Diabetes and mood

Many factors can affect your diabetes, including: stress, activity and exercise, illness, excitement, travel, work and routine changes, hormones, age or stage of life, food and drink, insulin type or dose, and injection site. Pinpointing the actual factor can sometimes be difficult or impossible. This ambiguity can lead to lowered motivation and feelings of powerlessness. Staying on top of your diabetes management can be tough, especially when results are not as you would like them to be. 

To make matters even more complicated, your mood and actions can be closely linked to your blood glucose levels. As you have probably already noticed, you may feel short-tempered and out of sorts when your blood glucose levels are high. Hypoglycemia also has its problems—you may find that a different side of your personality comes out when your blood glucose level is low. If you are usually loud and gregarious, you may become quiet and withdrawn. If you are naturally a serious person, you may find yourself laughing more. If you are normally even-tempered, you may become argumentative. At times, this may cause you embarrassment, but it is okay to tell people that your blood glucose is low and that you will be your normal self once you have had something to eat. In doing so, you are not using your diabetes as an excuse, you are stating a fact.

Having realistic goals and a good understanding of what diabetes is all about will go a long way toward your mental and emotional well-being. In addition, identifying other problems in your life that impact your diabetes and dealing with them one by one is also important. Again, it is critical that you are comfortable telling your health care team about your needs and priorities in order to make life as enjoyable as possible over the long term.

Staying the course: adults living with longstanding type 1 diabetes
Written by Michael Vallis, Ph.D. R. Psych.
Psychologist, CDHA Behaviour Change Institute
Associate Professor, Dalhousie University

Let’s face it: we live in an instant gratification, built-in obsolescent world. There was a time when old stuff was better; a well-worn leather jacket that got better with age, a vintage BMI that required just a little extra attention. But no longer. Now a computer is old after 2 years; and cellphones! Do we really need upgrades at the rate of 2 per year? So this is the context of our lives; societal attention deficit….can’t call it a disorder if it’s normal. 

So imagine being in the young middle age of life, and having had type 1 diabetes (T1D) since age 6. You’ve pretty much seen everything reading diabetes management, and yet you are asked to manage your disease on a continuous basis. Not so easy. This article is written to discuss psychological issues associated with this situation.

Psychological issues are recognized as important by healthcare providers but very little attention has been paid to these issues. Providers feel ill equipped to address these issues. Psychological awareness is generally low. But all is not bleak. There are some who are interested in understanding these psychological issues in diabetes, and a recent study was undertaken in seventeen different countries to explore Diabetes Attitudes Wishes and Needs (DAWN2™).
We have learned from this research and are beginning to consider ways of improving the recognition and management of psychological issues in diabetes. I will provide a brief overview here.

My first point to emphasize is that when we talk about psychological issues in diabetes we need to distinguish mental health disorders from diabetes related psychological issues. Imagine someone with diabetes presenting a psychological issue to a healthcare provider - it could be depression, anxiety, stress, interpersonal issues, etc. I think that one of the most important questions to ask the person at the very beginning is something to the effect of “is this issue you are experiencing related to your diabetes or separate from your diabetes?” If the issue is unrelated to diabetes our understanding of mental health issues is important. If the issue is intertwined with diabetes then management is really part of diabetes management. As a psychologist in diabetes this is an important distinction for me. It explains why I am trying to improve the management of psychological issues within diabetes programs and why I am trying to increase connections between diabetes programs and mental health programs. It is also important because evidence tells us that it is very common for psychosocial issues to be intertwined with the experience of living with diabetes.

Let me illustrate this with recent research findings. For some time now it has been recommended, as part of the Canadian Diabetes Association’s Clinical Practice Guidelines, that all persons living with diabetes be screened for depression. So we have become reasonably skilled at identifying depressive episodes. Yet recent research has begun to study depression in diabetes in more detail and has identified the concept of diabetes distress. Diabetes distress overlaps with depression, in that those with distress are more likely to have depression as well. But diabetes distress is about diabetes where the depression screening is about symptoms of depression. So the diabetes distress scale has four sub-scales; emotional burden (akin to depression), regimen distress, physician related distress, and interpersonal distress. Interestingly the frequency of encountering people with diabetes distress is much higher than the frequency of encountering people with depression. As well there is some evidence suggesting that when depression is detected and treated depression improves but not diabetes control. In contrast this research suggests that when diabetes distress is detected and treated distress improves and so does diabetes control. 

So let’s first talk about psychological concerns that may stem directly from the experience of living with diabetes. What is it about diabetes that might make people living with diabetes at risk? Well, when I think about diabetes from the perspective of a psychological stressor I identify the following characteristics of diabetes that make it stressful:

Diabetes can at times be OVERWHELMING. The number of tasks that have to be planned, measured, evaluated and recorded can get a bit much.

Diabetes can at times be COMPLEX. The number of factors that come into play in both planning for normal life activities and in determining blood glucose can feel like one needs a PhD in diabetes.

Diabetes can be CONSTANT. Few other diseases requires so much attention on such a regular basis (every few hours) everyday, regardless of what else is going on in a person’s life.

Diabetes can be UNFORGIVING. Risk of complications can never be eliminated and despite significant and prolonged efforts at self-care bad things can happen.
Diabetes can be plagued with UNCERTAINTY. If you feel dizzy did you get up too fast, or are you possibly low? There are many aspects of diabetes that leave a person uncertain. Uncertainty can breed worry and worry is anxiety.

As a result of these conditions those living with diabetes can run into difficulties with emotional distress. The dominant emotional issues experienced that can stem directly from living with diabetes include dysphoria, anxiety and irritability. Dysphoria refers to feelings of sadness and they can be mild and temporary or more severe and long-lasting. If the intensity of dysphoria is severe and long-lasting enough, the person might meet the criteria of clinical depression. Anxiety issues that are common often revolve around fear of hypoglycemia and fear of complications. Hypoglycemia is a near-traumatic experience and can leave people with significant worry and anxiety, especially over the possibility of nocturnal hypoglycemia. Irritability often stems from the demands of diabetes management and diabetes care.

Apart from emotional issues that a person with diabetes is at risk of because of their diabetes I also want to highlight the risk of relationship distress. I often describe diabetes as a personal disease and a family illness. Diabetes affects most aspects of a person’s life and therefore it is not a surprise to find that diabetes has some impact on relationships. It should not be a surprise to any that support from others is associated with better diabetes control and quality of life. It can be difficult to manage situations where family, friends or co-workers are making the tasks of diabetes less easy. One anecdotal experience I have had as a psychologist in diabetes is witnessing that the child friends of children with diabetes seem to easily adapt to diabetes in their friends. Yet adult friends of adults with diabetes appear much more rigid and non-supportive. Go figure! 

So now that I have made the point that many, if not most, of the psychological issues in living with diabetes are not due to mental disorders but are intricately tied to the experience of diabetes itself, let me also address mental health disorders. 

People living with diabetes are at greater risk than those without chronic disease of depression and anxiety problems. Clinical depression is diagnosed when the depressed mood becomes dominant and interfering and is associated with a number of other symptoms (disturbed sleep and appetite, hopelessness, agitation or withdrawal) for a long enough period of time. There are many effective treatments for depression, especially mild and moderate levels of depression (the most common) and these include lifestyle (aerobic exercise, socializing, journalling), psychotherapy (cognitive-behavioural therapy and interpersonal psychotherapy) and medications. Severe depressions are more difficult to treat and almost always are best treated by including medication in a comprehensive treatment plan. Anxiety disorders include needle phobias (not very common) as well somatic over concern or generalized anxiety disorder. 

It is also important to mention that there is a risk of insulin omission problems. This is most often seen in young women and is related to weight concerns and pursuit of thinness. Although the frequency of this is low it is extremely dangerous and any suspicion of insulin omission issues should be acted upon as quickly as possible. We recommend that anyone with this problem be seen by a psychologist or psychiatrist with expertise in eating disorders. 

My goal in writing this article has been to provide a general overview of the types of psychological issues associated with living with diabetes. The adult who has had diabetes for a long time might well encounter many of these issues at some time. In providing this overview I have two things in mind. The first is captured by the expression “to be forewarned is to be forearmed”. By highlighting these psychological issues people can be more able to identify them and take action. The second thing I have in mind is illustrated by the following - most people solve most of their problems on their own most of the time. In other words let’s bring these issues to the foreground and in that way we can also bring forward coping strategies. That might be the topic for another article if the invitation is extended to me again. 

Keeping an eye out for depression 
Living with diabetes makes you more than twice as likely to experience depression as those without the disease. 

It is important to be aware of the signs and symptoms so that you know when to seek help. 
Symptoms of depression can include extended periods (more than two weeks) of: 

  • Feeling sad or miserable most of the time 
  • Losing interest or pleasure in most of your usual activities 
  • Becoming withdrawn, not going out 
  • Stopping activities you used to enjoy 
  • Thoughts about being a failure, being worthless, life is not worth living 
  • Feeling overwhelmed, tearful, guilty, irritable 
  • Having physical symptoms such as feeling tired all the time, having a churning gut, irregular sleep patterns, or changing appetite 

Depression is treatable and most people recover with the right treatment. It is important to seek help sooner rather than later, so if you suspect you are experiencing symptoms of depression; speak to a trusted health care professional. 

Avoiding diabetes burn-out 
Having diabetes is like a job, and the day-to-day effort to manage it can become too hard and frustrating, especially when the results are not what you would like. Studies have shown that a majority of people living with diabetes experience worries, fears, and negative feelings at some stage. This can lead to diabetes burn-out.

Burn-out is much more than feeling a little down. It includes overwhelming feelings of helplessness and hopelessness. Signs might include not checking blood glucose levels, stopping or reducing insulin injections, not caring about your eating habits or exercise, and ignoring or trying to forget your diabetes most of the time. Diabetes burn-out is seen as one of the major psychological complications of diabetes. 

You need realistic expectations and practical strategies for managing the emotional side of diabetes. One simple strategy that can help is to change the way you think about your blood glucose levels. Rather than getting angry or upset, look at your blood glucose results as information to help you decide what to do next. Don’t waste time punishing yourself over a high number. Use what you know to plan ahead and make positive adjustments. Using words like high and low blood glucose instead of good and bad can really help. If you think you are experiencing burn-out or are at risk for experiencing it, ask yourself: 

  • What’s happening in my life that might be conflicting with diabetes care or making it harder? 
  • What problems outside of diabetes could be addressed? 
  • What are my expectations for my diabetes management—what do I want? 
  • Are my goals realistic right now? Perhaps they are too high or too low? 
  • What particular areas of diabetes are causing me problems? 

When the going gets tough, the tough get support! 

If things are not going so well with your diabetes, it’s important to work out why and see that you are not the problem. If your diabetes management is off track, then there are likely other problems getting in the way. This does not diminish your responsibility in dealing with the problems, but opens up possibilities for change. These problems might be directly related to your diabetes, such as a need for a management change, or they might be problems unrelated to your diabetes, such as depression or issues at work. 

Ultimately, you need to give yourself a break to identify and tackle the problems and get support. Talking to other people who understand is very important. 

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