Diabetes and Mental Health

Illustration Credits: Proactive for Her

Psychological Needs of Patients with Diabetes and role of clinical psychologists

By Wasim Kakroo

DIABETES is a serious and complex metabolic illness that has reached epidemic proportions in recent decades. According to the International Diabetes Federation, diabetes affects millions of people globally, with a projected increase to 592 million by 2035. Diabetes affects millions of people in India between the ages of 20 and 79.

The majority of diabetes care guidelines are centered on the medical aspects of initial management without considering the patient's psychological requirements. Although many people with diabetes deal with it effectively and  live healthy lives, however, several studies, including The Diabetes Attitudes, Wishes, and Needs study, have highlighted that psychological support in this group of patients is under-resourced and inadequate, resulting in poor quality of life (QoL) and reduced general well-being. Many people find it difficult to accept that they will have to take medications for the rest of their lives, resulting in poor treatment adherence and diabetes self-management. These psychosocial issues might ultimately lead to depressive or other psychological disorders, which are linked to poor self-care, poor metabolic outcomes, higher chances of death, increased health-care costs, lost productivity, and a lower quality of life. When diabetic complications take their toll on physical and mental (psychological) health, patients' emotional and psychological needs are compromised.

According to research, diabetes and its complications are significantly linked to psychological and psychiatric issues. Depression, poor eating habits, and fear of hypoglycemia are among the major issues related to mental health. Furthermore, when compared to healthy population, people with type 2 diabetes mellitus have a two-fold increased risk of comorbid depression, lowering their quality of life. Patients with diabetes, experience high levels of diabetes-specific emotional stress. This is linked to functional impairment, poor exercise, diet, and medication adherence, and poor glycemic control.

Identifying and supporting diabetic patients with psychosocial problems early in the course of diabetes is critical, as it may impede their capacity to adjust or exercise proper self-care responsibilities. Addressing psychological needs improves diabetes outcomes in terms of better glycemic control and a reduction in comorbid psychiatric problems like depression.

Effective diabetes self-management is an important part of living a healthy and fulfilling life. However, it necessitates a significant amount of personal motivation and behavioural change.

Because the emotional and psychological requirements of people living with diabetes are so diverse, it's critical to understand the whole spectrum of psychological issues that can arise in such patients. Following are the various levels of complexities found among this patient population depending upon the degree of severity:

  • Level 1 is linked to a general inability to cope with diabetes and its perceived effects.

  • Level 2 is linked to more severe coping challenges, resulting in significant anxiety or a lowered mood, as well as a reduced ability to self-care resultantly. At Level 1, general and diabetes-related chronic stress might develop to anxiety and depression symptoms at Level 2.

  • Level 3 is associated with diagnosable psychological illnesses that may be addressed solely through psychological interventions, such as mild and moderate depression, anxiety states, and obsessive/compulsive disorders.

  • Level 4 refers to more serious psychological issues that can be diagnosed and that necessitate biological treatments, medications, as well as consultations and interventions from a professional clinical psychologist.

  • Level 5 is associated with a serious and complex mental illness that necessitates psychiatric attention.

Concept of diabetes distress:

Stress is defined as “the consequence of the failure of an organism – human or animal – to respond appropriately to emotional or physical threats, whether actual or imagined.” A stress response can be characterised as a cognitive, emotional, physical, or behavioural level that, when activated for a long time, can have substantial, negative implications on the body. Stress has long been suspected of having a significant impact on the development of diabetes via a variety of behavioural and physiological processes. Unhealthy lifestyle behaviours such as insufficient eating behaviours in terms of quality and amount of food, low exercise levels, and smoking have been linked to behavior-induced emotional stress. Diabetes distress (DD) is defined as the distinctive, often concealed emotional burdens and worries that a patient suffers when they are trying to manage a severe chronic disease like diabetes. High levels of DD are frequent, but they are not the same as clinical depression.

Psychosocial stressors and clinical manifestation of diabetes:

In the presence of stress, numerous metabolic changes, such as peripheral vascular vasoconstriction, higher heart rate, increased muscle activity, and increased stress hormone synthesis lead to elevated blood glucose levels in order to provide the extra energy needed to resist stress. Emotional distress in diabetic patients has been linked to poor blood sugar control, a lack of self-care behaviour, and poor diabetes outcomes. According to studies, noncompliance with medication could be a key link between emotional distress and poor diabetes outcomes. One research has found a link between depressive symptoms, poor medication adherence, and diabetic self-care. Similarly, another study found that persistent depressed symptoms were linked to poor diet and exercise self-management over the next five years among patients with substance abuse. Depression and anxiety have also been linked to a rise in blood sugar levels. Other research has found that psychological favtors may have a role in metabolic, gastrointestinal, and sexual dysfunction, as well as neuropathic symptoms, in diabetic patients.

Despite the fact that insulin therapy remains the gold standard for diabetes management, nonadherence to insulin therapy is common among diabetic patients. The psychological barrier related with fear of needles/injections, insulin introduction, and overdosing can all contribute to poor treatment adherence. Anxiety about insulin injections is widespread among diabetics, and it is especially prevalent among insulin-naive patients.

Depression and anxiety among patients with diabetes:

Diabetes and psychiatric diseases have a bidirectional relationship that influences each other in a variety of ways and patterns. Psychiatric diseases may be an independent risk factor for the development of diabetes, or they may be an overlap of clinical presentations, or they may appear as a side effect of psychiatric medicine, or vice versa. Psychiatric illnesses are a set of behavioural or psychological symptoms that have an impact on a person's life. Although psychiatric problems cause hardship for those who suffer from them, depression is one of the most studied disorders and has been linked to a significant negative influence on diabetic patients. According to research, depression is the most frequent psychiatric condition among diabetics, with an estimated 41% of patients experiencing poor mental health and higher rates of depression and anxiety disorders. Physicians caring for people with diabetes should be aware of the possibility of co-morbid depression, which should be recognised and treated with a combination of advice related to lifestyle changes, antidepressant medications, and psychotherapy.

Another common psychological disorder among diabetic individuals is anxiety. According to a systematic analysis, diabetic patients have a higher prevalence of anxiety than those without diabetes, with 14 percent having generalised anxiety disorder, 27 percent having sub-syndromal anxiety disorder, and 40 percent having increased anxiety symptoms in comparison to those without diabetes.

Other psychological disorders found in patients with diabetes:

  1. Another psychiatric illness linked to diabetes is delirium, which is characterised by hypoglycemia episodes or diabetic ketoacidosis. It is linked to longer hospital stays, cognitive and functional decline, as well as deaths. In addition, these individuals frequently experience disorientation, confusion, and impaired sensorium. The mainstay of treatment is close observation and supportive care.

  2. Eating disorders are another type of psychological disorders that is widespread among diabetics. These conditions can wreak havoc on glycemic control and raise the risk of diabetes complications.

  3. Depression, obesity, and type 2 diabetes are more likely to occur together more often than not. Epidemiological and metabolic research suggests that the three diseases share pathogenic mechanisms. The cause–effect relationship, on the other hand, is less clear: depression may cause obesity and diabetes as a result of lifestyle factors such as sedentary habits, overeating, and poor self-care; diabetes, on the other hand, may be linked to depression due to the significant emotional, social, medical, and financial burdens associated with its management. Furthermore, the use of antidepressants, particularly newer generation drugs, increases body weight and leads to insulin resistance, resulting in type 2 diabetes.

  4. Insulin resistance may be a relationship between depressive problems and Alzheimer's disease, according to studies. In the central nervous system, insulin is required for glucose consumption and neuronal survival. Dysglycemia, or fluctuating glucose levels, can cause neuronal death and the production of neurofibrillary tangles, which is a hallmark of Alzheimer's disease.

How can a clinical psychologist help in the treatment of diabetes?

Diabetes management necessitates complex, ongoing, and demanding self-care behavior. Given that psychosocial impact is a substantial predictor of severity of illness in diabetic patients, incorporating psychosocial components into diabetes therapy at all levels is critical for better treatment adherence and adequate glycemic control. Psychosocial stress is well documented to be prevalent among people with diabetes. With the increased importance of psychosocial factors in the treatment of diabetes, there is a need for the development and implementation of effective, well-evaluated psychosocial interventions/therapies to help people cope with the daily demands of diabetes.

Most doctors feel that psychological issues are linked to poorer results, thus it is recommended that patients receive adequate psychological care and that unpleasant emotions related with diabetes are properly addressed. Treatment adherence and glycemic control have been demonstrated to improve with psychosocial therapies such as cognitive behavioural therapy, motivational therapy, problem-solving therapy, coping skills training, and family behaviour therapy provided by clinical psychologists. In light of these facts, psychosocial therapies have been acknowledged as an important component of diabetes treatment.

A few adjustments at the health-care delivery clinics are required to include the psychological intervention into the existing treatment regimen.

At every level of diabetes care, it's critical to include psychological screening and management.

It is critical to educate health-care professionals, diabetes patients, and their families about the necessity of psychological evaluation and intervention in addition to other recommended treatments.

There has to be a community-wide advocacy initiative to raise awareness of the psychological well-being of people with diabetes.

Diabetes and psychological disorders have a complex relationship. Their coexistence can have an impact on glycemic control, self-care, and quality of life. When personal efforts to deal with these challenges fail to benefit, the emotional and psychological needs of individuals with diabetes are often jeopardised, increasing the risk of diabetes-related complications. Complications like this result in a lower quality of life, higher mortality, higher health-care expenses, and lost productivity. By taking the help of a clinical psychologist in addressing the patient's psychosocial requirements, the psychological barrier to adherence and self-care can be addressed, with long-term advantages in terms of improved health outcomes and glycemic control. Thus endocrinologists and clinical psychologists together would be better able to create strategies aimed at improving diabetes outcomes and reducing disease burden if they focus on medical as well as psychological elements of diabetes patients.


  • Wasim Kakroo, is a licensed clinical psychologist (alumni of govt. Medical college Srinagar). He works at Kashmir life line and health centre-a free counseling service with toll free number, 1800 180 7020. Author can be reached at [email protected]

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