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Psychiatric considerations in patients with diabetes

Drs Brian O’Shea, Catherine McCollam, Marjorie Stokes and John Yek discuss how diabetes mellitus can impact on a patient’s mental health and well-being

The diabetic way of life brings its own particular stresses, and diabetes mellitus (DM) has direct effects on the nervous system. A diagnosis of DM may elicit anger, anxiety, depression, social withdrawal, or denial in the recipient.

DM often makes a patient feel uncomfortable, it reduces functional capacity, interferes with family life, and it leads to problems of adaptation during adolescence.
Common symptoms in insulin-dependent diabetics include loss of energy, fatigue, irritability, depression, and delay in psychosexual maturation.

Poor family function is associated with poor control of DM in juvenile-onset cases. Juvenile-onset DM is associated with reading problems and psychiatric difficulties in the child and/or his/her parents.

Abnormal eating attitudes are common in young insulin-dependent female diabetics, but are less likely in their male counterparts. Hyperglycaemia and glycosuria (which cause weight loss) and the emphasis on diet may promote eating disorders.

Hypoglycaemic response
Reducing insulin intake also reduces weight (and increases the chance of complications such as retinopathy and diabetic ketoacidosis). A so-called type-A behaviour pattern in childhood DM may be associated with an increased likelihood of a hypoglycaemic response to stress.

Poor control, demonstrated in glycosylated haemoglobin levels, is more common in diabetics with a psychiatric illness. Even after controlling for compliance, stress appears to adversely affect control. However, compliance with diet and exercise is reduced by depression.

Psychological factors play some role in ‘brittle’ cases, but it should be noted that the adolescent whose DM is difficult to control and who is prone to acting out also has labile diabetogenic hormones because he is an adolescent. Psychosocial stress may play a role in precipitating the disease and in non-compliance in some cases of DM.

Significant fears may develop in patients concerning blood sugar dyscontrol and complications such as blindness or amputation. Over-enthusiastic control by obsessional patients may lead to persistent hyperglycaemia (to avoid low blood sugar), excessive blood sugar monitoring, and episodes of hypoglycaemia.

Unaware of the physiological symptoms of hypoglycaemia
Some patients become unaware of the physiological symptoms of hypoglycaemia or cannot distinguish them from anxiety. Shame or helplessness may complicate attacks.

Patients may maintain excessively high blood sugars in order to avoid hypoglycaemia. Emphasis on building a relationship with the adolescent diabetic may prove better in terms of disease control than a rigid insistence on acceptable blood sugars.

Exogenous insulin is associated with low C-peptide levels. Oral hypoglycaemic drugs (detectable in blood and urine) may raise C-peptide levels (and mimic insulinoma) by stimulating beta islet cells.

Kawakami et al followed up almost 3,000 male employees in a Japanese company for eight years, screening them at entry with the Zung depression scale and yearly for DM.

Factors such as activity, alcohol, and obesity were controlled for.

Some 43 developed type 2 DM over the study period, and of these nine had moderate/severe depression at study onset. These nine cases had a 2.3-times increased risk for type 2 DM at follow-up relative to non-depressed/low level of depression at entry to the study.

Doubled the risk
Atlantis et al found that depressive symptoms doubled the risk of developing DM on follow up in the elderly independent of antidepressant drug use. A psychiatric diagnosis was recorded in one-half of patients being assessed for pancreatic transplantation, and one-quarter of patients had a lifetime history of major depression.

Henry Maudsley noted an excess of DM among schizophrenic patients. This connection was known before the antipsychotic era. All such patients, regardless of medication status, should be screened for diabetes. Aripiprazole and ziprasidone are probably the safest antipsychotic drugs in the presence of DM.

DM in women can lead to reduced sexual arousal, vaginal dryness, and anorgasmia. Bulimia nervosa patients who are also diabetic may deliberately omit their insulin. Drugs like beta-blockers may reduce arousal (and erection in the male). Sexual dysfunction may be associated with depression.

Impaired glucose tolerance
In a systematic review and meta-analysis, Gillies et al found that lifestyle interventions are at least as effective as drug treatment in reducing the rate of progression to type 2 diabetes in people with impaired glucose tolerance.

Apart from the usual precautions with alcohol (e.g. alcohol is a relative contraindication to warfarin therapy – risk of bleeding with warfarin), the diabetic must be aware of certain facts: alcohol is high in energy and carbohydrates; it can potentiate the hypoglycaemic action of oral hypoglycaemics and insulin; it causes hypoglycaemia by directly inhibiting gluconeogenesis and glucose output from the liver; it predisposes to lactic acidosis if the patient is taking a biguanide; and alcohol can cause a disulfiram-type reaction in people taking sulphonylureas.

Alcohol should be avoided in the presence of obesity, hypertension, hypertriglyceridaemia, or an independent alcohol-related problem (e.g. dependence).

A diabetic patient who is brought to an emergency department with hypoglycaemia may be mistaken for a belligerent drunk.

Cognitive impairment
Between 10 and 20 per cent of chronic DM cases may have cognitive impairment (sometimes vascular dementia) due to diseased large and small vessels. However, an 18-year follow up of type 1 diabetics (mean age of entry to study was 27 years) revealed no substantial cognitive dysfunction despite relatively frequent attacks of severe hypoglycaemia.

However, higher glycated haemoglobin values were associated with moderately reduced motor speed and psychomotor efficiency. Logroscino et al found that elderly women with type 2 DM had an increased likelihood of having poor cognitive function that worsens with time and that oral hypoglycaemic drugs might reduce this risk.

Declaration of interest: None.

Brian O’Shea FRCPsych
Catherine McCollam MRCPsych
Marjorie Stokes MRCPsych
John Yek MB
Newcastle Hospital, Co Wicklow

Posted in Diabetes on 19 November 2009
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abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Psychiatric considerations in patients with diabetes

Drs Brian O’Shea, Catherine McCollam, Marjorie Stokes and John Yek discuss how diabetes mellitus can impact on a patient’s mental health and well-being

The diabetic way of life brings its own particular stresses, and diabetes mellitus (DM) has direct effects on the nervous system. A diagnosis of DM may elicit anger, anxiety, depression, social withdrawal, or denial in the recipient.

DM often makes a patient feel uncomfortable, it reduces functional capacity, interferes with family life, and it leads to problems of adaptation during adolescence.
Common symptoms in insulin-dependent diabetics include loss of energy, fatigue, irritability, depression, and delay in psychosexual maturation.

Poor family function is associated with poor control of DM in juvenile-onset cases. Juvenile-onset DM is associated with reading problems and psychiatric difficulties in the child and/or his/her parents.

Abnormal eating attitudes are common in young insulin-dependent female diabetics, but are less likely in their male counterparts. Hyperglycaemia and glycosuria (which cause weight loss) and the emphasis on diet may promote eating disorders.

Hypoglycaemic response
Reducing insulin intake also reduces weight (and increases the chance of complications such as retinopathy and diabetic ketoacidosis). A so-called type-A behaviour pattern in childhood DM may be associated with an increased likelihood of a hypoglycaemic response to stress.

Poor control, demonstrated in glycosylated haemoglobin levels, is more common in diabetics with a psychiatric illness. Even after controlling for compliance, stress appears to adversely affect control. However, compliance with diet and exercise is reduced by depression.

Psychological factors play some role in ‘brittle’ cases, but it should be noted that the adolescent whose DM is difficult to control and who is prone to acting out also has labile diabetogenic hormones because he is an adolescent. Psychosocial stress may play a role in precipitating the disease and in non-compliance in some cases of DM.

Significant fears may develop in patients concerning blood sugar dyscontrol and complications such as blindness or amputation. Over-enthusiastic control by obsessional patients may lead to persistent hyperglycaemia (to avoid low blood sugar), excessive blood sugar monitoring, and episodes of hypoglycaemia.

Unaware of the physiological symptoms of hypoglycaemia
Some patients become unaware of the physiological symptoms of hypoglycaemia or cannot distinguish them from anxiety. Shame or helplessness may complicate attacks.

Patients may maintain excessively high blood sugars in order to avoid hypoglycaemia. Emphasis on building a relationship with the adolescent diabetic may prove better in terms of disease control than a rigid insistence on acceptable blood sugars.

Exogenous insulin is associated with low C-peptide levels. Oral hypoglycaemic drugs (detectable in blood and urine) may raise C-peptide levels (and mimic insulinoma) by stimulating beta islet cells.

Kawakami et al followed up almost 3,000 male employees in a Japanese company for eight years, screening them at entry with the Zung depression scale and yearly for DM.

Factors such as activity, alcohol, and obesity were controlled for.

Some 43 developed type 2 DM over the study period, and of these nine had moderate/severe depression at study onset. These nine cases had a 2.3-times increased risk for type 2 DM at follow-up relative to non-depressed/low level of depression at entry to the study.

Doubled the risk
Atlantis et al found that depressive symptoms doubled the risk of developing DM on follow up in the elderly independent of antidepressant drug use. A psychiatric diagnosis was recorded in one-half of patients being assessed for pancreatic transplantation, and one-quarter of patients had a lifetime history of major depression.

Henry Maudsley noted an excess of DM among schizophrenic patients. This connection was known before the antipsychotic era. All such patients, regardless of medication status, should be screened for diabetes. Aripiprazole and ziprasidone are probably the safest antipsychotic drugs in the presence of DM.

DM in women can lead to reduced sexual arousal, vaginal dryness, and anorgasmia. Bulimia nervosa patients who are also diabetic may deliberately omit their insulin. Drugs like beta-blockers may reduce arousal (and erection in the male). Sexual dysfunction may be associated with depression.

Impaired glucose tolerance
In a systematic review and meta-analysis, Gillies et al found that lifestyle interventions are at least as effective as drug treatment in reducing the rate of progression to type 2 diabetes in people with impaired glucose tolerance.

Apart from the usual precautions with alcohol (e.g. alcohol is a relative contraindication to warfarin therapy – risk of bleeding with warfarin), the diabetic must be aware of certain facts: alcohol is high in energy and carbohydrates; it can potentiate the hypoglycaemic action of oral hypoglycaemics and insulin; it causes hypoglycaemia by directly inhibiting gluconeogenesis and glucose output from the liver; it predisposes to lactic acidosis if the patient is taking a biguanide; and alcohol can cause a disulfiram-type reaction in people taking sulphonylureas.

Alcohol should be avoided in the presence of obesity, hypertension, hypertriglyceridaemia, or an independent alcohol-related problem (e.g. dependence).

A diabetic patient who is brought to an emergency department with hypoglycaemia may be mistaken for a belligerent drunk.

Cognitive impairment
Between 10 and 20 per cent of chronic DM cases may have cognitive impairment (sometimes vascular dementia) due to diseased large and small vessels. However, an 18-year follow up of type 1 diabetics (mean age of entry to study was 27 years) revealed no substantial cognitive dysfunction despite relatively frequent attacks of severe hypoglycaemia.

However, higher glycated haemoglobin values were associated with moderately reduced motor speed and psychomotor efficiency. Logroscino et al found that elderly women with type 2 DM had an increased likelihood of having poor cognitive function that worsens with time and that oral hypoglycaemic drugs might reduce this risk.

Declaration of interest: None.

Brian O’Shea FRCPsych
Catherine McCollam MRCPsych
Marjorie Stokes MRCPsych
John Yek MB
Newcastle Hospital, Co Wicklow

Posted in Diabetes on 19 November 2009
Tags: