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Psychological co-morbidity in Diabetes
mellitus : assessment and therapy
Prof. Dr. Claus Vögele
Disability-adjusted life-years (DALY):
sum of years lived with disability and years of life lost
20%
Co-morbidity of mental disorders with Diabetes mellitus:
a brief summary
•
Prevalence rates vary in relation to assessment techniques used.
Typically higher prevalence rates (in particular depression and anxiety
disorders) occur with the use of self-report scales as opposed to
clinical interviews.
•
Nevertheless ...
12-months estimated prevalence in mood disorders
1.4
1.3
12-months estimated prevalence in anxiety disorders
1.6
1.5
12-months estimated prevalence in anxiety disorders
1.3
1.3
Co-morbidity of mental disorders with Diabetes mellitus:
a brief summary
Mental Disorder
OR or observed prevalence
Mood Disorders
Major Depression
Dysthymia
1.4
1.3
Anxiety Disorders
GAD
Agoraphobia/Panic
Social Phobia
PTSD
1.6
1.5
1.3
1.3
Schizophrenia
15% versus 2-3% (comm.)
Psychological factors and physical conditions: concepts
Psychological factors
Causal role in
aetiology
Mental
Disorders as a
consequence
of the physical
condition
Psychological
factors
affect
prognosis/
treatment
Health risk behaviours
Neurobiological/psychophysiological processes
Depression as a risk factor for Diabetes:
neurobiological/psychoneuroendocrinological mechanisms
•
Depression is an independent risk factor for type 2 Diabetes (Eaton et
al., 1996; Kawakami et al., 1999)
Evidence for endocrinological mechanisms:
•
•
•
Depression is associated with
increased serum glucocorticoids, catecholamines, and growth
hormone (which counter the effects of insulin)
and
insulin resistance
and
secrection of inflammatory cytokines, which could facilitate
development of diabetes (Musselmann et a., 2003).
Psychological factors and physical conditions: concepts
Psychological factors
Causal role in
aetiology
Mental
Disorders as a
consequence
of the physical
condition
Psychological
factors
affect
prognosis/
treatment
CNS pathology
Treatment side effects
Responses to changed life-situation - Adjustment
Diabetes as a risk factor for Depression:
Nouwen et al., 2010
Anxiety Disorders common amongst Diabetics
•
Hypoglycaemia anxiety
– This can be associated with impaired perception of hypoglyaemic
symptoms, which increases the probability of unexpected hypoglycaemic
episodes and, therefore, the development of severe anxiety.
•
Specific type of blood-injection-injury phobia
– Can lead to irregular insulin injections with all adverse consequences.
•
Panic Disorder (with or without Agoraphobia)
– Panic attacks are often accompanied by very similar symptoms than
hypoglycaemic episodes. Hypoglycaemic episodes can, therefore,
contribute to the development of Panic Disorder.
Eating Disorders common amongst Diabetics
•
The management of Diabetes requires patients to constantly be aware
and check their food. The cognitive pattern (restrained eating) is
typical for patients with Eating Disorders.
•
Anorexia nervosa and Bulimia nervosa are not more prevalent
amongst Diabetics compared to community samples.
However:
•
EDNOS (sub-clinical Eating Disorders syndromes) are more than twice
as prevalent amongst young female Type-I diabetics.
•
Insulin-purging: deliberately reduced insulin intake in order to
promote weight-reduction and fat-loss
Psychological factors and physical conditions: concepts
Psychological factors
Causal role in
aetiology
Mental
Disorders as a
consequence
of the physical
condition
Psychological
factors
affect
prognosis/
treatment
Subjective disease model
Adherence
Physician-patient communication
Effects of severe mental illness on survival of people with
diabetes
Vinogradova et al., 2010
What needs to be done?
1.Psychological assessment
• Interview (DSM), Questionnaires
• Behavioural analysis:
Analysis of individual conditions maintaining pathological
processes
Subjective Disease Models
Illness Behaviour and Treatment Adherence
Assessment of Individual Resources
What needs to be done?
2.Psychological Treatment
Treatment of Co-morbid Mental Disorders
Depression: CBT and/or Pharamcotherapy
Anxiety Disorders: CBT
Blood glucose awareness training
Discrimination training (learning to discriminate between symptoms of
hypoglycaemia and panic reactions)
Exposure based techniques
Eating Disorders: CBT techniques
in particular mirror image exposure
What needs to be done?
2.Psychological Treatment
• Health Promotion and Support in Illness Coping
Stress Coping
Patient Education
Relaxation Training
Biofeedback
Who is / should be in charge?
Appropriately qualified Psychologists
e.g., Clinical Psychologists, Psychotherapists, Health Psychologists
Literatur