Mental-Health Risks of Diabetes Underrecognized

Nancy A. Melville

July 18, 2014

Among the wide-ranging comorbidities associated with diabetes, mental-health issues are probably among the most overlooked, despite their potential to compromise self-management and increase the risk for serious complications, according to a new viewpoint published online July 10 in the Journal of the American Medical Association.

"Despite the potential adverse effects of mental-health problems on diabetes outcomes and healthcare expenditures, only about one-third of patients with these coexisting conditions receive a diagnosis and treatment," write Barbara J. Anderson, PhD, of the Baylor College of Medicine department of pediatrics, in Houston, Texas, and colleagues.

Published data underscore the prevalence of mental-health illness associated with diabetes: rates of major depressive disorder, which affects 6.7% of adults in the United States, are 2 times greater among individuals with type 1 or type 2 diabetes across a lifespan. And depression is higher among youth with type 1 diabetes, compared with those without the disease, according to a 2011 meta-analysis (Gonzalez JS. Depression. In: Peters A, Laffel L, eds. Type 1 Diabetes Sourcebook. 2013:169-179).

While researchers work to better understand the mechanisms linking diabetes and depression, it's clear that the relationship is bidirectional, Dr. Anderson told Medscape Medical News. "Having depression raises your risk for onset of diabetes, just as having diabetes raises your risk for onset of depression," she said.

"Currently, the neuropsychology of diabetes and brain and neural-network changes in diabetes and depression are the 'new frontier' in behavioral research in diabetes," she added.

She also notes that physicians are not good at recognizing mental-health issues among diabetic patients, so education is needed to help them understand this and to encourage them to refer people to mental-health teams so they can get treatment.

Anxiety and Eating Disorders Also Common in Diabetes

The mental-health effects associated with diabetes aren't limited to depression, however — panic disorder, generalized anxiety disorder, and posttraumatic stress disorder (PTSD) are also common among those with diabetes, with or without comorbid depression, according to the report.

Importantly, because anxiety symptoms can overlap with symptoms of hypoglycemia, patients can be confused about whether or not low blood glucose is the cause, requiring immediate treatment.

And patients experiencing anxiety over the confusion may wind up overtreating themselves, resulting in blood glucose above target levels, the authors note.

While less is known about eating disorders in males with diabetes, the problem is significant among women — those with type 1 diabetes in fact have twice the risk of developing a full-blown eating disorder and a 1.9-fold risk of developing a subthreshold eating disorder, compared with those without diabetes, research shows.

One study found as many as 31% to 40% of women with type 1 diabetes between the ages of 15 and 30 in fact have disturbed eating behaviors, including binging and purging through insulin restriction (Goebel-Fabbri AE. Eating disorders. In: Peters A, Laffel L, eds. Type 1 Diabetes Sourcebook. 2013:180-186).

These eating disorders, like the other mental illnesses, can lead to cascading complications and worsening disease.

"Disordered eating behaviors persist and worsen over time," Dr. Anderson and colleagues note.

"Women with type 1 diabetes and eating disorders have poorer glycemic control, with higher rates of hospitalizations and retinopathy, neuropathy, and premature death compared with similarly aged women with type 1 diabetes without eating disorders."

Most Physicians Don't Recognize Mental-Health Issues in Diabetes

While most physicians recognize the challenges patients face in the self-management of diabetes, many fail to recognize the extent of the psychological toll those challenges can take, preventing them from taking action.

"Mental-health comorbidities of diabetes, including 'diabetes distress,' are not well-understood by many clinicians," Dr. Anderson said.

"In addition, clinicians frequently do not know that these mental-health comorbidities of diabetes are treatable, if a timely referral is made to a mental-health provider for diagnosis and treatment."

The American Diabetes Association recommends that clinicians routinely screen diabetes patients for psychological problems; however, few diabetes clinics do provide those mental-health screenings, says Dr Anderson.

But even simple steps to assess patients' mental health can help, she noted.

"Clinicians can ask their patients about their energy level, maintaining interest in work, activities, family, and friends, or use diabetes-specific screening tools such as the PAID [Problem Areas in Diabetes] by Dr. Bill Polonsky or the Diabetes Distress Scale by Dr. Larry Fisher to identify diabetes-specific emotional barriers to self-management."

She noted also the importance of being particularly aware of patients who may be at greater risk, including those with limited resources.

"The subgroup of patients at most risk are our patients who are always the most vulnerable within any chronic disease — those with limited access to good healthcare, those with limited resources and education, those with limited family and social support, and those with multiple life stressors in addition to a chronic disease."

The report was presented at Mental Health Issues of Diabetes: A National Conference, which received funding from Universal Health Services and was cosponsored by the Juvenile Diabetes Research Foundation. Dr. Anderson had no disclosures to report. Coauthor Louis H. Philipson, MD, from the University of Chicago, Illinois, is partially supported by a National Institutes of Health grant.

JAMA. Published online July 10, 2014.Article

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