2. Interface of Diabetes and Psychiatry Presentation By Dr. Reza Bidaki. MD Assistant professor of psychiatry Shahid Sadoughi of Yazd university of Medical Sciences

3. Introduction  The interface of diabetes and psychiatry has fascinated both endocrinologists and mental health professionals for years  in 17 th century Thomas Willis speculated that diabetes was caused by “ long sorrow and other depressions.”

4. 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.

5. History  Insulin coma therapy was used as a psychiatric treatment within a decade of isolation of insulin.

6. Co-occurring psychiatric disorders in patients with diabetes  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

7. 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

9. The Role of Stress  Stress : Increase blood glucose  Stimulate HPA Axis

10. 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

11. 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%

12. Symptoms of Depression  Anhedonia  Failure feeling  Hopelessness  Guilt feeling  Self-accusation  Retardation  Indecisiveness  Weight loss  Fatigue  Sadness  Suicide Ideation

13.  Prevalence of MDD is 200% rather than Non diabetic patients ( Nearly 46%)  Meta-Analysis  Anderson et al  2002

14. Depressive patients  Less obey of treatment  More Non-drug compliance  diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction)

15.  A recent metaanalysis has reported that depressed individuals have a 60% increased risk of developing diabetes  diabetes has been recognized as a “depressogenic” condition

16.  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

17. 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

18. 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

19. Bipolar disorder  Type 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

20. Anxiety disorder  The 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

21. Psychiatric disorders in Diabetic patients  Phobia : 21.6 %  GAD : 13 %  OCD : 1.3 %

22.  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

23.  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.

24. Comorbidity  In DM type I : MDD and OCD are more common  About DM type II : MDD and Somatization disorder

25. Fear of hypoglycemia  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

26. 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

27. 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%

28. 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, self- consciousness, and vulnerability

30. Adjustment with disease  It is difficult that persons accept their diseases and adjust self with it  The patients inform about disease, therefore deny and depression is inevitable

31. Risk factors for depression  Female  Duration  Complications  HbA 1 C  Family history for depression  Low education

32. Control of BS  Control of Blood sugar will improve mood

33. Schizophrenia  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 first- degree 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

34. Genetics  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 5- HT2C serotonin receptor or the beta3 adrenoreceptor

35. Dellirium  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 co- morbid psychiatric disorders are more likely to experience hypoglycemic delirium  outcomes : increased hospital stay, increased cognitive and functional deterioration, morbidity and mortality

36. Smoking 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

37. Alcohol  Prevalence of alcohol use in diabetic population has been reported to be around 50--60%  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

38. Intervention for Alcohol Use  Diabetics 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

39. Sleep Disorder

40.  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

41. Sleep disordes  Restless legs syndrome (RLS)  Periodic limb movements ( PLMD)

42. Risk factors  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 sleep- disordered breathing, central-type apneas and periodic breathing autonomic diabetic neuropath

43. Conclusion and Message  Comorbidity of diabetes and psychiatric disorders is common and can present in different patterns  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