The psychological impact of diabetes on mental health

On World Mental Health Day (10^th October) we look at some of the ways people living with diabetes can maintain good self-management of the condition and recognise the psychological impact of diabetes.

Having diabetes can take its toll, with the different aspects of self-management often feeling overwhelming. The responsibility for managing diabetes lies almost entirely in the hands of the person with this life-long condition.

People with different types of diabetes often have distinctive psychosocial needs. This article focusses on type 2 diabetes which is the most common form of the condition.

Impact on quality of life

The personal costs for those with type 2 diabetes are many. It can impact on relationships, on working and social life, and on psychological well-being, with a consequent effect on overall quality of life.

Constant monitoring, following a healthy diet and finding time for exercise can all lead to improved mental and emotional health.

The opposite may also be true; feeling depressed or anxious can lead to poor control of diabetes. This has been demonstrated in many studies and reviewed by Frank Snoek and his colleagues for The Lancet. The cyclical relationship between mental health and diabetes is illustrated in Figure 1 (page 6).

Importance of well-being

The importance of psychological and emotional well-being has now been recognised by not only Diabetes UK, but the National Institute for Health and Care Excellence (NICE) and there are guidelines for the management of diabetes and depression when they occur together.

NHS England has also recognised the importance of good mental health, advocating a holistic approach to care for people with diabetes which includes consideration of mental and emotional well-being as well as physical health (NHS England 2018). Diabetes UK has recommended that ever person with diabetes should be in receipt of 15 healthcare essentials - including getting psychological and emotional support, and that receiving more integrated care would improve outcomes and quality of life. This, they say, would also subsequently reduce healthcare costs.

A ‘stepped care’ approach to treating depression has been recommended by NICE which organises provision according to what is seen as the patient’s specific needs.

Identifying the symptoms

When someone goes to their GP to discuss feeling depressed or anxious, identification of symptoms starts with two questions:

1. During the last month, have you often been bothered by feeling down, depressed or hopeless?

2. During the last month, have you often been bothered by having little interest or pleasure in doing things?

If the answer is ‘yes’ to either of these questions, then further questions are asked in order to decide on the next step, and this is usually based on the severity of symptoms.

What support is available?

A service available to all those identified as having depressive symptoms is the Improving Access to Psychological Therapies (IAPT) service. GPs usually make the referral, however self-referral is also an option. The IAPT service consists of talking therapies such as cognitive behavioural therapy.

NICE guidelines, based on existing evidence, also recommend the use of physical activity groups, motivational interviewing, and group or family therapy.

Some people prefer group rather than individual support as it can promote a sense of belonging, sharing stories and feeling less isolated.

A recent systematic review of studies investigating the impact of different treatments in people with diabetes found that both psychological and pharmacological interventions had a moderate effect on depressive symptoms, but had no impact on quality of life. NICE are currently updating their guidance and evaluating the evidence which can inform their recommendations.

Specific guidelines for supporting people with long-term conditions (including diabetes) have only very recently (April 2018) been developed and are yet to be widely available. At the same time, direct access to psychological support in primary or secondary diabetes clinics remains scarce.

There is often a lack of confidence in talking about depression or other psychological and emotional problems, on the part of both the GP and the person with diabetes.

The treatment of diabetes and its physiological consequences is often seen as the main priority of care, with psychological well-being further down the list, and worries about the most appropriate service to offer or receive are common.