Diabetes, Depression and Chasing Away the Dybbuk

One night in the middle of my senior year of college when I could not get out of bed, and I could not taste my food, and I could not answer the phone, and I felt that there was something vile and rotten coursing through my blood, it suddenly occurred to me that perhaps there was a "dybbuk" dwelling within. According to Jewish folk wisdom a few centuries ago, the dybbuk was the dark, sick spirit that possessed people and caused all kinds of maladies. For a few minutes, I seriously entertained the possibility that a dybbuk prompted the inner darkness that descended upon me periodically. Then the realization that I was resorting to primitive superstition made me even more depressed, and I dropped the idea.

I got better, much better, over the years, but the dybbuk/black dog of depression never seemed very far away. And I could never fully account for it. Somehow my particular set of stories, and my particular capacity to overcome them, and what little I knew about biochemistry never came close to explaining it. Maybe it wasn't a dybbuk, but there often seemed to be something from somewhere outside of myself that grabbed hold, or threatened to grab hold, something beyond my control and imagining.

Then, on a winter evening in 2012, when thinking about thinking about writing about diabetes, I found a New York Times article by Alice Dembner with an evocative lede: "Millions of people face a two- headed beast - diabetes and depression - that gnaws at them from the inside out." It prompted me to hope there was a chance to understand the dybbuk --or whatever it was that grabbed hold of me--and maybe even find new ways to ensure that it never returned. She wrote: “The struggle of coping with diabetes feeds deep sadness. Depression gets in the way of dieting, exercising, and even taking the medicines that can control diabetes. The resulting downward spiral can make the depression unrelenting."

That seems obvious to me now, but I had not realized that, as the article noted, people with diabetes were much more likely to be depressed than people without it. What’s more, the brains of Type 1 diabetics (T1Ds) are, well, different: they are “less dense and less responsive in an area of the prefronotal cortex that helps control emotions and is believed to contribute to depression.” Both depressives and people with diabetes (PWDs) tend to have high levels of cortisol, one of the stress hormones. In fact, “scientists aren’t sure which comes first—the diabetes or the depression—or whether the sequence is different in people with Type 1 or Type 2 diabetes.”

Was it possible that there was a direct, biochemical link between T1D and my depression? Were they part of the same condition, different aspects of the same malady?

A little more Googling revealed that in 2009, researchers at the Joslin Diabetes Center found that the brains of people with T1D had abnormally high levels of the neurotransmitter glutamate, and this might be related to depressive symptoms and lower scores on tests of cognitive functions. “These findings could lead to new ways to both understand and treat these conditions,” said Alan Jacobson, who was Joslin’s Chief of Psychiatry at the time.

For awhile, I hoped that researchers were close to a Unified Theory of Diabetic Darkness, perhaps even new forms of treatment. No such luck. In 2010, in a “Dialogue on Diabetes and Depression,” Jacobson noted that although there is “a well-recognized association of depression with both type 1 and type 2 diabetes,” the manner in which their simultaneous presence develops “is not understand.” A bit more light has been shed on the matter since then, as described here. But scientists’ knowledge of diabetes and the brain is very elementary; they are like Renaissance mapmakers soon after the New World was discovered, who knew there was something fascinating out there but were capable of depicting it only with vague shapes.

I recently had lunch with Dr. Jacobson, who now runs the Winthrop Research Institute in Long Island. “Are there underlying causes of depression that are specific to diabetics’ brains? There have been some interesting findings but it’s far too early to tell,” he said. ”But chronic disease is a form of loss. When someone is diagnosed with diabetes or has problems with it, the feelings of helplessness and sorrow are not terribly different than they are in other forms of loss, like losing a relative. And that clearly affects brain function.”

So I don’t know precisely how much T1D had to do with the dybbuk I tried to scare away in college. But I’m persuaded there is some kind of biochemical connection between diabetes and inner darkness, and I'm still trying to look back to discern the impact of diabetes on my psyche. That process has had some benefits.

Depressed people tend to heap undeserved blame on themselves. Freud noticed that. For one thing, they often blame themselves for their own depression, their inability to snap out of it and join everyone else who seems to be dancing through life. Been there, done that. And people with diabetes (PWDs) often blame themselves for their inability to tame the beast of blood sugar. Very familiar with that one, too. Whatever else I learned on the quest for a Unified Theory of Dia-Darkness, I was continually reminded of the obvious but too easily ignored fact that neither diabetes nor depression were my fault.

I wish I'd been convinced of that a lot earlier. No medical professional who treated me ever mentioned that depression was often a complication of diabetes. To be fair, they might not have known. But it’s not too late for other PWDs and their loved ones to find out, and at least try to learn how to deal with diabetes’ emotional and psychological burdens, and to stave off needless self-recrimination. “Just being able to tell parents (of diabetics) that depression might be a part of it would be important,” Jacobson said. So would integrating mental health professionals into clinical diabetes care.

This integration happens in some settings, like Joslin, the Kovler Diabetes Center in Chicago, the Children's Hospital in Pittsburgh, a few others. Jacobson said health care professionals "are much more aware than they used to be" about diabetes and mental health issues. But only a tiny fraction of very sad PWDs are getting the attention they need. Moreover, the only institution devoted solely to helping people handle the psychological burdens of the disease, the Behavioral Diabetes Institute in San Diego, just announced that it is closing. Given our utterly screwed-up health care system, it is hard to imagine that attention to mental health will be part of the standard of diabetes care any time soon.

For now, a more aggressive, calculated approach to educating PWDs and their families about the potential for depression is warranted. Parhaps not all PWDs mistakenly blame themselves when they feel so bleak that they can’t get out of bed, or taste their food, or answer the phone. But all of them, and those with less severe depression, deserve to know what took me too many decade to learn.

Originally published in The Insulin Chronicles @ http://www.theinsulinchronicles.com/diabetes-depression-and-chasing-away-the-dybuk/

Great explanation of the physiology link of depression and diabetes. Thank you for sharing.

You're more than welcome. Hope it helps somebody somewhere….

thanks dan, that was very interesting.

Great blog, Dan!! I LOVE your concept of a D-dybbuk. I never thought of that before.

We are having a live interview with Dr. Alan Jacobson on the homepage of TuDiabetes on March 13th! I hope you can join in on that. I've been really looking forward to it because I think the connection between diabetes and depression is really interesting (and terribly overlooked by much of the medical industry).

Thanks. It's on my calendar.I've sent Alan the post and will be interested to see if I missed any nuances...

here are some articles about the topic.

http://www.diabetesforecast.org/2013/oct/depression-diabetes-danger.html

http://www.diabetesforecast.org/2010/jun/treating-diabetes-and-depression.html

http://www.diabetes.org/living-with-diabetes/complications/mental-health/depression.html

I did not dig very deep so this is a quick look

i remember reading these articles years ago.
i went through DEEP DEPRESSION in my 50's due to DIABETES, MENOPAUSE,BEING ALONE, BIG HOUSE I COULD NOT HANDLE, DAUGHTER LIVING SO FAR AWAY, ETC..., ETC. saw a psychiatrist for several years with medication.
I AM OK NOW.

Thoughtful piece. Just visited your website/bog--impressed! Now bookmarked & I look forward to reading more.

Thanks, Deborah.

Thanks for posting this here, Dan. I've lived with my own dybbuk for 40 years, a close cousin of yours, I think. I sure appreciate how you've pulled your research and insights together for us.

very good reading dan, thank you for sharing. i'll be celebrating my 50th diaversary this summer, guess it'll be my 49th depressaversary :) anyone's dybbuk from minsk? i'm just trying to dig myself out of a nasty depression at the moment, hoping for some relief.

Boy did this speak to me. I have been a PWD Type 1 for 53 years. Alot of nights in the darkness, feeling that most things were my fault. Depressed but not ever calling it that. I guess I too thought of dybbuk. I probably heard about that through my family and may have even integrated it into my thinking. Yikes. I am glad we can at least identify what it is we are thinking , feeling today. Thanks Dan , it helped.

Thank you so much for this article. As someone who was diagnosed with a chronic "genetic form of major depression" in 1987 and diabetes in 2004, I have often wondered why, since the diabetes has been more difficult to control, my depression (tho usually managed well) seems to 'come back' and everything feels so much more overwhelming. I have felt guilty/ashamed for having depression all this time, then since starting diabetes meds, insulin, etc...the doctors (3 different ones) have each somehow made me feel ashamed/guily for having diabetes...as if this is something I want and have complete control over. Your article makes me feel a little less alone, more sane and thankful for people like you who care so much. Thank you very much for this.

i was afflicted with depression way before my diabeties 2 began. Both can be debilitating. But with diabeties, I have found a way of taking the positives. For nearly 4 years I have never been as healthy and this is because of my diabeties. I'm not sayig that I rejoice in my suffering (because not eating what I use to eat or how I use to eat is suffering) what I am saying with the added knowledge of my body and food with the addition of exercise to my life I believe that have (well not beaten) but put him in his place for the meanwhile anyway.

Thank you. I'm a T2 but have heard we also have a higher propensity for depression. I am currently battling yet another bout with it and hopefully can convince myself this is just another piece of the D that I have to fight through.

Hi, Dan...for most of my adult life, I have been very familiar with the black dog/dybbuk, and I so appreciate your research and writing about it. I do hope that some day treatment for depression WILL become an integrated part of diabetes treatment. Meanwhile, until your dream of A Unified Theory of Diabetic Darkness has evolved, it is curiously helpful to imagine what this creature looks like, nipping at our heels! Thankyou so much.

I’ve had t1D for about 5 years and before that did not experience the omni-present darkness that is either close by, creeping up, or directly over me. I also started to do a bit of superficial searching in the last few months, and the stress hormone certainly came up, but not much else regarding mental health and D…thank you for this piece. I will be checking out each link you provide. :slight_smile:

Interesting stuff, Dan. Thanks
Have you (or any readers) read, or done,
THE DEPRESSION CURE by Stephen Ilardi?
He promotes a 6 step non-pharmaceutical lifestyle change. It sounds hopeful and within reach. Some of the steps we're already working on as diabetics.

Thanks, Mark. Have not read that. I confess to being a bit skeptical of approaches to any deep-seated psychological malady that rely on 6 steps or 12 steps. They work for some people, not for everyone. But will check that book out. The best book on depression, IMO, is The Noonday Demon by Andrew Solomon. Among other things, he describes how COMPLICATED it is, and shows how little is actually understood about it by researchers who study the brain….