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The existence of a relationship between diabetes, in all its forms, and a wide variety of mental health disorders, is widely acknowledged. Individuals who experience depressive episodes are between 40% and 60% more likely to develop type 2 diabetes than is the general population. Their episodes last longer and have a higher chance of recurrence, whilst the symptom burden is increased four-fold.
The presence of both disorders increases the all-cause mortality compared to diabetes alone. This cannot be explained purely by an increased rate of suicide. Alleviating depressive symptoms has a significant effect on mood but much less impact upon the control of blood sugar. Those experiencing Schizophrenia Spectrum Disorders are a particularly vulnerable group, perhaps due to shared biochemical pathways, but also to the side-effects of medication, lifestyle challenges and the stigma associated with severe mental health disorders that makes accessing services difficult.1
What is perhaps less well-appreciated, except by those who are living with diabetes, are the psychological effects of receiving the diagnosis and adjusting to the challenges of life-long management and the potential for serious complications. These individuals stand at the centre of complex interactions between biological, social and psychological forces.
Diabetes distress is a concept that consists of several closely related elements. Definitions vary but common features include:2
Because of the range of severity and variety of factors involved in living with diabetes, diabetes distress fluctuates over time, and is at its worst after diagnosis, during regime changes or as complications develop. Significant distress is linked to poorer self-management, elevated HbA1c levels, increased frequency of hypoglycaemia and impaired quality of life. It is also associated (when measured with the Diabetes Distress Scale) with increased mortality and cardiovascular complications.
Stressors – such as the pandemic, when people with diabetes were shielding and services support withdrew – can increase distress and leave many feeling cast adrift. In the UK, routine HbA1c testing reduced by 77%, and “care processes” – foot checks, BP monitoring and so forth – reduced to around 20% from 58%.3
If left unchecked, “Diabetes Burnout” may ensue. As with occupational burnout, the person experiences physical and emotional exhaustion particularly when, despite their best efforts, blood sugar control remains erratic. The feelings of helplessness and disengagement engendered in this situation mean that people “can’t be bothered” with the continued effort required. A contributing factor can be a lack of understanding from the health services that these individuals receive; for example, they may be perceived as unmotivated, poorly compliant, and troublesome, which engenders a vicious cycle. The signs may include missing medication doses or not monitoring blood sugar, unhealthy or risky behaviours (especially relating to food) or non-attendance at clinic.4
Being able to see past the blood sugar readings and a willingness to ask about and explore the meaning of the illness to the individual is key in the clinic. Some experts advocate the use of screening questionnaires; e.g., Problems Areas in Diabetes (PAID) or the Diabetes Distress Scale or more general quality of life questionnaires.
Other specific problems include fear of hypoglycaemia and psychological insulin resistance. Hypoglycaemia can be both serious and distressing to the extent that some people living with diabetes deliberately run their blood sugar levels high as a preventative measure or manage bodily symptoms as if they were due to hypoglycaemia – without any blood testing. If these behaviours persist, diabetic control worsens, and the risk of complications grows whilst quality of life diminishes.5
Psychological insulin resistance can occur when the medical advice is to add insulin to a regimen, usually in type 2 diabetes. The individual may experience a sense of personal failure and loss of control upon hearing this advice and a sense of facing much more serious challenges (including pain) in the future. In this situation, confidence about managing the changes is low and the personal benefits of the additional stress of ongoing self-management is questioned.6
As before, recognition is the key to addressing these problems and should be built into the holistic management of all individuals. Effective management, using person-centred approaches to motivation, coping skills, developing self-efficacy, and managing stress can improve the levels of HbA1c, lipids and blood pressure. Cognitive Behavioural Therapy (CBT) specifically tailored to address the issues in these problem areas has been used with some success. When mental health disorders arise, they need treatment in their own right.7
Each person with diabetes is unique – whether it’s Type 1 or Type 2, a young or older individual, insulin dependent or not, stable or unstable. Each individual brings their own experiences and resources to the table for what is going to be a long-term, day in/day out process that will have a profound effect on their lives in many ways. The value of talking about diabetes in the round is in identifying the need to provide interventions that can be personalised to help each individual living with diabetes to improve their quality of life and long-term outcomes.8
From an insurance perspective, improving recognition of co-morbid mental health problems (not just illness) is important as part of fully understanding the risks at underwriting and ensuring that interventions at claims stage are as targeted and effective as they can be to ensure the continued wellbeing of the claimant.
