Psychological co-morbidity in Diabetes mellitus : assessment and therapy

Prof. Dr. Claus Vögele

Disability-adjusted life-years (DALY):sum of years lived with disability and years of life lost

20%

Co-morbidity of mental disorders with Diabetes mellitus: a brief summary

• Prevalence rates vary in relation to assessment techniques used. Typically higher prevalence rates (in particular depression and anxiety disorders) occur with the use of self-report scales as opposed to clinical interviews.

• Nevertheless ...

12-months estimated prevalence in mood disorders

1.4 1.3

12-months estimated prevalence in anxiety disorders

1.6 1.5

12-months estimated prevalence in anxiety disorders

1.3 1.3

Co-morbidity of mental disorders with Diabetes mellitus: a brief summary

Mental Disorder OR or observed prevalence

Mood Disorders Major Depression 1.4Dysthymia 1.3

Anxiety Disorders GAD 1.6Agoraphobia/Panic 1.5Social Phobia 1.3PTSD 1.3

Schizophrenia 15% versus 2-3% (comm.)

Psychological factors

Mental Disorders as a consequence

of the physical condition

Psychological factors affect

prognosis/treatment

Causal role inaetiology

Health risk behavioursNeurobiological/psychophysiological processes

Psychological factors and physical conditions: concepts

Depression as a risk factor for Diabetes:neurobiological/psychoneuroendocrinological mechanisms

• Depression is an independent risk factor for type 2 Diabetes (Eaton et al., 1996; Kawakami et al., 1999)

Evidence for endocrinological mechanisms:

Depression is associated with • increased serum glucocorticoids, catecholamines, and growth hormone (which counter the effects of insulin)

and• insulin resistance

and• secrection of inflammatory cytokines, which could facilitate development of diabetes (Musselmann et a.,

2003).

Psychological factors

Mental Disorders as a consequence

of the physical condition

Psychological factors affect

prognosis/treatment

Causal role inaetiology

Psychological factors and physical conditions: concepts

CNS pathologyTreatment side effects

Responses to changed life-situation - Adjustment

Diabetes as a risk factor for Depression: Nouwen et al., 2010

Anxiety Disorders common amongst Diabetics

• Hypoglycaemia anxiety

– This can be associated with impaired perception of hypoglyaemic symptoms, which increases the probability of unexpected hypoglycaemic episodes and, therefore, the development of severe anxiety.

• Specific type of blood-injection-injury phobia

– Can lead to irregular insulin injections with all adverse consequences.

• Panic Disorder (with or without Agoraphobia)

– Panic attacks are often accompanied by very similar symptoms than hypoglycaemic episodes. Hypoglycaemic episodes can, therefore, contribute to the development of Panic Disorder.

Eating Disorders common amongst Diabetics

• The management of Diabetes requires patients to constantly be aware and check their food. The cognitive pattern (restrained eating) is typical for patients with Eating Disorders.

• Anorexia nervosa and Bulimia nervosa are not more prevalent amongst Diabetics compared to community samples.

However:

• EDNOS (sub-clinical Eating Disorders syndromes) are more than twice as prevalent amongst young female Type-I diabetics.

• Insulin-purging: deliberately reduced insulin intake in order to promote weight-reduction and fat-loss

Psychological factors

Mental Disorders as a consequence

of the physical condition

Psychological factors affect

prognosis/treatment

Causal role inaetiology

Psychological factors and physical conditions: concepts

Subjective disease modelAdherencePhysician-patient communication

Effects of severe mental illness on survival of people with diabetes Vinogradova et al., 2010

What needs to be done? 1.Psychological assessment

• Interview (DSM), Questionnaires

• Behavioural analysis:

Analysis of individual conditions maintaining pathological processes

Subjective Disease Models

Illness Behaviour and Treatment Adherence

Assessment of Individual Resources

What needs to be done?

2.Psychological Treatment

Treatment of Co-morbid Mental Disorders

Depression: CBT and/or Pharamcotherapy

Anxiety Disorders: CBT

Blood glucose awareness training

Discrimination training (learning to discriminate between symptoms of hypoglycaemia and panic reactions)

Exposure based techniques

Eating Disorders: CBT techniques

in particular mirror image exposure

What needs to be done?

2.Psychological Treatment

• Health Promotion and Support in Illness Coping

Stress Coping

Patient Education

Relaxation Training

Biofeedback

Who is / should be in charge?

Appropriately qualified Psychologists

e.g., Clinical Psychologists, Psychotherapists, Health Psychologists

Literatur