It’s estimated that 1 out of every 10 Americans takes an antidepressant — a number that’s probably on the rise amidst a global pandemic.
For people with type 1 diabetes (T1D), depression and anxiety are remarkably more common than among the general public. But is it safe and effective to take antidepressant medications if you live with this condition?
We’ll take a closer look at when, why, and how taking an antidepressant as a person with T1D could be a safe and beneficial approach to improving your mental health.
While studies have found that people with T1D are much more likely to experience depression than our non-diabetic peers, it’s important to differentiate between depression, anxiety, and a newer name for mental health challenges in those with diabetes: diabetes distress.
“Diabetes distress describes feelings of being overwhelmed, a depressed mood, and other symptoms of depression that are directly related to the day-to-day management and stress of living with diabetes,” explains Mark Heyman, PhD, a certified diabetes care and education specialist, director of the Center for Diabetes and Mental Health in San Diego, and host of the new podcast, Diabetes Psychologist.
While symptoms are similar to depression, clinically known as “major depressive disorder” (MDD), it’s important to differentiate because the most effective treatment path could be different.
For anyone struggling with diabetes distress, an antidepressant may not be helpful at all if their beliefs, resources, and diabetes education aren’t also addressed.
MDD is characterized first by a “combination of genes and stress that can affect brain chemistry and reduce the ability to maintain mood stability,” Heyman explained.
General anxiety disorder (GAD) can also be the result of brain chemistry combined with genetics, and life experiences.
One of the easiest ways to determine if you’re struggling with “diabetes distress” versus MDD or GAD, says Dr. Heyman, is to ask yourself: “If I took diabetes out of my life, would my symptoms of depression go away?”
“If most of those symptoms do not improve or disappear, then you can conclude that you’re struggling with ‘major depressive disorder’ rather than ‘diabetes distress,’” he says.
If you find you’re stuck in a pattern of believing that diabetes has ruined your life, for instance, or that you won’t be able to achieve something because of diabetes, working through those beliefs is essential, Heyman says.
While we can’t remove diabetes from the equation, we can evolve how we think and feel about it, he says.
Supporting his patients through this process, Heyman helps them explore: “How do we help you change your beliefs and understanding of how these things are interacting in your life — and reduce the stress of diabetes and its impact on your life?”
Other aspects of diabetes distress could be the result of inadequate diabetes technology, diabetes education, support, anxiety after severe hypoglycemia (low blood sugar), or the wrong medications — which could easily leave anyone feeling frustrated with unpredictable roller coaster blood sugars. Exhausting, frustrating, and indeed, depressing.
Heyman points to a “Diabetes Distress Scale” created by Bill Polonsky, PhD, founder of the Behavioral Diabetes Institute also in San Diego, that looks at stress related to different aspects of living with diabetes, such as: the daily burden of managing it, its impact on your relationships, and interactions with healthcare providers.
“These are explainable externally, which means that the emotional challenges you’re dealing with are a response to that stressor,” Heyman says.
While many of the feelings may be the same as MDD, it’s still important to identify prior to considering taking an antidepressant.
“Yes, MDD can be exacerbated by external factors in the world but it also has a strong neurochemical cause. When you have external stressors, like diabetes, those can cause changes to your neurotransmitters, so that’s not to say that antidepressants wouldn’t benefit but that wouldn’t be my first line of treatment,” Heyman says.
“The bottom line is that the feelings are the same, whether it’s MDD or diabetes distress. But it’s very important for the provider (to differentiate) because it determines how they approach helping you.”
“It’s common for a person to think, ‘I don’t want to take a pill to solve my problems,’” says Heyman, “but the truth is that antidepressants don’t solve your problems.”
Instead, he explains the benefits of antidepressants are to simply improve your ability to solve your own problems.
“It’s as if you’re walking through tall weeds, it’s over your head and you have no idea where you’re going,” Heyman says. “You have no idea what’s forward or what’s back — you can’t see clearly. Taking an antidepressant is like having a step stool that helps you see over the top of the weeds.”
Combined with therapy or other coping skills, an antidepressant can make your efforts that much more effective.
“It doesn’t ‘solve’ anything but it makes you more capable of dealing with the challenges that are affecting you,” Heyman says. “In my work, I will recommend antidepressants sometimes, but not to everyone.”
Similar to the lengthy list of options in diabetes medications these days, the variety of antidepressants can be a bit overwhelming.
Healthline lists every antidepressant drug in one of the following categories:
- selective serotonin reuptake inhibitors (SSRIs)
- serotonin and norepinephrine reuptake inhibitors (SNRIs)
- tricyclic antidepressants (TCAs)
- tetracyclic antidepressant
- dopamine reuptake blocker
- 5-HT1A receptor antagonist
- 5-HT2 receptor antagonists
- 5-HT3 receptor antagonist
- monoamine oxidase inhibitors (MAOIs)
- noradrenergic antagonist
Most of today’s most common and well-known antidepressants prescribed for depression and anxiety are in the category of SSRIs. These include:
- sertraline (brand name Zoloft)
- fluoxetine (Prozac, Sarafem)
- citalopram (Celexa)
- escitalopram (Lexapro)
- paroxetine (Paxil, Pexeva, Brisdelle)
- fluvoxamine (Luvox)
SSRIs work by affecting the way your brain manages serotonin, a chemical nerve that is considered a natural mood stabilizer.
Healthline’s guide explains: “When your brain releases serotonin, some of it is used to communicate with other cells, and some of it goes back into the cell that released it. SSRIs decrease the amount of serotonin that goes back into the cell that released it, leaving more available in your brain to communicate with other cells.”
Low serotonin levels are often believed to be one of the most common contributing factors to depression. Even within SSRIs, however, it can take a few months or beyond a year to find the right choice for you.
“Finding the right antidepressants for someone isn’t an exact science,” Heyman says.
“There’s a lot on the market, one that worked well for your friend may not work well for you. It’s important to be in communication with your doctor regularly as you’re starting a new medication to determine things like if you’re feeling better, if you’re tolerating the side effects, and if the dosage needs to be changed,” he adds.
While it can be a bit of a guessing game, your doctor will likely determine a good starting point based on your symptoms.
“If you have a family member who took an antidepressant and didn’t do well on that specific medication, that’s a good place to start,” says Heyman. “That genetic makeup is predictive of if that medication is helpful for you.”
And of course, no antidepressants work instantly. Most can take anywhere from two to six weeks to begin affecting your mental health.
In addition to common side effects like drowsiness and constipation, there’s a particular side effect that anyone with diabetes taking insulin and other medications that lower blood sugar should be aware of: the first week of taking an
“There is some research to show that particular antidepressants increase the risk of hypoglycemia in people with type 1 diabetes, like Zoloft and Paxil,” says Heyman.
By how much you may need to reduce your insulin doses is going to be very personal — and is another reason why you should stay in close contact with your healthcare team during those first weeks of a new medication.
Checking your blood sugar frequently, especially in the hours after eating, is also crucial.
“Low blood sugar is often listed as a side effect, and it’s something I warn my patients about. But it doesn’t happen in everyone,” he says.
However, that increased risk of hypoglycemia usually dissipates after the first week, at which your healthcare team can help you determine the right time to increase your insulin doses back to their normal levels.
Other research conducted at Saint Louis University School of Medicine in 2016 found that long-term use of antidepressants in people with type 2 diabetes actually improved blood sugar levels. The researchers claim that “taking antidepressants is linked to 95% higher odds that… blood sugar will be well controlled.” But they also acknowledge that the marked improvement may have come from simply treating depression in participating patients.
If you do opt to take an antidepressant, here are a few important things to keep in mind:
- These drugs can cause constipation. Try adding a tablespoon of pure, ground psyllium husk to your daily diet to combat that.
- Remember to take the medication consistently! “If you’re taking it haphazardly or you can’t afford to get it regularly, it won’t be effective,” Heyman says.
- Be aware that quitting an antidepressant cold-turkey is considered dangerous. Instead, if you want to stop taking the medication, talk to your healthcare team about a schedule that allows you to decrease your dose gradually to avoid those harsh cold-turkey side effects.
In summary, antidepressants may not solve your problems or make the burdens of living with T1D go away, but they may help give you more of the stamina and persistence needed to create your own solutions that help you face the disease another day with more confidence and success.