Download Interface of Diabetes and Psychiatry

Interface of
Diabetes
and
Psychiatry
Presentation By
Dr. Reza Bidaki . MD
Assistant professor of
psychiatry
Shahid Sadoughi of Yazd
university of Medical Sciences
Introduction
 The
interface of diabetes and psychiatry
has fascinated both endocrinologists and
mental health professionals for years
 in 17th century Thomas Willis speculated
that diabetes was caused by “long sorrow
and other depressions.”
History
Sir Henry Maudsley commented that “Diabetes is a
disease which often shows itself in families in which
insanity prevails” in “The Pathology of Mind” published
in 1879.
History

Insulin coma therapy was used as a
psychiatric treatment within a decade of
isolation of insulin.
Co-occurring psychiatric disorders in
patients with diabetes
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Impaired quality of life
Increased cost of care
poor treatment adherence
poor glycemia control (evidenced by
elevated HbA1c levels)
increased emergency room visits due to
diabetic ketoacidosis
phobia of needles and injections can present
difficulties with investigations and treatment
processes such as blood glucose testing and
insulin injection
Challenges
 One
of the biggest challenges in
management of psychiatric disorders
among those suffering from diabetes is
the low rates of detection
 Up to 45% of the cases of mental disorder
and severe psychological distress go
undetected among patients being
treated for diabetes
The
 Stress
Role
of Stress
: Increase blood glucose
 Stimulate HPA Axis
Psychological issue
 Diabetic
regimen and dietary habits
 Limitation in activity
 Invasive and rigid BS monitoring
 Insulin injection daily
 Fear of hyperglycemia
 Fear of hypoglycemia
 Fear of injection
 Decline in quality of life
Depression
 prevalence
of current depression
obtained from structured diagnostic
interviews in samples of diabetic subjects
was 8.5%-27.3%
 These rates are at least three times the
3%-4%
Symptoms of Depression
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Anhedonia
Failure feeling
Hopelessness
Guilt feeling
Self-accusation
Retardation
Indecisiveness
Weight loss
Fatigue
Sadness
Suicide Ideation
 Prevalence
of MDD is 200% rather
than Non diabetic patients ( Nearly 46%)
 Meta-Analysis
 Anderson
 2002
et al
Depressive patients
 Less
obey of treatment
 More Non-drug compliance

diabetes complications (diabetic
retinopathy, nephropathy, neuropathy,
macrovascular complications, and sexual
dysfunction)
A
recent metaanalysis has reported that
depressed individuals have a 60%
increased risk of developing diabetes

diabetes has been recognized as a
“depressogenic” condition
 Tricyclic
antidepressants (TCAs), selective
serotonine reuptake inhibitors (SSRIs),
selective serotonin, and norepinepherine
reuptake inhibitors, serotonin modulators
are the commonly used medications for
depression
 All of these have been associated with an
increased risk of development of diabetes
following intermittent as well as continued
long-term use
Novel anti-psychotics
 Introduction
of newer atypical
antipsychotic has attracted much
attention for their metabolic and
cardiovascular side effect

clozapine and olanzapine most likely
to cause them
 Similarly mood stabilizers such as lithium and sodium valproate
are associated with weight gain and impaired glycemia control
Comparison with other
Organic Diseases
a
significantly increased prevalence of
lifetime depression for diabetes (14.4%), as
well as for arthritis (14.3%), heart disease
(18.6%), hypertension (16.4%), and chronic
lung disease (17.9%) relative to healthy
control subjects (6.9%).

A controlled community interview study in Los Angeles
Bipolar
 Type
disorder
2 diabetes mellitus rates are three
times higher in patients with bipolar
disorder
 elevated risk of cardiovascular mortality,
the leading cause of death in bipolar
patients
Anxiety
 The
disorder
prevalence rate of generalized
anxiety disorder (GAD) : three times higher
than that reported in the general
population
 However, rates of panic disorder,
obsessive compulsive disorder (OCD),
post-traumatic stress disorder (PTSD), and
agoraphobia
Psychiatric disorders in
Diabetic patients
 Phobia
: 21.6 %
 GAD : 13 %
 OCD : 1.3 %

Phobic disorders are more common in people with
diabetes than in the
general population
Difficulty in distinguishing symptoms of anxiety from
those of hypoglycaemia, and the real dangers
associated with hypoglycaemia, complicate the
delivery of psychological interventions that are used
routinely in the treatment of phobias
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Clinical features such as sweating, anxiety,
tremor, tachycardia, and confusion are
shared by both hypoglycemic episodes and
anxiety disorders. This could present a
diagnostic challenge especially among
individuals having phobia of hypoglycemic
episodes
Chronically anxious individuals may be more
likely either to fail to perceive the initial
warning signs of hypoglycemia or to confuse
these with anxiety.
Comorbidity
 In
DM type I : MDD and OCD are
more common
 About
DM type II : MDD and
Somatization disorder
Fear of hypoglycemia
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Avoidance of
hypoglycaemia can
lead to deterioration
in diabetes control.
developed agoraphobia
with panic
disorder, associated
with fear of hypoglycaemia
and deterioration in glycaemic
control
Eating disorder

diabetic individuals with anorexia nervosa
may fail to eat after taking insulin, resulting in
hypoglycemia. Diabetic patients with bulimia
may intentionally lower their insulin dosage
during binging to avoid weight gain, resulting
in acute hyperglycemia, glycosuria, and
ketoacidosis. Such binging and purging
frequently results in wildly varying blood
glucose levels and poor glycemic control. An
increased risk of diabetic complications may
result
Bulimia nervosa
 no
difference in the prevalence of bulimia
between diabetic and nondiabetic
groups (5.6% versus 3.0%28 and 1.8%
versus 0.0%
Personality traits
 higher
levels of blood glucose (poorer
glycemic control) were associated with
lower scores for neuroticism and the
associated personality facets of anxiety,
angry hostility, depression, selfconsciousness, and vulnerability
Adjustment
 It
with disease
is difficult that persons accept their
diseases and adjust self with it
 The patients inform about disease ,
therefore deny and depression is
inevitable
Risk factors for depression
 Female
 Duration
 Complications
 HbA1C
 Family
history for depression
 Low education
Control of BS
 Control
mood
of Blood sugar will improve
Schizophrenia
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Association schizophrenia and diabetes is well
established
risk of type 2 diabetes in people with schizophrenia is
between two and four times Family history of type 2
diabetes is significantly higher even among the firstdegree relatives of patients of schizophrenia
positive family history may increase the risk of
developing diabetes in individuals with schizophrenia
up to threefold
people with diabetes and schizophrenia have higher
mortality rates than individuals with diabetes alone
Genetics
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chromosomes 2p22.1-p13.2 and 6g21-824.1 have also
been observed in linkage studies in type 2 diabetes.
the dopamine D5 receptor on chromosome 5 and the
tyrosine hydroxylase gene on chromosome 11 have
both been suggested as candidate genes in
schizophrenia and may also be implicated in
susceptibility to poor glycaemic control
increased rate of type II diabetes has been
observed in some patients treated with
antipsychotics. Potential neurochemical substrates of
this effect include the histamine H1 receptor, the 5HT2C serotonin receptor or the beta3 adrenoreceptor
Dellirium
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could be a manifestation of hypoglycemic
episodes or diabetic ketoacidosis
Delirium represents the severe end of the
spectrum of clinical manifestation of these
phases
Patients with diabetes suffering from comorbid psychiatric disorders are more likely to
experience hypoglycemic delirium
outcomes : increased hospital stay, increased
cognitive and functional deterioration,
morbidity and mortality
Smoking
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cessation
smoking cessation is of utmost importance to
facilitate glycemia control and limit the
development of diabetic complications
Early smoking cessation reduces the risk of
development of type 2 diabetes to the nonsmoker
level
Smoking cessation is an effective intervention in
the early course of microvascular and
macrovascular complications
The clinicians must prepared for possible weight
gain and increased risk of type 2 diabetes
following smoking cessation
Alcohol
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Prevalence of alcohol use in diabetic
population has been reported to be around
50--60%
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While consumption in higher amounts is
associated with an increased risk of type 2
diabetes
One of the commonest and serious concerns
associated with use of alcohol in diabetes is
emergence of hypoglycemia
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Intervention
 Diabetics
for Alcohol Use
having problem drinking (binge
drinking, alcohol abuse, or alcohol
dependence) should be offered
individualized comprehensive
interventions
 Medications in management of alcohol
dependence include disulfiram,
acamprosate, naltrexone, and
topiramate
Sleep Disorder
Sleep Disorder
common
 higher rates of insomnia, excessive
daytime sleepiness, and unpleasant
sensations in the legs
 71% of this population complain of poor
sleep quality and high rates of hypnotic
use
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Sleep disordes
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Restless legs syndrome (RLS)
Periodic limb movements ( PLMD)
Risk factors
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In type 1 diabetes : rapid changes in glucose levels
during sleep have been postulated to cause awakenings
For individuals with type 2 diabetes, sleep disturbances may
be related to obesity or obesity-associated sleep disorders,
such as sleep apnea
A strong association also exists between obesity, impaired
glucose tolerance, insulin resistance, and sleep-disordered
breathing
the severity of sleep-disordered breathing, as measured by
the apnea-hypopnea index, correlates with the severity of
glucose intolerance, insulin resistance, and diabetes
obstructive sleep apnea is the most common type of sleepdisordered breathing, central-type apneas and periodic
breathing autonomic diabetic neuropath
Conclusion and Message

Comorbidity of diabetes and psychiatric disorders
is common and can present in different
patterns
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Psychological approaches can help improve the
therapeutic adherence in diabetes care

Self-management is an essential component of
diabetes care. The presence of comorbid
psychiatric illness can make self-management
difficult to implement