Type 2 diabetes and mental health

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,¹⁰ and can face stigma, discrimination or a lack of understanding from friends or family members about their condition. Timely assessment of the impact of diabetes on people’s mental health can be incorporated into routine clinical reviews and, as a minimum, needs to be aligned to the annual cycle of care.

People with diabetes are more likely to experience other mental health problems:

• Diabetes has a bidirectional relationship with some psychological conditions, particularly major depression (however, the mechanisms of this relationship are as yet unknown).³
• Anxiety disorders and disordered eating are more common in people with diabetes.¹¹
• People with psychotic disorders (eg schizophrenia) have significantly increased rates of type 2 diabetes.¹¹

The main risk factors in type 2 diabetes for cognitive dysfunction, depression and psychological problems are illustrated in figure 2 in the article by Randväli et al.¹²

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).

Diabetes distress and other psychological conditions can negatively affect health outcomes due to suboptimal self-management and glycaemic outcomes.^10,13,14

General practitioners (GPs) also need to be aware that the metabolic effects of some psychotropic medications (eg the antipsychotic medications olanzapine and clozapine^{15, 16}) can increase the complexity of type 2 diabetes management or add additional burdens such as obesity (refer to ‘Managing multimorbidity in people with type 2 diabetes’). 

Figure 1. Psychosocial challenges experienced by people with diabetes at different phases of life¹¹ 

Diabetes distress 

Diabetes distress is a condition distinct from other psychological disorders and is estimated to affect 18–45% of people with diabetes.¹¹ Severe diabetes distress is experienced by 20% of people with insulin-treated type 2 diabetes and by 11% of those with non-insulin-treated type 2 diabetes.¹⁷

Although some symptoms often overlap with depressive symptoms, diabetes distress is a separate psychological condition that should be assessed for separately (Table 1).¹⁸ It is associated with suboptimal diabetes self-care and glycaemic outcomes^10,11

Causes of diabetes distress differ between individuals, but are commonly related to the following domains:¹⁹ 

• 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 do not 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.³

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: 

• Starting insulin booklet 
• a fact sheet of concerns about starting insulin. 

Fear of hypoglycaemia 

Experiences of hypoglycaemia, especially severe (requiring assistance) or nocturnal episodes, can be physically dangerous and psychologically 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 (often with alarms developed for hypoglycaemia) may help people who are averse to finger pricking. 

Other psychological and psychiatric conditions 

Increased understanding of the psychological aspects of the person with diabetes would allow clinicians to formulate strategies focusing on improvements in diabetes outcomes and reducing disease burden.²⁰ Other mental health conditions that can affect or are affected by diabetes include major depression, schizophrenia spectrum disorders, bipolar disorder, eating disorders and anxiety.³

Depression and diabetes are interlinked with a higher risk of developing diabetes in people who have a history of or current depression that is compounded if the person is overweight or obese and with a family history of depression. 

GPs play an essential role in assessing and supporting people with diabetes and mental health conditions by providing care and serving as the pivotal point for referral to appropriate mental health professionals that form the multidisciplinary care team. Collaborative care should be considered for people with diabetes and depression. Routine interval assessment for the presence of these conditions, particularly anxiety and depression, may be incorporated into the annual diabetes cycles of care, but also be provided opportunistically. Validated tools may support comparative interval assessment. Avoidance of stigmatisation and using appropriate language when managing people living with diabetes are foundational on building a trusted therapeutic care model.²¹

Medications used for the management of depression, particularly selective serotonin reuptake inhibitors (SSRIs) have been shown to improve glycaemic management. Any medication used, particularly antipsychotic agents when used in at-risk individuals (eg history of gestational diabetes, family history of diabetes, presence of visceral obesity), may need to be evaluated for risks of inducing hyperglycaemia and diabetes.³ 

Given the high prevalence of diabetes distress and other mental health conditions, people with type 2 diabetes should be assessed at the initial visit, at periodic intervals (eg at annual review) and when there is a change in condition, treatment or life circumstance. It is recommended to assess for diabetes distress, depression, anxiety, disordered eating and cognitive capacities.^2,11 GPs may decide to prioritise assessment of conditions according to each individual’s phase of living with diabetes (Figure 1); for example, assessing for cognitive impairment in older people (see ‘Dementia, cognitive decline and hearing impairment’ in the ‘Managing risks and other impacts of type 2 diabetes’ section). 

Information and guidance about how to have conversations with people about diabetes and mental health, including tips for using the screening tools detailed below, can be found in the NDSS publication Diabetes and emotional health: A handbook for health professionals supporting adults with type 1 or type 2 diabetes. 

If necessary, people should be referred to a mental health professional, preferably one with experience in psychosocial care for people with diabetes (Box 1).¹¹ 

Screening 

GPs can identify clinically significant diabetes distress and other mental health issues by having ongoing conversations with people about how they feel about their diabetes. Informal, open-ended questions can help get a sense of what the likely problems are for a person. For example: 

• ‘How is diabetes bothering you at the moment?’ 
• ‘What is the most difficult part of living with diabetes for you?’ 

For more information, refer to Diabetes Australia’s position statement Our language matters: Improving communication with and about people with diabetes²² and the American Diabetes Association article ‘The use of language in diabetes care and education’.²³ These publications provide recommendations for the language healthcare professionals and others should use when discussing diabetes through spoken or written words. 

If indicated, standardised tools can then be used to further assess for symptoms. Tools for assessing diabetes distress (Table 1) are freely available. 

The Patient Health Questionnaire (PHQ)-2 or PHQ-9 can be used to screen for depressive symptoms. 

• A PHQ-2 total score of ≥3 in a person who is not currently receiving treatment for depression requires assessment with the PHQ-9.²⁴
• PHQ-9 scores are interpreted as follows:
  • 0–4: no depressive symptoms (or a minimal level) 
  • 5–9: mild depressive symptoms – these people will benefit from watchful waiting 
  • 10–27: moderate-to-severe depressive symptoms – these people will benefit from a more active method of intervention. 

If depression is suspected from the PHQ-9, a formal clinical assessment for depression and management should be undertaken. 

In addition, the Depression, Anxiety and Stress Scale (DASS) may be helpful as an assessment tool for people with diabetes and mental health symptoms. The Kessler Psychological Distress Scale (K10) is widely recommended as a simple measure of psychological distress and is often used by GPs because it is available in consultation software.²⁵ 

To effectively use screening tools, GPs should be mindful of the person’s health literacy, being sure to explain what the tool is for and how it can help the person receive individualised support. 

Management 

The 7A’s model (see below) is a practical way to structure mental health care for people with diabetes, adapted from the 5A’s model often used for counselling in other areas (eg smoking cessation, obesity).¹⁸ The 7A’s model encourages healthcare professionals to: 

• be aware that people with diabetes might have emotional or mental health problems 
• ask about these problems, using open-ended questions 
• assess for emotional or mental health problems using a validated tool 
• advise people about identified problems 
• assist them with developing an achievable action plan 
• assign care, where appropriate, to another healthcare professional (eg psychologist, diabetes specialist or credentialled diabetes educator) 
• arrange follow-up care. 

More information about the 7A’s model can be found in the NDSS publication Diabetes and emotional health: A handbook for health professionals supporting adults with type 1 or type 2 diabetes.¹⁸ 

Versions of this model to specifically manage diabetes distress, fear of hypoglycaemia, psychological barriers to insulin use, depression, anxiety disorders and eating disorders can be found in the NDSS handbook summary cards.¹⁷ 

Management of mental health problems should be offered within diabetes care settings and general practices, using current supported care such as mental health care planning. GP mental health treatment plans provide a structured framework for GPs to undertake assessment, early intervention and management of people with a mental illness.²⁹ 

For more information, refer to The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders, which includes: 

• table 9: Pharmacological treatment based on clinical profile 
• table 10: Classes of antidepressants 
• figure 26: Management of major depression.³⁰ 

The NDSS has a range of resources regarding emotional health and diabetes. 

The NDSS and Diabetes Australia have developed resources to support people starting and using insulin to manage their diabetes (see ‘Psychological insulin resistance’): 

• Starting insulin booklet 
• a fact sheet of concerns about starting insulin. 

The NDSS and Diabetes Australia have published Diabetes and emotional health: A handbook for health professionals supporting adults with type 1 or type 2 diabetes. 

The Royal Australian and New Zealand College of Psychiatrists has developed clinical practice guidelines for mood disorders.