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Joslin’s Diabetes Deskbook, Updated 2nd Ed., Excerpt #38: Psychological Issues in the Treatment of Diabetes, Part 3 of 3

Nov 17, 2013

Barbara J. Anderson, PhD, CDE and Abigail K. Mansfield Marcaccio, PhD


The week’s excerpt answers the following questions:
  • What are the two different meanings for the term depression?
  • How often does depression in occur in those with diabetes?
  • What are the implications for better self-care for those with depression?
  • How do you identify Anxiety Disorders in those with diabetes?
  • What are the four ways anxiety disorders can complicate living with and managing diabetes?
  • What are the most common and potentially damaging source of anxiety for patients with diabetes?…


The term depression has at least two different meanings. First, people may say they feel "depressed" when they are having a bad day or temporarily "feeling blue." However, these short-lived drops in mood are very different from the psychiatric diagnosis of depression, a serious and often life-threatening chronic mental disorder as identified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. This depression, called major depression, is diagnosed on the basis of both mental symptoms (e.g., sadness, loss of pleasure, inability to concentrate) and physical symptoms (e.g. fatigue, changes in appetite and sleep patterns) that continue for an extended period of time and interfere with people’s work and family functioning.

The incidence of major depression in the general population is about 5% to 8%. Research has shown that major depression is about three times more common in people with diabetes than in the general population. Depression occurs equally often in type 1 diabetes and type 2 diabetes — in about 15% to 20% of patients. Similar to the higher incidence of major depression in women in the general population, major depression occurs more frequently in women with diabetes than in men with diabetes (Lustman — See Suggested Reading at end of chapter.). Although major depression is more common in patients with diabetes, diabetes does not necessarily cause depression. In fact, the complex interaction of genetic, psychological, and physical factors which likely cause major depression in people with diabetes is not yet precisely known. However, it is well documented that major depression impacts negatively on patients’ abilities to cope with diabetes emotionally and to carry out the self-care tasks that living with diabetes requires.

Researchers and clinicians studying major depression in persons with diabetes have identified three important issues:

1. Distinguishing depression from hyperglycemia — The symptoms of major depression and the symptoms of chronic hyperglycemia are often very similar (e.g., lethargy, fatigue, poor concentration, changes in appetite and sleep patterns). Therefore, it can be very difficult to diagnose depression in a person who simultaneously has chronic high blood glucose levels.

2. Depression and its implications for self-care — Living with diabetes often brings with it a broad range of diabetes-related distresses. It has been reported that the following diabetes-specific stressors occur frequently in patients with diabetes and can interfere with effective self-care (Polonsky et al, 2002. See Suggested Reading at end of chapter.):

  • not having clear and concrete goals for diabetes care
  • feeling discouraged and/or overwhelmed with the diabetes regimen
  • feeling scared when thinking about having and living with diabetes
  • uncomfortable interactions concerning diabetes with family, friends, or acquaintances who do not have diabetes
  • not knowing if the moods or feelings they are experiencing are related to blood glucose levels
  • feeling constantly concerned about food and eating
  • worrying about the future and the possibility of serious complications
  • feelings of guilt or anxiety when they get off-track with their diabetes management
  • feeling unsatisfied with their relationship with their diabetes physician
  • feeling that diabetes is taking up too much mental and physical energy every day
  • coping with complications of diabetes

3. Depression and its relationship to diabetes complications — Major depression has been identified as a risk factor for the development of complications of diabetes. In addition, major depression can also occur secondarily to the complications of diabetes. The onset of a long-term debilitating complication of diabetes, such as visual impairment or painful neuropathy, represents another "loss" for the person who has diabetes. Some patients feel very discouraged and angry that their hard work and diabetes management efforts did not protect them from debilitating complications. Other patients, however, may feel guilty and think that complications are the direct result of their inadequate self-care.

Support and Intervention

Because of the high prevalence of major depression among persons with diabetes, the range of diabetes-related stressors which face patients, and the connection between major depression and diabetes complications, it is critical for primary care providers to have a sense of the best available treatments for major depression — psychotherapy and medication.

  • Psychotherapy, which targets the symptoms of depression, is different from general supportive counseling. One system of psychotherapy that has been proven to be a useful treatment for persons who struggle with depression is cognitive-behavioral therapy. In addition, there are several new antidepressant medications (selective serotonin reuptake inhibitors or SSRIs) on the market that are effective and have minimal side effects.
  • It is important for primary care providers to refer their depressed patients to competent therapists in their local area. Make referrals to a qualified therapist (social worker, psychologist, or psychiatrist) who has experience in treating depression and in working with persons with diabetes. In addition, primary care providers should be aware of the inpatient psychiatric facilities in their local area that have experience with patients who have both depression and diabetes.
  • Some patients with major depression will require an inpatient psychiatric hospitalization in order to receive the level of treatment needed when depression becomes severe and life-threatening.
Anxiety Disorders 

Anxiety disorders, which are the most frequently diagnosed psychiatric disorder in the general population, represent a spectrum of behaviors from anxiety and avoidance behavior, to panic and phobic behavior, to obsessive and compulsive disorders. As with depression, we commonly think of being "anxious" as part of coping with new or difficult parts of everyday life. However, anxiety disorders are diagnosed when:

  • the anxiety or worry the person experiences is unrealistic or excessive
  • it extends over a 6-month period
  • behavior is characterized by symptoms of motor tension (trembling, twitching, feeling shaky, restless, and easily fatigued) and autonomic hyperactivity (shortness of breath, palpitations, accelerated heart rate, sweating, cold clammy hands, dry mouth, dizziness or lightheadedness, nausea, diarrhea, flushes or chills, frequent urination, and trouble swallowing)

Anxiety Disorders and Diabetes

Anxiety disorders can complicate living with diabetes and its management in the following four ways:

  1. Confusion between anxiety and hypoglycemia — The symptoms of autonomic hyperactivity listed above, which are part of a serious anxiety disorder, mirror the symptoms of hypoglycemia. This can make it very difficult for a person with diabetes to differentiate between feelings of anxiety and symptoms of low blood glucose, which should receive immediate treatment.
  1. Exacerbation of pre-existing injection/blood testing anxiety — There are several aspects of the diabetes treatment regimen that may be sources of extreme anxiety for some patients. For example, individuals who have been extremely anxious during routine injections or blood glucose checks may develop symptoms of a severe panic disorder when faced with injecting insulin or pricking a finger to monitor blood glucose levels. At this point it is important for the primary care physician to make a referral to a mental health professional skilled in helping persons with anxiety disorders and diabetes.
  1. Fear of hypoglycemia — The most common and potentially damaging source of anxiety for patients with type 1 diabetes, as well as for patients with type 2 diabetes taking blood glucose-lowering medication, is fear of hypoglycemia. Patients who are extremely anxious about low blood glucose levels will understandably strive to keep their blood glucose levels at a constantly higher target range than that recommended by their diabetes healthcare team. Behavioral scientists who study fear of hypoglycemia emphasize that it is not surprising that many patients experience fear and anxiety about hypoglycemia and its embarrassing consequences and have identified four groups of diabetes patients at high risk for fear of hypoglycemia (Gonder-Frederick, Cox, and Clarke, 1996. See Suggested Reading at end of chapter.):
  • newly-diagnosed patients who have not yet learned that they can deal effectively with hypoglycemia
  • patients who have had a recent or past traumatic episode of hypoglycemia
  • patients who are overly anxious in other areas of their lives
  • parents of children who have experienced severe hypoglycemia or episodes of serious low blood glucose in their children.
  1. Outside stresses and other externally caused sources of anxiety — An acute state of anxiety (such as caused by serious stresses) can trigger neuroendocrine responses leading to hyperglycemia. Thus, anxiety disorders can affect blood glucose directly through physiological pathways, as well as indirectly by interfering with the learning and execution of diabetes management skills.

Support and Intervention

Primary care providers need to be familiar with the treatments available for anxiety disorders: psychotherapy and medication for generalized anxiety disorders, and Blood Glucose Awareness Training for severe fear of hypoglycemia.

  • Psychotherapy and Medication. Sometimes symptoms of anxiety disorders, such as fatigue, sleep problems, difficulty concentrating, and irritability, are similar to those of major depression. Thus it is important to refer patients struggling with these symptoms to a mental health professional (social worker, psychologist, or psychiatrist) who has experience working with people with diabetes. There are several newer medications for treating anxiety in the context of therapy which are effective and not as habit-forming as older antianxiety medications.
  • Blood Glucose Awareness Training (BGAT). A group of psychologists and behavioral scientists at the University of Virginia have developed a behavioral treatment program that improves a patient’s ability to recognize, avoid, and treat hypoglycemia. This program is designed for patients who have lost their awareness of the symptoms of low blood glucose and/or patients who have a profound fear of low blood glucose. The American Diabetes Association has an interactive, online BGAT program, or you can contact the University of Virginia Behavioral Medicine Center in Charlottesville, VA, to find out if there is a BGAT program in your local area.

Support from medical personnel and family members is crucial in promoting and maintaining diabetes care. Primary care providers can foster this support by building strong relationships with their patients that attend to the emotional aspects of diabetes as well as the medical ones. They can also help families to provide support for the person with diabetes. Finally, primary care providers play a pivotal role in screening, diagnosis and referral when serious psychological barriers to mental and physical health arise.

Suggested Reading

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4TH ed. Washington, DC, American Psychiatric Association, 1994.

Goebel-Fabbri AE, Fikkan JL, Connell A, Vangsness L, Anderson BJ. Identification and treatment of eating disorders in women with type 1 diabetes mellitus. Treatments in Endocrinology. 2002; 1 (3): 155–162.

Gonder-Frederick L, Cox DJ, Clarke WL. Helping patients understand, recognize and avoid hypoglycemia. In B. Anderson & R. Rubin (Eds.) Practical Psychology for Diabetes Clinicians. American Diabetes Association, Alexandria, VA; 2002, 113–124.

Jones JM, Lawson ML, Daneman D, Omsted MP, Rodin G. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. British Medical Journal 2000; 320:1563–1566.

Lustman PJ, Griffith LS, Gavard JA, Clouse RE. Depression in adults with diabetes. Diabetes Care 15: 1631–1639, 1992.

Lustman PJ, Singh PK, Clouse RE. Recognizing and managing depression in patients with diabetes. In B. Anderson and R. Rubin (Eds.) Practical Psychology for Diabetes Clinicians. American Diabetes Association, Alexandria, VA; 2002, 229–238.

Peyrot M. Recognizing emotional responses to diagnosis. In B. Anderson and R. Rubin (Eds.) Practical Psychology for Diabetes Clinicians. American Diabetes Association,

Alexandria, VA; 2002, 211–218.

Polonsky, WH. Understanding and treating patients with diabetes burnout. In B.Anderson and R. Rubin (Eds.) Practical Psychology for Diabetes Clinicians. Alexandria, VA: American Diabetes Association, 2002, 219–228. 

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