- •The experience of living with diabetes is often associated with concerns specific to the illness and can cause conditions, such as diabetes distress, psychological insulin resistance and the persistent fear of hypoglycemic episodes.
- •A wide range of psychiatric disorders, including major depressive disorder, bipolar and related disorders, schizophrenia spectrum and other psychotic disorders, anxiety disorders, sleep disorders, eating disorders and stress-related disorders are more prevalent in people with diabetes compared to the general population.
- •People living with diabetes and depressive disorders are at increased risk for earlier all-cause mortality compared to people living with diabetes without a history of depression.
- •All individuals with diabetes should be regularly screened for the presence of diabetes distress, as well as symptoms of common psychiatric disorders.
- •Compared to those with diabetes only, individuals with diabetes and mental health concerns have decreased participation in diabetes self-care, a decreased quality of life, increased functional impairment, increased risk of complications associated with diabetes, and increased health-care costs.
- •Cognitive behaviour therapy, patient-centred approaches (e.g. motivational interviewing), stress management, coping skills training, family therapy and collaborative case management should be incorporated into primary care. Self-management skills, educational interventions that facilitate adaptation to diabetes, addressing co-occurring mental health issues, reducing diabetes-related distress, fear of hypoglycemia, and psychological insulin resistance are all helpful.
- •Individuals taking psychiatric medications, particularly (but not limited to) atypical antipsychotics, benefit from regular screening of metabolic parameters to identify glucose dysregulation, dyslipidemia and weight gain throughout the course of the illness so that appropriate interventions can be instituted.
- •Living with diabetes can be burdensome and anxiety provoking, with the constant demands taking a psychological toll. As a result, many people experience distress, decreased mood and disabling levels of anxiety. Diabetes is often associated with a significant emotional burden, distress over the self-care regimen and stress in relationships (with family and friends, as well as health-care providers).
- •It is important to recognize your emotions and talk to your friends, family and members of your diabetes health-care team about how you are feeling. Your team can help you to learn effective coping skills and direct you to support services that can make a difference for you.
- •Mood and anxiety disorders are particularly common in people with diabetes. Eating, sleeping and stress-related disorders are also common. Speak to your health-care providers about any concerns you have if you think you may be developing any of these problems.
- •Mental health disorders can affect your ability to cope with and care for your diabetes. In view of this, it is just as important to look after your mental health as it is your physical health.
- •People diagnosed with serious mental illnesses, such as major depressive disorder, bipolar disorder and schizophrenia, have a higher risk of developing diabetes than the general population.
Psychological Effects of Diabetes in Adults
|Diabetes Distress||Major Depressive Disorder|
|Assessment Instrument||Diabetes Distress Scale (17 items) |
|Patient Health Questionnaire for Depression: PHQ-9 (9 items) |
The PHQ-9: A new depression diagnostic and severity measure.
|Format||Self-report using ratings from 1 to 6 based on feelings and experiences over the past week||Self-report using ratings from 0 to 3 based on feelings and experiences over the past 2 weeks|
|Features||Emotional Burden Subscale (5 items)|
Physician-Related Distress Subscale (4 items)
Regimen-Related Distress Subscale (5 items)
Diabetes-Related Interpersonal Distress Subscale (3 items)
|Vegetative symptoms, such as sleep, appetite and energy level changes|
Emotional symptoms, such as low mood and reduced enjoyment of usual activities
Behavioural symptoms, such as agitation or slowing of movements
Cognitive symptoms, such as poor memory or reduced concentration or feelings of guilt; thoughts of self-harm
- Anderson R.M.
Psychiatric Conditions in Adults
Major Depressive Disorder
- •Female sex
- •Adolescents/young adults and older adults
- •Few social supports
- •Stressful life events
- •Poor glycemic control, particularly recurrent hypoglycemia
- •Higher illness burden
- •Longer duration of diabetes
- •Presence of long-term complications.
- •Physical inactivity (63) and overweight/obesity, which leads to insulin resistance
- •Psychological stress leading to chronic hypothalamic-pituitary-adrenal dysregulation and hyperactivity stimulating cortisol release, also leading to insulin resistance (64,65,66,67,68,69)
- •Hippocampal atrophy and decreased neurogenesis (70).
Schizophrenia Spectrum Disorders
- McEvoy J.P.
- Meyer J.M.
- Goff D.C.
- et al.
Stress, Trauma, Abuse and Neglect
Feeding and Eating Disorders
Substance Use Disorders
Children and Adolescents with Diabetes
- Korbel C.D.
- Wiebe D.J.
- Berg C.A.
- et al.
Feeding and Eating Disorders in Pediatric Diabetes
Other Considerations in Children and Adolescents
Prevention and Intervention
Type 2 Diabetes in Children and Adolescents
Considerations in Pregnancy
Considerations for Older People with Diabetes
Psychiatric Disorders and Adverse Outcomes
Screening and Assessment of Mental Health Symptoms
- •Diabetes-specific measures, such as the Problem Areas in Diabetes (PAID) Scale or the Diabetes Distress Scale (DDS) (163,164)
- •Quality of life measures, such as the WHO-5 screening instrument (165)
- •Depressive/anxiety symptoms, such as the Hospital Anxiety and Depression Scale (HADS) (166), the Patient Health Questionnaire (PHQ-9) (167,
The PHQ-9: A new depression diagnostic and severity measure.168), the Centre for Epidemiological Studies-Depression Scale (CES-D) (169) or the Beck Depression Inventory (BDI) (170).
- Kroenke K.
- Spitzer R.L.
Psychosocial (Non-Pharmacological) Treatments
|Cognitive Component||Behavioural Component|
|Record keeping to identify distressing automatic thoughts|
Understanding the link between thoughts and feelings
Learning the common “thinking errors” that mediate distress (e.g. all-or-nothing thinking, personalization, magnification, minimization, etc.)
Analyzing negative thoughts and promoting more functional ones
Identifying basic assumptions about oneself (e.g. “unless I am very successful, my life is not worth living) and being encouraged to adopt healthier ones (e.g. “when I am doing my best, I should be proud of myself”)
|Strategies to help get the person moving (behavioural activation)|
Scheduling pleasant and meaningful events
Learning assertive and effective communication skills
Focusing on feelings of mastery and accomplishment
Learning problem-solving strategies
Exposure to new experiences
Shaping behaviours by breaking them down into smaller steps to develop skills
- Polonsky W.H.
- Jackson R.A.
Monitoring Metabolic Risks
- •Patient factors (e.g. health behaviour choices, diet, tobacco consumption, substance use, exercise, obesity, low degree of implementation of education programs)
- •Illness factors (e.g. pro-inflammatory states from MDD or depressive symptoms, possible disease-related risks for developing diabetes) (221,222)
- •Medication factors (e.g. psychiatric medications have variable effects on glycemic control, weight and lipids)
- •Environmental factors (e.g. access to health care, availability of screening and monitoring programs, social supports, education programs).
|Unlikely||Likely||Very Likely||Highly Likely|
|Sedatives / hypnotics||Zolpidem||Zopiclone|
|Substance use disorder treatments||Buprenorphine|
- 1.Individuals with diabetes should be regularly screened for diabetes-related psychological distress (e.g. diabetes distress, psychological insulin resistance, fear of hypoglycemia) and psychiatric disorders (e.g. depression, anxiety disorders) by validated self-report questionnaire or clinical interview [Grade D, Consensus]. Plans for self harm should be asked about regularly as well [Grade C, Level 3 (155)].
- 2.The following groups of people with diabetes should be referred to specialized mental health-care professionals [Grade D, Consensus for all of the following]:
- a.Significant distress related to diabetes management
- b.Persistent fear of hypoglycemia
- c.Psychological insulin resistance
- d.Psychiatric disorders (i.e. depression, anxiety, eating disorders).
- 3.Collaborative care by interprofessional teams should be provided for individuals with diabetes and depression to improve:
- 4.Psychosocial interventions should be integrated into diabetes care plans, including:
- a.Motivational interventions [Grade D, Consensus]
- b.Stress management strategies [Grade C, Level 3 (175)]
- c.Coping skills training [Grade A, Level 1A (227) for type 2 diabetes; Grade B, Level 2 (228) for type 1 diabetes]
- d.Family therapy [Grade A, Level 1B (176,178,229)]
- e.Case management [Grade B, Level 2 (192)].
- 5.Antidepressant medication should be used to treat acute depression in people with diabetes [Grade A, Level 1 (78)] and for maintenance treatment to prevent recurrence of depression [Grade A, Level 1A (77)]. Cognitive behaviour therapy (CBT) can be used to treat depression in individuals with depression alone [Grade B, Level 2 (79)] or in combination with antidepressant medication [Grade A, Level 1 (138,184)].
- 6.Because of the risk of adverse metabolic effects of many antipsychotic medications (especially atypical/second and third generation) [Grade A, Level 1 (37)], regular metabolic monitoring should be performed in people with and without diabetes who are treated with these medications [Grade D, Consensus].
- 7.Children and adolescents with diabetes should be screened at diagnosis for major depressive disorder [Grade D, Consensus] and regularly for psychosocial difficulties, family distress or mental health disorders [Grade D, Consensus]. An expert in mental health and/or psychosocial issues should provide intervention when required; this individual may be part of the pediatric diabetes health-care team or enlisted by referral [Grade D, Consensus]. Individual and family educational interventions should be included to address stress or diabetes-related conflict when indicated [Grade D, Consensus].
- 8.Adolescents with type 1 diabetes should be regularly screened using non-judgemental questions about weight and body image concerns, dieting, binge eating and insulin omission for weight loss [Grade D, Level 2 (131)].
|Parameter||Baseline||1 month||2 months||3 months||Every 3 to 6 months||Annually|
|A1C preferred ± Fasting Plasma Glucose||x||x||x|
|Fasting lipid profile||x||x||x|
|Personal history, particularly alcohol, tobacco and recreational substance use||x||x||x|
Other Relevant Guidelines
- Nutrition Therapy, p. S64
- Glycemic Management in Adults With Type 1 Diabetes, p. S80
- Pharmacologic Glycemic Management of Type 2 Diabetes in Adults, p. S88
- Type 1 Diabetes in Children and Adolescents, p. S234
- Type 2 Diabetes in Children and Adolescents, p. S247
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