November 15, 2021| By Dr.
Chris Ball | Life/Health Consulting Medical
Officer, London
The
existence of a relationship between diabetes, in all its forms, and a wide
variety of mental health disorders, is widely acknowledged. Individuals who
experience depressive episodes are between 40% and 60% more likely to develop
type 2 diabetes than is the general population. Their episodes last longer
and have a higher chance of recurrence, whilst the symptom burden is increased
four-fold.
The
presence of both disorders increases the all-cause mortality compared to
diabetes alone. This cannot be explained purely by an increased rate of suicide.
Alleviating depressive symptoms has a significant effect on mood but much less
impact upon the control of blood sugar. Those experiencing Schizophrenia
Spectrum Disorders are a particularly vulnerable group, perhaps due to shared
biochemical pathways, but also to the side-effects of medication, lifestyle
challenges and the stigma associated with severe mental health disorders that
makes accessing services difficult.1
What is
perhaps less well-appreciated, except by those who are living with diabetes,
are the psychological effects of receiving the diagnosis and adjusting to the
challenges of life-long management and the potential for serious complications.
These individuals stand at the centre of complex interactions between
biological, social and psychological forces.
Diabetes
distress is a concept that consists of several closely related elements.
Definitions vary but common features include:2
·
The emotional burden of living with diabetes
·
The continual burden of daily self-management and potential
complications
·
The social impact of diabetes (stigma, discrimination, lack
of understanding)
·
The difficulties encountered between the person with diabetes and
the services provision aimed at helping them and the financial implications.
Because
of the range of severity and variety of factors involved in living with
diabetes, diabetes distress fluctuates over time, and is at its worst after
diagnosis, during regime changes or as complications develop. Significant
distress is linked to poorer self-management, elevated HbA1c levels, increased
frequency of hypoglycaemia and impaired quality of life. It is also associated
(when measured with the Diabetes Distress Scale) with increased mortality and
cardiovascular complications.
Stressors
– such as the pandemic, when people with diabetes were shielding and services
support withdrew – can increase distress and leave many feeling cast adrift. In
the UK, routine HbA1c testing reduced by 77%, and “care processes” – foot
checks, BP monitoring and so forth – reduced to around 20% from 58%.3
If left
unchecked, “Diabetes Burnout” may ensue. As with occupational burnout, the
person experiences physical and emotional exhaustion particularly when, despite
their best efforts, blood sugar control remains erratic. The feelings of
helplessness and disengagement engendered in this situation mean that people
“can’t be bothered” with the continued effort required. A contributing factor
can be a lack of understanding from the health services that these individuals
receive; for example, they may be perceived as unmotivated, poorly compliant,
and troublesome, which engenders a vicious cycle. The signs may include missing
medication doses or not monitoring blood sugar, unhealthy or risky behaviours
(especially relating to food) or non-attendance at clinic.4
Being
able to see past the blood sugar readings and a willingness to ask about and
explore the meaning of the illness to the individual is key in the clinic. Some
experts advocate the use of screening questionnaires; e.g., Problems Areas in
Diabetes (PAID) or the Diabetes Distress Scale or more general quality of
life questionnaires.
Other
specific problems include fear of hypoglycaemia and psychological insulin
resistance. Hypoglycaemia can be both serious and distressing to the extent
that some people living with diabetes deliberately run their blood sugar levels
high as a preventative measure or manage bodily symptoms as if they were due to
hypoglycaemia – without any blood testing. If these behaviours persist,
diabetic control worsens, and the risk of complications grows whilst quality of
life diminishes.5
Psychological
insulin resistance can occur when the medical advice is to add insulin to a
regimen, usually in type 2 diabetes. The individual may experience a sense
of personal failure and loss of control upon hearing this advice and a sense of
facing much more serious challenges (including pain) in the future. In this
situation, confidence about managing the changes is low and the personal
benefits of the additional stress of ongoing self-management
is questioned.6
As
before, recognition is the key to addressing these problems and should be built
into the holistic management of all individuals. Effective management, using
person-centred approaches to motivation, coping skills, developing
self-efficacy, and managing stress can improve the levels of HbA1c, lipids and
blood pressure. Cognitive Behavioural Therapy (CBT) specifically tailored
to address the issues in these problem areas has been used with some success.
When mental health disorders arise, they need treatment in their
own right.7
Each
person with diabetes is unique – whether it’s Type 1 or Type 2, a
young or older individual, insulin dependent or not, stable or unstable. Each
individual brings their own experiences and resources to the table for what is
going to be a long-term, day in/day out process that will have a profound
effect on their lives in many ways. The value of talking about diabetes in the
round is in identifying the need to provide interventions that can be
personalised to help each individual living with diabetes to improve their
quality of life and long-term outcomes.8
From an
insurance perspective, improving recognition of co-morbid mental health
problems (not just illness) is important as part of fully understanding the
risks at underwriting and ensuring that interventions at claims stage are as
targeted and effective as they can be to ensure the continued wellbeing of
the claimant.
Endnotes
1. Robinson D J
et al. (2018) Diabetes and Mental Health. Canadian Journal of Mental
Health 42 S130–S141. https://doi.org/10.1016/j.jcjd.2017.10.031.
2. Turin, A
& Radoljac, MD (2021) Psychosocial factors affecting the etiology and
management of type 1 diabetes mellitus: A narrative review. World Journal
of diabetes. 12. 1518-1529. Psychosocial factors
affecting the etiology and management of type 1 diabetes mellitus: A
narrative review (nih.gov),
https://dx.doi.org/10.4239/wjd.v12.i9.1518.
Chapter 3 - Diabetes
distress, Diabetes.org UK.
4. Turin, A
& Radoljac, MD (2021) Psychosocial factors affecting the etiology and
management of type 1 diabetes mellitus: A narrative review. World Journal
of diabetes. 12. 1518-1529. Psychosocial factors
affecting the etiology and management of type 1 diabetes mellitus: A
narrative review (nih.gov).
https://dx.doi.org/10.4239/wjd.v12.i9.1518.
5. Ibid, see
endnote 2.
6. Ibid, see
endnote 4.
7. Ibid, see
endnote 2.
8. Chapter 3 - Diabetes
distress, Diabetes.org UK.
https://www.genre.com/knowledge/blog/the-impact-of-diabetes-on-mental-health-en.html
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