Diabetes and psychiatry

Depression, generalized anxiety, eating disorders, schizophrenia, dementia and sexual dysfunction are common in diabetic patients.

Diabetic patients often suffer from a fear of early death. The need to keep their blood sugar at a normal level, to eat frequently and at specific time, to organize their lives differently from that of other people are restrictions that distress the patient. These people with personality type A are constantly under stress. The high anxiety level triggers out anger. As diabetic patients have to be careful and constantly be on the alert for possible complications, the support of their family becomes very important. Diabetic patients belong to the group of patients who are often referred to a psychiatrist by their doctor of internal medicine. However, diabetic patients tend to resist the possibility of benefitting from the vast resources that psychiatry has to offer. We talked to Prof. Dr. M.Kemal Arıkan.

– What kind of mechanism in diabetes brings the patient face to face with psychiatric problems?

Diabetes stands right in the middle of psychiatric, social and physiological processes and is a disease model which is of high interest to psychiatry. I would first like to give some brief explanatory information on diabetes.

-What is this information?

There are two types of diabetes. In Type 1 diabetes the autoimmune system is activated against the beta cells of the pancreas which leads to a destruction of these cells. Such patients need insulin. In Type 2 diabetes the cells fail to use insulin properly because of a resistance that has developed. The brain is very sensitive towards changes in glucose level. In diabetes the glucose level constantly changes and the neurovegetative system has to constantly work in order to compensate this. Furthermore, the levels of chemicals called cytokines in the body rises. We can add to that the effect of the stress hormones which, as you know, are glucagon, glucocorticoids, growth hormone and catecholamines which we hear of in every psychiatric disorder. If we go back to your question, a psychiatric picture presents itself due to the action of stress hormones, the imbalance of the vegetative system, cytokines and changes in the blood glucose level.

– Is there a link between the family’s and the public’s approach to the illness and the risk of psychiatric problems?

The support of the family is of vital importance to the diabetic patient. Diabetic patients have a specific life style. They have to eat little amounts of food regularly and frequently, exercise, watch their body weight, take their medication regularly and generally look after themselves. The importance of family support under these conditions is self-evident.

– Does that mean that there is a risk of complications?

Yes. The absence of adequate family support can result in serious complications. As you know, there a large number of serious complications that can develop in diabetes, like nephropathy, neuropathy, retinopathy and similar. If the patient does not take care of himself, damage can occur in the large and small blood vessels which can eventually lead to a leg amputation. All this shows how vital family support is.

– Does diabetes have an adverse effect on brain function?

Yes. As mentioned above, diabetes has a negative impact on the functions of the brain. MRI and PET findings indicate that in diabetes the left frontal area of the brain is particularly affected.

– We hear that diabetic patients usually are irritable and become easily upset. Does this have anything to do with anger control?

Anger as a sign of anxiety and is a common finding in diabetic patients. It becomes particularly marked when the glucose level rises.

– Is the diabetic personality linked to hasty, impatient, precise personality traits ?

There is a close link between diabetes and personality. In people referred to as type A who have the personality traits you mentioned, we see a rise in blood sugar, whereas in type B we see the opposite, where interestingly their blood sugar level remains low.

– Does the fact that diabetes is a life-long illness, trigger psychiatric complaints?

Particularly in type 1 diabetes it really does continue a life-time. As I explained earlier, with its biological mechanisms and the restrictions it brings to the patient’s life, diabetes of early onset carries a greater risk of psychiatric problems.

– Which psychiatric disorders do we see in diabetic patients?

The primary one is depression, but we also see generalised anxiety, eating disorders, schizophrenia and dementia.

– Do we see psychiatric problems in patients in whom diabetes started at an early age?

Yes. In diabetes of early onset the deterioration of cognitive functions can be more severe.

– Is there any data on psychological problems experienced in more advanced aged diabetics?

According to overseas data the likelihood of depression in diabetics is twice as high as in the normal population. Figures up to 14% are being expressed. In the native American population it is even higher. Unfortunately we do not have such data for our country.

– What is the psychological state of people with advanced diabetes who have continuously used insulin?

Continuous use of insulin could be experienced as disturbing as it sets the diabetic patient apart from other people. The patient may feel some kind of inadequacy, helplessness or deficiency. If we look at it from a biological point of view, the patient’s blood sugar level fluctuates after the administration of insulin. If the patient uses insulin irregularly then he can experience psychic stress.

– How does the impact of diabetes on the patient’s sexuality affect the patient? Can this lead to psychiatric problems?

This is a very important issue for diabetic patients. As I mentioned earlier, there are various complications that can occur with diabetes. In male patients there can be associated impotence. There are signs indicating that sexual dysfunctions does not only manifest in men but also in women. A sexually dysfunctioning person will feel inadequate, may have conflicts with his or her partner, suffer from depression or paranoid thoughts. Such psychiatric problems are a common result.

– Can patients, who are in the preferred position of having kept their spirits high, be taken to an even better position?

Of course. High spirits help in reducing the risk of diabetes-related complications. Furthermore, it strengthens the patient’s will to follow the treatment. In fact, some investigations show that being in high spirits helps with the body’s sugar regulation. It also increases the body’s resistance against stress.

– Diabetes and psychiatric disorders – which side acts as the trigger?

Diabetes and psychiatric disorders act as mutual triggers. Some studies emphasize that in many patients major depression was observed before the onset of diabetes. They conclude from this that diabetes results from depression. In reality diabetes has a hereditary aspect. However, when we look at single-egg twins, we would expect the disease to occur in both of the twins, but this is only true in 50% of the cases. It follows that there are certain social, psychological and similar factors at all play a role in triggering diabetes. On the other hand, it is a known fact that diabetes triggers depression. In short, either side can trigger the other.

– I observed in diabetics whom I know, that there anxiety with regards to the future is high. Do you share this view?

I definitely share this view. As I mentioned above, diabetes can lead to serious complications. Diabetes increases the risk of being overcome by other illnesses and dying of an early death. A patient who is witnessing this, will naturally be worried about the future. However there are no grounds for worry if the diabetes is properly regulated.

– Do diabetic patients have self-confidence problems?

Unfortunately they can experience such problems. Particularly young patients experience low self-esteem because their dependency on regular insulin intake sets them apart from others. In Type 2 diabetics we may come across self-esteem issues related to being overweight.

– Some diabetic patients resist going to the psychiatrist although they have been referred to one by the doctor of internal medicine. What is the reason for this?

They are afraid of being stigmatized as “mad”. Unfortunately, like in every other area of psychology, here too there is stigmatisation has an impact. The reality is that the vast resources of psychiatry would provide great opportunities and benefits to the patient, and could help to reduce the risk of complications, improve sugar regulation in the body, alleviate depression and increase resistance against stress.

– Compared the general population, is depression more common in diabetics?

The frequency of occurrence of depression in the general population is normally around 4-5 %. In the diabetics population this percentage at least doubles. I am talking here about the category of major depression with all the associated symptoms. With regards to being symptomatic, almost 3 out of 4 diabetics display symptoms of depression or conditions like fatigue, languor and similar.

– Do the two disciplines help each other during treatment? Do you consider this necessary?

Yes, definitely. This will increase the chances of success.

– Could we say that from time to time the diabetic patient disengages from life?

If because of the depression the patient suffers from an inability to enjoy life, then of course there can be serious episodes of disengagement from life.

– Is there a difference between male and female diabetics when it comes to the likelihood of developing psychiatric problems?

Yes. Depression and eating disorders are more common in women. In men sexual dysfunction is more common.

– How well do diabetic patients adapt to psychiatric treatment?

If the diabetic patient has difficulties complying with the diabetic treatment, then psychological problems are more likely to arise. It is therefore not surprising that this group of patients also has difficulties complying with the psychological treatment.

– Do diabetic patients need therapy alongside a drug treatment?

Yes. Psychotherapy and in particular cognitive behavioural therapy and relaxation through biofeedback give good results. In fact, it is reported that psychotherapy can help regulate the level of haemoglobin Ac1, which is one of the parameters of diabetes. Furthermore, as I have often mentioned before, is also very helpful in depression, anxiety, it improves the quality of life and compliance with treatment. Pharmacotherapy is an issue that has to be approached with care, as certain psychotropic drugs can directly cause to type 2 diabetes. These are more commonly drugs referred to as atypical antipsychotics. Certain antidepressants interfere with the sugar regulation in the body, with others it is the opposite, they regulate body sugar. Another issue that has to be taken into consideration is the interaction of diabetic medication with antidepressant drugs. If pharmacotherapyis applied after careful consideration of all the above issues then it will of course be at least as beneficial as psychotherapy.

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