Diabetes and mental health
Diabetes mellitus is a complex medical condition, largely self-managed by the patient and places significant medical, psychological and societal burdens on the person with diabetes as they come to terms with the diagnosis of a chronic illness associated with significant complications and treatment demands. Indeed, as any clinician will confirm, psychological and social factors play a key role in the management of diabetes, both in children and adults while psychiatric and psychological disorders may compromise the ability of the person with diabetes to perform the self-care needed to maintain optimal health and may result in poorer diabetes outcomes and premature mortality. Psychosocial issues are increasingly recognized as being of primary importance in diabetes care; psychological research in diabetes has made significant contributions in the past decades to a better understanding of inter-individual differences in patients’ cognitive, emotional and behavioural responses to the diagnosis of diabetes, its complications and the day-to-day management. Building on this growing body of scientific knowledge, psychological interventions have been developed to address the different psychological needs of people with diabetes and their families. This section considers the role of psychology and psychiatry in diabetes; the reader should however appreciate that the two fields overlap considerably.
René DescartesIn 1649, in one of his last publications, “The Passions of the Soul”, the famous French philosopher René Descartes proposed that humans could be divided into the body and mind or soul. While Descartes believed that the body worked like a machine and had the material properties of extension and motion following the laws of physics, he described the “mind” or “soul” as a non-material entity that lacked extension and motion, and did not follow the laws of physics. Descartes believed that the pineal gland was the seat of the soul where body and mind meet.
This distinction sowed the seeds for the separation of physical and mental health and has had profound effects on our understanding of how the mind and body interact. Latterly, however, there has been a greater understanding of the complex and fascinating relationship between mental and physical well-being. An appreciation of this connection has become central to the management and outcome of all chronic diseases, but is perhaps particularly relevant to diabetes. As noted by Glasgow, the range of issues addressed by psychology and the modalities of intervention has expanded significantly over the past decades.
Scope of the Field
Integrating behavioural sciences into diabetes care can contribute to improving treatment outcomes. Epidemiological and clinical research has helped to identify the major psychological issues that warrant attention in diabetes care, including coping difficulties and social stigma, stress, hypoglycaemia, weight management and diabetes-related complications. Of special interest is the fact that mental health problems, such as depression, anxiety and eating disorders, are common in people with diabetes, negatively affecting their quality of life and medical outcomes. It is important to recognize that diabetes care warrants a bio-psychosocial model.
This Diapedia section provides information on the current state of knowledge with regard to the role of psychology and psychiatry in diabetes and its clinical implications. We have chosen to group psychology and psychiatry in two separate sections but of course the reader should be aware of the overlap between the two fields.
Despite the impressive advances in diabetes medicine and technology in the past decades, treatment outcomes in diabetes are generally suboptimal. Roughly a third of people with diabetes have continued poor metabolic outcomes and are therefore at increased risk of diabetes-related complications and reduced quality of life. Behavioural research has helped to identify key barriers to diabetes self-management, including dysfunctional health beliefs, low feelings of self-efficacy, emotional distress and mood disorders, problematic eating and lack of social support. Psychology can help to optimize diabetes treatment and educational strategies based on health psychology theories and evidence from research into the role of cognitive, emotional and behavioural processes. There is increasing evidence that group interventions aimed at improving self-management in type 2 diabetes and psychological treatments in type 1 and type 2 diabetes have are effective in improving diabetes outcomes .
Psychology has also proven to be helpful in developing and evaluating diabetes prevention programs, aimed at helping persons at risk for diabetes to achieve lasting lifestyle changes. This psychology section covers a broad range of clinically relevant topics, from prevention to coping and measuring quality of life across the life-span.
Both diabetes and psychiatric disorders are common conditions, and therefore a degree of co-occurrence would be expected purely by chance. There is a growing body of evidence, however, that diabetes is associated more frequently than expected with a range of psychiatric morbidity, including mood disorders, distress, cognitive decline and eating disorders. Furthermore, it appears that people with mood and psychotic disorders are at increased risk of developing diabetes, emphasising the bi-directional relationship of diabetes and mental disorders.
Henry MaudsleyThe association between mental illness and diabetes has been recognised for many years. In the 17th century, Thomas Willis , the famous anatomist and founding member of the Royal Society, described how “diabetes is a consequence of prolonged sorrow”. Much later in 1879, Henry Maudsley  wrote in his celebrated textbook “Pathology of Mind”, when discussing the increased rates of diabetes observed among psychiatric patients, that “Diabetes is a disease which often shows itself in families in which insanity prevails. Whether one disease predisposes in any way to the other or not, or whether they are independent outcomes of a common neurosis, they are certainly found to run side by side, or alternately with one another more often than can be accounted for by accidental coincidence or sequence”.
Knowledge of the special problems that occur when diabetes and a psychiatric disorder coincide is essential if optimum care is to be provided. Co-morbid diabetes and mental illness has adverse implications for both physical and mental well-being. The risk of diabetes complications increases while morbidity and mortality associated with both conditions is disproportionately increased compared with the effects of either illness alone. Health costs are similarly more expensive.
Clinicians need to be aware of the increased risks of co-morbidity, and the need for screening and prompt treatment. Only by an equal emphasis on both diabetes and mental illness will the best outcomes be achieved for the patient. Diabetes health care professionals need to be able to provide “first response” management, and recognize when to refer more complex patients for whom specialist psychiatric or psychological management is essential. The topic of co-morbid diabetes and mental illness is attracting interest from researchers, and there is the potential for considerable progress in understanding the epidemiology and psycho-biological mechanisms involved. The increased availability of objective measures of glycaemic control and diabetes outcomes over the past few decades has opened up the possibility of a wide range of psycho-biological research.
^ Descartes R. “Les Passions de l’ame” (Passions of the Soul) 1649
^ Glasgow RE. Medical office-based interventions. In: Frank J. Snoek & Chas T. Skinner (Eds.). Psychology in Diabetes Care, 2nd Edition, Wiley, p. 109, 2005
^ Deakin TA, McShane CE, Cade JE, Williams R. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003417. DOI: 10.1002/14651858.CD003417.pub2
^ Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 2004 May 15;363(9421):1589-97. Review.
^ Winkley K, Ismail K, Landau S, Eisler I. Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials. BMJ. 2006 Jul 8;333(7558):65. Epub 2006 Jun 27. Review.
^ Willis T. Pharmaceutice rationalis sive diabtriba de medicamentorum operantionibus in humano corpore. 1675. Oxford.
^ Maudsley H. The Pathology of Mind. 3rd edition. London: MacMillan, 1879