Diabetics in Distressby Jennifer Gibson, PharmD | August 23, 2014
Diabetes affects millions of people in the United States and remains one of the leading causes of death. The disease is associated with a myriad of complications and comorbid conditions, but mental health issues are often overlooked. “Diabetes distress” is a relatively new term that describes the psychological manifestations of diabetes management.
A recent report in the Journal of the American Medical Association claims that two-thirds of patients with diabetes and mental health problems are undiagnosed and untreated.
This failure to recognize psychological conditions associated with a chronic disease leads to poor healthcare outcomes and increases healthcare expenditures. According to the report, major depressive disorder, anxiety, and eating disorders occur frequently among people with diabetes, often more frequently than among people without the disease. These conditions result in complications including blindness, amputations, stroke, cognitive decline, decreased quality of life, and premature death.
The relationship between mental health and diabetes has been the topic of much research in recent decades and, while we still do not know the exact mechanisms that link the two conditions, we understand that the relationship is bidirectional. That is, having mental health problems increases the risk of diabetes and the risk of diabetes increases the risk of mental health problems. Diabetes is linked to many types of cognitive and psychological deficits and the connection is likely due to abnormal structure, function, and chemical composition of neurons and glia.
Today, in an overcrowded and overworked healthcare system, patients do not often receive holistic care. Diseases are treated by protocols and procedures, and treatments are prescribed based on test results. Of course, measurable results are appropriate, but there is more to a patient with diabetes than blood glucose levels. Physicians fail to recognize mental health issues in diabetic patients and, as such, the conditions remain untreated.
One factor that complicates the issue is that many symptoms of mental health conditions overlap with physical manifestations of diabetes. For example, symptoms of anxiety mimic symptoms of low blood sugar, which can confuse patients and providers alike. Eating disorders develop in as many as 40% of women with type 1 diabetes, likely stemming from the control of food behaviors required to manage the disease.
The challenges of self-management of diabetes are recognized by healthcare providers, but the psychological toll that those challenges take are not often recognized. Diabetes distress is a distinct diagnosis from major depressive disorder but describes the emotional burden involved in the complex behaviors and pressures of self-management of the disease.
The American Diabetes Association’s standards of care direct that patients with diabetes should receive routine screenings for mental health problems. Even simple questions about a patient’s energy level or interest in work, family, or social activities can suggest a condition that needs further investigation or support. Such basic screenings are particularly important for patients at the highest risk of complications related to diabetes: patients with limited access to healthcare, patients with limited resources and education, patients with limited family or social support, and patients with multiple life stressors.
The good news is that mental health conditions are treatable once diagnosed. Antidepressant medications are effective in patients with diabetes and do not adversely affect blood glucose levels. Further, improved insulin signaling with antidiabetic medications leads to improved cognitive function in psychiatric conditions.
In diabetes, as in nearly all chronic diseases, the best healthcare treats the whole patient. We do not fully understand the link between mental health and diabetes, but we do understand the link between successful treatment of mental health issues and diabetes outcomes. By monitoring the mental health of patients with diabetes, the physical health of patients will improve.
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