Orlando, Florida - Diabetes is a unique and complex disease affecting more than 30 million Americans, and the individual living with diabetes is solely responsible for daily diabetes management. The added stress of this responsibility significantly increases their risk for depression and anxiety. Research has indicated that symptoms of depression have been shown to be associated with worsened blood glucose levels and increased diabetes-related complications. Therefore, diabetes prevention programs and increased awareness, screening and care for the mental health aspects of diabetes are key components in improving the quality of life for people with prediabetes (more than 84 million have prediabetes) and diabetes.
Symposia presentations at the ADA’s 78th Scientific Sessions® at the Orange County Convention Center focused on the correlation between mental health and diabetes and on diabetes prevention initiatives.
Mental Health Disorders and Diabetes Distress Among Adults with Diabetes
A bidirectional relationship exists between diabetes and mental health. Recommendations on appropriate psychosocial care for people with diabetes indicate health care providers should be trained to screen for and identify signs of mental health disorders and diabetes distress, as well as be prepared to direct patients to appropriate care.
“A need exists for comprehensive care for people with diabetes that addresses both their physical and mental health,” said Mary Beth Weber, PhD, MPH, assistant professor of Global Health and Epidemiology at Emory University’s Rollins School of Public Health. “Because mental health disorders are a risk factor for diabetes and occur more frequently among people with diabetes, patients should be empowered to adopt health-promoting behaviors; be educated in diabetes self-management; taught self-efficacy for decision making and be directed to counseling and/or medications as needed. Effective, combined management of diabetes and mental health disorders is vital to improving overall health outcomes for people with diabetes.”
Weber also notes some medicines used for mental health conditions may increase diabetes risk and diabetes risk factors, such as weight gain and increased body fat, and recommends that physicians select anti-psychotic medications with a lower risk of diabetes risk factors. Additionally, 18-45 percent of people with diabetes have diabetes distress, a state of emotional distress stemming from coping with the demands of diabetes and diabetes management. People with both diabetes and mental illness, or those who report having diabetes distress, often fare worse than other people with diabetes alone, reporting worse health status, poorer glycemic control and more risk factors, such as smoking and physical inactivity, that can worsen their health.
“Coordinated diabetes care must be practiced to properly address the needs of individuals with both diabetes and mental health disorders,” said Weber. “Coordinated care for people with diabetes and mental health disorders, possibly with the assistance of care coordinators, could be a potential solution. Physicians providing care to patients with diabetes must be aware of existing tools for screening for mental health disorders and diabetes distress and be knowledgeable about local resources for screening and care. Finally, diabetes prevention efforts are needed targeting individuals with mental health disorders.”
Research Perspective of Diabetes and Depression—The Neuroendocrine Link
People with diabetes are twice as likely to have depression as people without diabetes. Sherita Hill Golden, MD, the Hugh P. McCormick Family Professor of Endocrinology and Metabolism and Executive Vice-Chair of the Department of Medicine at the Johns Hopkins University School of Medicine, discussed the connection between diabetes and depression.
According to Dr. Golden, researchers now understand that the relationship between depression and diabetes is reciprocal in that people with T2D are more likely to develop depression over time, and people with depression are more likely to develop T2D.
“Clinicians across multiple disciplines should routinely screen patients with depression for diabetes and inversely screen patients with diabetes for depression,” said Dr. Golden. “Addressing and treating both conditions together may have a beneficial effect on stress hormones and will be the subject of future ongoing research.”
Dr. Golden has done research in the Multi-Ethnic Study of Atherosclerosis (MESA), a medical research study involving more than 6,000 men and women from six communities in the U.S. that is sponsored by the National Heart Lung and Blood Institute of the National Institutes of Health. Study participants are seen at clinics in six different states, including one site at Johns Hopkins University.
In the MESA study, Dr. Golden has found that people with T2D had a 50 percent higher risk of developing depression over three years, compared to those without T2D, even after factoring in obesity markers of diabetes severity and other risk factors for depression. Research also demonstrated that people with depression had a 21 percent higher risk of developing T2D over three years, which was only partially explained by obesity, poor health behaviors and elevated inflammation.
Dr. Golden discussed how depression and diabetes share a common abnormal stress hormone profile. One potential explanation for the higher risk of T2D in those with depression that was not explored in the original study was the role of the body’s stress hormones—cortisol and adrenaline—which are made by the adrenal glands. Abnormal patterns of stress hormones represent one of several shared mechanisms linking T2D and depression.
“If researchers can identify and intervene on these shared risk factors, then medical professionals can develop new ways to prevent and treat both conditions simultaneously,” said Dr. Golden. “A better understanding of the biological links between T2D and depression will open the door to developing new drug interventions that target these mechanisms. That will allow us to develop new ways to prevent and treat both T2D and depression and complement existing successful behavioral approaches.”
Updates to The National Diabetes Prevention Program
The CDC-led National Diabetes Prevention Program (National DPP) is a partnership of public and private organizations working to prevent or delay T2D. A year-long, evidence-based lifestyle change program, the National DPP is based on research which showed that people with prediabetes who take part in a structured lifestyle change program can cut their risk of developing T2D by 58 percent (71 percent for people over 60 years old). This finding was the result of the program helping people lose 5 to 7 percent of their body weight through healthier eating and 150 minutes of physical activity a week.
“Implementation has demonstrated that the year-long program could be modified for delivery in a group setting by community-based organizations and lay health workers and still maintain its effectiveness in achieving the outcomes necessary to prevent or delay the onset of type 2 diabetes,” said Ann Albright, PhD, RD Director of the Division of Diabetes Translation at the Centers for Disease Control and Prevention. “Additionally, the program is cost effective and can be cost saving depending on the risk level of the participants enrolled, and whether an individual chooses to participate in a group setting or as an individual.”
To successfully build the infrastructure for nationwide delivery of the National DPP lifestyle change program, CDC and its partners are working in four key areas simultaneously to increase: 1) the supply of quality program delivery organizations across the nation; 2) awareness and demand for the program among people at risk; 3) identification and referral of people with prediabetes through the health care sector; and 4) coverage for the intervention among public and private payers.
From its inception, CDC has sought to establish an all-payer system supporting coverage for the National DPP lifestyle change program. Dr. Albright summarized efforts to expand coverage through Medicare and Medicaid, state/public employee benefit plans, and commercial health plans and self-insured employers. Learnings to date have been incorporated into the National DPP Coverage Toolkit. The Coverage Toolkit provides information about all aspects of covering the National DPP lifestyle change program for a wide variety of payer audiences, including state public health, Medicaid, Medicaid managed care organizations, commercial plans, and Medicare. The goal of these efforts is to help ensure long-term sustainability of the program and remove cost barriers to participation, so that the program will be accessible to all people who need it.
“We have a proven lifestyle change program that can help the estimated 84 million American adults with prediabetes prevent or delay type 2 diabetes,” said Dr. Albright. “Through the National DPP, the CDC and its partners are building an infrastructure for nationwide delivery of the program—the first effort of its kind in the U.S., and a key part of this infrastructure is health benefit coverage for the program through an all-payer system. This will eliminate cost as a barrier to participation and help ensure that the National DPP is accessible to everyone who needs it.”
To help support health care providers in the area of psychosocial support, the ADA issued its Position Statement: Psychosocial Care for People with Diabetes in December 2016, and it is included within the ADA’s 2018 Standards of Medical Care in Diabetes. The ADA is partnered with the American Psychological Association to present in-person, professional education courses for mental health providers to earn certification in providing support for the complexities associated with living with and managing diabetes to people with diabetes. Providers who have completed the Mental Health Provider Diabetes Education Program are listed in the freely available ADA Mental Health Provider Directory—for physicians and patients.