Maxy sez:: Suicide and Diabetes: What Caregivers Should Know

When emotional health and diabetes collide, suicide is a real risk. Learn how to help your loved ones avoid this tragic choice.
By Madeline R. Vann, MP    Medically Reviewed by Farrokh Sohrabi, MD

As many as one in five people with diabetes think about suicide, some on a daily basis. People considering suicide don't always advertise their plans, but those with diabetes might be doing so by neglecting their diabetes management. A statewide study of patients in Texas revealed that depression and diabetes led to poor diabetes control. And although no in-depth research into diabetes and suicide exists, the study authors suggest that one sign of worsening emotional health might be giving up on the hard work of controlling diabetes.

Also of great concern, according to a study published in The Primary Care Companion to the Journal of Clinical Psychiatry, are data that suggest that people with diabetes might go so far as to commit insulin suicide, intentionally overdosing with the very medication that can help them achieve and maintain blood sugar control.

Emotional Health and Diabetes: Depression and Suicide

The connection point between diabetes and suicide is depression. About 16 percent of the general population experience depression, but the percentage is nearly doubled among those with diabetes. To better understand depression and diabetes, family medicine expert David Katerndahl, MD, and colleagues at the University of Texas Health Science Center at San Antonio looked at diabetes control and depression symptoms among 106 patients over the course of five years.
Though their research did not address suicide risk specifically, Dr. Katerndahl said, "I looked at the results from our question about how frequently patients thought about suicide over the past two weeks and found that 20 percent had thought about suicide and 6 percent thought about it daily." The results of the study show a link between depression, poor compliance with diabetes treatment, and a lower qualify of life .

"Diabetes and depression is a toxic combination," said psychologist Susan Guzman, PhD, director of clinical services for the Diabetes Behavioral Institute in San Diego. "Mortality rates in people who have both are about 2.5 times the rates in people with either or neither."

Decades of Diabetes Leading to Depression

Ed Cook, a San Diego resident, was diagnosed with diabetes 38 years ago. For much of the time, the government administrator and, after retirement, entrepreneur felt life was balanced despite his illness. But as Cook, now 66, gradually lost his vision and then his driver's license, his business, and most recently, one toe to amputation, depression infiltrated his life. A religious person, he struggled against thoughts of suicide and sought help from Guzman.

"The complications led me to severe depression," Cook admitted. He entered treatment, which included anti-depressants for a time, and he now regularly attends both therapy and support groups. "It helps to know I am not alone," he said. "Diabetes is not the end of the world."

But Cook also acknowledges that his battle is not over. Periodically, he still feels some despair as he continues to face the screenings and health assessments, such as vascular checkups, that are intended to catch complications before they do too much damage. Still, through prayer and therapy, he said, he's come to see that even now he has a role and a purpose. "I try to be an encouragement to people," he said.

This shift in attention is part of the treatment process, noted Guzman. At their worst, people with depression and diabetes may feel like a collection of flawed body parts under the thumb of the illness. But as the depression subsides, they can see that they are more than just the label and experience of diabetes.

Suicide by Insulin
Complicating the issue is the ability of people with diabetes to commit suicide using the very same tools that keep them alive. At one point, Cook floated the idea of an intentional insulin overdose to Guzman, but she pointed out that it's a permanent solution to a temporary problem, not to mention risking severe side effects from the overdose if you survive it.

How widespread is insulin suicide? According to research published in the Journal of Clinical Psychiatry, an analysis of overdose-related calls to a poison center suggested that 95 percent of insulin overdoses were deliberate. But Guzman noted that this is an area that needs more study.

Katerndahl understands how life with diabetes can look grim to patients, especially if they have seen older relatives living with some of the more severe complications of diabetes. But he said it's also important to remember that modern medicine offers many more options for disease management than the diabetes programs older relatives were following decades ago.

How Caregivers Can Help: Tips for Preventing Suicide

As a caregiver, it can be hard to tell when a loved one's blue mood turns to depression and potentially to thoughts of suicide, but often there are clues. "More than half of the time, people who complete suicide have talked about it," said Guzman.

Here are suggested actions to take:
Note any changes in self-care. Katerndahl's research supports what other studies have shown: Depression correlates with poor diabetes management compliance. If someone used to be on top of diabetes control but now makes less effort, talk to the person or the person's doctor about what's going on.
Know the risk factors for suicide. There are many risk factors for suicide, including recent unemployment, childhood traumas, social isolation, family conflict, and personality traits such as aggression, impulsivity, or shame. For people with diabetes, experiencing severe complications that require amputations or the loss of independence can also be risk factors.

Encourage substance abuse treatment. Alcohol and substance abuse both increase the risk for suicide, warned Guzman. If your loved one is struggling with an addiction in addition to diabetes and depression, investigate treatment options.
Don't argue. You have to take any talk of suicide seriously, which means getting help, not debating the matter. Trying to reason with someone who's depressed and considering suicide won't help, said Guzman. Avoid saying things like, "But you have so much to live for." Instead, sympathize with the person's concerns and offer the hope that depression treatment could ease suffering. From his own experience, Cook said that even at his worst, the people in his life who were positive and encouraging were like a lifeline.
Suggest depression screening. Doctors can (and should, argues Katerndahl) provide depression screening tools to but you can also find them online. Encourage your loved one to complete one.
Call the doctor. If you are very concerned and your loved one can't or won't get help, calling the doctor is an option. Privacy laws prevent doctors from discussing a patient's status with you, but they don't prevent you from sharing your concerns with the doctor, who might be able to find a solution.
Remove weapons. Taking away guns, knives, and even prescription medications may be necessary if you feel suicide is imminent. Limiting access to insulin might be necessary for severely depressed insulin-dependent people, with family members or doctors taking over responsibility for giving insulin.action. "Don't sit on it. You're better off talking to the patient or the physician and, if it turns out your wrong, that's fine. You don't want to end up second-guessing yourself." Your care and insistence could make the difference in your loved one's life. "Getting treated for depression was a godsend," said Cook.
"Look for any kind of warning signs," said Katerndahl, and take 
control.