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World Diabetes Day: Interaction and impact of diabetes on mental health

For World Diabetes Day on the 14th November 2018, Nisha Shahrukh - Medical Writer at Mednet Group has written an article depicting the impact diabetes has on mental health. Including a case study showing the perspective of a young person newly diagnosed with type 1 diabetes.
In the UK alone, diabetes is thought to affect more than 4.5 million people which is more than any other serious health condition in the UK [1]. This number is rising fast as around 700 people are diagnosed with diabetes everyday [1]. The leading UK charity for people affected by diabetes, Diabetes UK, found that one of the key things patients were asking for, was more support for their emotional and psychological health [1].

As diabetes is a chronic, metabolic disorder, it can impact physical, social and mental health, including the psychological well-being of patients [2]. Additionally, psychosocial problems, which are most commonly seen in diabetic patients, can cause serious and negative effects on patient well-being and social life, if left unaddressed [2].

Addressing psychosocial aspects in treatment interventions, can help patients overcome the psychological barriers, which are associated with adherence and self-care for diabetes [2]. Identifying and supporting patients with psychosocial problems, early in the onset of diabetes can promote psychosocial well-being and improve patient ability to adjust or take adequate responsibility in diabetes self-management [2].

How Diabetes Affects Mental Health


Diabetes can affect mental health in several ways. Often, patients find it difficult to accept that they will have to take medication, or possibly even insulin injections on a lifelong basis, which can result in poorer treatment adherence and diabetes self-management [3]. Research indicates that patients with diabetes suffer from high levels of diabetes-specific emotional stress [4, 5], which is associated with functional impairment, poor adherence to diet, exercise and medications [6, 7, 8].

There is evidence which indicates that diabetes and its related complications can be strongly associated with psychological and psychiatric issues [6, 9], which can include depression [10], poor eating habits [11] and developing a fear of hypoglycaemic episodes [12].

All these psychosocial problems can develop into depressive and psychological disorders which can be associated with poor self-care behaviours, a loss of productivity and decreased quality of life [2].

Bearing this in mind, it is important to identify and support patients who have developed psychosocial problems early on in their diabetes, as it can affect their ability to make lifestyle adjustments and take adequate responsibility for their self-care [2].



Depression and Diabetes Distress


Depression and diabetes distress are two of the most common mental health conditions faced by type 2 diabetics [13]. Depression exists in one in five adult diabetics (14), and diabetes distress affects one third of adult diabetics [15]. Diabetes distress is distinct from depression as it is caused by the emotional burden of managing diabetes [15]. Both conditions can overlap - a study found that 4.5% of adult diabetics screened positive for both mental health conditions [16]. Moreover, depression and diabetes distress can increase patient risk for mortality, poor disease management, poor quality of life, work absenteeism and other diabetes-related complications [15, 17].

Diabetes and depression can both increase the risk of both macrovascular complications (such as cardiovascular diseases) [18] and microvascular complications (such as retinopathy, neuropathy and nephropathy) [19].

Early recognition and routine screening for these conditions, along with evidence-based treatment approaches for depression and diabetes distress could improve the control of HbA1c (average blood sugar levels for the last two to three months), blood pressure and cholesterol in addition to overall patient wellbeing and benefits in the form of medical cost savings [20, 21].

Living With Diabetes: Emotional And Psychological Effects


Patients find that living with diabetes can be exhausting and usually require additional support to help them better manage their condition and protect their mental health. Diabetes UK carried out focus groups, online surveys and events speaking with a total of 9000 diabetics across the UK. They found that a fear of hypoglycaemic episodes was a constant concern for type 1 diabetics [22]. Some patients reported that they felt isolated as they were managing an invisible condition [22] and one third of patients said that they would be interested in receiving support and counselling from a trained professional [22].

Patients are clearly looking for support, as statistics suggest three in five diabetic patient experiences emotional or mental health problems, which are a direct result of their diabetics [23].  However, one third of diabetics have found support in self-help materials found in books, videos and online resources [23].




By guiding patients to resources of support, such as self-help reading materials, online sources or diabetic groups, patients can be enabled to take control of their condition and improve their mental health. Many newly diagnosed patients have difficulty in accepting and understanding their diabetes, therefore it is vital to give them the opportunity to discuss their condition openly and guide them to clinics or support groups who can offer not just medical support for their diabetes, but also mental health support.    

Case Study- Emma*

I was diagnosed with type 1 diabetes at the age of 18 only 3 months after leaving home to move away for University.



The most useful support that I had access to was a diabetic consultant I could go to about any issues or questions as I started to adjust to life with diabetes – I went to see her in person and she gave me her mobile number and I was able to contact her at any point which helped a lot – questions on what food I should avoid, how to handle exercise – anything that popped up that I wouldn’t have thought of whilst in the hospital.  

When I returned to University this stopped – as she was located back where my parents lived which was a real shame as it was a really useful resource and someone to just talk to.  A support network like that whilst away from home would be really useful.



Other people I have spoken to have been given very different advice but this really did make it a lot easier to take on board as it gave me the confidence that my life wasn’t going to drastically change!
*Name changed for anonymity 

References
1.        Diabetes UK (2017) The Future of Diabetes [online] Available at: https://www.diabetes.org.uk/resources-s3/2017-11/1111B%20The%20future%20of%20diabetes%20report_FINAL_.pdf [Accessed November 2018]
2.        Kalra, S., Jena, B.N. and Yeravdekar, R., 2018. Emotional and psychological needs of people with diabetes. Indian journal of endocrinology and metabolism22(5), p.696.
3.        Kalra, S., Sridhar, G.R., Balhara, Y.P.S., Sahay, R.K., Bantwal, G., Baruah, M.P., John, M., Unnikrishnan, A.G., Madhu, K., Verma, K. and Sreedevi, A., 2013. National recommendations: Psychosocial management of diabetes in India. Indian journal of endocrinology and metabolism17(3), p.376.
4.        Pouwer, F., Skinner, T.C., Pibernik-Okanovic, M., Beekman, A.T., Cradock, S., Szabo, S., Metelko, Z. and Snoek, F.J., 2005. Serious diabetes-specific emotional problems and depression in a Croatian–Dutch–English Survey from the European Depression in Diabetes [EDID] Research Consortium. Diabetes research and clinical practice70(2), pp.166-173.
5.        Kokoszka, A., Pouwer, F., Jodko, A., Radzio, R., Mućko, P., Bieńkowska, J., Kuligowska, E., Smoczyńska, O. and Skłodowska, Z., 2009. Serious diabetes-specific emotional problems in patients with type 2 diabetes who have different levels of comorbid depression: a Polish study from the European Depression in Diabetes (EDID) Research Consortium. European Psychiatry24(7), pp.425-430.
6.        Lustman, P.J., Anderson, R.J., Freedland, K.E., De Groot, M., Carney, R.M. and Clouse, R.E., 2000. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes care23(7), pp.934-942
7.        Ciechanowski, P.S., Katon, W.J. and Russo, J.E., 2000. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Archives of internal medicine160(21), pp.3278-3285.
8.        Ciechanowski, P.S., Katon, W.J., Russo, J.E. and Hirsch, I.B., 2003. The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes. General hospital psychiatry25(4), pp.246-252.
9.        Snoek, F.J. and Skinner, T.C., 2002. Psychological counselling in problematic diabetes: does it help?. Diabetic Medicine19(4), pp.265-273.
10.     Anderson, R.J., Freedland, K.E., Clouse, R.E. and Lustman, P.J., 2001. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes care24(6), pp.1069-1078.
11.     Peveler, R.C., Bryden, K.S., Neil, H.A.W., Fairburn, C.G., Mayou, R.A., Dunger, D.B. and Turner, H.M., 2005. The relationship of disordered eating habits and attitudes to clinical outcomes in young adult females with type 1 diabetes. Diabetes Care28(1), pp.84-88.
12.     Cox, D.J., Irvine, A., Gonder-Frederick, L., Nowacek, G. and Butterfield, J., 1987. Fear of hypoglycemia: quantification, validation, and utilization. Diabetes care10(5), pp.617-621.
13.     Owens-Gary, M.D., Zhang, X., Jawanda, S., Bullard, K.M., Allweiss, P. and Smith, B.D., 2018. The Importance of Addressing Depression and Diabetes Distress in Adults with Type 2 Diabetes. Journal of General Internal Medicine, pp.1-5.
14.     Roy, M., Sengupta, N., Sahana, P.K., Das, C., Talukdar, P., Baidya, A. and Goswami, S., 2018. Type 2 diabetes and influence of diabetes-specific distress on depression. Diabetes research and clinical practice143, pp.194-198.
15.     Fisher, L., Skaff, M.M., Mullan, J.T., Arean, P., Glasgow, R. and Masharani, U., 2008. A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with type 2 diabetes. Diabetic medicine25(9), pp.1096-1101.
16.     Snoek, F.J., Bremmer, M.A. and Hermanns, N., 2015. Constructs of depression and distress in diabetes: time for an appraisal. The Lancet Diabetes & Endocrinology3(6), pp.450-460.
17.     Zhang, X., Norris, S.L., Gregg, E.W., Cheng, Y.J., Beckles, G. and Kahn, H.S., 2005. Depressive symptoms and mortality among persons with and without diabetes. American Journal of Epidemiology161(7), pp.652-660.
18.     Lin, E.H., Rutter, C.M., Katon, W., Heckbert, S.R., Ciechanowski, P., Oliver, M.M., Ludman, E.J., Young, B.A., Williams, L.H., McCulloch, D.K. and Von Korff, M., 2010. Depression and advanced complications of diabetes: a prospective cohort study. Diabetes care33(2), pp.264-269.
19.     Ascher-Svanum, H., Zagar, A., Jiang, D., Schuster, D., Schmitt, H., Dennehy, E.B., Kendall, D.M., Raskin, J. and Heine, R.J., 2015. Associations between glycemic control, depressed mood, clinical depression, and diabetes distress before and after insulin initiation: an exploratory, post hoc analysis. Diabetes Therapy6(3), pp.303-316.
20.     Katon, W., Unützer, J., Fan, M.Y., Williams, J.W., Schoenbaum, M., Lin, E.H. and Hunkeler, E.M., 2006. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes care29(2), pp.265-270.
21.     Young-Hyman, D., De Groot, M., Hill-Briggs, F., Gonzalez, J.S., Hood, K. and Peyrot, M., 2016. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes care39(12), pp.2126-2140.
22.     Diabetes UK (2017) The Future of Diabetes [online] Available at: https://www.diabetes.org.uk/resources-s3/2017-11/1111B%20The%20future%20of%20diabetes%20report_FINAL_.pdf [Accessed November 2018]
23.     Diabetes UK (2017) Three In Five People With Diabetes Experience Emotional Or Mental Health Problems [online] Available at: https://www.diabetes.org.uk/about_us/news/three-in-five-people-with-diabetes-experience-emotional-or-mental-health-problems [Accessed November 2018]

14th November 2018

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