of the patients started on T. Escitalopram
showed lower fasting and post-lunch blood sugar values on follow up, which was clinically and statistically
significant.
*
Professor and Head, Dept. of
Psychiatry, **Professor, Dept. of
Medicine, ***Associate Professor,
Dept. of Psychiatry, ****Resident,
Dept. of Psychiatry, K.J. Somaiya
Medical College and Research
Centre, Everard Nagar, Sion,
Mumbai-400 022
Received: 23.08.2011;
Accepted: 12.06.2013
896 
Introduction
D
iabetes Mellitus (DM) is one of the most common chronic medical diseases
worldwide with an estimated prevalence of detected DM being 3 to 4% in the
general population. 1 One of the consistent findings among various studies on diabetes
has been the high prevalence of depression with or without comorbid anxiety among
patients of DM. 2-5 Major depression is associated with increased medical utilisation
and costs, higher symptom burden, increased functional impairment including poor
© JAPI • december 2013 • VOL. 61
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Journal of the association of physicians of india • december 2013 • VOL. 61 31-45
7
9
46-60
27
34
> 60
Sex :
Male
5
18
15
34
Female
Education
Illiterate
24
27
3
2
Primary
2
7
Secondary
17
18
Graduate
12
28
Post-graduate
Occupation
Self-Employed
5
6
16
18
Service
5
13
Housewife
16
20
Retired / Others
Marital Status
Single
2
10
--
1
Married
37
57
Widow/ Widower
Annual Gross Income (lac)
< 1.5
2
2
21
21
1.5-5
8
28
>5
10
12
self care, non compliance to treatment and other
decrements in quality of life, and increased rates of
mortality. 6,18 Identification and effective treatment of
comorbid depression is thus an essential component
of high quality clinical care of patients with chronic
medical illness like DM in the specialty medical
setting.
Patients with depression have been shown to
exhibit insulin resistance and decreased glucose
tolerance, and conversely increases in serotonergic
function results in increased sensitivity to insulin and
reduces plasma glucose levels. 7-9 Recent studies have
shown that short-term administration of Tricyclic
antidepressants (TCA) such as nortryptiline and
imipramine may lead to reduced fasting blood glucose,
while longer use increases baseline values due to their
catecholamine profile. Thus they successfully treat
depression but also lead to deterioration in glucose
control. The other class of antidepressants studied in
© JAPI • december 2013 • VOL. 61
nt
na
io
at
up
cc
A
bs
e
l
l
ia
17.9
O
Fi
na
nc
l
na
rs
o
te
--
In
--
rp
e
ca
Patients Without
Depression
Ph
y
si
Age (Years) :
18-30
Patients with
Depression
12.8
7.7
5.1
l
Table 2 : Socio-Demographic Profile
20.5
al
21
18
61
ci
Depression with Anxiety
Depression without Anxiety
Absent
35.9
40
35
30
25
20
15
10
5
0
So
Table 1 : Prevalence of depression with / without anxiety.
Sample size – 100
Fig. 1 : Prevalence of Type of Stressors among depressed
patients (%)
this context is Selective Serotonin Re-uptake Inhibitors
(SSRI), such as fluoxetine, sertraline and escitalopram.
They have been shown to improve both dietary
compliance and HbA1c levels in addition to reduction
in severity of depression and anxiety.
The role of stress as one of the most common
aetiological factors for both depression and diabetes
has been well established. 10-14 Stress may lead to
deterioration of glycaemic control via its effects on
the neuroendocrine system wherein the psychological
reaction to stressors leads to the activation of the
hypothalamo-pituitary-adrenal (HPA) axis, leading in
turn to various endocrine abnormalities, such as high
cortisol and low sex steroid levels, that antagonise the
actions of insulin, or it may impact more indirectly
via changes in health behaviours, such as regimen
adherence, smoking, or drinking practices. At the
same time, an increase in visceral adiposity (increased
girth) is seen, which plays an important role in
diabetes by contributing to insulin resistance.
Considering the ever increasing population of
diabetics in our country and the significant causal
relationship of depression and glycaemic control
established by current literature, this study was
undertaken.
Aims and Objectives
1. To study prevalence of depression and anxiety
in patients of Type 2 Diabetes Mellitus with an
increase in blood glucose levels.
2. To study the socio-demographic profile and
role of stressors in patients of Type 2 Diabetes
Mellitus.
3. To study the effects of anti- depressant medication
on blood glucose levels in patients of Type 2
Diabetes Mellitus.
Inclusion Criteria
1. Patients more than 18 years of age.
2. Patients diagnosed with Type 2 Diabetes Mellitus,
compliant on treatment and on regular follow up
with diabetologist.
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Journal of the association of physicians of india • december 2013 • VOL. 61
Table 3 : Mean fasting blood sugar (FBS) and post-lunch blood
sugar (PLBS) levels
FBS
PLBS
*
Baseline
179.44
251.39
Follow Up
153.42
197.47
T value
2.27
3.08
P value
0.029*
0.004*
p < 0.05
3. Patients with spikes or increase in the blood
glucose levels from previously maintained
baseline within last three months
Exclusion Criteria
1. Patients having history of prior psychiatric
illness and / or prior treatment with psychiatric
medicines.
2. Patients with a current diagnosis on Axis 1 of DSM
IV-TR other than depression and anxiety.
3. Patients with Type 1 Diabetes Mellitus.
Material and Methods
Sample Size : 100
Consecutive 100 patients diagnosed with Type
2 Diabetes Mellitus (DM) fulfilling the inclusion
and exclusion criteria were included in the study.
Ethics committee approval was taken for the study.
The socio-demographic details of the patients were
collected using a specially designed semi-structured
proforma.
Patients were evaluated for psychiatric disorders
using DSM IV TR criteria for diagnosis and Montgomery
Asberg Depression Rating Scale (MADRS) and
H a m i l t o n A n x i e t y R a t i n g S c a l e ( H A M - A) we r e
used thereafter to assess the severity of depression
and anxiety, respectively. Patients detected with
depression and / or anxiety were started on T.
Escitalopram (10 mg); keeping the management of
DM unchanged. Patients were reviewed after 6 weeks
from date of initial assessment and blood glucose
levels were repeated. Data thus collected was analysed
using SPSS software.
Results and Discussion
A total of 100 patients diagnosed with Type 2
Diabetes Mellitus were studied and as seen in Table
1, the prevalence of depression with / without anxiety
among them was 39%. A large meta-analytic study by
Anderson et al 2 reported prevalence rate of comorbid
depression with diabetes between 18 – 30 % across
different clinical settings, which were lower than the
findings in our study. Current estimates of lifetime
prevalence of depression in general population across
cultures range from 4-19%. 3-5
Table 2 shows the comparison of socio-demographic
898 
profiles of patients with / without depression. Among
depressed patients - 27(69%) were in the age group
46-60. There was a female preponderance with 24
(61%) patients being female. Majority among these
patients- 37 (94%) were married. Almost half the
patients – 17(44%) had secondary education, whereas
12 (30%) were graduates. 16 patients (40%) were
housewives and 21(54%) reported annual gross
incomes lower than 1.5 lac per annum. This data is in
line with most major epidemiological studies which
report higher prevalence rates for depression among
females and older age groups. 3-5
The prevalence of stressors among depressed
patients was 84% (33) and as seen in Figure 1, among
stressors, the highest prevalence was reported for
interpersonal stress (35.9%) and the least reported
single major stressor was physical stress (5.1%).
36 patients with depression with / without anxiety
were started on T. Escitalopram (10 mg) and in 17
(47%) patients, reduction in mean glucose levels
was seen as compared to their baseline values. 16
(44.44%) patients reported no significant change in
blood sugar levels whereas an increase was seen in 3
(8.33%) patients.
As seen in Table 3, there was reduction of mean
fasting blood sugar (FBS) levels from baseline value of
179.44 mg/dl to follow-up value of 153.42 mg/dl. This
difference was found to be statistically significant [t =
2.27, p = 0.029]. Also, the results show the mean follow
up post lunch blood sugar (PLBS) levels(197.47 mg/dl)
were lower than the mean baseline values (251.39 mg/
dl) and this difference was also found to be statistically
significant [t = 3.08, p = 0.004]. A study by Lustman
et al in 1997 16 had reported a positive correlation
of treatment-type independent improvement in
depression with glycaemic control. The same study
had also reported long term use of Nortryptiline
to be associated with hyperglycaemia among these
patients. Lin et al in 2006 17 also reported negative or
no benefit with Nortryptiline. A study by Klouse et
al in 2006 19 had reported significant improvement in
glycaemic control with use of Sertraline. The study
further demonstrated superior efficacy of Selective
Serotonin Re-uptake Inhibitors (SSRIs) such as
fluoxetine, sertraline and escitalopram, as a class of
anti-depressant medicine over tricyclics, as reported
by other studies as well. 15,23 Few specific features of
escitalopram make it a promising medication for
use in diabetes. These include i) a benign side effect
profile, even among SSRIs; ii) high tolerance in
elderly patients; iii) rapid action with efficacy often
demonstrated in as little as 1-2 weeks, which in turn
could help improve compliance and iv) its efficacy for
treatment of anxiety, which co-occurs frequently with
depression as well as diabetes. 22 Hence it was chosen
as the antidepressant medication for this study.
© JAPI • december 2013 • VOL. 61
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Journal of the association of physicians of india • december 2013 • VOL. 61 Conclusions
1. Prevalence of depression among patients of Type
2 Diabetes Mellitus was 39%.
2. The patients’ socio-demographic profile indicated
a female preponderance, majority being married
and belonging to middle to lower educational and
income levels.
3. Stressors were present in a significant majority of
affected patients(84%).
4. 47% of the patients started on the anti-depressant
escitalopram showed a reduction in the blood
sugar levels from their baseline values, which was
clinically and statistically significant.
Implications
The study underscores the need for screening
and treatment of depression and anxiety in patients
of diabetes. Positive response to anti-depressant
therapy indicated a favourable overall outcome in
the management of a chronic illness such as diabetes
and raises the chances of holistic therapy for similar
ailments.
The high prevalence of stressors has important
implications for lifestyle changes, coping strategies
and long-term management for reduction in stress
levels.
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