Shine a Light on Diabetes and Mental Health
Appropriate screening tools can help identify individuals at increased risk for or with anxiety, depression, and eating disorders.
Individuals with diabetes are at increased risk for anxiety, depression, and eating disorders.1
Additionally, diabetes can lead to mental health issues related to diabetes distress.2 Mental health issues may be barriers to diabetes self-management and may increase the risk for long- and short-term diabetes complications.1
Despite the profound impact mental health issues can have on diabetes care, only about one-third of individuals with diabetes are diagnosed and treated.1 Without appropriate, timely identification and management of comorbid mental health issues, the patient’s health and financial well-being can be significantly affected. Substantial cost to the health care system can also occur.
The lifetime prevalence of generalized anxiety disorder in individuals with diabetes is approximately 20%.3 Disease complications and progression, failing to meet glucose goals, fear of hyperglycemia or hypoglycemia, hypoglycemia unawareness, and insulin administration are commonly reported concerns.4,5 Preexisting fears of needles and blood may be heightened with a diabetes diagnosis and may lead to severe anxiety or panic disorders.1 Additionally, individuals exhibiting excessive diabetes self-management behaviors may have obsessive-compulsive disorder.6
Fear of hyperglycemia or hypoglycemia unawareness may compel some patients to purposefully maintain blood glucose levels above goals. Parents of children with type 1 diabetes (T1D) may also encourage this practice because of the same fear.1 Furthermore, symptoms of hypoglycemia, such as heart palpitations, sweating, and tremors, can mimic symptoms of anxiety disorders, making it difficult for people with anxiety and diabetes to discern the difference.
Having type 2 diabetes (T2D) increases the risk of developing major depression disorder (MDD) and having MDD increases the risk for developing type 2 diabetes, which suggests they may have a bidirectional relationship.1 Antidepressants and psychotherapy for depression treatment in individuals with diabetes have shown minimal effects on glycemic management and moderate effects on depression. The collaborative care model, a primary care model integrating behavioral health and general medicine, has shown significant positive effects on both depression and glycemic management.1,7
Women with T1D have a 2-fold increased risk for eating disorders.1 Eating disorders, such as binge eating and caloric purging with insulin restriction, can be seen in 31% to 40% of women aged 15 to 30 years who have diabetes.1,8 Comorbid diabetes and eating disorders increase the risk for poor glycemic management, hospitalizations, neuropathy, retinopathy, and premature death.1
Diabetes distress is significant psychological stress resulting from the emotional burden of managing the chronic, progressive disease without any “vacation days.”1,9 Over any 18-month period, approximately 38% to 48% of individuals with diabetes have diabetes distress.10 High levels of diabetes distress can negatively affect diabetes management and quality of life, leading to poor dietary and exercise behaviors and medication adherence as well as declining glycemic management.9,10 Mindful cognitive behavioral and social problem-solving approaches and self-compassion programs have been shown to decrease diabetes distress.11
Metabolic surgery recipients may be at an increased risk of anxiety, depression, developing or worsening substance abuse, and suicide ideation. Clinicians and patients should address significant underlying mental health conditions before considering surgery.12-14 Following metabolic surgery, the clinical team should assess recipients’ mental health regularly.14
Issues in Children
Profound developmental changes occur during the transition from childhood to adolescence and adulthood. Managing diabetes during this dynamic period can be challenging. Premature responsibility transfer from caregiver to child can result in suboptimal diabetes management and burnout.15 Routine assessment of diabetes distress, psychosocial issues, and social determinants in patients and caregivers is necessary.
The pharmacist can play an active role in diabetes and mental health management (Table 17,9,12,15-18). Appropriate screening tools can help identify those with or at increased risk for anxiety, depression diabetes distress, eating disorders, and diabetes distress (Table 216,19-21). With timely intervention, pharmacists can positively affect diabetes and mental health outcomes.
About The Authors
Maria S. Charbonneau, PharmD, is a clinical assistant professor of pharmacy practice at Western New England University College of Pharmacy and Health Sciences in Springfield, Massachusetts.
Camille C. Charbonneau, PharmD, BCPS, CDOE, CVDOE, is a clinical pharmacist at CharterCARE Provider Group in Johnston, Rhode Island.
1. Ducat L, Philipson L, Anderson B. The mental health comorbidities of diabetes. AMA. 2014;312(7):691-692. doi:10.1001/jama.2014.8040
2. Diabetes and mental health. Mental Health America. Accessed May 9, 2022. https://www.mhanational.org/diabetes-and-mental-health
3. Li C, Barker L, Ford ES, Zhang X, Strine TW, Mokdad AH. Diabetes and anxiety in US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabet Med. 2008;25(7):878-881. doi:10.1111/j.1464-5491.2008.02477.x
4. Smith KJ, Beland M, Clyde M, et al. Association of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res. 2013;74(2):89-99. doi:10.1016/j.jpsychores.2012.11.013
5. Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L. A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns.2007;68(1):10-15. doi:10.1016/j.pec.2007.05.003
6. Diagnostic and Statistical Manual of Mental Disorders.5th ed. American Psychiatric Association;2013.
7. Learn about the collaborative care model. American Psychiatric Association. Accessed May 9, 2022. https://www.psychiatry.org/psychiatrists/practice/professional-interests/integrated-care/learn
8. Weinger K, Beverly EA. Barriers toachieving glycemic targets: who omits insulin and why?.Diabetes Care.2010;33(2):450-452. doi:10.2337/dc09-2132
9. Fisher L, Skaff MM, Mullan JT, et al. Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics. Diabetes Care.2007;30(3):542-548. doi:10.2337/dc06-1614
10. Aikens JE. Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care. 2012;35(12):2472-2478. doi:10.2337/dc12-0181
11. Friis AM, Johnson MH, Cutfield RG, Consedine NS. Kindness matters: a randomized controlled trial of a mindful self-compassion intervention improves depression, distress, and HbA1c among patients with diabetes. Diabetes Care.2016;39(11):1963-1971. doi:10.2337/dc16-0416
12. Conason A, Teixeira J, Hsu CH, Puma L, Knafo D, Geliebter A. Substance use following bariatric weight loss surgery. JAMA Surg.2013;148(2):145-150. doi:10.1001/2013.jamasurg.265
13. King WC, Chen JY, Mitchell JE, et al. Prevalence of alcohol use disorders before and after bariatric surgery. JAMA.2012;307(23):2516-2525. doi:10.1001/jama.2012.6147
14. Greenberg I, Sogg S, M Perna F. Behavioral and psychological care in weight loss surgery: best practice update. Obesity (Silver Spring).2009;17(5):880-884. doi:10.1038/oby.2008.571
15. Siminerio LM, Albanese-O’Neill A, Chiang JL, et al.; American Diabetes Association. Care of young children with diabetes in the childcare setting: a position statement of the American Diabetes Association. Diabetes Care.2014;37(10):2834-2842
16. Screening for depression and diabetes distress in adults with type 2 diabetes. CDC. Updated January 2017. Accessed May 9, 2022. https://www.cdc.gov/diabetes/pdfs/managing/Depression_Diabetes_Distress_Brief_508.pdf
17. Diabetes and mental health. CDC. May 7, 2021. Accessed May 9, 2022. https://www.cdc.gov/diabetes/managing/mental-health.html
18. Cox DJ, Gonder-Frederick L, Polonsky W, Schlundt D, Kovatchev B, Clarke W. Blood glucose awareness training (BGAT-2): long-term benefits. Diabetes Care.2001;24(4):637-642. doi:10.2337/diacare.24.4.637
19. Sapra A, Bhandari P, Sharma S, Chanpura T, Lopp L. Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus. 2020;12(5):e8224. doi:10.7759/cureus.8224
20. Davis WA, Bruce DG, Dragovic M, Davis TME, Starkstein S. The utility of the diabetes anxiety depression scale in type 2 diabetes mellitus: the Fremantle Diabetes Study phase II. PLoS One. 2018;13(3):e0194417. doi:10.1371/journal.pone.0194417
21. Draznin B, Aroda VR, et al; American Diabetes Association Professional Practice Committee. 14. Children and adolescents: standards of medical care in diabetes-2022. Diabetes Care.2022;45(suppl1):S208-S231. doi:10.2337/dc22-S014