Diabetes treatment and management isn't cheap. Do you need help paying for diabetes treatment? Financial assistance is available.

Where to Get Financial Assistance to Pay for Diabetes Treatment

Diabetes treatment is expensive. According to the American Diabetes Association, people with diabetes spend an average of $11,744 a year on health care expenses—more than twice the amount spent by people without diabetes.

Many people who have diabetes need help paying for their care. For those who qualify, a variety of governmental and nongovernmental programs can help cover health care expenses. This publication is meant to help people with diabetes and their family members find and access such resources.

On this page:

• Medicare 
• Medicaid
• State Children's Health Insurance Program (SCHIP)
• Health Insurance for Those Not Eligible for Medicare or Medicaid
• Health Insurance after Leaving a Job
• Health Care Services
• Hospital Care
• Kidney Disease: Resources for Dialysis and Transplantation
• Prescription Drugs and Medical Supplies
• Prosthetic Care
• Classroom Services
• Technological Assistance
• Food and Nutrition Assistance for Women with Diabetes or Gestational Diabetes
• Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) Benefits
• Local Resources
• Acknowledgments
• National Diabetes Education Program

Medicare

Medicare is federal health insurance for the following groups:

• people 65 or older
• people younger than 65 with certain disabilities or amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease
• people of any age with end-stage renal disease—permanent kidney failure requiring dialysis or a kidney transplant

Medicare Health Plans

People with Medicare can choose how to get their health and prescription drug coverage. The following options are available:

• Original Medicare
• Medicare Advantage Plans—such as health maintenance organizations (HMOs) or preferred provider organizations (PPOs)
• other Medicare health plans

Original Medicare. Original Medicare, managed by the Federal Government, has two parts: Medicare Part A is hospital insurance and Medicare Part B is medical insurance. People in this plan usually pay a fee for each health care service or supply they receive.

People who are in Original Medicare can add prescription drug coverage—Medicare Part D—by joining a Medicare Prescription Drug Plan. These plans are run by insurance companies and other private companies approved by Medicare.

People can also choose to buy insurance to help fill the gaps in Part A and Part B coverage. This insurance is known as Medigap or Medicare Supplement Insurance.

Medicare Advantage Plans. Medicare Advantage Plans are health plan options, like an HMO or PPO, approved by Medicare and offered by private companies. These plans are part of Medicare and are sometimes called Part C or MA Plans. Medicare Advantage Plans provide Medicare Part A and Part B coverage and usually Medicare Part D coverage. The companies that run these plans must follow rules set by Medicare. Not all Medicare Advantage Plans work the same way. People considering one of these plans should find out the plan's rules before joining.

Other Medicare Health Plans. Other Medicare health plans include Medicare Cost Plans, Demonstrations/Pilot Programs, and Programs of All-Inclusive Care for the Elderly (PACE). These plans provide hospital and medical insurance coverage, and some also provide prescription drug coverage.

Medicare Covers Diabetes Services and Supplies

Original Medicare helps pay for the diabetes services, supplies, and equipment listed below. Coinsurance or deductibles may apply. In addition, Medicare covers some preventive services for people who are at risk for diabetes. A person must have Medicare Part B or Medicare Part D to receive these covered services and supplies.

Medicare Part B helps pay for

• diabetes screening tests for people at risk of developing diabetes
• diabetes self-management training
• diabetes supplies such as glucose monitors, test strips, and lancets
• insulin pumps and insulin if used with an insulin pump
• flu and pneumonia shots
• foot exams and treatment for people with diabetes
• eye exams to check for glaucoma and diabetic retinopathy
• medical nutrition therapy services for people with diabetes or kidney disease, when referred by a doctor
• therapeutic shoes or inserts, in some cases

Medicare Part D helps pay for

• diabetes medicines
• insulin, but not insulin used with an insulin pump
• diabetes supplies like needles and syringes for injecting insulin

People who are in a Medicare Advantage Plan or other Medicare health plan should check their plan's membership materials and call for details about how the plan provides the diabetes services, supplies, and medicines covered by Medicare.

More details are available by calling 1-800-MEDICARE (1-800-633-4227) and requesting the free booklet Medicare Coverage of Diabetes Supplies & Services. 

More Information about Medicare

More information about Medicare is available at www.medicare.gov, the official U.S. Government website for people with Medicare. The website has a full range of information about Medicare including free publications like Medicare & You, the official Government handbook about Medicare, and Medicare Basics—A Guide for Families and Friends of People with Medicare. Through the Medicare website, people can also

• find out if they are eligible for Medicare and when they can enroll
• learn about their Medicare health plan options
• find out what Medicare covers
• find a Medicare Prescription Drug Plan
• compare Medicare health plan options in their area
• find a doctor who participates in Medicare
• get information about the quality of care provided by nursing homes, hospitals, home health agencies, and dialysis facilities

Calling 1-800-MEDICARE (1-800-633-4227) is another way to get help with Medicare questions, order free publications, and more. Help is available 24 hours a day, every day, and is available in English, Spanish, and other languages. TTY users should call 1-877-486-2048.

Medicare information can also be obtained from the following agencies or programs:

• Each state has a State Health Insurance Assistance Program (SHIP) that provides free health insurance counseling. A state's SHIP may have a unique name. SHIP counselors can help people choose a Medicare health plan or a Medicare Prescription Drug Plan. The phone number for the SHIP in each state is available by calling Medicare or visiting www.medicare.gov and selecting "Find Helpful Phone Numbers and Websites" under "Search Tools."
• The Social Security Administration can provide information about eligibility for Medicare. People can contact the agency at 1-800-772-1213, visit its website at www.socialsecurity.gov, or check with their local Social Security office to learn if they are eligible for Medicare.
• State Medical Assistance (Medicaid) offices in each state can provide information about help for people with Medicare who have limited income and resources. The phone number for each state's Medicaid office can be obtained by visiting www.medicare.gov or calling Medicare.

People who enroll in Medicare can register for MyMedicare.gov, a secure online service, and use the site to access their personal Medicare information at any time. People can view their claims, order forms and publications, and see a description of covered preventive services.

Help for Diabetics with Medicare Who Have Limited Income and Resources

Diabetics who have Medicare and have limited income and resources may qualify for help paying for some health care and prescription drug costs from one of the following programs:

• Extra help paying for Medicare prescription drug coverage. Those who meet certain income requirements may qualify for extra help from Medicare to pay prescription drug costs. People can apply for this help by calling Social Security; visiting www.socialsecurity.gov to apply online; visiting their local Social Security office; or by contacting their State Medical Assistance (Medicaid) office. Each state's SHIP can provide information and answer questions about this program.
• State pharmacy assistance programs (SPAPs). Several states have SPAPs that help certain people pay for prescription drugs. Each SPAP makes its own rules about how to provide drug coverage to its members. Information about each state's SPAP can be obtained by calling Medicare or the state's SHIP.
• Medicaid programs for people with Medicare. State Medicaid programs help pay medical costs for some people with Medicare who have limited income and resources. People who qualify for both Medicare and Medicaid may get coverage for services that aren't fully covered by Medicare, such as nursing home and home health care. States also have programs called Medicare Savings Programs that pay Medicare premiums and, in some cases, may also pay Medicare Part A and Part B deductibles and coinsurance. More information is available at www.medicare.gov. The phone number for the State Medical Assistance (Medicaid) office for each state can be obtained by calling Medicare. Each state's SHIP can also provide more information.

Medicaid

Medicaid, also called Medical Assistance, is a joint federal and state government program that helps pay medical costs for some people with limited income and resources. Medicaid programs and income limits for Medicaid vary from state to state. The State Medical Assistance (Medicaid) office can help people find out whether they qualify for Medicaid or provide more information about Medicaid programs. To contact a state Medicaid office, people can

• visit "Find Helpful Phone Numbers and Websites" or call 1-800-MEDICARE (1-800-633-4227) and say "Medicaid"
• check the government pages of the phone book for the local department of human services or department of social services, which can provide the needed information

State Children's Health Insurance Program (SCHIP)

SCHIP is a federal and state government partnership to expand health coverage to uninsured children from families with income that is too low to afford private or employer-sponsored health insurance but too high to qualify for Medicaid. Free or low-cost coverage is available to eligible children younger than 19.

SCHIP provides an extensive package of benefits including doctor visits, hospital care, and more. Information about the program is available at www.insurekidsnow.gov or by calling 1-877-KIDS-NOW (1-877-543-7669). Callers to the toll-free, confidential hotline are automatically connected to their state's program.

Health Insurance for Those Not Eligible for Medicare or Medicaid

People who are not eligible for Medicare or Medicaid may be able to purchase private health insurance. Many insurers consider diabetes that has already been diagnosed a pre-existing condition, so finding coverage may be difficult for people with diabetes. Insurance companies often have a specific waiting period during which they do not cover diabetes-related expenses for new enrollees, although they will cover other medical expenses that arise during this time.

Certain state and federal laws may help. Many states now require insurance companies to cover diabetes supplies and education. The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, limits insurance companies from denying coverage because of a pre-existing condition. Information about HIPAA is available at www.dol.gov/dol/topic/health-plans/portability.htm.

More information about these laws is available from each state's insurance regulatory office. Some state offices may be called the state insurance department or commission. This office can also help identify an insurance company that offers individual coverage. The National Association of Insurance Commissioners' website, www.naic.org/state_web_map.htm, provides a membership list with contact information and a link to the website for each state's insurance regulatory office.

Health Insurance after Leaving a Job

When leaving a job, a person may be able to continue the group health insurance provided by the employer for up to 18 months under a federal law called the Consolidated Omnibus Budget Reconciliation Act, or COBRA. People pay more for group health insurance through COBRA than they did as employees, but group coverage is cheaper than individual coverage. People who have a disability before becoming eligible for COBRA or who are determined by the Social Security Administration to be disabled within the first 60 days of COBRA coverage may be able to extend COBRA coverage an additional 11 months, for up to 29 months of coverage. COBRA may also cover young people who were insured under a parent's policy but have reached the age limit and are trying to obtain their own insurance.

More information is available by calling the U.S. Department of Labor at 1-866-4-USA-DOL (1-866-487-2365) or visiting www.dol.gov/dol/topic/health-plans/cobra.htm.

If a person doesn't qualify for coverage or if COBRA coverage has expired, other options may be available:

• Some states require employers to offer conversion policies, in which people stay with their insurance company but buy individual coverage.
• Some professional and alumni organizations offer group coverage for members.
• Some insurance companies also offer stopgap policies designed for people who are between jobs.

Each state insurance regulatory office can provide more information about these and other options. The National Association of Insurance Commissioners' website, www.naic.org/state_web_map.htm, provides a membership list with contact information and a link to the website for each state's insurance regulatory office. Information about consumer health plans is also available at the U.S. Department of Labor's website at www.dol.gov/dol/topic/health-plans/consumerinfhealth.htm.

Health Care Services

The Bureau of Primary Health Care, a service of the Health Resources and Services Administration, offers primary and preventive health care to medically underserved populations through community health centers. For people with no insurance, fees for care are based on family size and income. Information about local health centers is available by calling 1-888-ASK-HRSA (1-888-275-4772) and asking for a directory, or by visiting the Bureau's website at www.bphc.hrsa.gov.

Many local governments have public health departments that can help people who need medical care. The local county or city government's health and human services office can provide further information.

Hospital Care

People who are uninsured and need hospital care may be able to get help from a program known as the Hill-Burton Act. Although the program originally provided hospitals with federal grants for modernization, today it provides free or reduced-fee medical services to people with low incomes. The Department of Health and Human Services administers the program. More information is available by calling 1-800-638-0742 (1-800-492-0359 in Maryland).

Kidney Disease: Resources for Dialysis and Transplantation

Kidney failure, also called end-stage renal disease, is a complication of diabetes. People of any age with kidney failure can get Medicare Part A—hospital insurance—if they meet certain criteria. To qualify for Medicare on the basis of kidney failure, a person must

• need regular dialysis

or

• have had a kidney transplant

and must

• have worked long enough—or be the dependent child or spouse of someone who has worked long enough—under Social Security, the Railroad Retirement Board, or as a government employee

or

• be receiving—or be the spouse or dependent child of a person who is receiving—Social Security, Railroad Retirement, or Office of Personnel Management benefits

People with Medicare Part A can also get Medicare Part B. Enrolling in Part B is optional. However, a person needs to have both Part A and Part B for Medicare to cover certain dialysis and kidney transplant services.

Those who don't qualify for Medicare may be able to get help from their state to pay for their dialysis treatments. More information about dialysis and transplantation is available by

• calling Social Security at 1-800-772-1213 or visiting www.socialsecurity.gov for information about the required amount of time needed under Social Security, the Railroad Retirement Board, or as a government employee to be eligible for Medicare based on kidney failure
• visiting www.medicare.gov to read or download the booklet Medicare Coverage of Kidney Dialysis and Kidney Transplant Services or calling 1-800-MEDICARE (1-800-633-4227) to request a free copy; TTY users should call 1-877-486-2048
• reading the National Kidney and Urologic Diseases Information Clearinghouse's publication Financial Help for Treatment of Kidney Failure, available at www.kidney.niddk.nih.gov or by calling 1-800-891-5390
• visiting Medicare's "Dialysis Facility Compare" at www.medicare.gov/dialysis for important information about chronic kidney disease and dialysis, including choosing a dialysis facility

Information about financing an organ transplant is available from the following organization:

United Network for Organ Sharing (UNOS)
P.O. Box 2484
Richmond, VA 23218
Phone: 1-888-894-6361 or 804-782-4800
Fax: 804-782-4817
Internet: www.unos.org

Prescription Drugs and Medical Supplies

Health care providers may be able to assist people who need help paying for their medicines and supplies by directing them to local programs or even providing free samples.

Prescription drug coverage for those eligible for Medicare is available through Medicare's Prescription Drug Plans and many Medicare Advantage Plans. More information is available at the Medicare website at www.medicare.gov.

Drug companies that sell insulin or diabetes medications usually have patient assistance programs. Such programs are available only through a physician. The Pharmaceutical Research and Manufacturers of America and its member companies sponsor an interactive website with information about drug assistance programs at www.PPARx.org.

Also, because programs for the homeless sometimes provide aid, people can contact a local shelter for more information about how to obtain free medications and medical supplies. The number of the nearest shelter may be listed in the phone book under Human Service Organizations or Social Service Organizations.

Prosthetic Care

People who have had an amputation may be concerned about paying their rehabilitation expenses. The following organizations provide financial assistance or information about locating financial resources for people who need prosthetic care:

Amputee Coalition of America
900 East Hill Avenue, Suite 205
Knoxville, TN 37915-2566
Phone: 1-888-AMP-KNOW (1-888-267-5669)
Fax: 865-525-7917
Internet: www.amputee-coalition.org

Easter Seals
230 West Monroe Street, Suite 1800
Chicago, IL 60606
Phone: 1-800-221-6827
Fax: 312-726-1494
Internet: www.easterseals.com

Classroom Services

Public agencies and other organizations that provide services and assistance, such as providing special equipment, to children with diabetes and other disabilities and to their families are listed on the State Resource Sheets published by the National Dissemination Center for Children with Disabilities (NICHCY). Each state's resource sheet lists the names and addresses of agencies in the state. The free resource sheets are available by contacting

College-aged students who have diabetes-related disabilities may be faced not only with the costs of tuition, but also with additional expenses generally not incurred by other students. These costs may include special equipment and disability-related medical expenses not covered by insurance. Some special equipment and support services may be available at the educational institution, through community organizations, through the state vocational rehabilitation agency, or through specific disability organizations. The names and addresses of these and other agencies are also listed in the State Resource Sheets available from the NICHCY.

The HEATH Resource Center, an online clearinghouse on postsecondary education for individuals with disabilities, offers information about sources of financial aid and the education of students with a disability. Contact the clearinghouse at

The George Washington University
HEATH Resource Center
2134 G Street NW
Washington, DC 20052-0001
Phone: 202-973-0904
Fax: 202-994-3365
Internet: www.heath.gwu.edu

Technological Assistance

Assistive technology, which can help people with disabilities function more effectively at home, at work, and in the community, can include computers, adaptive equipment, wheelchairs, bathroom modifications, and medical or corrective services. The following organizations provide information, awareness, and training in the use of technology to aid people with disabilities:

Alliance for Technology Access (ATA)
1304 Southpoint Boulevard, Suite 240
Petaluma, CA 94954
Internet: www.ATAccess.org

Food and Nutrition Assistance for Women with Diabetes or Gestational Diabetes

Food, nutrition education, and access to health care services are available through the U.S. Department of Agriculture's Women, Infants, and Children (WIC) program. The WIC program provides assistance to women during pregnancy or the period following childbirth and to infants and children up to age 5. Applicants must meet residential, financial need, and nutrition risk criteria to be eligible for assistance. Having diabetes or gestational diabetes is considered a medically based nutrition risk and would qualify a woman for assistance through the WIC program if she meets the financial need requirements and has lived in a particular state the required amount of time. The WIC website provides a page of contact information for each state and Indian tribe. Contact the WIC's national headquarters at

Supplemental Food Programs Division
Food and Nutrition Service—USDA
3101 Park Center Drive
Alexandria, VA 22302
Internet: www.fns.usda.gov/wic

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) Benefits

The Social Security Administration pays disability benefits through the SSDI and SSI programs. These benefits are not the same as Social Security benefits. To receive SSDI benefits, a person must be unable to work and must have earned the required number of work credits. SSI is a monthly amount paid to people with limited income and resources who are disabled, blind, or age 65 or older and meet certain other conditions.

More information is available by calling Social Security at 1-800-772-1213 or contacting the local Social Security office for more information. TTY users should call 1-800-325-0778. A "Benefit Eligibility Screening Tool" is available at www.socialsecurity.gov to check whether a person is eligible for benefits.

Local Resources

Local resources such as the following charitable groups may offer financial help for some of the many expenses related to diabetes:

• Lions Clubs International can help with vision care. Visit www.lionsclubs.org.
• Rotary International clubs provide humanitarian and educational assistance. Visit www.rotary.org.
• Elks clubs provide charitable activities that benefit youth and veterans. Visit www.elks.org.
• Shriners of North America offer free treatment for children at Shriners hospitals throughout the country. Visit www.shrinershq.org.
• Kiwanis International clubs conduct service projects to help children and communities. Visit www.kiwanis.org.

In many areas, nonprofit or special-interest groups such as those listed above can sometimes provide financial assistance or help with fundraising. Religious organizations also may offer assistance. In addition, some local governments may have special trusts set up to help people in need. The local library or local city or county government's health and human services office may provide more information about such groups.

The National Diabetes Information Clearinghouse (NDIC) gathered information from various agencies and organizations to try to provide the most comprehensive and helpful information possible. Changes may occur in these programs from the time this fact sheet is published. Please contact each organization directly for the most up-to-date information. The NDIC welcomes corrections and updates to the information in this fact sheet. Updates should be sent to ndic@info.niddk.nih.gov.

Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. The Medicare information in this publication was reviewed by subject matter experts at the Centers for Medicare & Medicaid Services.

National Diabetes Education Program

1 Diabetes Way
Bethesda, MD 20814-9692
Internet: www.ndep.nih.gov

The National Diabetes Education Program is a federally funded program sponsored by the U.S. Department of Health and Human Services' National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to reduce the morbidity and mortality associated with diabetes.

National Diabetes Information Clearinghouse

1 Information Way
Bethesda, MD 20892-3560
Internet: www.diabetes.niddk.nih.gov

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Source: NIH Publication No. 09-4638, May 2009

Here are four key steps to help you manage and control your diabetes and live a long and active life.

4 Steps to Control Diabetes

Step 1: Learn about diabetes.

Step 2: Know your diabetes ABCs.

Step 3: Manage your diabetes.

Step 4: Get routine care.

Where to get help

Diabetes is a serious disease. It affects almost every part of your body. That is why a health care team may help you take care of your diabetes:

• doctor
• dentist
• diabetes educator
• dietitian
• eye doctor
• foot doctor
• mental health counselor
• nurse
• nurse practitioner
• pharmacist
• social worker
• friends and family

You are the most important member of the team.

The marks on this page show actions you can take to manage your diabetes.

Help your health care team make a diabetes care plan that will work for you.

Learn to make wise choices for your diabetes care each day.

Step 1: Learn About Diabetes

Diabetes means that your blood glucose (blood sugar) is too high. There are two main types of diabetes.

Type 1 diabetes - the body does not make insulin. Insulin helps the body use glucose from food for energy. People with type 1 diabetes need to take insulin every day.

Type 2 diabetes - the body does not make or use insulin well. People with type 2 diabetes often need to take pills or insulin. Type 2 is the most common form of diabetes.

Gestational diabetes - may occur when a woman is pregnant. Gestational diabetes raises her risk of getting another type of diabetes, mostly type 2, for the rest of her life. It also raises her child's risk of being overweight and getting diabetes.

Diabetes is serious.

You may have heard people say they have "a touch of diabetes" or "your sugar is a little high." These words suggest that diabetes is not a serious disease. That is not correct. Diabetes is serious, but you can learn to manage it!

All people with diabetes need to make healthy food choices, stay at a healthy weight, and be physically active every day.

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Taking good care of yourself and your diabetes can help you feel better. It may help you avoid health problems caused by diabetes such as: 

• heart disease and stroke.
• eye problems that can lead to trouble seeing or going blind.
• nerve damage that can cause your hands and feet to feel numb. Some people may even lose a foot or a leg.
• kidney problems that can cause your kidneys to stop working.
• gum disease and loss of teeth.

When your blood glucose (blood sugar) is close to normal you are likely to:

• have more energy.
• be less tired and thirsty and urinate less often.
• heal better and have fewer skin or bladder infections.
• have fewer problems with your eyesight, feet, and gums.

Ask your health care team what type of diabetes you have.

Learn why diabetes is serious.

Learn how caring for your diabetes helps you feel better today and in the future.

Step 2: Know Your Diabetes ABCs. (A1C, Blood Pressure, and Cholesterol)

Talk to your health care team about how to manage your A1C (blood glucose or blood sugar), Blood pressure, and Cholesterol when you have diabetes. This will help lower your chances of having a heart attack, a stroke, or other diabetes problems. Here's what the ABCs of diabetes stand for:

A for the A1C test (A-one-C)

The A1C test shows what your blood glucose (blood sugar) has been over the last three months. The A1C goal for most people with diabetes is below 7. High blood glucose (blood sugar)levels can harm your heart and blood vessels, kidneys, feet, and eyes.

B for Blood pressure.

The goal for most people with diabetes is below 130/80.

High blood pressure makes your heart work too hard. It can cause heart attack, stroke, and kidney disease.

C for Cholesterol.

The LDL goal for most people with diabetes is less than 100.
The HDL goal for most people with diabetes is above 40.

LDL or "bad" cholesterol can build up and clog your blood vessels. It can cause a heart attack or a stroke. HDL or "good" cholesterol helps remove cholesterol from your blood vessels.

Ask your health care team:

• What you can do to reach your targets
• What should your ABC numbers should be
• What your A1C, blood pressure, and cholesterol numbers are

Write down all your numbers.

Step 3: Manage Your Diabetes

Many people avoid the long-term problems of diabetes by taking good care of themselves. Work with your health care team to reach your ABC goals (A1C, Blood Pressure, Cholesterol): Use this self-care plan.

• Use your diabetes meal plan. If you do not have one, ask your health care team about one.
  • Make healthy food choices such as fruits and vegetables, fish, lean meats, chicken or turkey without the skin, dry peas or beans, whole grains, and low-fat or skim milk and cheese.
  • Keep fish and lean meat and poultry portion to about 3 ounces (or the size of a deck of cards). Bake, broil, or grill it.
  • Eat foods that have less fat and salt.
  • Eat foods with more fiber such as whole grains cereals, breads, crackers, rice, or pasta.
• Get 30 to 60 minutes of physical activity on most days of the week. Brisk walking is a great way to move more.
• Stay at a healthy weight by using your meal plan and moving more.
• Ask for help if you feel down. A mental health counselor, support group, member of the clergy, friend, or family member who will listen to your concerns may help you feel better.
• Learn to cope with stress. Stress can raise your blood glucose (blood sugar). While it is hard to remove stress from your life, you can learn to handle it.
• Stop smoking. Ask for help to quit.
• Take medicines even when you feel good. Ask your doctor if you need aspirin to prevent a heart attack or stroke. Tell your doctor if you cannot afford your medicines or if you have any side effects.
• Check your feet every day for cuts, blisters, red spots, and swelling. Call your health care team right away about any sores that do not go away.
• Brush your teeth and floss every day to avoid problems with your mouth, teeth, or gums
• Check your blood glucose (blood sugar). You may want to test it one or more times a day. Keep a record of your blood glucose numbers. Be sure to take this record to your doctor visits.
• Check your blood pressure if your doctor advises.
• Report any changes in your eyesight to your doctor.

• Talk with your health care team about your blood glucose targets. Ask how and when to test your blood glucose and how to use the results to manage your diabetes.
• Use this plan as a guide to your self-care.
• Discuss how your self-care plan is working for you each time you visit your health care team.

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Step 4: Get Routine Care to Avoid Diabetes Health Problems

See your health care team at least twice a year to find and treat any problems early. Ask what steps you can take to reach your goals.

If you have diabetes, at each visit be sure you have a:

• blood pressure check
• foot check
• weight check
• review of your self-care plan shown in Step 3

If you have diabetes, two times each year get:

• A1C test - it may be checked more often if it is over 7

If you have diabetes, once each year be sure you have a:

• cholesterol test
• triglyceride test - a type of blood fat
• complete foot exam
• dental exam to check teeth and gums - tell your dentist you have diabetes
• dilated eye exam to check for eye problems
• flu shot
• urine and a blood test to check for kidney problems

If you have diabetes, at least once get a:

• Pneumonia shot

Ask your health care team about these and other tests you may need. Ask what the results mean.

Write down the date and time of your next visit.

Keep a record of your diabetes care.

If you have Medicare, ask your health care team if Medicare will cover some of the costs for

• learning about healthy eating and diabetes self-care
• special shoes, if you need them
• medical supplies
• diabetes medicines

Where to Get Help for Diabetes:

Many of these groups offer items in English and Spanish.

National Diabetes Education Program
1-800-438-5383
www.ndep.nih.gov

American Association of Diabetes Educators
1-800-TEAM-UP4 (800-832-6874)
www.diabeteseducator.org

American Diabetes Association
1-800-DIABETES (800-342-2383)
www.diabetes.org

American Dietetic Association
1-800-366-1655
www.eatright.org

American Heart Association
800-AHA-USA1 (800-242-8721)
www.americanheart.org

Centers for Disease Control and Prevention
1-877-232-3422
www.cdc.gov/diabetes

Centers for Medicare & Medicaid Services
1-800-MEDICARE (800-633-4227)
www.medicare.gov/health/diabetes.asp

National Institute of Diabetes and Digestive and Kidney Diseases
National Diabetes Information Clearinghouse
1-800-860-8747
www.niddk.nih.gov

It may seem that the solution is to put everyone with psychosis on Geodon and Abilify at first and then move to the more risky antipsychotics if needed. And in fact, that is what Dr. William Wilson, M.D., Professor of Psychiatry and Director, Inpatient Psychiatric Services Oregon Health and Science University recommends.

"I try to start at the bottom with the low metabolic risk drugs," says Dr. Wilson. "I then work my way up- so I start with Abilify, Geodon and Risperdal. I do this with bipolar disorder and schizophrenia, but it's not always possible as some drugs are sedating and some are agitating."

People respond to antipsychotics very, very differently. Some may get a great deal of relief from a drug with a low diabetes risk, while it may be ineffective for others. There is a trade-off. What if an antipsychotic drug with high diabetes risk is truly the best drug for someone? For example, Zyprexa has a very high metabolic syndrome risk and yet it's one of the most effective drugs for agitated psychosis as it has a strong sedating effect before it starts to work effectively. In contrast, Abilify has no known diabetes risk and yet it can be agitating and take time to work in the system.

If someone is acutely psychotic, it's easy to see why Zyprexa may be the first choice. Psychosis can significantly impair a person's ability to function on a basic level in society. Thus, dealing with the psychosis must come first and the risk of diabetes may have to come second.

But if a person is already on a high risk antipsychotic and has gained weight around the stomach, what are the solutions?

Diet and exercise are always the first step in treating weight gain associated with an antipsychotic. It may be possible to get the weight, especially around the stomach to a reasonable level so that a person can continue a medication that works for them. However, since this is not always possible, there are two options that a person can try along with weight management and exercise changes:

1. Talk with your prescriber about Metformin (glucophage), a drug used to help monitor type 2 diabetes blood sugar levels. Recent research has shown a connection between starting Metformin along with a high risk antipsychotic in order to minimize weight gain. This is still in the beginning stages but is definitely something to discuss with your healthcare professional.

2. Switching Antipsychotic Medications: The most effective way to reduce weight gain and thus metabolic syndrome risk from a high-risk antipsychotic is by switching to a less risky antipsychotic. Dr. Peter Weiden, Professor of Psychiatry, University of Illinois at Chicago, writes, "Switching to Geodon or Abilify is the most direct and effective way to reverse weight gain induced by other second-generation antipsychotics (atypicals)."

The problem, as always, is about access to healthcare. Switching takes time and careful monitoring until the person is stabilized on the new drug. It takes a commitment that may not always be possible if the person is psychotic or they are in social services. Dr. Weiden also notes that reducing the dosage isn't effective as it can lead to relapse. Not everyone is a candidate for switching, but it should always be explored if antipsychotic weight gain puts a person at risk for diabetes.

If you are unfamiliar with antipsychotics, my article, Psychosis 101, has a detailed description of the medications and how they work. The following information on diabetes risk in antipsychotic medications comes from two papers from the Journal of Clinical Psychiatry: Antipsychotic Medications: Metabolic and Cardiovascular Risk by Dr. John W. Newcomer and Switching Antipsychotics as a Treatment Strategy for Antipsychotic-Induced Weight Gain by Dr. Peter J. Weiden. Both researchers show conclusive evidence that the risk of diabetes from certain antipsychotics is high and must be addressed immediately within the entire healthcare community.

There are six atypical antipsychotics in use today:

• Clorazil (clozapine)
• Zyprexa (olanzipine)
• Seroquel (quetiapine)
• Risperdal (risperidone)
• Abilify (aripiprazole)
• Geodon (ziprasidone)

(a newer antipsychotic called Saphris was not a part of the metabolic syndrome studies cited in the article.)

Numerous and well-documented studies have shown a serious and potentially dangerous connection between certain second-generation antipsychotics and the risk of diabetes because of their connection to metabolic syndrome. Those atypical antipsychotics with the highest risk for developing diabetes are:

• Clorazil (clozapine)
• Zyprexa (olanzipine)

In a major NIMH study (the CATIE project), Zyprexa was associated with relatively severe metabolic effects. Subjects taking Zyprexa showed a major weight gain problem and increases in glucose, cholesterol, and triglycerides. The average weight gain over the 18-month study period was 44 pounds.

Medium risk antipsychotics are:

• Seroquel (quetiapine)
• Risperdal (risperidone)

Abilify and Geodon do not have a significant risk of metabolic syndrome and thus are not considered a diabetes risk (although the FDA has ordered all makers of antipsychotic drugs to include a warning about a possible link with diabetes on their product label). The term high-risk antipsychotics used throughout this article refers to Clozaril and Zyprexa and, in some cases, Seroquel and Risperdal.

Average Weight Gain From Atypical Antipsychotics

The percentages in the list below represent the typical long-term weight gain associated with each atypical antipsychotic drug. For example, a person who weighs 100 pounds before taking Zyprexa, on-average gains 28 pounds after starting the medication. Of course, all of these numbers are averages, but they are supported by numerous research studies.

Zyprexa (olanzipine) > (more than) 28% weight gain (High diabetes risk due to an increase in glucose levels. Zyprexa has the highest average weight gain of 2 lbs a month.)

Clozaril (clozapine) >28% weight gain ( High diabetes risk due to an increase in glucose levels.)

Seroquel (quetapine) > 23% (Not enough research to associate the weight gain from Seroquel to a high diabetes risk - though risk seems to be moderate as there can be significant weight gain.)

Risperdal (risperidone) > 18% (Risperdal can cause weight gain but is considered at a lower risk for causing diabetes.)

Geodon (ziprazidone) < 10% (Considered weight neutral. There is no known diabetes risk in Geodon and some studies have found that it improves metabolic variables.)

Abilify (aripiprazol) <8% (Considered weight neutral. There is no known diabetes risk with Abilify and in some cases has lead to mild weight loss.)

(ED. NOTE: The FDA ordered all pharmaceutical manufacturers to include in their product label that antipsychotics carry a risk of diabetes.)

The time it takes to gain the weight varies. For some, it's within a few months, for others it happens over years. Some of the weight gain stops at a certain point, while other drugs cause weight gain that continues until a person stops the drug. As mentioned before, this weight gain often happens without a change in diet or exercise for the patient, though it's also very common for the drugs to increase the appetite to an obsessive point and the person never feels satisfied after eating. In some cases, a person doesn't gain weight at all, in others, a person will keep gaining until they become morbidly obese.

Read why some atypical antipsychotic drugs can induce weight gain quickly and lead to the development of metabolic syndrome.

"When the second-generation antipsychotics, Clozaril and Zyprexa, first came out, we were excited because they didn't have the motor problems seen in the first generation drugs. I gave a speech in Eugene, Oregon in the late 90s where I talked about the new antipsychotics and how they caused less tardive dyskinesia. As I was talking, I heard laughter in the back of the room from some of the nurses. One of them said, "There are less motor side effects, but they are all porking up!" - Dr. William Wilson, M.D. Professor of Psychiatry and Director, Inpatient Psychiatric Services Oregon Health & Science University

Antipsychotics open a new world for those with psychiatric disorders. They promote clear thinking, improved functioning at work, better social interaction skills and are especially effective for those with thought disorders that affect their ability to function in society.

When the second-generation antipsychotics (SGAs), the atypical antipsychotics, hit the market in the 90s, enthusiasm was high because they carried a low risk of motor difficulty side-effects (tardive dyskinesia). But as Dr. Wilson says in the quote above, these SGAs came with an unexpected problem: excessive weight gain around the stomach.

Though weight gain is certainly a side effect of first-generation antipsychotic drugs such as Thorazine,  atypical antipsychotic medication-induced weight gain is very different as it happens quickly, goes straight to the stomach, often without a person changing their diet or exercise level ("Can You Prevent Diabetes and Metabolic Syndrome?").

Research eventually showed that this weight gain is directly related to insulin resistance. This specific insulin-related stomach fat leads to a myriad of risks for those who take the drugs including:

• heart disease
• stroke
• diabetes

When you combine all of these risk factors together, the result is the word you are now very familiar with: metabolic syndrome.

Why many with diabetes develop depression and how to treat depression associated with diabetes.

"At some point, over 50% of people with diabetes will have clinical depression. Currently, one-third of my patients are on antidepressants."

- Dr. Andrew Ahmann, Endocrinologist and Director of the Harold Schnitzer Diabetes Health Center at Oregon Health and Science University

It's well researched that those with diabetes are two times more likely to be depressed than the general population. It's not completely clear why people with diabetes develop depression. It's the common chicken and the egg situation that is often present when mental health is involved. This leads to the questions:

1. Does diabetes cause physiological depression due to hormonal changes involving insulin and neurotransmitters?
2. Or does the diagnosis of a serious and chronic illness lead to feelings of helplessness, sadness and a lack of interest in life that then turns into depression?

According to numerous studies, it's both. A person with diabetes may be more physiologically susceptible to depression though the connection is not clear, but there is a definite connection for many people regarding what's called reactive depression. In this case, the depression is a reaction to the diabetes diagnosis.

Reactive Depression

Those diagnosed with diabetes may have a higher risk of depression due to the pressure and worry of having a complicated, difficult to treat and possibly chronic illness. This can lead to fear, sadness and frustration. It also drastically changes life plans, dreams and goals. This is especially true for those who have to monitor their glucose levels throughout the day and adjust their insulin accordingly.

When this type of reactive depression happens, the desire to monitor glucose carefully goes down and the 'what's the point' feeling can seriously hamper a person's ability to monitor the illness carefully.

When the illness is not monitored diligently, the result can be serious physical and psychological complications from diabetes. Diabetes, especially insulin-dependent type I diabetes, completely changes a person's life. What was once commonplace, such as deciding what to eat or sitting at a three-hour baseball game with friends, becomes a complicated and stressful change in life that requires a commitment to diabetes management.

The first few months following a diagnosis can be very difficult, as it takes time for acceptance. Dr. Ahmann tells HealthyPlace.com, "I think that, for now, we can't say for sure what causes the depression. It's partly related to having to live with a chronic disease every day. If you look at people without diabetes, they probably feel they are handling as much as they can. They may already feel overwhelmed. When you add diabetes it gets much worse. Every time you exercise, eat, or get upset, you have to monitor your blood sugar. There is no question that we expect there to be some physiological issue with depression separate from just feeling overwhelmed, but we are just not sure what it is." The reactive depression theory is supported by similar research regarding cancer diagnoses and depression.

Here is how Joe, a 45-year-old man with childhood-onset diabetes type 1 describes the difficulty of diabetes management:

"I have to think of diabetes 24 hours a day. Sometimes I think about the people at work who can just have lunch and talk with colleagues. I feel I miss critical conversations and networking because I have to go to the bathroom and test and shoot up and I have trouble getting forward at work.

Most people go to the meetings where you meet new people and you build relationships and I get so little opportunity to do that. There is not a solution to this. It makes me depressed. I then have to make extra time to build relationships.

When you're working for other people, it's the expectation that you are there for networking. If I were at a conference and one of my folks was constantly absent during a critical time, I would be upset. That's the depressing fact that there is very little I can do. If there's a mid-morning break, that's my chance to check my blood levels and by the time I get back, people are sitting down and I've missed a conversation." (Joe talks more about his diabetes and how he found a solution to many of his diabetes complications in section three.)

No matter what the reason, a person with diabetes has a higher risk of depression. The goal is to manage the depression so that a person with diabetes can take care of themselves physically.

Both type 1 and type 2 diabetes have serious complications that can lead to heart disease, stroke, nerve damage, even death.

If the section on the warning signs and symptoms of diabetes didn't raise your level of concern regarding diabetes, this section will. Diagnosed diabetes, especially if ineffectively managed, leads to a very large number of physical complications. The following takes you through the possible short-term and long-term complications of diabetes. These vary depending on whether the person has type 1 diabetes or type 2 diabetes.

Diabetes is associated with long-term complications that affect almost every part of the body. The disease often leads to blindness, heart and blood vessel disease, stroke, kidney failure, amputations, and nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes.

In 2007, diabetes cost the United States $174 billion. Indirect costs, including disability payments, time lost from work, and reduced productivity, totaled $58 billion. Direct medical costs for diabetes care, including hospitalizations, medical care, and treatment supplies, totaled $116 billion.

Short-term Diabetes Complications

• Diabetic Ketoacidosis - The body begins to break down fat if the cells are starved for energy. This can produce toxic acids called ketones which can cause heart, brain and central nervous system damage.

• Hyperglycemia (high blood sugar) - When you have a high concentration of sugar in your blood, it affects your body's ability to do its job effectively. Sustained high levels of blood sugar can lead to amputations, nerve damage, blindness, heart and kidney disease.

• Hypoglycemia (low blood sugar) - Your brain and body need glucose to function. If your blood sugar is too low, the result can be unconsciousness, seizures and even death.

Long-term Diabetes Complications

Heart Disease and Stroke

75% of people with diabetes will die of heart disease or stroke, and according to the American Diabetes Association, they are more likely to die at a younger age than people who don't have diabetes. Diabetics have the same cardiovascular risk as those who have already had a heart attack. In addition, they are 2-4 times more likely to suffer a stroke.

Diabetic Neuropathy and Nerve Damage

One of the most common complications of diabetes is diabetic neuropathy. Neuropathy means damage to the nerves that run throughout the body, connecting the spinal cord to muscles, skin, blood vessels, and other organs. About half of all people with diabetes have some form of nerve damage.

The symptoms of diabetic neuropathy usually start with tingling, numbness, burning or pain that begins at the tips of the toes or fingers and over a period of months or years gradually spreads upward. If it isn't treated, a diabetic could lose all sense of feeling in the affected limbs. Damage to the nerves related to digestion can cause problems with nausea, vomiting, diarrhea or constipation. For men, it may lead to problems with erectile dysfunction.

Kidney Disease (nephropathy)

Diabetes can damage the kidneys and cause them to fail. Failing kidneys lose their ability to filter out waste products, resulting in kidney disease; requiring the diabetic to undergo dialysis or a kidney transplant.

About 10-21 percent of people with diabetes develop kidney disease. Factors that can influence kidney disease development include genetics, blood sugar control, and blood pressure.

The better a person keeps diabetes and blood pressure under control, the lower the chance of getting kidney disease.

Eye Damage and Blindness (diabetic retinopathy)

Diabetes can damage the retina. Each year, 12-24,000 people lose their sight because of diabetes. Diabetes is the leading cause of new blindness cases in people, ages 20-74.

Diabetes and Foot Complications

Foot problems occur when there is nerve damage or poor blood flow to the feet caused by artery disease. Left untreated, you can lose feeling in your feet and cuts and blisters can become serious infections. Severe damage might require toe, foot or even leg amputation.

• Nerve Disease and Amputations: About 60 to 70 percent of people with diabetes have mild to severe forms of diabetes-related nerve damage, which can lead to lower limb amputations. In fact, diabetes is the most frequent cause of non-traumatic lower limb amputations. The risk of a leg amputation is 15 to 40 times greater for a person with diabetes. Each year, 82,000 people lose their foot or leg to diabetes.
• Impotence due to diabetic neuropathy or blood vessel blockage: Impotence afflicts approximately 13 percent of men who have type 1 diabetes and eight percent of men who have type 2 diabetes. It has been reported that men with diabetes, over the age of 50 have impotence rates as high as 50 to 60 percent.

600 People a Day Die from DIabetes Complications

These statistics are scary, but not inevitable. In fact, as you will discover throughout this article, a change in diet and exercise alone can have a huge impact on the risk of diabetes complications.

Diabetes is widely recognized as one of the leading causes of death and disability in the United States. In 2006, it was the seventh leading cause of death. However, diabetes is likely to be underreported as the underlying cause of death on death certificates. In 2004, among people ages 65 years or older, heart disease was noted on 68 percent of diabetes-related death certificates; stroke was noted on 16 percent of diabetes-related death certificates for the same age group.

Source: NDIC

Learn about prediabetes, the last step before a diabetes diagnosis. Especially important for people taking antipsychotic medication. Also, info on insulin resistance and what the glucose test numbers really mean.

Type 1 diabetes comes on full force and immediately needs insulin; it's not a given that type 2 diabetes will show up with the same intensity. In fact, there are two stages that a person passes through before receiving a type 2 diabetes diagnosis:

1. insulin resistance
2. prediabetes

Prediabetes

People with prediabetes, a state between "normal" and "diabetes," are at a higher risk for developing diabetes, heart attacks, and strokes. This is very important information because those at risk of diabetes from high-risk antipsychotic drugs start with prediabetes. The main risk factor and sign of prediabetes in those with a psychiatric disorder is being overweight, especially around the middle. 

Insulin Resistance

When a person is insulin resistant, the pancreas is usually producing enough insulin, but for unknown reasons, the body cannot use it effectively. Insulin resistance is closely related to excess fat in the belly. If untreated, insulin production eventually decreases and a person is diagnosed with type 2 diabetes. It's thought that the stomach fat weight gain associated with high-risk antipsychotics is due to insulin resistance. If a person does have a high blood sugar rating, it's assumed that insulin resistance is present as well.

One important problem to note is that those with insulin resistance and/or prediabetes may not have any diabetes symptoms except for a higher than normal, though not dangerous, blood glucose level.

Learn about hypoglycemia causes, low blood glucose levels, low blood sugar symptoms and hypoglycemia treatment.

What is Low Blood Glucose?

Low blood glucose, also called hypoglycemia (HY-poh-gly-SEE-mee-uh), is when your blood glucose is lower than normal. Blood glucose is too low when it's below 80 mg/dL. If you don't eat or drink something to bring your blood glucose level back to normal, you could pass out. Then you might need emergency treatment at a hospital. If you have low blood glucose several times a week, tell your diabetes doctor or diabetes educator. You might need a change in your diabetes medicines, meal plan, or activity routine.

Hypoglycemia Causes

Diabetes Medicines

Some diabetes medicines can cause low blood glucose if there isn't a balance between your medicines, food, and activity. Ask your doctor whether your diabetes medicines can cause hypoglycemia.

Other diabetes medicines do not cause low blood glucose on their own. But when they are taken with certain other diabetes medicines, they can increase the risk of low blood glucose.

Other Causes of Low Blood Glucose

Low blood glucose can happen if you skip or delay a meal, eat too little at a meal, get more exercise than usual, or drink alcoholic beverages on an empty stomach.

Low Blood Sugar Symptoms

Low blood glucose can make you feel:

• hungry
• dizzy
• nervous
• shaky
• sweaty
• sleepy
• confused
• anxious
• weak

Low blood glucose can also happen while you sleep. You might cry out or have nightmares, sweat a lot, feel tired or confused when you wake up or have a headache when you wake up.

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Hypoglycemia Treatment

For treatment of low blood sugar, follow these steps:

1. If you feel like your blood glucose is low, check your blood glucose level with your blood glucose meter.
2. If your blood glucose is below 80 mg/dL, have a serving of a "quick fix" food or drink right away. See the list of Quick-fix Foods and Drinks for Low Blood Glucose below. If you can't check your blood glucose but you feel like your blood glucose level is low, have something from the quick-fix list.
3. After 15 minutes, check your blood glucose again. If it's still below 80 mg/dL, have another serving of a quick-fix food or drink.
4. Check your blood glucose again 15 minutes later. If it's 80 mg/dL or above, you'll feel better soon. If your blood glucose is still low, have another serving of a quick-fix food or drink. Keep doing so until your blood glucose is 80 mg/dL or above.
5. When your blood glucose has reached 80 mg/dL or above, think about when your next meal will be. If it will be more than an hour before your next meal, have a snack.

Quick-fix Foods and Drinks for Low Blood Glucose

• 3 or 4 glucose tablets
• 1 serving of glucose gel—the amount equal to 15 grams of carbohydrate
• 1/2 cup (4 ounces) of any fruit juice
• 1/2 cup (4 ounces) of a regular—not diet—soft drink
• 1 cup (8 ounces) of milk
• 5 or 6 pieces of hard candy
• 1 tablespoon of sugar or honey

Always carry a quick-fix food or drink. You also can keep quick-fix foods in your car, at work, or wherever you go. Then you'll be ready to take care of yourself if your blood glucose dips too low.

In-depth look at increasing the effectiveness of antidepressants for relief of depression symptoms, treatment strategies for treatment-resistant depression.

Importance of Continuation of Treatment

There is a period of time following the relief of depression symptoms during which discontinuation of the antidepressant treatment would likely result in a depression relapse. The NIMH Depression Collaboration Research Program found that four months of treatment with antidepressant medication or cognitive behavioral and interpersonal psychotherapy is insufficient for most depressed patients to fully recover and enjoy lasting remission. Their 18-month follow-up after a course of treatment found depression relapses of between 33 and 50 percent of those initially responding to a short-term treatment.

The currently available data on the continuation of treatment indicate that patients treated for the first episode of uncomplicated depression who exhibit a satisfactory response to an antidepressant should continue to receive a full therapeutic dose of that antidepressant medication for at least 6-12 months after achieving full remission. The first eight weeks after symptom resolution is a period of particularly high vulnerability to relapse. Patients with recurrent depression, dysthymia or other complicating features may require a more extended course of treatment.

Refractory Depression, Treatment-Resistant Depression

Refractory depression (aka treatment-resistant depression) occurs in as many as 10 to 30 percent of depressive episodes, affecting nearly a million patients. Katherine A. Phillips, M.D. (a 1992 NARSAD Young Investigator) has found that failure to provide adequate doses of medication for sufficient periods of time is perhaps the most common cause of apparent treatment resistance. Once the clinician has determined that a patient is truly treatment-refractory, many treatment approaches can be tried. Phillips recommends the following treatment strategies for refractory depression:

• Augmentation with lithium, and perhaps other agents
• Combining antidepressants
• Switching antidepressants

Antidepressant Augmentation Strategy

Lithium: Efficacy has been reported when lithium is added to existing antidepressants, with a reported response rate of 30 to 65 percent. However, what constitutes an adequate dose and blood level is unclear.

Thyroid hormone: It appears that triiodothyronine (T3) sometimes accelerates response to, and increases the efficacy of tricyclic antidepressants, with a reported response rate of about 25%.

Psychostimulants: Although evidence for the efficacy of this strategy is weak, stimulants are of value in depressed patients with adult attention-deficit hyperactivity disorder a diagnosis that can easily be missed and they may be of value in yet-to-be-defined subpopulations of patients with refractory depression, such as the medically ill and elderly.

Combining Antidepressants Strategy

SSRIs with tricyclics: Several studies have shown a good response when fluoxetine is added to tricyclics and when tricyclics are added to fluoxetine. It is important to monitor tricyclic levels because fluoxetine can raise tricyclic levels by 4- to 11- fold and thereby cause tricyclic toxicity.

SSRIs with trazodone: Trazodone may be worth trying either alone or in combination with fluoxetine or tricyclics if other approaches have failed.

Switching Antidepressants

When switching antidepressants, it is probably best to switch from one antidepressant class to another since most patients who fail to respond to one adequate tricyclic trial will be resistant to other tricyclics. There are many treatment strategies for refractory depression, but relatively few are derived from controlled studies. In particular, studies that compare different treatment strategies are limited. At this time, treatment approaches for refractory patients are based largely on clinical experience and must be highly individualized.

Summary

There has been impressive progress in the understanding and treatment of depression in the past three decades; however, a number of important issues remain. Although we have gained important clues as to the causes and mechanisms underlying depression, the precise biological and psychological determinants are unknown. In 20 to 30 percent of patients, current treatments are inadequate, and even among patients who respond initially, relapse is not uncommon.

NOTE: You should always check with your doctor before making any changes in your medications.

Source: Information for this article came from "Practice Guidelines for Major Depressive Disorder in Adults", in the Supplement of the American Journal of Psychiatry.