Diabetes and Mental Health

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

David J. Robinson MD, FRCPC, FAPA Meera Luthra MD, FRCPC Michael Vallis PhD, RPsych

  • Key Messages
  • Recommendations
  • Figures
  • Full Text
  • References

Key Messages

  • Psychiatric disorders, particularly major depressive disorder (MDD), generalized anxiety disorder and eating disorders, are more prevalent in people with diabetes compared to the general population.
  • People diagnosed with serious mental illnesses, such as MDD, bipolar disorder and schizophrenia, have a higher risk of developing diabetes than the general population.
  • All individuals with diabetes should be regularly screened for the presence of depressive and anxious symptoms.
  • Compared to those with diabetes only, individuals with diabetes and mental health disorders have decreased medication adherence, decreased compliance with diabetes self-care, increased functional impairment, increased risk of complications associated with diabetes, increased healthcare costs and an increased risk of early mortality.
  • The following treatment modalities should be incorporated into primary care and self-management education interventions to facilitate adaptation to diabetes, reduce diabetes-related distress and improve outcomes: motivational interventions, stress management strategies, coping skills training, family therapy and collaborative case management.
  • Individuals taking psychiatric medications, particularly atypical antipsychotics, benefit from regular screening of metabolic parameters.

Introduction

Research is increasingly demonstrating a relationship between mental health disorders and diabetes. Patients with serious mental illnesses, particularly those with depressive symptoms or syndromes, and patients with diabetes share reciprocal susceptibility and a high degree of comorbidity ( Figure 1).

The mechanisms behind these relationships are multifactorial. Some evidence shows that treatment for mental health disorders may actually increase the risk of diabetes, particularly when second-generation (atypical) antipsychotic agents are prescribed (1). Biochemical changes due to the mental health disorders themselves also may play a role (2). Lifestyle changes and symptoms of mental health disorders are also likely to contribute (3).

Depression

The prevalence of clinically relevant depressive symptoms among patients with diabetes is in the range of 30% (4–6). The prevalence of major depressive disorder (MDD) is approximately 10% (7,8) , which is double the overall prevalence in people without a chronic medical illness. Individuals with depression have an approximately 60% increased risk of developing type 2 diabetes (9). The prognosis for comorbid depression and diabetes is worse than when each illness occurs separately (10). Depression in patients with diabetes amplifies symptom burden by a factor of about 4 (11). Episodes of MDD in individuals with diabetes are likely to last longer and have a higher chance of recurrence compared to those without diabetes (12).

Studies examining differential rates for the prevalence of depression in type 1 vs. type 2 diabetes have yielded inconsistent results (4,13). 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 (14).

Risk factors for developing depression in individuals with diabetes are as follows:

  • Female gender
  • Adolescents/young adults and older adults
  • Poverty
  • Few social supports
  • Stressful life events
  • Poor glycemic control, particularly with recurrent hypoglycemia
  • Longer duration of diabetes
  • Presence of long-term complications (15–19)

Risk factors (with possible mechanisms) for developing diabetes in patients with depression are as follows:

  • Physical inactivity and obesity, which leads to insulin resistance, and
  • Psychological stress, leading to chronic hypothalamic-pituitary-adrenal activation with cortisol release (20–25).

Comorbid depression worsens clinical outcomes in diabetes, possibly because the accompanying lethargy lowers motivation for self-care, resulting in lowered physical and psychological fitness, higher use of healthcare services and reduced adherence to medication regimens (26,27). Depression also appears to worsen cardiovascular mortality (28,29). Treating depressive symptoms more reliably improves mood than it does glycemic control (30–33).

Bipolar Disorder

Patients with bipolar disorder have been found to have prevalence rates estimated to be double that of the general population for metabolic syndrome and triple for diabetes (34–36).

Figure 1
The interplay between diabetes, major depressive disorder, and other psychiatric conditions.

Anxiety

Anxiety is commonly comorbid with depressive symptoms (37). One study estimated that 14% of individuals with diabetes suffered from generalized anxiety disorder, with double this figure experiencing a subclinical anxiety disorder and triple this figure having at least some anxiety symptoms (38).

Eating Disorders

Eating disorders, such as anorexia nervosa, bulimia nervosa and binge eating, have been found to be more common in individuals with diabetes (both type 1 and type 2) than in the general population (39,40). Depressive symptoms are highly comorbid with eating disorders, affecting up to 50% of patients (41). Type 1 diabetes in young adolescent women appears to be a risk factor for development of an eating disorder, both in terms of an increased prevalence of established eating disorder features (42,43) as well as through deliberate insulin omission or underdosing (called diabulimia). Night eating syndrome (NES) has been noted to occur in individuals with type 2 diabetes who have depressive symptoms. This is characterized by the consumption of >25% of daily caloric intake after the evening meal and waking at night to eat, on average, at least 3 times per week. NES can result in weight gain, poor glycemic control and an increased number of diabetic complications (44).

Schizophrenia

Schizophrenia (SZ) and other psychotic disorders may contribute an independent risk factor for diabetes. People diagnosed with psychotic disorders were reported to have had insulin resistance/glucose intolerance prior to the advent of antipsychotic medication; however, this matter is still open to debate (45,46). The Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE) study found, at baseline, that of the individuals with SZ who participated in the study, 11% had diabetes (type 1 and 2 combined) (1). The prevalence of metabolic syndrome was approximately twice that of the general population (47). Whether the increased prevalence of diabetes is due to the effect of the illness, antipsychotic medications or other factors, individuals with psychotic disorders represent a particularly vulnerable population.

Monitoring Metabolic Risks

Patients with diabetes and comorbid psychiatric illnesses are at an elevated risk for developing metabolic syndrome, possibly due to a combination of the following factors (48) :

  • Patient factors (e.g. lifestyle choices, diet, tobacco consumption, substance use, exercise, obesity, low degree of implementation of education programs)
  • Illness factors (e.g. proinflammatory states from MDD or depressive symptoms, possible disease-related risks for developing diabetes) (49,50)
  • Medication factors (i.e. psychiatric medications have a variable effect on glycemic control, weight and lipids)
  • Environmental factors (e.g. access to healthcare, availability of screening and monitoring programs, social supports, education programs)

Psychiatric medications (primarily second-generation/atypical antipsychotics, but in some cases antidepressants as well) have the potential to affect weight, lipids and glycemic control in patients without diabetes (1,30,51). A weight gain of between 2 to 3 kg was found within a 1-year time frame with amitriptyline, mirtazapine and paroxetine (51). A study of patients with type 2 diabetes and SZ who were treated with antipsychotic medications also showed worsening glycemic control requiring the addition of insulin therapy over a 2-year period with a hazard ratio of 2.0 (52). The reported weight gain over a 1-year period ranges from <1 kg to >4 kg for various antipsychotic medications. Olanzapine and clozapine have been shown to have the greatest weight gain, with a mean increase of >6 kg over a 1-year span compared with 2 to 3 kg for quetiapine and risperidone, and 1 kg for aripiprazole and ziprasidone, also over a 1-year time frame. The main impact on lipid profile is an increase in triglyceride and total cholesterol levels, especially with clozapine, olanzapine and quetiapine (1,53).

Regular and comprehensive monitoring of metabolic parameters is recommended for all persons who receive antipsychotic medications, whether or not they have diabetes. Table 1 outlines a Psychiatric Medication Metabolic Monitoring Protocol adapted from recommendations made by various organizations, including the American Diabetes Association–American Psychiatric Association, Australian and Belgian consensus groups.

Psychological Effects of Diabetes

Diabetes, both type 1 and 2, is a psychologically challenging disease for patients and their family members (57). It interferes with quality of life and is a risk factor for diabetes-related distress as well as the psychiatric disorders listed above. Challenges accompanying the diagnosis of diabetes include adjustment to the disease, adherence to the treatment regimen and psychosocial difficulties at both a personal and an interpersonal level (58,59). Stress, deficient social supports and negative attitudes toward diabetes can impact on self-care and glycemic control (60–64). 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 depressive or anxiety symptoms) and methods to arrive at mental disorder diagnoses (e.g. structured interviews leading to Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition, Text Revision] [DSM-IV-TR] diagnoses [42]) have been assessed. Given that the person with diabetes carries out 95% of diabetes management (65) , identifying depressive syndromes in diabetes is important since depression is a risk factor for poor diabetes self-management (66–68) and outcomes, including early mortality (69,70). MDD has been found to be underdiagnosed in people with diabetes (71).

Table 1
Psychiatric medication metabolic monitoring protocol
A1C, glycated hemoglobin; BMI, body mass index.
Parameter Baseline 1 month 2 months 3 months Every 3–6 months Annually
Weight (BMI) x x x x x  
Waist circumference x     x   x
Blood pressure x     x   x
Fasting glucose and/or A1C x     x x  
Fasting lipid profile x     x x  
Personal history, particularly alcohol, tobacco and recreational substance use x     x   x
Family history x         x

Diabetes distress describes the despondency and emotional turmoil related specifically to having the condition, the need for continual monitoring and treatment, persistent concerns about complications and the potential erosion of personal and professional relationships. Distinguishing between diabetes distress, MDD and the presence of depressive symptoms is important (72,73) because these psychological experiences are different, and, of the three, diabetes distress may be most strongly related to adverse diabetes outcomes (72,74,75).

Table 2
Comparison of main features and assessment methods: diabetes distress vs. depression
  Diabetes distress Major depressive disorder
Assessment Instrument Diabetes Distress Scale (17 items) Patient Health Questionnaire for Depression: PHQ-9 (9 items)
Format Self-report using ratings from 1–6 based on feelings and experiences over the past week Self-report using ratings from 0–3 based on feelings and experiences over the past 2 weeks
Features Emotional 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 changes
Emotional symptoms, such as low mood and reduced enjoyment of usual activities
Behavioural symptoms, such as agitation or slowing of movements
Cognitive symptoms, such as poor memory or reduced concentration or feelings of guilt; thoughts of self-harm

Screening for Psychological/Psychiatric Symptoms

Individuals with diabetes should be regularly screened for psychological distress and psychiatric disorders via directed interviews. No data presently demonstrate the superiority of one particular depression screening tool over another (76). Currently available screening instruments have a sensitivity of between 80% and 90% and a specificity of 70% to 85% (76). A website that contains a wide variety of downloadable scales that are in the public domain is available here. Patient Health Questionnaire (PHQ) Screeners are available at www.phqscreeners.com.

Table 3
Features of cognitive behavioural therapy that can be applied to diabetes treatment
Cognitive component Behavioural component
Record keeping to identify distressing automatic thoughts
Understanding the link between thoughts and feelings
Learning the common “thinking errors” that mediate distress (e.g. all-or-nothing thinking, personalization, magnification, minimization, etc.)
Analyzing negative thoughts and promoting more functional ones
Identifying basic assumptions about oneself (e.g. “unless I am very successful, my life is not worth living”) and being encouraged to adopt healthier ones (e.g. “when I am doing my best, I should be proud of myself”)
Strategies to help get the person moving (behavioural activation)
Scheduling pleasant events; learning assertive and effective communication skills
Focusing on feelings of mastery and accomplishment
Learning problem-solving strategies
Exposure to new experiences
Shaping behaviours by breaking them down into smaller steps to develop skills

Screening instruments fall into three categories:

  • Diabetes-specific measures, such as the Problem Areas in Diabetes (PAID) Scale (77,78) or the Diabetes Distress Scale (DDS) (79)
  • Quality of life measures, such as the WHO-5 screening instrument (80)
  • Depressive/anxiety symptoms, such as the Hospital Anxiety and Depression Scale (HADS) (81) , the Patient Health Questionnaire (PHQ-9) (82,83) , the Centre for Epidemiological Studies–Depression Scale (CES-D) (84) or the Beck Depression Inventory (BDI) (85)

Table 2 illustrates the differences between the principal features and assessment methods of diabetes distress and MDD.

Treatment of Psychological/Psychiatric Risk Factors

Given the burden associated with the demands of diabetes self-management, efforts to promote well-being and moderate distress should be incorporated into diabetes management for all individuals (86). Motivational interventions (68,87,88) , coping skills, self-efficacy enhancement, stress management (89,90) and family interventions (91–93) all have been shown to be helpful. Case management by a nurse working with the patient’s primary care physician and providing guideline-based, patient-centred care resulted in improved glycated hemoglobin (A1C), lipids, blood pressure and depression scores (94). Individuals with diabetes distress and/or psychiatric disorders benefit from professional interventions, either some type of psychotherapy or prescription medication. Evidence from systematic reviews of randomized controlled trials supports cognitive behaviour therapies (CBT) and antidepressant medication, both solely or in combination (33,95). No evidence presently shows that the combination of CBT and medication is superior to these treatments given individually. A pilot study of 50 patients with type 2 diabetes who initially had a moderate level of depression at baseline showed an improvement in the severity of their depression (moving to the mild range) with a 12-week intervention of 10 CBT sessions combined with exercise in the form of 150 minutes of aerobic activity weekly. This effect was sustained at 3 months (96). Online resources are available to help healthcare providers learn CBT skills (e.g. www.moodgym.org). Table 3 illustrates some of the major features of CBT as applied to diabetes care.

Gains from treatment with psychotherapy are more likely to benefit psychological symptoms and glycemic control in adults than will psychiatric medications (which usually only reduce psychological symptoms) (98). A meta-analysis of psychological interventions found that glycemic control (A1C) is improved in children and adolescents with type 1 diabetes (99). Furthermore, evidence suggests interventions are best implemented in a collaborative fashion and when combined with self-management interventions (95).

Treatment with Medication

Psychiatric medications have the capacity to affect metabolic parameters and cause changes in weight, glycemic control and lipid profile and, in some cases, can have immunomodulating effects (22,100–103). A key review estimated and compared the effects of antipsychotics—both the newer ones and the conventional ones—on body weight (104). The consensus statement issued by the American Diabetes Association in 2004 contains recommendations regarding almost all of the atypical agents currently available in Canada (55) , as does the Canadian Diabetes Association position paper from 2005 (105). A comprehensive review and meta-analysis looked at the effect of antidepressants on body weight (51).

The CATIE study investigated 4 aspects of the effectiveness of antipsychotic medications: efficacy, tolerability, emergence of medical problems and patient choice (1,106). The results did indicate that some antipsychotic medications were more likely to cause weight gain, worsen glycemic control and induce unfavourable changes in lipid profile. However, when these effects were considered in the context of efficacy, tolerability and patient choice, no conclusive statements could be made about which medications to clearly use or which to clearly avoid. Consequently, all 4 aspects are important and reinforce the need for regular and comprehensive metabolic monitoring. Should medical problems arise while a patient is taking psychiatric medications, clinical judgement will dictate, on a case-by-case basis, as to whether modifications such as diet or exercise, adding a medication to address the emergent issue (e.g. side effect or medical complication) or changing the psychiatric prescription, is the most reasonable step (107). Handbooks are available that allow clinicians to quickly review the major side effect profiles of psychiatric medications (108,109).

Recommendations

  1. Individuals with diabetes should be regularly screened for subclinical psychological distress and psychiatric disorders (e.g. depressive and anxiety disorders) by interview [Grade D, Consensus] or with a standardized questionnaire [Grade B, Level 2 (110)].
  2. Psychosocial interventions should be integrated into diabetes care plans, including
    • Motivational interventions [Grade D, Consensus]
    • Stress management strategies [Grade C, Level 3 (90)]
    • Coping skills training [Grade A, Level 1A for type 2 diabetes (111) ; Grade B, Level 2, for type 1 diabetes (112)]
    • Family therapy [Grade A, Level 1B (91,93,113)]
    • Case management [Grade B, Level 2 (94)]
  3. Antidepressant medication should be used to treat acute depression [Grade B, Level 2 (31)] and for maintenance treatment to prevent recurrence of depression [Grade A, Level 1A (32)]. Cognitive behaviour therapy (CBT) alone [Grade B, Level 2 (33)] or in combination with antidepressant medication [Grade A, Level 1 (95)] may be used to treat depression in individuals with diabetes.
  4. Antipsychotic medications (especially atypical/second generation) can cause adverse metabolic changes [Grade A, Level 1 (1)]. Regular metabolic monitoring is recommended for patients with and without diabetes who are treated with such medications [Grade D, Consensus].

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