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Diabetes and Mental Health
Chapter 18
David J. Robinson, Meera Luthra,
Michael Vallis
Canadian Diabetes Association 2013 Clinical Practice Guidelines
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
1. Psychiatric disorders, particularly depression, anxiety and eating disorders, are prevalent in diabetes
2. Mental illness increases risk of diabetes and diabetic complications
3. Patients taking psychiatric medications need metabolic screening
4. Screening for depression and anxiety is important in patients with diabetes
2013Key Points
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
1. Psychiatric disorders, particularly depression, anxiety and eating disorders, are prevalent in diabetes
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
2. Mental illness increases risk of diabetes and diabetic complications
• Non-adherence to medication and self-care• Functional impairment• Risk of complications • Healthcare costs• Risk of early mortality
Mental Illness
Diabetes
Depression increases risk of
DM by 60%!
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Psychoactive Medications May Predispose to Diabetes
• Especially second-generation antipsychotics (olanzapine, clozapine, risperidone, quetiapine, aripiprazole, ziprasidone)
• Biochemical and lifestyle factors may also contribute
• Co-morbid mental illness can worsen diabetes control
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
3. Patients taking high-risk psychiatric medications need metabolic screening
Parameter Base-line
1 mo 2 mos 3 mos Every 3-6 mos
Annually
Weight (BMI) X X X X X
Waist circumference X X X
Blood pressure X X X
Fasting glucose and/or A1C
X X X
Fasting lipids X X X
Personal history of alcohol, tobacco, recreational drugs
X X X
Family history X X
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Depressive symptoms in 30% of patients with diabetes
• Major depressive disorder in 10%
• Co-morbid depression worsens clinical outcomes in DM– Lower physical fitness?– Poor medication adherence?
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Diabetes Distress
• Despondency and emotional turmoil related to
diabetes, the need for monitoring and treatment,
preoccupation with complications, and loss of
relationships
• Related to poorer outcomes
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Websites with psychological / psychiatric scales:www.phqscreeners.com
www.outcometracker.org/scales_library.php.
4. Screening for depression and anxiety is important in patients with diabetes
Purpose Tools
Diabetes-specific •Problem Areas in Diabetes (PAID) Scale•Diabetes Distress Scale (DDS)
Quality of Life •WHO-5
Depression/Anxiety •Hospital Anxiety and Depression Scale (HADS)
•Patient Health Questionnaire (PHQ-9)•Beck Depression Inventory (BDI)
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Treatment
• Cognitive-behavioural therapy
• Other psychotherapy
• Antidepressant medication
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Other Psychiatric Associations
• Bipolar disorder
• Anxiety
• Eating disorders
• Schizophrenia and other psychotic disorders
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 1
1. Individuals with diabetes should be regularly
screened for subclinical psychological distress and
psychiatric disorders (eg. Depressive and anxiety
disorders) by interview [Grade D, Consensus] or with a
standardized questionnaire [Grade B, Level 2]
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 2
2. Psychosocial interventions should be integrated
into diabetes care plans [Grade B, Level 2], including
– Motivational interventions [Grade B, Level 2]
– Stress management strategies [Grade B, Level 2]
– Coping skills training [Grade A, Level 1A for type 2 diabetes;
Grade B, Level 2, for type 1 diabetes]
– Family therapy [Grade A, Level 1B]
– Case management [Grade B, Level 2]
2013
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 3
3. Antidepressant medication should be used to
treat acute depression [Grade A, Level 1A] and for
maintenance/prophylactic treatment of depression
[Grade A, Level 1A]. Cognitive-behaviour therapy (CBT)
alone [Grade B, Level 2] or in combination with
antidepressant medication [Grade A, Level 2] may be used
to treat people with depression in diabetes.
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
Recommendation 4
4. Antipsychotic medications (especially
atypical/second generation) can cause adverse
metabolic changes [Grade A, Level 1]. Regular
metabolic monitoring is recommended for patients
with and without diabetes who are treated with such
medications [Grade D, Consensus]
2013
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guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals
1-800-BANTING (226-8464)
http://diabetes.ca – for patients