What's Depression Got to Do with It?

Depression and Diabetes: Is There a Link?

Evidence suggests that an association between depression and diabetes exists, ^1-4 but it is not clear which comes first or why they are often linked. What is clear is that both depression and diabetes can be effectively managed and treated.^5,6

Anyone can develop depression, but people with diabetes may be at greater risk.^7,8 Depression might result from the daily burden of having diabetes.¹ Recent research has reported that depression is twice as common in people who have diabetes than it is in people who do not have this disease.² In addition, the chances of becoming depressed increases as diabetes complications worsen.⁹

Additional information from research on depression and diabetes suggests that depression alone may also increase the likelihood of a person developing type 2 diabetes.^10,11 In fact, research shows that depressed adults have a 37% increased risk of developing type 2 diabetes.¹²

Clinical depression is one of the most costly illnesses in the world. It is also a leading cause of disability in the United States and worldwide.¹¹ Approximately 70% of people who have depression are employed; depression results in 400 million lost work days a year.^13,14 It is estimated that the annual salary-equivalent cost of major depression due to work loss in the U.S. labor force is between $42 billion and $46 billion per year, with over 75% being attributed to indirect costs, such as lost productivity.^15-17

Although depression can occur at any age, it tends to affect people in their prime working years, 25-44 years of age, and, if untreated, can last a lifetime.¹⁸

Employers should know that there are several treatment options available to assist employees who are experiencing depression in the workplace. Research has shown that 80% of those who seek treatment show improvement.¹⁹ Depression does not have to be a debilitating disease.

What are the Symptoms of Depression?

Depression is a medical condition that should be diagnosed and treated by a trained healthcare professional, such as a primary care provider, psychiatrist, psychologist, or a social worker. Occupational health nurses, wellness coordinators, employers, supervisors and co-workers can be the first to recognize signs of depression in a fellow employee.

Depression is more than occasionally feeling sad, stressed, or irritable. People with depression tend to have some of the following symptoms most of the day for at least two weeks:^20,21

• Frequent feelings of sadness that last most of the day
• Decreased interest in most things that were once enjoyed
• Loss of self-esteem or feelings of guilt and worthlessness
• Sleep problems, such as sleeping too much or having trouble sleeping
• Difficulty concentrating or making decisions
• Unintentional changes in weight (weight loss or gain)
• Irritability or restlessness
• Decreased energy
• Possible thoughts of death or suicide

Who Gets Depression?

While anyone can develop depression—there are some differences based on gender.

• Women are twice as likely to become depressed as men.^22-24 About 10-25% of all women will be depressed during their lives.²³
• Men have a lower risk for depression than women, but when they are depressed they are more likely to go undiagnosed and less likely to seek help. Men may experience the typical symptoms of depression, but they may also feel more angry and irritable.²³  They may also be more likely to try and relieve their condition with alcohol or drug abuse. Depression increases the risk for suicide and men who have suicidal thoughts are more likely to die of suicide than women with suicidal thoughts. However, suicidal thoughts in all individuals should be taken very seriously and the person who has those thoughts should be evaluated by a mental health professional.^23-25

Why is Depression in Diabetes Serious?

Depression in diabetes is very concerning for several reasons:

• Individuals who are depressed may have more difficulty following the medical treatment that their health care team establishes challenging. For example, depressed persons might not take their medication as prescribed or monitor their glucose levels as health care professionals recommend.^26,27
• Depression can result in poor physical and mental functioning, so a person is less likely to maintain regular physical activity.²⁸
• Individuals who are depressed might adopt unhealthy behaviors, such as a sedentary lifestyle and/or a poor diet.²⁹
• Social isolation is also common for people who are depressed, which decreases opportunities for social support that is often needed for self-management of diabetes.^30,31
• Untreated depression in diabetes can result in
  • Hyperglycemia (high blood glucose)
  • Poor metabolic control
  • Decreased quality of life
  • Increased health care usage and costs
  • Increased risk of mortality^{26,29, 32-34}

Untreated depression places people with diabetes at risk for complications that could be avoided.^26,32,35 These complications include—

• Heart disease
• Blindness
• Amputations
• Erectile Dysfunction
• Stroke
• Kidney disease

Why Should Employers Be Concerned?

Depression in people who also have diabetes is associated with increased health care costs. Total health care expenditures for individuals with depression was 4.5 times higher than for individuals without depression.³⁶

Like diabetes, depression is serious, common and costly, but also potentially preventable and definitely treatable. Yet many people who have both diabetes and depression do not seek treatment for their depressive symptoms.³⁷ Although depression affects more than 19 million Americans every year, fewer than half seek treatment.³⁸

Depression is often unrecognized and undertreated in health care settings.³⁹ Researchers have found that only 30% of patients with depression and diabetes receive adequate treatment for depression and fewer than 20% complete more than four visits for psychotherapy.³²

There are many reasons why employees may be reluctant to seek out help for depression⁴⁰:

• Cost. Some people may avoid seeking medical attention for chronic conditions, such as depression and diabetes, because of the additional cost and burden that it may place on the individual or family budget. There could also be concern about the cost associated with lost time from work.
• Stigma. Many people feel there is a stigma associated with depression. Employees might also be concerned with how employers and colleagues will respond if the employee discloses that he or she is depressed.
• Shame. Some employees may be embarrassed or self-conscious about needing to ask for help, or may view depression as a “weakness” or as being their fault.
• Being uninformed.
  • Some employees may not be aware of available treatment options. Some who have begun treatment might not have been aware that medications take time to yield the desired levels for benefit. Such persons sometimes discontinue medications before the medications had time to work.
  • Some employees may be unaware of health benefits that their employer provides and what their insurance may cover.
  • In addition, some individuals may be unaware that they are depressed or they may believe that they can take care of themselves on their own.
• Cultural differences. Research regarding ethnic minorities’ attitudes toward seeking professional mental health care has yielded inconsistent results. For example, in one study, mistrust and opinions about mental illness was found to negatively impact help-seeking behavior among African Americans.⁴¹ Other studies have found more positive attitudes towards mental health treatment and medication options for African Americans and Hispanics.⁴²

How Does Depression Impact Job Functioning?

Depression can interfere with job functioning in several ways. For example, depression can affect a person’s ability to perform tasks, to think clearly, or to communicate with others.⁴³

People who suffer from depression sometimes have difficulty—

• Sustaining concentration
• Maintaining stamina
• Handling pressures, deadlines, and multiple tasks
• Interacting with others
• Responding to negative feedback
• Responding to change

Untreated depression can manifest itself in the following ways at the work site:

• Consistent late arrivals or frequent absences
• Irritability
• Substance use or abuse
• Low morale
• Increased lack of cooperation or an inability to work with others
• Decreased productivity
• Problems concentrating
• Safety problems as a result of problems with attention
• Poor work or missed deadlines
• Decreased interest in one’s work
• Frequent complaints of body aches or fatigue

Employers, supervisors, and co-workers can be the first to recognize significant changes in an employee’s work habits, behaviors, performance, and attendance. However, employers must also be aware that individuals with psychiatric or physical disabilities have rights, which are covered under the Americans with Disabilities Act.

What Legal Rights do Employees have When They have a Physical or Psychiatric Disability?

The Americans with Disabilities Act:

• prohibits employment discrimination against individuals with disabilities in the private sector, and in state and local governments, ⁴⁴ and it
• prohibits discrimination in all employment practices, including:
  • job application procedures,
  • hiring,
  • firing,
  • advancement,
  • compensation,
  • training, and
  • other terms, conditions, and privileges of employment.⁴⁴

The Americans with Disabilities Act covers qualified individuals with physical and psychiatric disabilities, such as mental disorders.⁴⁵ Diabetes or depression would be considered a disability under the Americans with Disabilities Act if the disease substantially limits one or more of a person’s major life activities, such as eating or caring for oneself.^39,40 Diabetes would also be considered a disability when it causes side effects or complications that substantially limit a major life activity.⁴⁶

The Americans with Disabilities Act prohibits employers from asking employees and job applicants whether they have a psychiatric or physical disability.⁴⁵ Disclosure about one’s mental or physical condition is a personal decision and an employee should not be coerced into informing an employer or colleagues about their health. However, if the employer has concrete reasons to believe that a physical or psychiatric condition may be affecting an employee’s ability to perform their job, the employer may ask questions or have the employee obtain a medical examination.⁴⁶

If an employee discloses that he or she has a physical or psychiatric disability, the employer may only ask whether there is a need for a reasonable accommodation and type of accommodation needed.⁴⁶

For more information about disability and diabetes in the workplace please visit: www.eeoc.gov/laws/types/diabetes.cfm.

What Accommodations Must an Employer Make for an Employee with a Disability?

Individuals with disabilities can perform all types of jobs in a variety of settings. However, employers may exclude such persons from certain positions because of stereotypes and fears about what types of work such individuals can perform. Employees with diabetes and/or depression may require a change in their workplace setting to allow them to better manage their condition.⁴⁶

Under the Americans with Disabilities Act, employers must make reasonable accommodations to individuals with a known disability.³⁷ Examples of reasonable accommodations might include:^42,46

• Time-off for scheduled medical appointments
• Regular work schedules
• Meal breaks
• A place to test blood sugar levels
• Clear delineation of performance expectations
• Schedules which allow for flex-time
• Extending additional leave to allow an employee to keep his or her job after a hospitalization.

Think back to the case study of Cindy S, repeated here.

Points to consider:

What legal protection does Cindy S. have under the Americans with Disabilities Act?

• In order for Cindy to have any legal protection under the Americans with Disabilities Act, the diabetes or the depression must substantially limit Cindy’s major life activities. More information is needed to determine whether her condition(s) limit her major life activities, such as thinking, eating, or caring for herself.

What accommodations must the employer make to assist Cindy S. in returning to the work site?

• If it has been determined that diabetes or depression substantially limits Cindy’s major life activities, then her employer must make reasonable accommodations. These adjustments could include:
  • Time-off for scheduled medical appointments
  • A place to test blood sugar levels
  • Schedules which allow for flex-time

How can the employer assist Cindy S. if she discloses that she has depression?

• The employer should handle this situation with confidentiality.
• Employers should not attempt to treat a person with diabetes, but instead provide the employee with the assistance needed to receive the appropriate care.
• If an employee assistance program exists, the employer should assist the employee with seeking such services.

How Can an Employer Help an Employee who is Depressed?

If an employee is struggling with depression, the employer can be a valuable resource.

In reaching out to an employee who has disclosed that he or she is suffering from depression, employers should remember to handle this situation with confidentiality.

Employers should avoid trying to diagnose or treat a person with depression. Instead, the primary objective of the employer should be to assist the employee with receiving the appropriate, professional help needed, such as through an employee assistance program, which may be available at the work site.

In providing assistance to an employee with depression, employers should—

• Be empathetic and understanding
• Avoid critical or shaming statements
• Emphasize that depression is treatable
• Provide information to employees about symptoms of depression and treatment options.⁴⁷

Employers can also raise awareness about depression by—

• Educating management and employees about depression and effective treatment options
• Informing employees of the availability of an employee assistance program
• Provide an easily accessible behavioral health system
• Including depression recognition screenings and stress management at health fairs
• Developing a return-to-work plan for employees who have been absent from work due to depression

To learn more about depression resources that are available, please visit the “Resources” section of this Web page.

Can Depression be Treated?

There is good news! Depression, with or without diabetes, can be treated. It is important to diagnose depression early and accurately to reduce the risk of developing diabetes and/or diabetes complications. Treating depression has also been found to improve diabetes control.^42,43 In addition, appropriate treatment and monitoring of depression can increase workplace productivity, lower absenteeism, and decrease disability costs.⁴⁸

There are currently a variety of highly effective interventions available for treating depression. The majority of depressive disorders can be treated with either psychotherapy (talk therapy), antidepressants, or both treatments together. A combination of psychotherapy and medication has been identified as being most effective.¹⁸ Psychotherapy allows people the opportunity to learn skills to reduce their depression or to address underlying issues associated with the depression.

In treating diabetes and depression, it is important for the health care team (e.g., the family doctor, endocrinologist, diabetes health care team, psychiatrist, social worker, or clinical psychologist) to all work closely together. Occupational health nurses or other work site medical professionals also play an important role in this health care team. Work site medical professionals may have suggestions for employers on how to deal with depression in the workplace. In addition, such health professionals may also be able to provide employees with referrals for mental health professionals who practice in specific communities near the work site or that are convenient for the employee.

Where Can Employers Find More Information about Diabetes at Work?

The National Diabetes Education Program (NDEP), which is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, provides information for employers on its Web site: www.cdc.gov/diabetes/diabetestatwork.com.

Diabetes at Work can help businesses and managed care companies to assess the impact of diabetes in the workplace, and provide intuitive information to help employees manage their diabetes and take steps toward reducing risks for related complications, such as heart disease.

Diabetes at Work can help you:

• Develop a diabetes prevention or management program.
• Estimate the number of employees in your company with diabetes.
• Estimate the total cost of diabetes in your company.
• Choose or design a health plan for people with diabetes.
• Obtain support from leadership for a diabetes program.

NDEP also maintains a Web site, www.YourDiabetesInfo.org, which has educational materials on diabetes prevention and control for business professionals. On the YourDiabetesInfo.org Web site, employers can find out more information about diabetes, such as:

• How business leaders can become more involved in workplace and community activities to help control diabetes related complications to reduce the human and economic impact of this serious disease.
• How to plan a workshop for employers and business coalitions to address diabetes in the workplace.

Resources for Diabetes Prevention and Control

The following resources provide information, products, and tools about diabetes prevention and control:

American Association of Diabetes Educators
www.diabeteseducator.org*

American Diabetes Association
www.diabetes.org*

Centers for Disease Control and Prevention
www.cdc.gov/diabetes

Diabetes Action Research and Education Foundation
www.diabetesaction.org*

Diabetes Education and Sports Association
www.diabetes-exercise.org*

Diabetes Prevention Program
www.bsc.gwu.edu/dpp/manuals.htmlvdoc*

National Diabetes Information Clearinghouse
diabetes.niddk.nih.gov
diabetes.niddk.nih.gov/spanish/index.asp (Spanish Web page)

The National Diabetes Education Program
www.YourDiabetesInfo.org*
www.cdc.gov/diabetes/ndep
www.cdc.gov/diabetes/diabetesatwork
www.betterdiabetescare.nih.gov

Resources for Depression

Several resources are available for employers and employees who are dealing with depression issues at the workplace. These resources include:

American Psychiatric Association
www.psych.org*
www.healthyminds.org*

American Psychological Association
www.apa.org*

A Pathway for Life Long Mental Health: A Mental Health Resource Guide
www.freedomfromfear.org*

Depression and Bipolar Support Alliance
www.dbsalliance.org*

Depression Health Center
www.webmd.com/depression/default.htm

Depression Screening Test: An Online Self-test for Depression
psychcentral.com/depquiz.htm

Depression—You Don’t Have to Feel that Way. American Family Physician. Published by the American Academy of Family Physicians. March 1, 2000.
www.aafp.org/afp/20000301/1523ph.html*

Mental Health Matters: Self Help Center: Video and Audio Tapes.
www.mental-health-matters.com/selfhelp/m_media.php

National Alliance on Mental Illness
www.nami.org*

National Business Group on Health. An Employer’s Guide to Behavioral Health Services: A Roadmap and Recommendations for Evaluating, Designing, and Implementing Behavioral Health Services.
www.businessgrouphealth.org/pdfs/fullreport_behavioralhealthservices.pdf [PDF – 770 KB]*

National Institute of Mental Health
www.nimh.nih.gov

• For NIMH’s publications on depression, please call Toll-free 1-800-421-4211
• For NIMH’s publication on diabetes and depression, visit:
  www.nimh.nih.gov/health/publications/depression-and-diabetes/complete-index.shtml

National Mental Health Association
www.nmha.org*

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