Diabetes and Mental Health

Abstract

Key Messages•The experience of living with diabetes is often associated with concerns specific to the illness and can cause conditions, such as diabetes distress, psychological insulin resistance and the persistent fear of hypoglycemic episodes.•A wide range of psychiatric disorders, including major depressive disorder, bipolar and related disorders, schizophrenia spectrum and other psychotic disorders, anxiety disorders, sleep disorders, eating disorders and stress-related disorders are more prevalent in people with diabetes compared to the general population.•People living with diabetes and depressive disorders are at increased risk for earlier all-cause mortality compared to people living with diabetes without a history of depression.•All individuals with diabetes should be regularly screened for the presence of diabetes distress, as well as symptoms of common psychiatric disorders.•Compared to those with diabetes only, individuals with diabetes and mental health concerns have decreased participation in diabetes self-care, a decreased quality of life, increased functional impairment, increased risk of complications associated with diabetes, and increased health-care costs.•Cognitive behaviour therapy, patient-centred approaches (e.g. motivational interviewing), stress management, coping skills training, family therapy and collaborative case management should be incorporated into primary care. Self-management skills, educational interventions that facilitate adaptation to diabetes, addressing co-occurring mental health issues, reducing diabetes-related distress, fear of hypoglycemia, and psychological insulin resistance are all helpful.•Individuals taking psychiatric medications, particularly (but not limited to) atypical antipsychotics, benefit from regular screening of metabolic parameters to identify glucose dysregulation, dyslipidemia and weight gain throughout the course of the illness so that appropriate interventions can be instituted.Key Messages for People with Diabetes•Living with diabetes can be burdensome and anxiety provoking, with the constant demands taking a psychological toll. As a result, many people experience distress, decreased mood and disabling levels of anxiety. Diabetes is often associated with a significant emotional burden, distress over the self-care regimen and stress in relationships (with family and friends, as well as health-care providers).•It is important to recognize your emotions and talk to your friends, family and members of your diabetes health-care team about how you are feeling. Your team can help you to learn effective coping skills and direct you to support services that can make a difference for you.•Mood and anxiety disorders are particularly common in people with diabetes. Eating, sleeping and stress-related disorders are also common. Speak to your health-care providers about any concerns you have if you think you may be developing any of these problems.•Mental health disorders can affect your ability to cope with and care for your diabetes. In view of this, it is just as important to look after your mental health as it is your physical health.•People diagnosed with serious mental illnesses, such as major depressive disorder, bipolar disorder and schizophrenia, have a higher risk of developing diabetes than the general population. •The experience of living with diabetes is often associated with concerns specific to the illness and can cause conditions, such as diabetes distress, psychological insulin resistance and the persistent fear of hypoglycemic episodes.•A wide range of psychiatric disorders, including major depressive disorder, bipolar and related disorders, schizophrenia spectrum and other psychotic disorders, anxiety disorders, sleep disorders, eating disorders and stress-related disorders are more prevalent in people with diabetes compared to the general population.•People living with diabetes and depressive disorders are at increased risk for earlier all-cause mortality compared to people living with diabetes without a history of depression.•All individuals with diabetes should be regularly screened for the presence of diabetes distress, as well as symptoms of common psychiatric disorders.•Compared to those with diabetes only, individuals with diabetes and mental health concerns have decreased participation in diabetes self-care, a decreased quality of life, increased functional impairment, increased risk of complications associated with diabetes, and increased health-care costs.•Cognitive behaviour therapy, patient-centred approaches (e.g. motivational interviewing), stress management, coping skills training, family therapy and collaborative case management should be incorporated into primary care. Self-management skills, educational interventions that facilitate adaptation to diabetes, addressing co-occurring mental health issues, reducing diabetes-related distress, fear of hypoglycemia, and psychological insulin resistance are all helpful.•Individuals taking psychiatric medications, particularly (but not limited to) atypical antipsychotics, benefit from regular screening of metabolic parameters to identify glucose dysregulation, dyslipidemia and weight gain throughout the course of the illness so that appropriate interventions can be instituted. •Living with diabetes can be burdensome and anxiety provoking, with the constant demands taking a psychological toll. As a result, many people experience distress, decreased mood and disabling levels of anxiety. Diabetes is often associated with a significant emotional burden, distress over the self-care regimen and stress in relationships (with family and friends, as well as health-care providers).•It is important to recognize your emotions and talk to your friends, family and members of your diabetes health-care team about how you are feeling. Your team can help you to learn effective coping skills and direct you to support services that can make a difference for you.•Mood and anxiety disorders are particularly common in people with diabetes. Eating, sleeping and stress-related disorders are also common. Speak to your health-care providers about any concerns you have if you think you may be developing any of these problems.•Mental health disorders can affect your ability to cope with and care for your diabetes. In view of this, it is just as important to look after your mental health as it is your physical health.•People diagnosed with serious mental illnesses, such as major depressive disorder, bipolar disorder and schizophrenia, have a higher risk of developing diabetes than the general population. Research has shown an increasingly clear relationship between diabetes and a variety of mental health issues. These include diagnosable psychiatric disorders, and other problems that are specific to the experience of living with diabetes. “Diabetes distress” refers to the negative emotions and burden of self-management related to living with diabetes. This term is used to describe the despondency and emotional turmoil specifically related to living with diabetes, in particular the need for continual monitoring and treatment, persistent concerns about complications, and the potential erosion of personal and professional relationships (1Hagger V. Hendrieckx C. Sturt J. et al.Diabetes distress among adolescents with type 1 diabetes: A systematic review.Curr Diab Rep. 2016; 16: 9Crossref PubMed Scopus (23) Google Scholar, 2Polonsky W.H. Fisher L. Earles J. et al.Assessing psychosocial distress in diabetes: Development of the diabetes distress scale.Diabetes Care. 2005; 28: 626-631Crossref PubMed Scopus (405) Google Scholar). “Psychological insulin resistance” is the reluctance or refusal to initiate insulin therapy, which may delay the start of a necessary treatment for a period of time (3Polonsky W.H. Hajos T.R. Dain M.P. et al.Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population.Curr Med Res Opin. 2011; 27: 1169-1174Crossref PubMed Scopus (55) Google Scholar). Fear of hypoglycemia is another common diabetes-specific concern. The presence of psychiatric and diabetes-specific psychosocial issues is associated with reduced participation in self-management activities and can lead to a decrease in quality of life. Psychiatric disorders among individuals with diabetes increases the risk of diabetes complications and early mortality (4Egede L.E. Nietert P.J. Zheng D. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes.Diabetes Care. 2005; 28: 1339-1345Crossref PubMed Scopus (275) Google Scholar). Diabetes is a demanding chronic disease for both individuals and their families (5Snoek F.J. Kersch N.Y. Eldrup E. et al.Monitoring of Individual Needs in Diabetes (MIND): Baseline data from the Cross-National Diabetes Attitudes, Wishes, and Needs (DAWN) MIND study.Diabetes Care. 2011; 34: 601-603Crossref PubMed Scopus (56) Google Scholar). It is associated with a number of challenges, including adjusting to a new diagnosis, diabetes distress impairing self-management, psychological insulin resistance, and fear of hypoglycemia. In addition, a range of psychiatric disorders can arise that contributes to greater complexity in both assessment and treatment. For instance, distinguishing between diabetes distress, major depressive disorder (MDD) and the presence of depressive symptoms is important. Although these constructs have some shared symptomatology, diabetes distress has been most shown to have the strongest effect in causing adverse diabetes outcomes (6Fisher L. Skaff M.M. Mullan J.T. et al.Clinical depression versus distress among patients with type 2 diabetes: Not just a question of semantics.Diabetes Care. 2007; 30: 542-548Crossref PubMed Scopus (247) Google Scholar, 7Gonzalez J.S. Fisher L. Polonsky W.H. Depression in diabetes: Have we been missing something important?.Diabetes Care. 2011; 34: 236-239Crossref PubMed Scopus (100) Google Scholar, 8Fisher L. Glasgow R.E. Strycker L.A. The relationship between diabetes distress and clinical depression with glycemic control among patients with type 2 diabetes.Diabetes Care. 2010; 33: 1034-1036Crossref PubMed Scopus (124) Google Scholar, 9Fisher L. Mullan J.T. Arean P. et al.Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses.Diabetes Care. 2010; 33: 23-28Crossref PubMed Scopus (247) Google Scholar) (Table 1).Table 1Comparison of main features and assessment methods: diabetes distress vs. major depressive disorderDiabetes DistressMajor Depressive DisorderAssessment InstrumentDiabetes Distress Scale (17 items) 2Polonsky W.H. Fisher L. Earles J. et al.Assessing psychosocial distress in diabetes: Development of the diabetes distress scale.Diabetes Care. 2005; 28: 626-631Crossref PubMed Scopus (405) Google ScholarPatient Health Questionnaire for Depression: PHQ-9 (9 items) 167Kroenke K. Spitzer R.L. The PHQ-9: A new depression diagnostic and severity measure.Psychiatr Ann. 2002; 32: 509-515https://www.healio.com/psychiatry/journals/psycann/2002-9-32-9/{b9ab8f2c-53ce-4f76-b88e-2d5a70822f69}/the-phq-9-a-new-depression-diagnostic-and-severity-measureCrossref Google Scholar, 168van Steenbergen-Weijenburg K.M. de Vroege L. Ploeger R.R. et al.Validation of the PHQ-9 as a screening instrument for depression in diabetes patients in specialized outpatient clinics.BMC Health Serv Res. 2010; 10: 235Crossref PubMed Scopus (68) Google ScholarFormatSelf-report using ratings from 1 to 6 based on feelings and experiences over the past weekSelf-report using ratings from 0 to 3 based on feelings and experiences over the past 2 weeksFeaturesEmotional Burden Subscale (5 items)Physician-Related Distress Subscale (4 items)Regimen-Related Distress Subscale (5 items)Diabetes-Related Interpersonal Distress Subscale (3 items)Vegetative symptoms, such as sleep, appetite and energy level changesEmotional symptoms, such as low mood and reduced enjoyment of usual activitiesBehavioural symptoms, such as agitation or slowing of movementsCognitive symptoms, such as poor memory or reduced concentration or feelings of guilt; thoughts of self-harmCBT, cognitive behavioural therapy. Open table in a new tab CBT, cognitive behavioural therapy. Diabetes distress is comprised of 4 interconnected domains, which include: 1) the emotional burden of living with diabetes; 2) the distress associated with the diabetes self-management regimen; 3) the stress associated with social relationships; and 4) the stress associated with the patient-provider relationship. Diabetes distress is associated with elevated glycated hemoglobin (A1C levels), higher diastolic blood pressure (BP) and increased low-density lipoprotein cholesterol (LDL-C) levels (10Winchester R.J. Williams J.S. Wolfman T.E. et al.Depressive symptoms, serious psychological distress, diabetes distress and cardiovascular risk factor control in patients with type 2 diabetes.J Diabetes Complications. 2016; 30: 312-317Abstract Full Text Full Text PDF PubMed Google Scholar, 11Strandberg R.B. Graue M. 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Skriver M.V. et al.Psychological distress, cardiovascular complications and mortality among people with screen-detected type 2 diabetes: Follow-up of the ADDITION-Denmark trial.Diabetologia. 2014; 57: 710-717Crossref PubMed Google Scholar), and have lower quality of life (14Carper M.M. Traeger L. Gonzalez J.S. et al.The differential associations of depression and diabetes distress with quality of life domains in type 2 diabetes.J Behav Med. 2014; 37: 501-510Crossref PubMed Scopus (15) Google Scholar). Risk factors for developing diabetes distress include being younger, being female, having lower education, living alone, having a higher body mass index (BMI), lower perceived self-efficacy, lower perceived provider support, poorer quality diet, greater perceived impact of glycemic excursions and greater number of diabetes complications (15Pintaudi B. Lucisano G. Gentile S. et al.Correlates of diabetes-related distress in type 2 diabetes: Findings from the benchmarking network for clinical and humanistic outcomes in diabetes (BENCH-D) study.J Psychosom Res. 2015; 79: 348-354Abstract Full Text Full Text PDF PubMed Google Scholar, 16Wardian J. Sun F. Factors associated with diabetes-related distress: Implications for diabetes self-management.Soc Work Health Care. 2014; 53: 364-381Crossref PubMed Google Scholar). Psychological insulin resistance refers to a strong negative response to the recommendation from health-care providers that a person may benefit from adding insulin to his or her diabetes regimen. This can be a common reaction, particularly for individuals with type 2 diabetes who may have previously been successfully managed with noninsulin antihyperglycemic agents. Individuals may hold maladaptive beliefs that requiring insulin is a sign of personal failure in their self-management, or that their illness has become much more serious. Further, many people report fear and anxiety about having to self-administer injections, or have a low level of confidence in their ability to manage their blood glucose with insulin (17Bahrmann A. Abel A. Zeyfang A. et al.Psychological insulin resistance in geriatric patients with diabetes mellitus.Patient Educ Couns. 2014; 94: 417-422Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 18Holmes-Truscott E. Skinner T.C. Pouwer F. et al.Explaining psychological insulin resistance in adults with non-insulin-treated type 2 diabetes: The roles of diabetes distress and current medication concerns. Results from Diabetes MILES-Australia.Prim Care Diabetes. 2016; 10: 75-82Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). Fear of hypoglycemia is a common occurrence. Hypoglycemic experiences, especially serious or nocturnal episodes, can be traumatic for both individuals and their family members. A common strategy to minimize fears of hypoglycemia is compensatory hyperglycemia, where individuals either preventatively maintain a higher blood glucose (BG) level, or treat hypoglycemia in response to perceived somatic symptoms without objective confirmation by capillary blood glucose concentrations (19Hendrieckx C. Halliday J.A. Bowden J.P. et al.Severe hypoglycaemia and its association with psychological well-being in Australian adults with type 1 diabetes attending specialist tertiary clinics.Diabetes Res Clin Pract. 2014; 103: 430-436Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 20Nefs G. Bevelander S. Hendrieckx C. et al.Fear of hypoglycaemia in adults with Type 1 diabetes: Results from Diabetes MILES—The Netherlands.Diabet Med. 2015; 32: 1289-1296Crossref PubMed Google Scholar, 21Polonsky W.H. Fisher L. 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Diabetes management strategies ideally incorporate a means of addressing the psychosocial factors that impact on individuals and their families. Both symptom measures (e.g. self-report measures of various symptoms) and methods to arrive at psychiatric diagnoses (e.g. structured interviews leading to Diagnostic and Statistical Manual of Mental Disorders Fifth Edition [DSM-5 diagnoses] (30American Psychiatric Association Diagnostic and statistical manual of mental disorders.5th edn. American Psychiatric Association, Arlington2013Crossref Google Scholar) have been assessed. Given that the person with diabetes is directly responsible for 95% of diabetes management (31Anderson R.M. 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Dain M.P. et al.Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population.Curr Med Res Opin. 2011; 27: 1169-1174Crossref PubMed Scopus (55) Google Scholar). Depression in people with diabetes amplifies symptom burden by a factor of about 4 (49Ludman E.J. Katon W. Russo J. et al.Depression and diabetes symptom burden.Gen Hosp Psychiatry. 2004; 26: 430-436Crossref PubMed Scopus (0) Google Scholar). Episodes of depression in individuals with diabetes are likely to last longer and have a higher chance of recurrence compared to those without diabetes (50Peyrot M. Rubin R.R. Persistence of depressive symptoms in diabetic adults.Diabetes Care. 1999; 22: 448-452Crossref PubMed Google Scholar). Episodes of severe hypoglycemia have been correlated with the severity of depressive symptoms (51Kikuchi Y. Iwase M. 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Clouse R.E. et al.The prevalence of comorbid depression in adults with diabetes: A meta-analysis.Diabetes Care. 2001; 24: 1069-1078Crossref PubMed Google Scholar, 54Li C. Ford E.S. Zhao G. et al.Prevalence and correlates of undiagnosed depression among U.S. adults with diabetes: The Behavioral Risk Factor Surveillance System, 2006.Diabetes Res Clin Pract. 2009; 83: 268-279Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar). One study found that the requirement for insulin was the factor associated with the highest rate of depression, regardless of the type of diabetes involved (55Katon W.J. Simon G. Russo J. et al.Quality of depression care in a population-based sample of patients with diabetes and major depression.Med Care. 2004; 42: 1222-1229Crossref PubMed Google Scholar). Treatment with metformin may enhance recovery from MDD (56Guo M. Mi J. Jiang Q.M. et al.Metformin may produce antidepressant effects through improvement of cognitive function among depressed patients with diabetes mellitus.Clin Exp Pharmacol Physiol. 2014; 41: 650-656PubMed Google Scholar). Risk factors for developing depression in individuals with diabetes are as follows (57Eaton W.W. Shao H. Nestadt G. et al.Population-based study of first onset and chronicity in major depressive disorder.Arch Gen Psychiatry. 2008; 65: 513-520Crossref PubMed Scopus (235) Google Scholar, 58Kendler K.S. Karkowski L.M. Prescott C.A. Causal relationship between stressful life eve