Saturday , November 18 2017
Home / Specialties / Mental Health / Practical Diabetes Care, 3rd Ed., Excerpt #37: Psychological Aspects of Diabetes Part 1 of 4

Practical Diabetes Care, 3rd Ed., Excerpt #37: Psychological Aspects of Diabetes Part 1 of 4

David Levy, MD, FRCP

alt

Introduction

That there is a close link between long-term conditions and psychological functioning is to state the obvious. But the complexity of the relationship, especially in a condition that spans a lifetime, such as diabetes, has only relatively recently been explored. In addition, the therapeutic options, once the often very subtle problems have been identified, are only just emerging. Finally, the literature is full of studies describing cross-sectional associations, many of them expected or unsurprising, but only longitudinal studies can uncover causality; fortunately, detailed and validated measures of psychological function are now routinely included in many current large-scale RCTs, and the next few years should give us a much clearer understanding of the dynamics of psychological aspects of diabetes and, more importantly, an insight into therapies. Because the fundamental processes at work in type 1 and type 2 diabetes are different, it is worthwhile discussing them separately, especially in relation to the intimate association between family functioning and type 1 diabetes in young people.

Type 1 diabetes

The literature on the effect of psychological and psychosocial stresses on people with type 1 diabetes has rapidly increased since DCCT published, and there is a view that family stresses, particularly over the imperative for ‘good’ glycemic control, established by the DCCT, have increased since then, especially in relation to questions of blood glucose testing, disordered eating and the closely linked problem of omitting insulin doses.

Events around the time of diagnosis

About one-third of children develop a clinically significant adjustment disorder in the 3–12 months following the diagnosis of type 1 diabetes; although this usually resolves, if it persists it is associated with later psychological difficulties. Although less common, major depression and generalized anxiety disorder are at their peak in the year following diagnosis; parents also respond to the diagnosis with a form of post-traumatic stress disorder, twice as commonly in mothers than fathers. The theme of increased psychological problems in mothers, usually the main carers in young people with diabetes, is recurrent. There is little evidence from retrospective studies that psychological events are more frequent in the run-up to clinical diagnosis, but hospital admission or serious illness, unrelated to diabetes, is much more common, a finding that ties in with clinical experience and also with the concept of a physical stressor precipitating the final autoimmune insult to residual [3-cell function.

Eating disorders in type 1 diabetes (Box 13.1)

These are difficult to diagnose (standard questionnaires are too complicated for routine use), but repeated sensitive questioning based on the clues in the box may help. Formally diagnosed eating disorders are rare in type 1 diabetes, but they carry a high mortality and are frequently associated with characteristic advanced complications, especially retinopathy, peripheral neuropathy (though rarely with foot ulceration) and visceral autonomic neuropathy, especially gastroparesis. Because of the very poor control often associated with gastroparesis (see Chapter 10) this is likely to be a factor accelerating the progression of other microvascular complications. Disordered eating behavior is much more common than formal eating disorders.

PDCChapt13Box13.1

Insulin omission

Missing insulin is an early learned method for weight control and loss, and repeated sensitive questioning is required to assess it in individu- als. Nearly 40% of patients between 15 and 30 years old report intentional insulin omission. Overall, up to age 60, one-third omit insulin, and it is surprisingly common even in older women aged between 45 and 60. More extreme omission, effectively stopping insulin treatment entirely for up to 2 weeks at a time, is common during adolescence and early adulthood. Taking more daily injections is associated with insulin omission – again no surprise – so there is no point suggesting more injections for people in poor control if the current injections are not being taken. Try to fix the underlying problem first.

 

References:

  1. Goebbel-Fabbri  AE,  Fikkan  J,  Connell  A,  Vangsness  L,  Anderson  BJ. Identification and treatment of eating disorders in women with type 1 diabetes mellitus. Treat Endocrinol 2002;1:155–62. PMID: 15799208.
  2. Goebbel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care 2008;31:415–19. PMID: 18070998.
  3. Tattersall RB. Brittle diabetes revisited: the Third Arnold Bloom Memorial Lecture. Diabetic Med 1997;14:99–110. PMID: 9047086.
  4. Saunders SA, Williams G. Difficult diabetes. In: DeFronzo R, Ferrannini E, Keen H, Zimmet P (eds) International Textbook of Diabetes Mellitus, 3rd edn, chapter 87. Oxford: Wiley-Blackwell, 2004.
  5. deWit M, Delemaare-van de Waal HA, Bokma JA et al. Monitoring and discussing health-related quality of life in adolescents with type 1 diabetes improve psychological well-being: a randomized controlled trial. Diabetes Care 2008;31:1521–6. PMID: 1850924.
  6. Northam EA, Lin A, Finch S, Werther GA, Cameron FJ. Psychosocial well-being and functional outcomes in youth with type 1 diabetes 12 years after disease onset. Diabetes Care 2010;33:1430–7. PMID: 20357379.
  7. Cameron FJ, Northam EA, Ambler GR, Daneman D. Routine psychological screening in youth with type 1 diabetes and their parents: a notion whose time has come? Diabetes Care 2007;30:2716–24. PMID: 17644619.
  8.  Weissberg-Benchell J, Wolpert H, Anderson BJ. Transitioning from pediatric to adult care: a new approach to the post-adolescent young person with type 1 diabetes. Diabetes Care 2007;30:2441–6. PMID: 17666466.
  9. Ismail K, Winkley K, Stahil D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes Care 2007;30:1473–9. PMID: 17363754.
  10. Mezuk B, Eaton WW, Albrecht S, Golden SH. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care 2008;31:2383–90. PMID: 19033418.
  11. Rubin RR, Ma Y, Marrero DG et al. Elevated depression symptoms, antidepressant medicine use, and risk of developing diabetes during the Diabetes Prevention Program. Diabetes Care 2008;31:420–6. PMID: 18071002.
  12. Delahanty LM, Grant RW, Wittenberg E et al. Association of diabetes-related emotional distress with diabetes treatment in primary care patients with type 2 diabetes. Diabetic Med 2007;24:48–54. PMID: 17227324.
  13. Rubin RR, Gaussoin SA, Peyrot M et al.  Cardiovascular  disease  risk  factors, depression symptoms and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes. Diabetologia 2010;53:1581–9. PMID: 20422396.
  14. Jenkins DJ. Psychological, physiological, and drug interventions for type 2 diabetes. Lancet 2004;363:1569–70. PMID: 15145627.