People with diabetes can face a number of psychosocial challenges, which can change over the course of their lives with the condition (Figure 1). It is common for people with diabetes to sometimes feel overwhelmed, guilty or frustrated by the considerable burden of self-care and management required by diabetes. They might also feel worried about their current or future diabetes management and health outcomes,3 and can face stigma, discrimination or a lack of understanding from friends or family members about their condition.
Diabetes distress is a clinically recognised emotional response to living with diabetes and the medical, financial and social impacts of diabetes. Other common diabetes-specific psychological responses are fear of hypoglycaemia and psychological insulin resistance (refer below).
In addition, people with diabetes are more likely to experience other mental health problems:
- Diabetes has a bi-directional relationship with some psychological conditions, particularly major depression (however, the mechanisms of this relationship are as yet unknown).2
- Anxiety disorders and disordered eating are more common in people with diabetes.4
- People with psychotic disorders (eg schizophrenia) have significantly increased rates of type 2 diabetes.4
Diabetes distress and other psychological conditions can negatively affect health outcomes due to sub-optimal self-management and glycaemic outcomes.3,5,6
General practitioners (GPs) also need to be aware that the metabolic effects of some psychotropic medications (eg the antipsychotic medications olanzapine and clozapine)7 can increase the complexity of type 2 diabetes management or add additional burdens such as obesity (refer to the section ‘Managing multimorbidity in people with type 2 diabetes’).
Psychosocial challenges experienced by people with diabetes at different phases of life
Diabetes distress is a condition distinct from other psychological disorders and is estimated to affect 18–45% of people with diabetes.4 Severe diabetes distress is experienced by 20% of people with insulin-treated type 2 diabetes and 11% of those with non–insulin-treated type 2 diabetes.8
Although some symptoms often overlap with depressive symptoms, diabetes distress is a separate psychological condition that should be assessed for separately (Table 1).9 It is associated with sub-optimal diabetes self-care and glycaemic outcomes.3,6
Causes of diabetes distress differ between individuals, but are commonly related to the following domains:10
- emotional and cognitive distress – for example:
- worries about long-term diabetes-related complications
- fears about loss of quality of life
- guilt, anger, frustration or burnout associated with the ongoing need for care
- interpersonal distress – for example:
- feeling unsupported or misunderstood by loved ones
- regimen or management distress – for example:
- difficulty keeping up with dietary recommendations
- stress from changes to treatment (eg changing from oral to injectable therapy)
- stress related to the need for ongoing glucose self-monitoring
- fear associated with reviews of glycated haemoglobin (HbA1c) and not achieving target levels
- distress arising from interactions with healthcare professionals – for example:
- feeling that treating clinicians don’t understand concerns or take them seriously.
Psychological insulin resistance
Psychological insulin resistance refers to a person’s strong negative thoughts and feelings about starting, using or intensifying insulin therapy.2
This may be due to fear and anxiety about having to self-administer injections, concerns about insulin and its effects (eg hypoglycaemia or weight gain) or misplaced beliefs (eg that requiring insulin means they have failed to self-manage their diabetes or that the condition has become much more serious).
The National Diabetes Services Scheme (NDSS) and Diabetes Australia have developed resources to support people starting and using insulin to manage their diabetes:
Fear of hypoglycaemia
Experiences of hypoglycaemia, especially severe (requiring assistance) or nocturnal episodes, can be traumatic. Some level of concern about hypoglycaemia is adaptive and is a motive to respond to low glucose levels on time. However, fear of hypoglycaemia (extreme fear in response to risk or occurrence of hypoglycaemia) can lead to unhelpful strategies to avoid hypoglycaemia, such as:
- maintaining a higher blood glucose level (compensatory hyperglycaemia)
- treating perceived symptoms without confirming hypoglycaemia by self-monitoring.
Left unmanaged, in the long term these behaviours can affect glycaemic outcomes and reduce quality of life. Technology such as continuous glucose monitoring or flash monitoring may help people who are averse to finger-pricking.
Other psychological and psychiatric conditions
Other mental health conditions that can affect or are affected by diabetes include major depression, schizophrenia spectrum disorders, bipolar disorder, eating disorders and anxiety.2