Nicole recently blogged about her late aunt's battle with the dual diagnosis of depression and diabetes, and wondered why -- with modern medical care available to her, and with prescriptions to deal with both illnesses -- her aunt took neither, allowing her body to destroy itself piece by piece, taking only the medications prescribed to her for pain.
While I don't presume to have known Nicole's aunt Margaret, I can see a number of issues that can complicate the combined issue of self-care and chronic disease in general, and diabetes in particular.
The first issue -- the one we can expect to pop up with increasing frequency as the costs of healthcare continue to rise and as people leave (or choose not to join) healthcare professions -- is that of whether or not people with chronic diseases merit care (or what sort of care we merit). Allocating limited medical resources is not as straightforward as we should like; an article in The Lancet describes some key moral and ethical issues such as: who needs the resources soonest; who is (individually) likely to benefit the most from having those resources; who is likely to contribute most to the society as a whole after having been allocated resources; and how to allocate those resources so the greatest number of people can individually benefit.
Inside that framework, people with chronic diseases in general take up more resources -- doctors' time, pharmaceuticals, medical office waiting and examining space, hospital space, etc. -- than people who are generally healthy. For example, as a person with Type 2 diabetes, my regular physician visits are scheduled quarterly, rather than annually. Because of my diabetes and hypertension, I need more consults than the average person for illness, injury, dental care, and so on. In a world of limited medical resources, my doctor could help four or five people live past injuries and acute illnesses, rather than helping me to "keep hanging on". In that strict "needs of the many" sense, I am taking up "more than my fair share" of medical resources. If I were a strict Darwinist, or perhaps a particular brand of socialist -- someone who believed I had no right to take up that extra share of services -- my next logical reaction might be, without any depression or form of mental illness involved, to remove myself from that list of people needing care in the quickest, cheapest manner possible -- suicide.
But most of us -- myself included -- are too caught up in living, and too afraid of dying, to force a quick death upon ourselves. Instead, we either try to take the best care of ourselves we can and try to put off the need for more-frequent, higher-level social and medical resources, or we choose to ignore our illnesses in such a manner that they will eventually force us to choose death. (Or, we live in complete denial of our chronic illnesses to the point that we are forced to choose death even when we would rather continue to live.)
Nicole writes, "[She] seemed unwilling to sacrifice the things she liked to eat, the time she needed to test her bloodsugar and monitor her disease..." I've written before about how the eating patterns dictated by diabetes would be, in any other circumstance, evidence of disordered eating. Our mental health professionals tell us that eating disorders are often indicative of other, deeper mental health issues -- including depression.
Now, there are a number of things to be said about what we call "mental illness". One of the more important ones is how closely-tied those behaviors are to creativity. History is strewn with literary, musical, and artistic geniuses who (by today's terms) are considered to have lived with depression, schizophrenia, obsession, and various neuroses. Some were able to effectively self-treat with herbs, drugs, and alcohol; others were not as lucky. Many of the 18th and 19th century's most creative artists died young -- not because of the poor state of contemporary medical care, not because of their dependence on mind-altering substances, but because they could not effectively market their genius, maintain a "day job", or tear themselves away from their creative realities long enough to care for themselves properly.
Related to that is a popular belief that antidepressants cause a sort of "Stepford Wives" effect -- that they work by eliminating all emotion, that they dull the senses, rip one away from one's own vivid perception of reality and place one into a numbed state where one can only react by rote, not feeling anything nor being affected by it, and unable to harness one's creativity. Some people say they would prefer to be depressed than to be numbed in that way. Others would rather the numbness than to have to confront the pain. Could it be that for some subset of people with depression, mental anguish translates into physical pain? It would certainly account for the popularity of narcotics among some of history's most notable artistic geniuses -- and it could account for Nicole's aunt Margaret taking her pain medication, but not the other medications.
But we are forgetting what might be one of the most important issues when dealing with a dual diagnosis of diabetes and depression: the effect of antidepressants upon one's blood glucose levels. If you listen to the "small print warning" of many TV and radio commercials for antidepressants, one of the side effects they mention is "...[raised] blood sugar. In some cases, extremely high blood sugar may lead to coma and death..." So: if you are depressed because you have diabetes and you're having trouble getting your blood glucose levels under control, you may be prescribed a drug that will make your blood glucose levels worse, so that your PCP and endo and so on will chide you for that poor control and make you even more depressed, requiring another drug that will raise your blood glucose levels even more...
Given that possibility, some of us would rather "man up" and accept a depression we can hope to overcome with time and counseling than to deal with the potentially fatal complications of poor glucose control.
