By Marc Braman, MD, MPH

MB (Marc Braman, MD, MPH):
Our topic this session is “Diabetes & Mental Health.” I’m Dr. Marc Braman and I’m joined by medical student, Marc Anderson. Welcome, Marc.

MA (Marc Anderson):
Thank you for having me, Dr. Braman.

MB:
Marc, what questions do you have about diabetes and mental health?

MA:
Well, first question, from a mental health standpoint, what challenges do those with diabetes face?

MB:
Actually, many people don’t realize how big of an association there is between mental health and diabetes, which is why we need to talk about this. There are many potential mental health issues that someone with diabetes may face. The diagnosis itself can cause a fair amount of psychological distress. We covered in another topic how stress plays a huge role in diabetes. As a person lives with and learns to manage their condition, they can face many challenges. Problems can be with obtaining care, diabetes education and learning how to self-manage their condition, economic hardships, fear of complications, perceived hopelessness and helplessness. Consequently, diabetes is associated with high rates of depression and an array of anxiety disorders. In addition, diabetics at higher risk of these problems, like those living in poverty or who already suffer from mental illness, have the least access to crucial mental health care and diabetes services.

MA:
Wow, that is quite an association. Now, for depression, how common is it in the diabetic population?

MB:
Studies have reported that the prevalence of clinically significant depressive symptoms ranges from 25-35% in the diabetic population and the prevalence (or how many people out of a group) of clinically diagnosed depression, known as major depressive disorder (MDD) is around 10%. These numbers may not seem like much but they are more than double the rates of depression and depressive symptoms in people without any chronic illnesses, though this may be true for other substantial chronic medical problems as well.

MA:
Wow, those are impressive numbers. Now, how does depression affect diabetes management and outcomes?

MB:
In a number of ways. Depression not only causes problems for those with diabetes, but research shows it may increase your risk of getting diabetes by 60%. For those with diabetes, having depression resulted in higher rates of complications, increased burden of symptoms and decreased self-management abilities. From a lifestyle medicine standpoint, depression is particularly bad for diabetics because it has been shown to increase the risk of cardiovascular problems and be extremely detrimental to following a good exercise and diet routine.

MA:
What about anxiety disorders?

MB:
Yes, we don’t want to forget those. Generalized anxiety disorder and related conditions like PTSD, social phobias, obsessive compulsive disorder and other things like body dysmorphic disorder (where one perceives their body badly) are common among diabetes patients. Estimates are that roughly 1 in 5 diabetics suffer from an anxiety condition.

Anxiety & depression often go together so there are a lot of similarities. Anxiety may may come from or be caused by fear of complications and declining health, lack of social support, issues with treatment, and economic challenges, among other things. The flip side is that anxiety disorders have been shown to cause problems with self-management and treatment, social issues, increased symptom burden and increased risk of other serious mental disorders like depression.

MA:
Wow, so it sounds like both anxiety and depression can cause major problems for those with diabetes. Don’t those with diabetes also suffer from higher rates of eating disorders?

MB:
Yes they do, conditions like anorexia, bulimia, binge eating syndrome and night eating syndrome are more common in diabetics. Additionally, about half of diabetics that suffer from an eating disorder also suffer from depression and those that don’t are 4 times more likely to get depressed. Diabetics with eating disorders frequently suffer from high and low blood sugar, intentionally skip medications, have issues with proper weight control and fail to stick to a healthy diet. So as you can imagine, eating disorders can be particularly dangerous for diabetics because of how important good nutrition is for managing diabetes.

MA:
So what is the best way to identify, manage and treat mental health issues in someone with diabetes?

MB:
Much like diabetes itself, care of the diabetic patient can be complex. It requires collaborative, patient-centered care that involves the patient, physicians, family, friends, diabetes educators, mental health professionals and often community/social resources. Patients should be screened regularly for mental health problems and if there are concerns or signs of mental illness, treatment should be pursued quickly and collaboratively.

MA:
How can lifestyle medicine be used to treat these illnesses?

MB:
Lifestyle medicine is all about treating the causes of disease as primary or foundational treatment. Interventions that treat the lifestyle causes: like exercise, family and social support groups, therapy, and stress coping skills like meditation, have been shown to be extremely effective at treating both the mental and physical challenges of those with diabetes. We know that a person exists as a whole: body, mind and spirit. Only when we address the whole person do we really provide effective treatment. If we improve mental health, we can’t help but improve physical health.

MA:
Wow, that’s absolutely fascinating and I can imagine that there are a lot of implications there for really impressive care.

Thank you so much, Dr. Braman.

MB:
Thank you, and good luck with your mental health and diabetic patients.

Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Young-Hyman, Deborah, Mary De Groot, Felicia Hill-Briggs, Jeffrey S. Gonzalez, Korey Hood, and Mark Peyrot. Diabetes Care 39.12 (2016): 2126-140. Web. 21 Nov. 2016.

Diabetes and Mental Health. Canadian Journal of Diabetes 37 (2013): 87-92. Web. 21 Nov. 2016.

Relationship of Depression and Diabetes Self-Care, Medication Adherence, and Preventive Care. Lin, E. H.b., W. Katon, M. Von Korff, C. Rutter, G. E. Simon, M. Oliver, P. Ciechanowski, E. J. Ludman, T. Bush, and B. Young. Diabetes Care 27.9 (2004): 2154-160. Web. 21 Nov. 2016.

A Call for More Effectively Integrating Behavioral and Social Science Principles Into Comprehensive Diabetes Care. Fisher, L., and R. E. Glasgow. Diabetes Care 30.10 (2007): 2746-749. Web. 22 Nov. 2016.

Marc Braman, MD, MPH

Dr. Braman is board certified in preventive medicine/public health and occupational/environmental medicine. He is founding member, second President and first Executive Director of American College of Lifestyle Medicine and founder and current president of the Lifestyle Medicine Foundation which created LifestyleFACTS.org. He provides lifestyle medicine care in a wide variety of settings as well as initiating efforts to establish professional standards for the field of lifestyle medicine and planning and conducting national professional conferences in lifestyle medicine.

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