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
  • Highlights
  • 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.

Highlights of Revisions

  • The chapter title has been changed from "Psychological Aspects of Diabetes" to "Diabetes and Mental Health" to more accurately reflect the content of the chapter.
  • A table with a suggested screening schedule for psychiatric medication use has been added.


  1. 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 (1)].
  2. 2.Psychosocial interventions should be integrated into diabetes care plans, including
    • Motivational interventions [Grade D, Consensus]
    • Stress management strategies [Grade C, Level 3 (2)]
    • Coping skills training [Grade A, Level 1A for type 2 diabetes (3) ; Grade B, Level 2, for type 1 diabetes (4)]
    • Family therapy [Grade A, Level 1B (5-7)]
    • Case management [Grade B, Level 2 (8)]
  3. 3.Antidepressant medication should be used to treat acute depression [Grade B, Level 2 (9)] and for maintenance treatment to prevent recurrence of depression [Grade A, Level 1A (10)]. Cognitive behaviour therapy (CBT) alone [Grade B, Level 2 (11)] or in combination with antidepressant medication [Grade A, Level 1 (12)] may be used to treat depression in individuals with diabetes.
  4. 4.Antipsychotic medications (especially atypical/second generation) can cause adverse metabolic changes [Grade A, Level 1 (13)]. Regular metabolic monitoring is recommended for patients with and without diabetes who are treated with such medications [Grade D, Consensus].


  1. Pignone M, Gaynes BN, Rushton JL, et al. Screening for depression: systematic evidence review. Systematic Evidence Review No. 6. AHRQ Publication. No. 02- S002. Rockville, MD Agency for Healthcare Research and Quality 2002.
  2. Soo H, Lam S. Stress management training in diabetes mellitus. J Health Psychol 2009;14:933-43.
  3. Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet 2004;363:1589-97.
  4. Grey M, Boland EA, Davidson M, et al. Short-term effects of coping skills training as an adjunct to intensive therapy in adolescents. Diabetes Care 1998; 21:902-8.
  5. Keogh KM, Smith SM, White P, et al. Psychological family intervention for poorly controlled type 2 diabetes. Am J Manag Care 2011;17:105-13.
  6. Wysocki T, Harris MA, Buckloh LM, et al. Randomized, controlled trial of behavioral family systems therapy for diabetes: maintenance and generalization of effects on parent-adolescent communication. Behav Ther 2008;39:33-46.
  7. Ellis DA, Frey MA, Naar-King S, et al. The effects of multisystemic therapy on diabetes stress among adolescent wit chronically poorly controlled type 1 diabetes: findings from a randomized controlled trial. Pediatrics 2005;16:826-32.
  8. Katon WJ, Lin EHB, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med 2010;363:2611-20.
  9. Lustman PJ, Freedland KE, Griffith L, et al. Fluoxetine for depression in diabetes; a randomized double-blind placebo-controlled trial. Diabetes Care 2000;23: 618-23.
  10. Lustman PJ, Clouse RE, Nix BD, et al. Sertraline for prevention of depression recurrence in diabetes mellitus. Arch Gen Psychiatry 2006;63:521-9.
  11. Lustman PJ, Clouse RE, Freedland KE, et al. Effects of nortriptyline on depression and glucose regulation in diabetes: results of a double-blind placebocontrolled trial. Psychosom Med 1997;59:241-50.
  12. van der Feltz-Cornelis CM, Nuyen J, Stoop C, et al. Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis. Gen Hosp Psychiatry 2010;32:380-95.
  13. Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005;353:1209-23.


Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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