Addressing the Psychological Impact of Diabetes

Diabetes is a chronic long-term condition (LTC) characterised by the inability to metabolise glucose effectively (Torpy, 2011)¹³. Diabetes affects 347 million people worldwide with Type 2 diabetes making up 90-95% of all cases of diabetes (Centres for Disease Control and Prevention, 2011)⁴. 

The impact of diabetes

A diagnosis of diabetes is associated with reduced life expectancy, significant morbidity, increased risk of co-morbidities such as heart disease, stroke and reduced quality of life (American Diabetes Association, 2003)¹. Among the many co-morbidities associated with diabetes, mental health difficulties also feature prominently. An individual living with diabetes is at a 2-3 times greater risk of developing depression than the general public (Vamos et al., 2009)¹⁴. Furthermore, individuals living with diabetes have been identified as having a 3 times greater risk of developing generalised anxiety disorder (GAD) (Balhara, 2011)² as well as higher prevalence of specific phobias related to diabetes such as needle phobia or fear of hypoglycaemia (Green, Fahrer & Catalan, 2001)⁶. 

Which comes first - diabetes or depression?

There is an ongoing, chicken and egg debate around the causal pathways between type 2 diabetes and mental health difficulties. From a clinical perspective the link is not that surprising when taking into account the extensive, unrelenting and often overwhelming self-management required for an individual with diabetes such as monitoring of their diet, exercise, general health, stress levels, blood sugar levels, and adherence to medication regimes (Golden et al., 2008)⁷. However, the direct link may not always be apparent to the person themselves. As with other long-term conditions such as chronic pain which we discussed previously there are various reasons for this including;

• Individuals living with LTCs may not identify with a diagnosis of “depression” or “anxiety” as they may not realise the extent to which their condition is impacting their mood
• In other cases, these feelings can also get brushed aside by the person experiencing them, as they may view them as less important when compared with the physical pain they experience on a regular basis

CBT and its effectiveness

Emerging research has shown approaches such as Cognitive Behavioural Therapy (CBT) to be effective in treating mental health difficulties in those living with diabetes (Safren et al., 2014, Harvey et al., 2015)¹¹. Up until now the common practice amongst most healthcare professionals was to view an individual’s physical health and mental health as separate thus people would be offered stand-alone mental health interventions. However, research has shown such stand-alone interventions show improvements in the depression and anxiety symptoms but have not consistently seen improvements in physical symptoms, mortality and health related quality of life (Cimpean & Drake, 2011)⁵. 

In contrast, when CBT interventions have been adapted to acknowledge and incorporate the complexities of living with a long-term condition such as diabetes, participants have reported improvements in mental health symptoms as well as improvements in areas related to their ability to cope with their LTC such as treatment adherence and quality of life (Thompson, Delaney, Flores &  Szigethy, 2011)¹². Currently, there is limited clear guidance on how to best adapt CBT based interventions for an individual living with an LTC such as diabetes.

Guidance that is available (Beatty & Koczware, 2010; Hadart, 2013; NICE, 2009)³ recommends adapting interventions to:

• Tailor content so that it feels relevant to the client in order to promote engagement
• Emphasise the complex interaction between physical and mental health through psychoeducation, examples and homework
• Be sensitive to some negative thoughts being more realistic in the context of an LTC
• Acknowledge and validate the challenges of living with an LTC
• Adapt physical/behavioural interventions to reflect the physical burden of living with an LTC
• Be free of clinical jargon

SilverCloud Health recently launched an online CBT programme ‘Space in Diabetes from Depression & Anxiety’, which has been tailored for individuals with diabetes in the following ways to promote user identification and engagement:

• Educational content specific to living with diabetes such as psychoeducational quizzes & personal stories
• Educational content to show links between mental and physical health and wellbeing
• Softened mental health terminology
• Condition appropriate behavioural interventions to accurately reflect the burden of living with an LTC
• Health advice tailored to somebody living with an LTC

The core aim of our online CBT based diabetes programme is not to treat the physical aspects of the condition but instead to address an individual’s mental health difficulty. We have endeavoured to ensure our range of LTC programmes including our programme for diabetes takes stock of the wider context of living with a long-term condition. We have created the  programme content for individuals living with diabetes to make the programme feel relevant to individuals with symptoms of depression and anxiety living with diabetes to ultimately improve the user’s ability to cope with a variety of physical and mental health challenges they may face in their lives.   

In SilverCloud Health we are committed to evidence-based practice. Therefore, research is currently being undertaken to assess the clinical feasibility of the Space in Diabetes from Depression and Anxiety programme within an IAPT service alongside its acceptability to individuals living with Diabetes. So, watch this space…. 

References:

1. American Diabetes Association. (2003). Economic costs of diabetes in the US in 2002. Diabetes Care. 26, 917-932.
2. Balhara, Y.P.S. (2011). Diabetes and psychiatric disorders. Indian J Endocrinol Medicine, vol 15 (4), 274-283.
3. Beatty, L. & Koczwara, B. (2010). An effectiveness study of a CBT group program for women with breast cancer. Clinical Psychologist, 14(2), 45–53.  doi:10.1080/13284207.2010.500307
4. Centers for Disease Control and Prevention. (2011). National diabetes fact sheet, 2011 Retrieved from http://www.cdc.gov/diabetes/pubs/pdf/ ndfs_2011.pdf.
5. Cimpean, D. & Drake, R.E. (2011). Treating co-morbid medical conditions and anxiety/ depression. Epidemiology and Psychiatric Sciences, vol 20, no 2, pp 141–50.
6. Green, L., Feher, M. & Catalan J. (2000) Fears and phobias in people with diabetes. Diabetes Metab Res Rev, 16:287–93.
7. Golden, S.H., Lazo, M., Carnethon, M., Bertoni, A.G., Schreiner, P.J., Roux, A.V.D., Lyketsos, C. (2008). Examining a bidirectional association between depressive symptoms and diabetes. Journal of American Medical Association, 299 (23), 2751– 2759.
8. Hadert, A. (2013). Adapting Cognitive Behavioural Therapy Interventions for Anxiety or Depression to Meet the Needs of People with Long-Term Physical Health Conditions. Exeter: University of Exeter.
9. Harvey, J. N. (2015). Psychosocial intervention for the diabetic patient. Diabetes Metab Syndr Obes, 8, 29-43.
10. NICE (2009). Depression in adults with chronic physical health problem: recognition and management. London: National Institute for Health and Care Excellence.
11. Safren, S.A., Gonzalez, J.S., Wexler, D.J., Psaraoa, C., Delahanty, L.M., Blashill, A.J., Margolina, A.L. & Cagliero, E. (2014). A randomised controlled trial of cognitive behaviour therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes. Diabetes Care, 37 (3), 625-33.
12. Thompson, R.D., Delaney, P., Flores, I. &  Szigethy, E. (2011). Cognitive-behavioral therapy for children with comorbid physical illness. Child and Adolescent Psychiatric Clinics of North America, vol 20, no 2, pp 329
13. Torpy, J. M. (2011). Diabetes. Journal of American Medical Association, 305 (24), 2592.
14. Vamos, E.P., Mucsi, I., Keszei, A., Kopp, M.S. & Novak, M. (2009). Comorbid depression is associated with increased healthcare utilization and lost productivity in persons with diabetes: a large nationally representative Hungarian population survey. Psychosomatic Medicine, vol 71, no 5, pp 501–48.