Studies have shown that patients living with diabetes are at increased risk for developing depression, anxiety, and eating disorders, among other mental health problems. “Mental health comorbidities of diabetes can compromise adherence to diabetes treatments, which in turn can increase risks for serious short- and long-term complications,” says Mark Peyrot, PhD. Failure to adhere to diabetes medication regimens can result in the development of cardiovascular disease, stroke, blindness, amputations, and cognitive decline. It can also decrease quality of life and increase risks for premature death.
When mental health comorbidities of diabetes go undiagnosed and untreated, the financial cost to society and healthcare systems is substantial and health outcomes for patients are also impacted. “Among the wide-ranging comorbidities associated with diabetes, mental health issues are among the most overlooked,” Dr. Peyrot says. “This remains true despite the potential of mental health problems to compromise self-management and increase risks for serious complications.” Studies indicate that only about one-third of patients with these coexisting mental health conditions receive a diagnosis and treatment for them.
Depression, Anxiety, & Eating Disorders
Major depressive disorder affects nearly 7% of all adults in the United States and is more likely to be diagnosed in people with diabetes. “Diabetes is a risk factor for depression and depression is a risk factor for diabetes,” Dr. Peyrot says. Depression among patients with diabetes has been linked to poor self-care, poor glycemic control, more long-term complications, and a decreased quality of life. Fortunately, depression can be successfully treated in people with diabetes using collaborative care models that involve psychotherapy and antidepressants. These treatments can improve depressive symptoms and may have a positive effect on glycemic control.
Many patients with diabetes also have comorbid anxiety disorders, such as generalized anxiety disorder, panic disorder, or PTSD. “Some of these disorders may occur in conjunction with depression,” explains Dr. Peyrot. Some studies show that eating disorders are a problem for women with type 1 diabetes, but less is known about these conditions in men with diabetes. “Patients with disturbed eating behaviors often purge through insulin restriction,” says Dr. Peyrot. Like the other mental health conditions, eating disorders tend to persist and worsen over time and can lead to cascading complications and worsening disease.
According to standards of care from the American Diabetes Association, people with diabetes should be treated by a multidisciplinary medical team. Physicians are also recommended to routinely screen for psychosocial problems, including depression and diabetes-related distress, anxiety, eating disorders, and cognitive impairment (Table).
“Physicians often do not assess or manage mental health conditions until they become severe,” Dr. Peyrot says. “It’s important that physicians routinely assess diabetes-specific psychological factors that increase risk for mental health disorders and poor diabetes outcomes—such as fear of hypoglycemia and complications, difficulties with diabetes self-management, and lack of practical and emotional support—and support patients in their efforts to overcome these barriers to effective self-management. Despite these barriers, there are simple steps clinicians can take to assess and support their patients.”
When physician support is not sufficient to manage emerging psychological issues, formal screening is recommended, along with referral to or consultation with mental health specialists. In addition to patients with poor diabetes outcomes, studies suggest that diabetes patients who are at greatest risk of mental health issues are those who are considered most vulnerable within any chronic disease. This includes people with:
♦ Limited access to good healthcare.
♦ Limited resources and education.
♦ Limited family and social support.
♦ Multiple life stressors in addition to a chronic disease.
“Many mental health comorbidities of diabetes are treatable, but it is critical that timely referrals are made to mental-health providers for diagnosis and treatment,” Dr. Peyrot says. He adds that clinicians should recognize the importance of screening patients for these conditions early so that they will be more likely to be referred to mental health teams at a time when they can provide effective treatment for those problems.
Considering the vast burden of diabetes, identifying and treating mental health comorbidities among patients with diabetes should be a priority, according to Dr. Peyrot. “The high prevalence and costs of mental health and diabetes, combined with evidence that behavioral factors are important for effective diabetes self-care, create an important opportunity,” he says. “Mental health screening and treatment need to be integrated into multidisciplinary diabetes care teams in order to improve outcomes and decrease healthcare expenditures.”
Readings & Resources (click to view)
Ducat L, Philipson LH, Anderson BJ. The mental health comorbidities of diabetes. JAMA. 2014;312:691-692. Available at: http://jama.jamanetwork.com/article.aspx?articleid=1888681.
American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(suppl):S14-S80.
Kessler RC, ChiuWT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication Arch Gen Psychiatry. 2005;62:617-627.
Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care. 2002;25:464-470.
Anderson BJ, Mansfield AK. Psychological issues in the treatment of diabetes. In: Beaser RS, ed. Joslin’s Diabetes Deskbook. 2nd ed. Boston, MA: Joslin Diabetes Center; 2007:641-661.