Psychiatric Annals

CME Article 

Facing Diabetes: A Guide for Psychiatric Providers

Maria C. Prom, MD

Abstract

Chronic medical conditions, such as diabetes mellitus, are often closely intertwined with psychiatric disorders. Therefore, when treating patients with psychiatric illness and co-occurring diabetes, it is important to understand the pathophysiology of diabetes and its management, as well as the impact of psychiatric management on diabetes and on the need for support of patients while managing their diabetes. Here, we review the chronic medical condition diabetes, and its screening, management, and risks for comorbid mental illness. We also review the role of psychiatry in the screening, monitoring, and management of diabetes, as well the crucial relationship between the use of psychotropic medications and diabetes. [Psychiatr Ann. 2019;49(2):60–64.]

Abstract

Chronic medical conditions, such as diabetes mellitus, are often closely intertwined with psychiatric disorders. Therefore, when treating patients with psychiatric illness and co-occurring diabetes, it is important to understand the pathophysiology of diabetes and its management, as well as the impact of psychiatric management on diabetes and on the need for support of patients while managing their diabetes. Here, we review the chronic medical condition diabetes, and its screening, management, and risks for comorbid mental illness. We also review the role of psychiatry in the screening, monitoring, and management of diabetes, as well the crucial relationship between the use of psychotropic medications and diabetes. [Psychiatr Ann. 2019;49(2):60–64.]

Chronic medical conditions, such as diabetes mellitus (DM), are frequently comorbid with psychiatric disorders. In people with mental illness and a comorbid medical condition, the term “comorbid” often signifies more than just a coexistence of illnesses, as worsening of a chronic medical illness affects mental illness, and mental illness, in turn, adversely affects chronic medical illnesses. In caring for those with mental illness, it is important to understand this relationship and to have more than just a rudimentary understanding of these chronic medical conditions, their management, and how psychiatric management of patients' mental illness can interfere with management of their chronic medical conditions. Armed with such knowledge, we can better support patients and/or their family members in managing these chronic conditions, reducing complications, and improving quality of life.

Pathophysiology of Diabetes

DM is a chronic medical condition characterized by elevated serum glucose levels due to insufficient insulin production or insulin resistance. Diabetes is divided into four categories. Type 1 diabetes is characterized by loss of pancreatic beta-cells from autoimmune destruction leading to insulin deficiency. Type 2 diabetes is characterized by peripheral insulin resistance and an eventual decrease in beta-cell insulin secretion secondary to genetic and environmental factors. A third major category is gestational diabetes mellitus, which is when insulin resistance occurs during pregnancy. A fourth category of DM involves other causes, including monogenic diabetes syndromes (such as maturity-onset diabetes of the young and neonatal diabetes), and results from other medical conditions or medications that adversely affect the pancreas, insulin production, and absorption. Such conditions include exocrine pancreatic disease (eg, pancreatitis, cystic fibrosis), post-transplantation states, cancers, infections, trauma, surgery, and glucocorticoid treatment. A condition termed “pre-diabetes” occurs when there are abnormally elevated serum glucose levels that do not yet reach the level for diagnosis of diabetes.1,2

Prevalence and Risk Factors for Developing Diabetes

The prevalence of DM is estimated to be 9.4% in the United States, although this prevalence increases with age.3 Approximately 25% of people with DM are older than age 65 years, and the majority them (90%–95%) have type 2 DM.3 Notably, the Centers for Disease Control and Prevention found that 23.8% of adults with DM are unaware of, or do not report, having DM.3 Certain races and ethnic groups (specifically Native Americans/Alaska Natives [15.1%], non-Hispanic blacks [12.7%], and Hispanics [12.1%]) have a greater prevalence of DM compared to non-Hispanic whites (7.4%) and Asians (8%).3 An increased prevalence and incidence of DM is also associated with a lower education level, such that 12.6% of adults with less than a high school education are diagnosed with DM versus 7.2% of adults with more than a high school education.3

Several risk factors and conditions are associated with developing DM, including familial genetic predisposition, an elevated body mass index (BMI), older age, race/ethnicity (black, Hispanic, Native American, Asian, Pacific Islander), history of cardiovascular disease, hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans, physical inactivity, dietary patterns, smoking, and sleep patterns (<6 hours and >8 hours). Additionally, certain medications, such as glucocorticoids, thiazide diuretics, and psychiatric medications, can increase the risk of developing DM.1,2

Management of Diabetes

DM can lead to multiple long-term medical complications, including cardiovascular disease, diabetic retinopathy, diabetic kidney disease, and diabetic neuropathy.4 Risk factors for complications include smoking, overweight and obesity, physical inactivity, hypertension, hyperlipidemia, and hyperglycemia.3 As such, management of blood glucose levels through pharmacologic interventions is not the only important factor in managing diabetes and preventing long-term complications. Many of these risk factors are best managed by behavioral changes, such as changes in diet, an exercise regimen, and weight loss. In fact, behavioral patterns (such as blood glucose monitoring, blood pressure monitoring, and diabetic and nondiabetic medication adherence) are crucial for managing many aspects of DM and preventing long-term complications.

Pharmacologic options for DM continue to change as new medications are developed; therefore, it is important to remain up to date on pharmacologic management of diabetes, particularly because these medications can have drug interactions with psychiatric medications. Additionally, some medications for DM have psychiatric side effects. Current pharmacological management of DM includes oral and injectable medications, all with the same purpose (to lower blood glucose levels), although they achieve their effects by different mechanisms of action. Oral agents are reviewed by medication class in Table 1. Insulin is the primary management for those with type 1 DM and is also used in type 2 DM when patients can no longer be managed on oral medications alone. Insulin is available in several formulations, including rapid acting, short acting, immediate acting, long acting, pre-mixed (a combination of long and short acting), and in a concentrated formulation for those requiring high doses. Additionally, some patients have insulin pumps.5

Noninsulin Diabetes Medications by Class

Table 1.

Noninsulin Diabetes Medications by Class

Diabetes and Mental Illness

DM and mental illness are frequently comorbid. People with DM have higher rates of mental illness, and people with mental illness have higher rates of DM. Here we discuss the relationship between DM and mental health, including subclinical psychological distress related to DM, psychiatric symptoms related to blood glucose derangements and DM medication management, comorbid mental illness, and risks related to psychiatric medications.

Many people with DM develop subclinical symptoms of depression or anxiety that do not meet the Diagnostic and Statistical Manual of Mental Disorders, fifth edition6 criteria for a depressive or anxiety diagnosis. One such situation is so common, that it has been termed “diabetes distress,” and it refers to the emotional reaction, fears, worries, and stress experienced by people with DM related to receiving a new diagnosis, difficulties managing the illness, fear of complications, difficulties with providers, or lack of psychosocial support. The prevalence of diabetes distress is estimated at 18% to 45%. Diabetes distress can adversely affect a patient's management of their diabetes (affecting glucose monitoring, medication adherence, diet, and exercise).7,8

Additionally, people with DM often experience psychiatrically related symptoms secondary to derangements of glucose levels and side effects from medications used to manage DM. Patients frequently develop episodes of hyperglycemia or hypoglycemia with poor blood glucose management, and this may lead to agitation, confusion, irritability, or anxiety. Additionally, medications used to control DM can have psychiatrically related side effects (eg, depression, anxiety, nightmares, insomnia, agitation, and confusion).5 Although we do not review all of the medications for DM and their related side effects here, we do note that it is important to consider the potential for side effects from these medications when evaluating or treating patients for mental health issues, particularly if patients have had changes in their chronic mental illness with the initiation of new medications to manage DM.

People with type 1 and type 2 DM are at increased risk for anxiety, depression, and eating disorders.9 The specific incidence and prevalence of these disorders varies; however, lifetime rates of depression in people with type 1 and type 2 DM are estimated at 2 to 3 times that of the general population, with a prevalence of major depressive disorder estimated at 11% and depressive symptoms estimated at 30%.10,11 Generalized anxiety disorder is estimated to have a lifetime prevalence of 19.5% in patients with DM, and the odds ratio for anxiety disorders in patients with DM as a whole is estimated at 1.20, and for anxiety symptoms at 1.48.12,13 Eating disorders are also more common in those with DM: women with type 1 DM have twice the risk of developing an eating disorder and a greater prevalence of bulimia nervosa as compared to those in the general population.14,15 Additionally, type 2 DM is associated with an increased prevalence of binge eating disorders.16,17

Alternatively, patients with mental illness are at greater risk of developing DM, likely from factors such as lifestyle, diet, inactivity, and use of psychiatric medications. For instance, the relative risk of developing DM in patients with depressed mood is estimated at 1.17 or higher for those taking antidepressants (with a relative risk of 1.25).18 Patients with severe mental illness, including primary psychotic disorders and bipolar disorder, are at much greater risk for developing DM, with an estimated risk ratio of 1.70.19 The prevalence of type 2 DM in patients with psychotic disorders is estimated at 22% in those with schizophrenia and 13.4% in those with other nonaffective psychosis.20 Estimates of the prevalence in patients with severe mental illness who have been treated with antipsychotics range from 17% to 28%.21

Psychiatry's Role in Screening and Monitoring for Diabetes

Psychiatrists can play an important role in screening and monitoring for pre-diabetes and DM. This is particularly important for patients with severe mental illness in whom the risk of developing DM is higher than average, adherence to treatment for DM is poor, and visits to a primary care physician may be few and far between. It is also necessary to monitor patients on psychotropic medications because they are a risk factor for developing DM.

For the general population, the American Diabetes Association (ADA) recommends testing for DM for those with at least one risk factor (Table 2) and who are overweight or obese (defined as BMI ≥23 kg/m2 for people with Asian ancestry and ≥25 kg/m2 for other racial and ethnic groups.)1 Testing should be conducted annually for people with pre-diabetes, and women diagnosed with gestational diabetes should be tested every 3 years after their diagnosis. All other patients should be tested starting at age 45 years; if their results are normal, they should be retested every 3 years after.1 The United States Preventive Services Task Force (USPTF) similarly recommends screening for adults age 40 to 70 years who have overweight or obesity.22 The USPTF also recommends earlier screening when there is a family history of DM, a history of gestational diabetes or polycystic ovarian syndrome, and if a person is from a high-risk racial or ethnic group.22

American Diabetes Association Testing Recommendations for Patients at Risk

Table 2.

American Diabetes Association Testing Recommendations for Patients at Risk

Options for testing for DM include a fasting plasma glucose, a 2-hour plasma glucose value from a 75-g oral glucose tolerance test, or hemoglobin A1c.1 Testing options and resultant diabetes staging and diagnosis are reviewed in Table 3.

Diagnostic Testing and Criteria for Staging and Diagnosis of Diabetes Mellitus

Table 3.

Diagnostic Testing and Criteria for Staging and Diagnosis of Diabetes Mellitus

Management of patients taking certain psychotropic medications requires additional specific screening. The ADA recommends specific screening when a patient is taking second-generation antipsychotics (SGAs).23 The ADA recommends baseline screening when there is a personal and/or family history of obesity, DM, dyslipidemia, hypertension, or cardiovascular disease, as well as measuring weight and height (for BMI), waist circumference, blood pressure, fasting plasma glucose level, and fasting lipid profile. Further ADA screening recommendations for SGA initiation are provided in Table 4.23

ADA Recommendations on Metabolic Screening for Second-Generation Antipsychotics

Table 4.

ADA Recommendations on Metabolic Screening for Second-Generation Antipsychotics

Once DM is diagnosed, management (along with metabolic monitoring) should be performed in coordination with the patient's primary care provider or endocrinologist. Psychiatric providers should play a role in ensuring that patients are seen in follow-up by their medical providers and should be monitored, especially when patients are more adherent with their psychiatric follow-up than they are for their medical follow-up. (For the most up-to-date resources for recommendations for screening, diagnosis, and management of DM, see the American Diabetes Association,1,4,5,23 US Centers for Disease Control,3 and the USPTF.22)

The Role of Psychiatry in the Management of Diabetes

Like many chronic medical conditions, DM is a disease not just of genetics but one of environment as well; moreover, the risk of developing DM and its subsequent successful management are greatly affected by behavior. As such, successful management of DM and prevention of long-term complications for those with comorbid mental illness necessitates more than just stabilization of mental illness through use of psychiatric medications or therapy that is focused on the comorbid mental illness. Rather, behaviorally based interventions for DM management should be integrated into psychiatric care.

Behavioral modification to improve DM and comorbid metabolic risk factors includes diet, exercise, weight loss, improved blood glucose monitoring and management, medication adherence, smoking cessation, and management of alcohol or substance use. Opportunities for behavioral interventions by psychiatric providers can range from education about DM to therapy that is focused on management of DM. Interventions known to improve management of DM include cognitive-behavioral therapy, motivational interviewing, and use of support groups.24–26 Other therapies could also be used, depending on the individual patient, but these interventions are not as well studied.27

Conclusion

The presence of DM and comorbid mental illness is an important topic for psychiatric providers, because they can play a crucial role in a patient's management of diabetes and mental illness. Psychiatric support that is focused on screening, monitoring, and behavioral management of DM may improve a patient's success in managing his or her DM and preventing serious long-term medical and mental-health complications. It is essential that psychiatric providers understand this serious chronic medical condition and its relationship with psychiatric management to ensure early intervention and appropriate management of illness.

References

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Noninsulin Diabetes Medications by Class

Medication Class Medication Name
Biguanide Metformin
Sulfonylureas (second generation) Glipizide Glimepiride Glyburide
Meglitinides Nateglinide Repaglinide
Thiazolidinediones Pioglitazone Rosiglitazone
Alpha-glucosidase inhibitors Acarbose Miglitol
Sodium-glucose co-transporter-2 inhibitors Canaglifozin Dapagliflozin Empagliflozin
Glucagon-like peptide- 1 agonists Albiglutide Dulaglutide Exanetide Liraglutide Lixisenatide
Dipeptidyl peptidase-4 inhibitors Alogliptin Linagliptin Sitagliptin Saxagliptin
Bile acid sequestrants Colesevelam
Dopamine-2 agonists Bromocriptine
Amylin mimetics Pramlintide

American Diabetes Association Testing Recommendations for Patients at Risk

Testing is recommended for patients with one or more of the following risk factors and who have overweight or obesitya <list-item>

First-degree relative with diabetes

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High-risk race/ethnicity (Native American, Alaska Native, Hispanic, non-Hispanic black)

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History of cardiovascular disease

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Hypertension

</list-item><list-item>

Hyperlipidemia

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Polycystic ovarian syndrome

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Physical inactivity

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Other clinical conditions associated with insulin resistance

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Diagnostic Testing and Criteria for Staging and Diagnosis of Diabetes Mellitus

Screening Test Pre-Diabetes Diabetes
Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L) ≥126 mg/dL (7.0 mmol/L)
Hemoglobin A1c 5.7%–6.4% (39–47 mmol/mol) ≥6.5% (48 mmol/mol)
Oral glucose tolerance test 140–199 mg/dL (7.8–11.0 mmol/L) ≥200 mg/dL (11.1 mmol/L)

ADA Recommendations on Metabolic Screening for Second-Generation Antipsychotics

Time After Initiation of SGA Recommended Metabolic Screening
Baseline Weight/BMI Waist circumference Blood pressure FPG Fasting lipid profile
4 Weeks Weight/BMI
8 Weeks Weight/BMI
3 Months Weight/BMI Blood pressure FPG Fasting lipid panel
Quarterly Weight/BMI
Annually Waist circumference Blood pressure FPG Fasting lipid panel (vs every 5 years if normal)
Authors

Maria C. Prom, MD, is a Fellow in Consultation-Liaison Psychiatry, Massachusetts General Hospital (MGH); and a Clinical Fellow in Psychiatry, Harvard Medical School.

Address correspondence to Maria C. Prom, MD, MGH, 55 Fruit Street, WRN 6, Boston, MA 02114; email: mprom@partners.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20190104-01

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