Psychological comorbidities in diabetes: An overview

Gowri. P

Consultant Diabetologist, 1win, Trichy

Background

Epidemiology

Diabetes is becoming an increasingly pressing issue around the globe. Around 11% of Indians are diagnosed with diabetes, with a higher burden in urban compared to rural regions (16% vs 8%). Tamil Nadu has a 14.4% prevalence of diabetes, which is higher than the national average.

Introduction

People with Type 2 Diabetes have multiple comorbidities- microvascular and macrovascular complications.

Often a less diagnosed comorbidity is present  – Psychological comorbidity:- Depression, Anxiety, Diabetes distress, Eating disorders, Phobia reactions, Schizophrenia and Alzheimer’s disease.

Significance of addressing psychological issues

Individuals with T2DM and a psychological comorbidity are at increased risk of

  • Hyperglycemia,
  • Diabetic complications- retinopathy, nephropathy, neuropathy, sexual dysfunction and coronary heart disease
  • Poor quality of life,
  • Increased health care costs.

Pathophysiology of psychiatric disorders in diabetes

Complex of biological, psychological and social mechanisms

  • Neuroendocrine Dysregulation -HPA axis dysfunction, catecholamine imbalance
  • Inflammation and oxidative stress
  • Insulin resistance
  • Gut-Brain Axis Dysregulation (microbiome changes, short chain fatty acids)
  • Neurovascular damage
  • Genetic and Epigenetic factors.

Depression and Anxiety

Depression & Anxiety – highly prevalent, persistent and recurrent leading to a significant negative impact on both clinical outcomes and QoL.

Prevalence rates for depression in persons with type 1 diabetes (21.3%) vs. type 2 diabetes (27%)

Depression – Anhedonia, Hopelessness, Fatigue, Sadness, Suicidal ideation

Anxiety – Fear, Sweating, Tremor, Tachycardia, Confusion

At the time of diagnosis,

When complications occur

Fear of hypos & complications

Side effects of drugs

Disordered eating behavior/Eating disorders

Commonly seen in adolescents adult females with Type 1 diabetes. The necessity to adhere to specific dietary guidelines, monitor blood sugar levels vigilantly, and manage drug administration – detrimental attitudes toward food and body image.

  • Diabulimia – patient deliberately takes an inadequate amount of insulin in order control their body weight
  • Bulimia nervosa – cycles of binge eating followed by purging.
  • Anorexia nervosa – severe food restriction
  • Binge eating disorder – consuming an unusually large amount of food within a short period and no purging.
  • Night eating syndrome – waking up at midnight and overeating.
  • Orthorexia – obsession with healthy eating

Diabetes Distress

Diabetes distress – negative emotional state where people experience feelings such as stress, guilt, worry or denial that arise from living with diabetes and the burden of self-management (Kreider KE et al., 2017).

If left unaddressed, can result in poor treatment adherence, selfcare and quality of life which in turn can cause suboptimal glycemic control, poor metabolic outcomes and increased mortality (Perrin et al., 2017)

Cognitive Impairment and Dementia

Persons with diabetes have a 47% increased risk for all-cause dementia.

Contributing factors- Neurodegeneration due to Chronic hyperglycemia, Insulin resistance and vascular damage

Mechanisms: Glucotoxicity can result in structural damage and functional impairment of brain cells and neurons, hemorrhage of cerebral blood vessel, and increased accumulation of amyloid beta.

Schizophrenia and Diabetes

Individuals with schizophrenia have double the likelihood of developing type 2 diabetes compared to those without schizophrenia. Stubbs et al., 2015

Smoking, poor diet, obesity, atypical antipsychotics and lower levels of physical activity in patients with schizophrenia also contribute to increased risk of diabetes and CVD. Price and Ismail, 2018

Screening tools

1. Standardized psychiatric diagnostic interviews

  • Mini-International Neuropsychiatric Interview

2. Brief paper-and-pencil self-report measures

  • Beck Depression Inventory
  • Diabetes Distress Scale
  • Brief Illness Perception Questionnaire
  • Hamilton Anxiety Rating Scale
  • Patient Health Questionnaire
  • Mini Mental State Examination Score

This screening test should be taken;

  • At the time of diagnosis,
  • when complications occur,
  • Any adverse life event
  • Annually

Treatment

Three types of therapeutic modalities have been utilized to ameliorate psychological issues in patients with diabetes:

  • Psychotherapy
  • Diabetes self management education and support
  • Pharmacotherapy
  • Collaborative care model

Psychotherapy

Cognitive behavioral therapy (CBT) can improve medication adherence, depressive symptoms, and glycemic control in patients with type 2 diabetes.

Other effective approaches include Psychoeducation, Interpersonal therapy, motivational interviewing, psychodynamic therapy, and Web-based therapeutic approaches

Pharmacology

  • All SSRIs seem to be equally efficacious at reducing depressive symptoms at appropriate doses with excellent safety profile. Markowitz et al., 2011
  • Sertraline and fluoxetine may have a slight benefit to glycemic control but these results have not been widely replicated. van der Feltz-Cornelis et al., 2010; Ye et al., 2011
  • Medications should be selected based upon side effect profiles, patient preferences, and individual response to treatment. National Collaborating Centre for Mental Health, 2011
  • Tricyclic antidepressants and monoamine oxidase inhibitors are rarely recommended for patients with diabetes because of unfavorable side effect profile

Diabetes self-management education & support

Diabetes self-management education is an effective treatment for diabetes distress

  • Sigaram,
  • Vidiyal,
  • Diacare clubs – face-face or online group sessions

Collaborative care

The collaborative care model is an evidence-based care delivery model designed to provide psychiatric consultation in the primary care setting and has been adapted to a variety of medical specialty clinics. Katon et al., 1995. Raney et al., 2015

Conclusion

Higher rates of psychiatric disorders such as eating disorders, depression, anxiety, delirium, and dementia among individuals with diabetes. Diabetes distress is distinct from major depressive disorder and adversely affects diabetes management. The collaborative care model provides an effective framework to treat psychological comorbidity in diabetes

Take Home Message

  • Co-morbidity of diabetes and psychiatric disorders is common and can have different presentations
  • Integrate comprehensive care approach in diabetes care, recognising psychological impact alongside physical ailments to enhance patient outcomes.

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