1. Diabetes and Psychiatric Disorders: Can they Co-exist?
Evelyn Parrish, PhD, APRN-BC
Associate Professor
College of Nursing
University of Kentucky

2. Objectives
Upon completion of this activity, participants will be able to:
Discuss the impact of mental health comorbidities on diabetes management.

3. Disclosures PsychU- Speakers Bureau
Shire Pharmaceutical – Speakers Bureau

4. Prevalence Physical and Psychiatric
Physical and psychiatric illnesses are closely interwoven.
60% of patients needing mental health care are being treated by medical practitioners
50-80% of the patients treated in medical clinics have a diagnosable psychiatric illness, and 10-20% of medical patients suffer primarily from an emotional disorder
50% of patients in psychiatric clinic populations have undiagnosed medical conditions
10% of self-referred psychiatric patients have symptoms that are due solely to a medical illness

5. Prevalence of Diabetes
Diabetes is a serious global health issue, currently affecting 425 million people world wide
By 2045 it is expected to affect 690 million people world wide

6. Stress
Stress=increased blood glucose
Stimulate HPA Axis

7. Medical-psychiatric interface
Medications
Medical illness
Psychiatric illness

8. Treatment Challenges
Psychiatric disorders in patients with diabetes has a low detection rate
Approximately 50% of those with a psychiatric disorder is not recognized nor treated in patients diabetes

9. Psychological Issues Diabetic regimen and dietary considerations
Blood sugar monitoring
Insulin injection
Fear of hyperglycemia
Fear of hypoglycemia
Fear of injection
Decrease in quality of life

10. Common Co-Morbid Diabetes and Psychiatric Disorder
Diabetes Mellitus type I: Major Depression and Obsessive Compulsive Disorder
Diabetes Mellitus type II: Major Depression and Somatization Disorder

11. Chronic Illness and Depression
Heart attack %
Cancer – 25%
Diabetes – 15-20%
COPD – 40%
Chronic pain – 30-54%

12. Prevalence of Depression
Mental and Behavioral Disorders are leading cause of disability globally
Leading cause of disability in the U.S. age 18-25
Affects approximately 16 million American adults
Prevalent in women than in men

13. Prevalence of Diabetes and Depression
Doubles risk of having depression, approximately 1 in every 5 patients are affected
The rate of Depression for the general population is 3-5% the rate with Diabetes is between 15-20%
Depression is under-recognized and undertreated in patients with Diabetes
When they co-exist, they may worsen the other

14. Symptoms of Depression
Anhedonia
Hopelessness
Helplessness
Indecisiveness
Weight gain/loss
Fatigue
Sadness
Suicidal ideation

15. Symptoms of Depression in Patients with Diabetes
Impaired quality of life
Increased cost of care
Poor treatment adherence
Poor glycemic control
Increased ED visits due diabetic ketoacidosis
Disruptions in life (family, social, work)

16. Depressed Patients Less likely to adhere to treatment
Diabetes complications

17. Depression Goal of Treatment
Complete remission of symptoms in all areas of functioning including social, occupational, and family

18. Anxiety Disorders
Patients with diabetes are 20% more likely to have an anxiety disorder
Patients with diabetes have increased rates of obsessive compulsive disorder, post-traumatic stress disorder, and agoraphobia
Difficulty differentiating symptoms of diabetes from anxiety disorders

19. Symptoms of Anxiety in Patients with Diabetes
Fear
Sweating
Tremor
Tachycardia
Confusion

20. Other Co-morbidities Eating Disorders Alcohol Use Schizophrenia
Bipolar Affective Disorder
Delirium
Smoking Cessation
Sleep Disorders

21. Treatment Assess severity- PHQ9, BDI, State-Trait Anxiety Scale, etc.
Education regarding illness, severity, and treatment
Antidepressants, anxiolytics, etc.
Psychotherapy .

22. Ramifications of Failure to Achieve Remission
Higher rate of relapse
Higher utilization of medical services
Lowered quality of life
Workplace issues

23. Treatment Resistant Depression
60-70% have favorable response
5-10% fail to respond
-Failure to respond leads to questions of appropriate diagnosis and treatment
-Undiagnosed medical illness is a major factor in failure to respond

24. Treatment Resistance Potential reasons for “treatment resistance”
Under-treated depression
Incorrect diagnosis of psychiatric disorder
Undiagnosed co-occurring psychiatric disorder
Undetected substance abuse disorder
Undiagnosed sleep disorder
Undiagnosed co-occurring medical condition

25. Summary
Diagnosis of a chronic medical condition serves as sufficient suspicion for an in-depth screening for psychiatric co- morbidities
Diagnosis of a psychiatric disorder serves as sufficient suspicion for an in-depth screening for associated physical conditions
Goal is for symptom remission, improved quality of life, and improved management of chronic physical illness and level of functioning

26. Take Away Message
Co-mordity of diabetes and psychiatric disorders is common and can have different presentations
Psychological approaches can improve therapeutic adherence in diabetes care
Patient engagement and empowerment are essential components of their care