Appropriate screening tools can help identify individuals at risk for or with anxiety, depression, and eating disorders.
People with diabetes have an increased risk of anxiety, depression and eating disorders.1
In addition, diabetes can lead to psychological problems related to diabetes problems.2 Mental health problems can hinder self-management of diabetes and increase the risk of long- and short-term diabetes complications.1
Despite the profound impact mental health issues can have on diabetes care, only about a third of people with diabetes are diagnosed and treated.1 Without appropriate, timely identification and treatment of comorbid mental health problems, the patient’s health and financial well-being can be significantly affected. There can also be significant health care costs.
The lifetime prevalence of generalized anxiety disorder in persons with diabetes is approximately 20%.3 Disease complications and progression, failure to meet glucose goals, fear of hyperglycemia or hypoglycemia, hypoglycemia unawareness, and insulin delivery are commonly reported issues.4.5 Pre-existing fears of needles and blood can be heightened with a diabetes diagnosis and lead to severe anxiety or panic disorders.1 In addition, individuals who exhibit excessive self-management behavior in diabetes may have obsessive-compulsive disorder.6
Fear of hyperglycemia or hypoglycemia ignorance can force some patients to deliberately keep blood glucose levels above targets. Parents of children with type 1 diabetes (T1D) may also encourage this practice because of the same fear.1 In addition, symptoms of hypoglycemia, such as palpitations, sweating, and trembling, can mimic symptoms of anxiety disorders, making it difficult for people with anxiety and diabetes to tell the difference.
Having type 2 diabetes (T2D) increases the risk of developing major depressive disorder (MDD), and having MDD increases the risk of developing type 2 diabetes, suggesting that they may be in a two-way relationship.1 Antidepressants and psychotherapy for the treatment of depression in individuals with diabetes have shown minimal effects on glycemic management and moderate effects on depression. The collaborative care model, a primary care model that integrates 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 of eating disorders.1 Eating disorders, such as binge eating and purging calories with insulin restriction, affect 31% to 40% of women ages 15 to 30 with diabetes.1,8 Comorbid diabetes and eating disorders increase the risk of poor glycemic management, hospitalizations, neuropathy, retinopathy and premature death.1
Diabetes distress is a significant psychological stress that results from the emotional burden of managing the chronic, progressive disease without any “vacation days”.1.9 Over an 18-month period, approximately 38% to 48% of individuals with diabetes have diabetes.10 High levels of diabetes stress can negatively affect diabetes management and quality of life, leading to poor diet and exercise behavior and adherence to treatment, as well as declining glycemic management.9.10 Mindful cognitive-behavioral and social problem-solving approaches and self-compassion programs have been shown to reduce diabetes problems.11
Recipients of metabolic surgery may be at increased risk for anxiety, depression, developing or worsening substance abuse, and suicidal thoughts. Physicians and patients should address important underlying mental health conditions before considering surgery.12-14 After metabolic surgery, the clinical team should regularly assess the mental health of the recipients.14
Problems in children
Dramatic developmental changes occur during the transition from childhood to adolescence and adulthood. Managing diabetes during this dynamic period can be challenging. Premature transfer of responsibility from caregiver to child can lead to suboptimal diabetes management and burnout.15 Routine assessment of diabetes problems, psychosocial problems 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 individuals with or at increased risk for anxiety, depression, diabetes distress, eating disorders, and diabetes distress (Table 216.19-21† With timely intervention, pharmacists can have a positive impact on diabetes and mental health outcomes.
About the Authors
Maria S. Charbonneau, PharmDis a clinical assistant professor of pharmacy practice at the Western New England University College of Pharmacy and Health Sciences in Springfield, Massachusetts.
Camille C. Charbonneau, PharmD, BCPS, CDOE, CVDOEis a clinical pharmacist at CharterCARE Provider Group in Johnston, Rhode Island.
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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. Diabetes Med† 2008;25(7):878-881. doi:10.1111/j.1464-5491.2008.02477.x
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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. Use of generalized anxiety disorder-2 (GAD-2) and GAD-7 in primary care. 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