Psychosocial Factors and Diabetes

Introduction

For the therapy and long-term prognosis of people with diabetes mellitus, somatic and psychosocial factors play an equally important role. In diabetes therapy, the patient plays a decisive role, as he or she must implement the essential therapeutic measures of diabetes in his or her personal everyday life in a lasting and self-responsible manner. The prognosis of diabetes patients therefore depends to a large extent on the extent to which they succeed in doing so against the background of their social, cultural, family, and professional environment. The following psychosocial factors are of central importance:

• Acquisition of knowledge and skills for self-treatment and their implementation in everyday life,

• Emotional and cognitive acceptance of diabetes,

• Coping with diabetes and its possible consequences in all affected areas of life and different stages of the disease (e. g. stress specific to the diabetes illness, acute and subsequent complications),

• Identification and modification of behavioral patterns that prevent successful self-treatment,

• Successful handling of crises and/or problems related to the illness (e. g. psychological problems such as depression, anxiety, eating disorders).

The present recommendations for psychosocial interventions in diabetes mellitus refer only to adult patients. The important areas of “social legal consequences of diabetes” (e. g. profession, driver’s license, Disabilities Act) or “diabetes and migrants” are not covered in this guideline.

Psychoeducation/Patient education

Definition

• Diabetes education is a systematic and goal-oriented process in which a person is enabled, through the acquisition of knowledge and skills about the disease and its treatment, to integrate diabetes into his or her own life in the best possible way on the basis of his or her own decisions, to avoid acute or long-term negative consequences of diabetes and to maintain quality of life. It represents an essential and indispensable element of diabetes therapy.

• Structured education and treatment programs for people with diabetes are characterized by a comprehensible, goal-oriented structure in the teaching of the training content. As a rule, this means that the essential contents and goals as well as the methodology and didactics are described in a curriculum and corresponding documents, such as working materials, and are available for both the educators and persons being educated. Diabetes education should be integrated into the treatment of diabetes; this is also expressed by the term “education and treatment programs”.

Target group

• The target group for diabetes education courses is all people affected by the metabolic disease diabetes mellitus, as well as their relatives and/or caregivers.

• For patients who cannot implement their diabetes therapy independently and safely (e. g. people with cognitive disabilities, geriatric patients), structured education should also be offered to the appropriate caregivers (e. g. care staff).

• Diabetes education should be offered immediately after diagnosis and as the disease progresses.

Goals of structured diabetes education and treatment programs

• The following topics are among the central elements of contemporary diabetes education concepts: information about diabetes, possible comorbidities, complications, and suitable therapy measures. Furthermore, it is vital to practice skills for implementing the therapy and self-treatment in everyday life, to motivate patients to adopt a health-promoting lifestyle and their social competence, and to promote coping skills and strategies for maintaining quality of life. Since many patients have difficulties implementing the therapy measures, it is important to ensure that sufficient space is provided in the diabetes education for support with diabetes-specific problems. Adequate support for these problems should be developed together with the patient (see info box “Goals of diabetes education”).

• In order to achieve these goals, the selection of diabetes education courses must take into account the type of diabetes, the form of therapy, the level of knowledge and education to date, the risk profile and prognosis of the disease, the motivational, cognitive, behavioral, psychological, and special cultural prerequisites of the patients, as well as special problem situations related to the disease.

Forms of diabetes education

• Basic education: Basic education and treatment programs, which should be conducted as soon as possible after the manifestation of diabetes or the switch to a different therapy regime, are designed to work with the patient to develop basic knowledge and skills for implementing diabetes therapy, making informed decisions, and managing the disease. The training should take place in a structured form in homogeneous groups.

• Repeat, refresher, and supplementary education: Repetition, refresher, or supplementary training measures have the primary goal of supporting patients with difficulties in implementing therapy in everyday life and offering concrete assistance with problems related to diabetes (e. g., lack of knowledge or skills, problem areas in therapy results, complications or problems in everyday life), taking into account changes in the course of life (see info box “Indications for diabetes education”).

• Problem-specific education and treatment programs: These are aimed at patients in special, diabetes-specific problem situations (e. g. the occurrence of secondary diseases or special problems such as hypoglycemia problems). In contrast to basic education programs, these group programs target specific patient groups. Individual training: in certain situations, individual training can also be useful.

Certified education and treatment programs

A list of education programs for adults with diabetes mellitus certified by the Federal Office for Social Security (Bundesamt für Soziale Sicherung, BAS) and the German Diabetes Society (Deutsche Diabetes Gesellschaft – DDG) is provided below ([Tab. 1]).

Tab. 1 Education programs certified in Germany by the Federal Office for Social Security (Bundesamt für Soziale Sicherung, BAS) or the German Diabetes Society (Deutschen Diabetes Gesellschaft, DDG).

Title of the education program, authors and source	Evidence class	Approval
		BAS	DDG
Treatment and education program for intensified insulin therapy (for type 1 diabetes). Jörgens V. & Grüßer M. (Cologne: Deutscher Ärzteverlag)	IIa	yes	yes
PRIMAS: Living with type 1 diabetes – An education and treatment program for an autonomous life with type 1 diabetes. Kulzer, Hermanns, Ehrmann, Bergis, Haak. (Mainz: Kirchheim-Verlag)	Ib	yes	yes
Training program for people with type 2 diabetes who do not inject insulin, Berger, Grüsser, Jörgens, Kronsbein & Mühlhauser. (Cologne: Deutscher Ärzteverlag)	IIa	yes	yes
More diabetes self-management for type 2: An education and treatment program for people with non-insulin-dependent type 2 diabetes (Basic). Kulzer, Hermanns, Maier, Haak & Reinecker. (Mainz: Kirchheim-Verlag)	Ib	yes	yes
Treatment and education program for patients with type 2 diabetes who inject insulin (conventional insulin therapy) Berger, Grüsser, Jörgens, Kronsbein & Mühlhauser. (Cologne: Deutscher Ärzteverlag)	IIa	yes	yes
Treatment and education program for people with type 2 diabetes who inject normal insulin (preprandial insulin therapy). Berger M., Grüßer M., Jörgens V. (Cologne: Deutscher Ärzteverlag)	IIa	yes	yes
More diabetes self-management type 2: Education and treatment program for people with type 2 diabetes and conventional intensified insulin therapy (MEDIAS 2 ICT). Kulzer, Hermanns, Maier, Mahr, Haak & Reinecker. (Mainz: Kirchheim-Verlag)	Ib	yes	yes
Type 2 diabetes under discussion – education program for people with type 2 diabetes who do not inject insulin. Brinkmeier, Frank & Tewes. (Heidelberg: Spektrum Akademischer Verlag)	III	yes	no
Diabetes & behavior – education program for people with type 2 diabetes who inject insulin. Brinkmeier, Frank, Tewes & Tegtbur. (Mainz: Kirchheim Verlag)	IIb	yes	no
LINDA – education program for people with type 1 or type 2 diabetes. Feulner-Krakow G. & Krakow D. (Forchheim: Diabetespraxis Forchheim)	IIa	yes	no
For feet’s sake (BARFUSS) – Structured treatment and education program for people with diabetes and diabetic foot syndrome. Anlauf-Wilhelm et al. (Obtain via the Verband der Diabetes-Beratungs- und Schulungsberufe in Deutschland e. V. [VDBD])	IIb	no	yes
Blood glucose perception training (BGAT III). Fehm-Wolfsdorf, Kerner & Peters. (Lübeck: Lübecker Institut für Verhaltensmedizin – Lübeck Institute for Behavioral Medicine)	Ib	yes	yes
HyPOS – how to better detect, prevent and manage hypoglycemia: A structured education and treatment program for insulin-dependent diabetes patients with hypoglycemia problems. Kulzer, Hermanns, Kubiak, Krichbaum & Haak. (Mainz: Kirchheim)	Ib	yes	yes
Stay fit and grow older with diabetes. Structured education program for type 2 diabetics of advanced age who inject insulin. Zeyfang & Feucht. (Munich: Elsevier)	Ib	yes	yes
DiSko Education (DiSko: how diabetics come to sports). Siegist, Zimmer & Klare. (Obtain via the Diabetes and Sport Working Group of the DDG)	IIa	yes	yes
FLASH education and treatment program for people who use flash glucose monitoring. Kulzer, Hermanns, Ehrmann, Schipfer, Kröger & Haak. (Mainz: Kirchheim)	Ib	no	yes

Cognitive impairments and dementia

Cognitive impairments are presented as group F0 in the International Classification of Mental Disorders (ICD-10) of the World Health Organization (WHO). This group includes mental illnesses with a verifiable etiology in a cerebral disease, brain injury or other damage leading to brain dysfunction. The dysfunction or disorder can be primary such as illnesses, injuries or dysfunctions that directly or specifically affect the brain, or secondary as in systemic diseases or disorders that affect the brain as one of many other organs or body systems.

In patients with diabetes, transient cognitive impairments due to acute hypo- or hyperglycemia must be distinguished from persistent mild, everyday functions that do not restrict cognitive performance and clinically-relevant dementia.

Transient cognitive decline in performance

Patients with diabetes should therefore be informed about both acute cognitive impairment due to hypoglycemia and pronounced hyperglycemia (blood glucose levels above 171 mg/dl). Possible consequences for school, study and work performance as well as safety risks at work and in road traffic need to be discussed:

• Cognitive performance is impaired in patients with diabetes in all age groups with blood glucose levels below approximately 60 mg/dl.

• The impairments affect processing speed, complex psychomotor tasks, and emotional status, each of which is closely related to glucose levels.

• Acutely-elevated blood glucose levels can also impair concentration and cognitive performance. This also has a negative impact on working memory, attention, and emotional mood.

Cognitive impairment and mild cognitive impairments (MCI)

It is not yet possible to make reliable statements on the prevalence of MCI in diabetes on the basis of the available data due to the heterogeneity of the methods, operationalization of cognitive performance and the patient populations involved.

Dementia in diabetes

Patients with type 2 diabetes should be informed about the association between a long-term inadequate metabolic control and an increased risk of dementia.

• Patients with type 2 diabetes have a 2 to 4-fold increased risk of vascular dementia and a 1.5 to 2-fold increased risk of Alzheimer’s dementia.

Risk factors for cognitive impairment in diabetes

• Chronic hyperglycemia

• Diabetes duration

• Age

• Hypertension

• Lipid metabolic disorders

• Obesity

• Stroke

• Depression

• Smoking

• Inflammatory processes

• Rheological factors

• Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis

• Hypoglycemia

Screening and diagnostics

The early diagnosis of cognitive impairment is relevant in diabetes to ensure that a patient is still able to responsibly and reliably coordinate his or her (insulin) therapy and the appropriate diet on his or her own. In the risk group of elderly people (older than 65 years and with a long diabetes duration) and with cardiovascular comorbidity and clinical evidence of MCI, annual dementia screening should be performed.

• Possible indications of cognitive impairment:

  • Hypoglycemia due to incorrect insulin dosage,

  • Considerable fluctuations in the glucose level due to incomplete medication intake and/or malnutrition,

  • Difficulties in measuring blood glucose, handling the insulin pen, calculating insulin dose, or responding appropriately to hypoglycemic symptoms.

• The diagnosis of dementia is extremely serious diagnosis for affected persons and their relatives, which can lead to great psychological stress. Before the diagnosis is made, the highest possible diagnostic certainty should therefore be ensured. In addition to information about the diagnosis, the patient, relatives, and people in the patient’s environment should also be given comprehensive information on support and counseling services.

• Indications are provided by patients’ self-reported problems, e. g., memory disorders, difficulty finding words, retaining things, looking for or finding things, or concentrating.

• General, established short tests for the diagnosis of dementia can be used as screening instruments or as orientation aids in monitoring the course of the disease and for assessing its severity:

  • Dementia detection test (DemTect)

  • Mini mental status test

  • Clock sign test

  • Test for early detection of dementia separate from depression

  • Reisberg scales for external assessment

• Furthermore, the recording of everyday activities with the Barthel Index or the Instrumental Activities of Daily Living (IADL) scale is useful to assess the need for help in general and in diabetes therapy.

• Further in-depth neuropsychological early and differential diagnosis should be guided by the recommendations of the evidence-based guidelines on dementia.

Therapy of diabetes with cognitive impairments

• When choosing therapy goals and principles, the heterogeneity of the physical and mental performance and the associated risks of this patient group should be taken into account.

• In elderly persons with significant cognitive and/or functional impairment, HbA1c levels at which hypoglycemia is safely avoided should be targeted. However, hyperglycemia leading to the exacerbation of geriatric syndromes or dehydration should also be avoided, i. e., HbA1c values around 8% (64 mmol/mol) should be aimed for.

• Simple therapy concepts and dietary recommendations adapted to daily routines should protect against feeling overwhelmed and should maintain quality of life. Simple antihyperglycemic therapies carried out by caretakers with little stress on the patients make more sense here than concepts that are too demanding for both parties.

• In dementia patients, syndromes and hypoglycemic events that impair the quality of life must be avoided and HbA1c values are secondary.

Addictions – alcohol and tobacco

Alcohol

Alcohol addiction is no more common in people with diabetes than in the general population. People with a dependency disorder often have comorbid mental illnesses.

Interaction of alcohol consumption and diabetes

• Moderate alcohol consumption has a protective effect on the development of type 2 diabetes compared to low consumption or abstinence.

• The level of insulin resistance is lowest in people with regular moderate alcohol consumption but increases in both heavy drinkers and people who abstain from alcohol.

• People with diabetes should be educated that moderate, low-risk alcohol consumption is compatible with good metabolic control and diabetes prognosis, but that increased alcohol consumption increases the risk of hypoglycemia. About one in five severe hypoglycemic events that lead to hospitalization are caused by alcohol consumption.

• People with diabetes with a risky alcohol consumption or an alcohol dependency should also be educated about the dangers of alcohol, especially with regard to poorer metabolic control and the risk of secondary diseases.

Screening and diagnostics of alcohol addiction/abuse or harmful use

Because of the negative effects of substance addiction on diabetes therapy, early diagnosis is important. Part of the clinical picture is that affected persons deny an alcohol dependency or alcohol abuse and its negative effects for a long time.

Screening

People with diabetes should be asked regularly – at least once a year – about their alcohol consumption, and if there is any suspicion of risky or harmful alcohol consumption, screening or further diagnosis of harmful alcohol consumption or alcohol dependency should be carried out.

• In practice, the four questions of the CAGE-G questionnaire (CAGE-G) have proven to be useful for screening for harmful alcohol consumption (see info box “CAGE-G questions…”)

• Munich alcoholism test (MALT)

• Trier alcoholism inventory (TAI)

• Lübeck Alcohol Addiction and Abuse Screening Test (LAST)

The Alcohol Use Disorders Identification Test (AUDIT, German versions: AUDIT-G-L and AUDIT-G-M or the Brief Alcohol Screening Instrument for primary Care [BASIC]) aim to detect risky or harmful alcohol consumption.

Diagnostics

• The questions for a diagnostic clarification according to the ICD-10 criteria can be found in the info box “Questions on alcohol addiction”.

• Laboratory indicators of alcohol addiction such as gamma-glutamyl transferase (gamma-GT), carbohydrate-deficient transferrin (CDT) or mean corpuscular volume of red blood cells (MCV) can support a diagnosis but are not sensitive enough on their own to detect an alcohol addiction in patients in clinical practice.

• Furthermore, it may be useful to additionally screen for somatoform disorders, depression or anxiety disorders in those affected, since many people with a dependency problem have comorbid mental disorders.

Therapy of alcohol-related diseases

Because of the increased health risks associated with addiction and its negative impact on diabetes treatment, treating addiction is of particular importance for patients with diabetes. For forms of low to moderate alcohol consumption or occasional “binge drinking”, short-term interventions (behavioral medical interventions) are appropriate, while special addiction therapies are needed for more severe forms of alcohol addiction/abuse. Every person with diabetes with an alcohol-related addiction disorder should be offered the possibility to participate in an appropriate therapeutic intervention to treat the addiction disorder.

Smoking

In Germany, about 21% of people with type 1 diabetes and 13% with type 2 diabetes smoke. The proportion of smokers has declined in recent years.

Interaction of smoking and diabetes

• People with an increased risk of type 2 diabetes should be advised that smoking increases the risk of developing impaired glucose tolerance as well as the manifestation of type 2 diabetes.

• People with diabetes should be educated about the fact that smoking, as an independent risk factor, increases the risk of cardiovascular diseases such as stroke, heart attack or coronary heart disease.

• Smoking is an independent risk factor for increased mortality for people with diabetes.

• People with diabetes who smoke should be educated about the positive health effects of not smoking.

Screening

• Because of the importance smoking plays in the prognosis of diabetes, it is important that every person with diabetes is asked regularly – at least once a year – about their tobacco consumption. It must be taken into account that those affected often deny their addiction and underestimate the negative effects in terms of the risk of diabetes-related or associated secondary and concomitant diseases.

• The degree of addiction depends, among other things, on the number of cigarettes smoked daily (cigars, pipe), at what time the morning cigarette is smoked and the daily smoking profile, the depth of inhalation and the brand of cigarette used.

• The Fagerström test (FTND-G) (see info box “Fagerström test”) is recommended for determining nicotine addiction. This test allows the severity of the addiction to be assessed on the basis of 6 questions, which can be asked orally or in the form of a short, written questionnaire.

Diagnostics

• A detailed history of smoking habits (number of cigarettes smoked daily, daily smoking profile) is important for the diagnosis of a tobacco addiction. For a diagnostic clarification according to the ICD-10 criteria, the questions listed in the “Nicotine addiction” info box are suitable in practice.

• Patients with a tobacco addiction should also be screened for somatoform disorders, depression, and anxiety disorders, since many people with an addiction problem have comorbid mental disorders.

Therapy for nicotine addiction

• Because of the increased health risks associated with tobacco addiction and its negative impact on the prognosis, especially for people with diabetes, the therapy for addiction is of particular importance here.

• The problem of smoking – especially with regard to the risk of diabetes-related or associated secondary and concomitant diseases – should be adequately addressed in the consultation. The consultation procedure described above can be helpful in practice for every diabetes patient who smokes (see info box “Consultation procedure”).

• In addition to general explanations and information, psycho-educative measures, psychological/psychotherapeutic interventions, and medication are used as therapeutic procedures.

• For people with diabetes, there are no long-term results on the effectiveness of drug-based nicotine replacement therapies for smoking cessation.

• Observe interactions: There are important restrictions on the use of or warnings which must be observed when prescribing Champix® and Zyban® for persons with diabetes.

Schizophrenia

According to the International Classification of Mental Disorders (ICD-10) of the World Health Organization (WHO), schizophrenia is classified in the F2 group.

• The lifetime prevalence of schizophrenia in the general population is about 1%.

• Manifestation of the disease is often preceded by a prodromal stage, in which initially unspecific, later more indicative symptoms are noticed.

• It is unclear whether the frequency of schizophrenia in people with diabetes mellitus is different from that of the general population.

• The prevalence rate of diabetes in patients with schizophrenia is about twice as high as in mentally healthy individuals. The prevalence of the metabolic syndrome is also increased.

Interactions between schizophrenia and diabetes

• The higher prevalence of diabetes mellitus and metabolic syndrome has a significant impact on the health of schizophrenic patients. Their life expectancy is significantly shortened.

• Cardiovascular diseases are a major cause of the shortened life expectancy, the development of which is considerably promoted by the higher prevalence of diabetes mellitus. The increased suicide rate of those affected contributes only to a lesser extent to the shortened life expectancy.

Screening (diabetes)

• Patients with schizophrenia and their relatives and caregivers should be informed about the risk of weight gain and diabetes mellitus.

• In patients with schizophrenia, examinations of body weight, waist circumference, blood pressure, fasting blood glucose and fasting blood lipids should be performed at the intervals specified in [Tab. 2] .

Tab. 2 Examinations to be performed regularly in patients with schizophrenia.

Examination	Start of therapy	After 4 and 8 weeks	After 3 months	Every 3 months	Annually
Medical history	×				×
Body weight (BMI)	×	×	×	×
Waist circumference	×				×
Blood pressure	×		×		×
Fasting blood glucose	×		×		×
Fasting blood lipids	×		×		×

Therapy

Treatment of schizophrenia

• The therapy of schizophrenia follows a multimodal concept, which includes pharmacotherapy, psychotherapy, sociotherapy, occupational therapy, patient education and family work.

• For patients with schizophrenia who already have diabetes mellitus or are overweight/obese at manifestation, the primary use of antipsychotics that are not associated with weight gain should be considered. The weight gain is pronounced for the substances clozapine and olanzapine, intermediate for quetiapine and risperidone and small to absent for amisulpride, aripiprazole and ziprasidone.

• If pronounced weight gain or diabetes mellitus occurs under antipsychotic treatment, a dose reduction or change of antipsychotic drug may be considered. The risks of such a measure should be considered, in particular discontinuation of treatment with clozapine, with regard to possible exacerbation of schizophrenia.

Therapy of obesity and diabetes

• In patients with schizophrenia, the prevention of weight gain should be given high priority in the treatment plan.

• Overweight patients with schizophrenia should be offered nutritional counseling and instructions for increased physical activity at the beginning of therapy and as it progresses.

• The treatment of diabetes mellitus should be integrated into the overall therapy concept of schizophrenia and current evidence-based diabetes guidelines should be followed.

Depression

The depressive symptoms are classified according to the International Classification of Mental Disorders (ICD-10) of the World Health Organization (WHO) as follows: depressive episode (F32.x), recurrent depressive disorder (F33.x), persistent affective disorders (F34.x), other or unspecified affective disorders (F38, F39), adjustment disorders (F43.2x). The depressive episode is the one most frequently associated with diabetes. In terms of differential diagnosis, depressive syndromes must be distinguished from depressive symptoms in schizophrenic disorders (F20), personality disorders (F6), post-traumatic stress disorders (F43.1) and schizoid-depressive disorders in schizoid-affective disorders.

• Depression is a risk factor for the development of type 2 diabetes. People who suffer from depressive symptoms have an increased incidence of type 2 diabetes.

• People with diabetes have an increased risk of developing depression by a factor of about 2 compared to the normal population.

• It is higher in women compared with men, in clinical and in non-controlled samples compared with population-based samples, and varies by disorder definition and instruments used.

• The risk of developing depression increases with the development and number of diabetes complications.

Interaction between diabetes and depression

Depression in people with diabetes is associated with:

• A significant reduction in the general and diabetes-specific quality of life and therapy satisfaction,

• A higher rate of functional limitations (including sick days from work),

• Lower adherence to therapeutic recommendations, especially nutritional recommendations,

• More frequent discontinuation of weight loss programs (overweight patients with type 2 diabetes),

• Greater frequency of nicotine addiction,

• Less physical activity and movement,

• Less favorable metabolic control (HbA1c),

• A significantly increased risk of developing concomitant and secondary diseases,

• A significantly increased mortality risk,

• Higher costs of medical care.

Depressive symptoms are also associated with numerous psychoneuroendocrinological changes, including activation of the innate immune system, alteration of the HPA axis, glucocorticoid receptor function, increased insulin resistance and activation of the autonomic nervous system.

Screening

• Only half of the cases of depression in people with diabetes are detected.

• People with diabetes mellitus should be screened for the presence of clinical or subclinical depression on a regular basis, at least once a year and during critical disease phases (diagnosis, hospitalization, development of secondary complications, problematic disease behavior, impaired quality of life).

• Patients suffering from a depressive disorder often consult their doctor because of unspecific physical complaints and trivialize the psychological symptoms. Weakness, increased fatigue, apathy, irritability, anxiety, sexual problems, sleep disorders, loss of appetite and weight loss can – in addition to the characteristic symptoms – be symptoms of depression.

• Depression should be considered for differential diagnosis in these non-specific complaints.

• In cases of severe ketoacidosis or hypoglycemia, a differential diagnosis should be made to determine whether they are the expression of an attempt at suicide, for example in the context of depressive disorders or self-harming behavior.

• The central diagnostic instrument is the doctor-patient dialogue. During a patient-centered conversation, the physician should use screening questions for depressive disorders and ask about depressed moods, loss of interest and enjoyment in activities, and the loss of motivation or drive in addition to questions on diabetes-specific stress. In practice, the two screening questions have proven to be effective (see info box “Depression screening”).

• Depression screening questionnaire:

  • WHO-Five Well-being Index (WHO-5) – integrated in the “Diabetes Health Passport” (Gesundheits-Pass Diabetes)

  • Patient Health Questionnaire (PHQ-9)

  • CES-D scale (Center for Epidemiological Studies Depression Scale)

  • Beck Depression Inventory (BDI-II)

  • Hospital Anxiety and Depression Scale (HADS-D)

Diagnostics

• The following criteria are used to diagnose a depressive disorder and determine its severity according to ICD-10:

  • Severity of the current episode

  • Type and duration of depressive symptoms

  • Occurrence of depressive episodes in the medical history

  • Presence of a somatic syndrome

  • Presence of psychotic symptoms (in severe episodes)

• The PHQ-9 questionnaire which includes the diagnosis criteria of depression can be used to support the physician-patient conversation.

• Since the depressive symptoms often develop in direct relationship to other diabetes-related problems and complications, the correlation of the depressive symptoms with the diabetes-related somatic changes should be considered.

• Compared to the general population, the risk of suicide increases by a factor of 30 in people suffering from depression. If there are signs of depression, the patient’s suicidal tendency should be clinically assessed at every point of contact and, if necessary, the patient should be asked about suicidal thoughts, impulses, and preparatory actions.

• Depression often occurs together with other mental disorders. The presence of two or more comorbid disorders in an individual usually complicates the course of the disease and makes therapy more difficult.

• Depression screening and structured depression diagnosis, while increasing the detection rate, only improve the treatment of depression when combined with structured treatment programs.

Therapy

• The following measures are available for the treatment of depression: Active watchful waiting, psychotherapy, psychopharmacotherapy, combination treatment, light therapy, waking therapy, electroconvulsive therapy, sports and exercise therapy, occupational therapy or creative therapies supplement these procedures (see info box “Therapy steps for depression”).

• Often, motivational work by the primary care physician or diabetologist is needed in advance of treatment for depression in people with diabetes. Therapy motivation is not a prerequisite for therapy but is often a (partial) success of a general practitioner or diabetological treatment. This is particularly effective if fixed cooperation structures between a medical or psychological psychotherapist, psychiatrist, primary care physician and diabetologist have been established.

• Psychotherapy should be offered to all patients with mild, moderate, and severe depression, depending on the patient’s preference. It can be offered to patients with adjustment disorders.

• The treatment of depression in people with diabetes should be delivered by therapists with psychological and diabetological knowledge, if possible.

• If there is diabetes-related stress, it should be taken into account in the psychotherapeutic treatment. Patients with diabetes mellitus, depending on their preference, should be offered antidepressant pharmacotherapy, especially in cases of moderate to severe depression.

• Antidepressants should not generally be used for the initial treatment of mild depressive episodes, but only after careful consideration of the benefit-risk ratio.

• In the presence of a mild depressive episode, antidepressant pharmacotherapy should only be suggested to the patient if the patient expresses interest and if the patient has had positive experiences with treatment using antidepressants in the past, if the other treatment methods are not sufficient or if the patient suffers from recurrent depression with at least moderate episodes in the past.

• In cases of moderate and severe depression, the combination of pharmacotherapy with psychotherapy should be investigated.

• If pharmacotherapy is planned for a comorbidity of diabetes mellitus and depressive disorder, selective serotonin reuptake inhibitors (SSRI) should be offered. The side effects of tricyclic antidepressants, especially weight gain and blood glucose increase, should be weighed, monitored over time, and only accepted if there is a specific indication for the use of tricyclics, such as in diabetic neuropathy. Changes in insulin sensitivity and blood glucose levels with antidepressant therapy are observed.

• Treatment should be carried out as part of an overall treatment plan that gradually integrates therapeutic options depending on the patient’s motivation and preference, the severity of the depression and the conditions in which it develops.

• During the treatment of depression, regular monitoring of the treatment results should be carried out.

• If there are current problems with diabetes self-treatment (e. g. elevated HbA1 levels, hypoglycemia), diabetes education and treatment programs can be offered as complementary measures, especially for patients with mild and moderate depression, if they have not previously participated in a training program and are able to do so despite their depressive symptoms.

• Patients with diabetes and comorbid mild or moderate depression may be advised to use adapted physical training/physical activity as an accompanying measure, taking into account possible contraindications.

Anxiety disorders and diabetes-related anxiety

Most anxiety disorders in patients with diabetes are not specific to this patient group and can be classified according to the International Classification of Mental Disorders (ICD-10) of the World Health Organization (WHO).

In addition, there are exclusively diabetes-related anxiety disorders, such as hypoglycemia anxiety, which cannot be assigned per se to a specific ICD-10 category, as they can meet the criteria for different mental disorders depending on how they surface.

• Hypoglycemia anxiety: excessive fear of possible future hypoglycemia. Typically, there are difficulties in differentiating between physical symptoms of anxiety and those of the adrenergic phase of hypoglycemia. To avoid possible hypoglycemia, significantly-elevated blood glucose levels are usually accepted. Depending on the severity of the anxiety, the criteria for a “phobic disorder” (F40.0), a “panic disorder” (F41.0) or a “generalized anxiety disorder” (F40.1) may be met.

• Anxiety about the consequences of diabetes/anxiety about progression: disorder caused by excessive anxiety and worry about possible acute and long-term complications of diabetes. Depending on the severity of the anxiety, the criteria of a “generalized anxiety disorder” (F41.1), “anxiety and depressive disorder, mixed” (F41.2) or “adjustment disorder, anxiety and depressive reaction, mixed” (F43.22) may be met.

• About 20% of patients with diabetes show increased anxiety symptoms, without necessarily having an anxiety disorder in the sense of a clinical diagnosis. Anxiety disorders in patients with diabetes are about 20% more common than in the general population.

• The term “psychological insulin resistance” is used to describe the exaggerated fears of patients with type 2 diabetes of insulin treatment. In most cases, the criteria for a psychological disorder according to ICD-10 are not met. The main fears relate to injections and blood glucose monitoring, hypoglycemia, weight gain, complications, and concerns about stigmatization because of insulin injection treatment.

• Severe hypoglycemic events increase the probability of subsequent anxiety disorders in patients with type 2 diabetes. Single, unemployed women with diabetes complications have a higher risk for anxiety symptoms. In addition, anxiety correlates with higher age, lower weight, and depression symptoms.

• Fear of diabetes-related complications and hypoglycemia are the most severe disease-specific stresses in people with diabetes. These can be a significant emotional barrier and can lead to problems in diabetes self-management. Syringe phobias only occur very rarely.

Interaction between diabetes and comorbid anxiety disorders

• Diabetes patients with an additional anxiety disorder are not only affected by their mental disorder. They also have an above-average burden both in dealing with their diabetes and in their general health-related quality of life.

• There is evidence that anxiety is associated with poor metabolic control, diabetes complications, mortality, mental comorbidity, poor quality of life and poor state of health.

Screening

• The physician consultation is of central importance in the diagnosis of anxieties requiring treatment.

• Especially for patients who have intense or recurring concerns about their health and/or somatic symptoms, it is advisable to check whether some of these symptoms are caused by an anxiety disorder.

• Targeted screening questions are suitable for detecting anxiety disorders or pathological diabetes-related anxieties (see info box “Screening questions for anxiety disorders”).

Questionnaire:

• Patient Health Questionnaire (PHQ-D)

• Registration of fears of insulin therapy: Barriers to Insulin Treatment Questionnaire: (BIT)

• Identification of pathological hypoglycemia anxiety: Hypoglycemia Fear Survey (HFS)

• Since a number of somatic disease factors can also cause anxiety symptoms (e. g. hyperthyroidism, migraine, coronary heart disease, asthma), a somatic differential diagnosis must be performed to exclude somatic causes.

• In order not to promote hypochondriac anxiety, it is recommended, after an initial diagnostic clarification, to continue a more extensive somatic diagnosis only if there is a justified suspicion of certain organic diseases or resistance to therapy.

Diagnostics

Diagnosis of an anxiety disorder ([Fig. 1]):

• Number, severity, and duration of symptoms

• Extent of the individual burden caused by the disorder

• Impairment of the functional level

• Current diabetes-related and general developmental context of the anxiety disorder

• Previous anxiety disorders and possible treatment results

• If an anxiety disorder is diagnosed, screening for depression, somatoform disorders and substance abuse should also be carried out.

Fig. 1 Graduated anxiety treatment in diabetes mellitus.

Therapy

• If a person with diabetes mellitus is diagnosed with an anxiety disorder or diabetes-related exaggerated anxiety, the diagnosis should be explained, and treatment offered ([Fig. 2]). Every intervention requires continuous monitoring.

• Therapy recommendations for anxiety treatment based on findings in people without diabetes can (as long as there is no corresponding advance in the state of research) generally also be applied to people with diabetes (see info box “EXPLANATORY MODEL”).

• Anxiety disorders or exaggerated diabetes-related fears that do not greatly impair the patient’s functional level can be treated within the framework of primary care by psychoeducation and behaviorally-oriented bibliotherapy or Internet-based behavioral therapy for anxiety disorders.

• Anxiety disorders or exaggerated diabetes-related fears that have not responded to primary care measures, or moderate or severe anxiety disorder should be treated within the framework of outpatient psychotherapy. The first method of choice here is behavioral therapy. For generalized anxiety disorders, relaxation procedures can be recommended as an alternative or in combination.

• Anxiety disorders that have not responded to behavioral therapy should be treated by changing the therapy options. In addition to other psychotherapeutic methods (alone or in combination), psychopharmacological interventions are particularly suitable.

• If psychopharmacological therapy is offered, SSRI should be offered as the method of first choice. Benzodiazepines should only be offered for short-term crisis intervention. Neuroleptics should not be offered in the treatment of anxiety disorders.

• Complex, treatment-resistant severe anxiety disorders should generally be treated on an inpatient or semi-inpatient basis as part of tertiary care. As a rule, psychopharmacological and psychotherapeutic measures should be offered in combination for this degree of severity.

• The therapy of anxiety disorders in diabetes should be carried out by therapists with psychodiabetological knowledge if possible.

Fig. 2 Algorithm for medical history/anxiety diagnostics in diabetes mellitus.

Eating disorders

Eating disorders are classified according to the International Classification of Mental Disorders (ICD-10) of the World Health Organization (WHO) as follows: F50.0- *Anorexia nervosa (AN), F50.2- *Bulimia nervosa (BN). In the 4th edition of the American psychiatric classification scheme “Diagnostic and Statistical Manual of Mental Disorders” (DSM V) the “Eating Disorder Not Otherwise Specified” (EDNOS) is introduced. In parallel, the ICD-10 (2) distinguishes “atypical bulimia nervosa” (F50.3); “eating attacks in other mental disorders” (F50.4) and “unspecified eating disorders” (F50.9).

• Currently, the prevalence for women with anorexia nervosa at risk age between 15 and 35 years is about 0.4%. In the case of anorexia nervosa, there is often comorbidity with other mental illnesses, especially with depression, anxiety disorders or obsessive-compulsive disorders.

• The prevalence of bulimia nervosa is higher in type 1 diabetes compared to anorexia nervosa and varies between 0.0 and 3.0%.

• Data on the mean frequency of EDNOS in controlled studies vary between 3.0 and 9.0% in patients with type 1 diabetes.

• Data on the average frequency of insulin purging (intentional omission of insulin as a means of weight loss) varies between 5.9 and 39.0% depending on the study and region.

Interaction between diabetes and eating disorders

Eating disorders are associated with people with diabetes who:

• Are usually overweight and obese in type 2 diabetes,

• Have poor glycemic control in type 1 diabetes,

• Have a significantly increased risk for the development of diabetes complications (already in the case of pathological eating behavior without full-blown eating disorders; insulin purging),

• Have a significantly increased mortality risk in anorexia nervosa and advanced insulin purging.

Screening

• In the general medical setting, an eating disorder should be considered for the following risk factors:

  • Young women with low body weight

  • Female patients who present with weight worries, but are not overweight

  • Women with cycle disorders or amenorrhea

  • Patients who appear malnourished

  • Patients with gastrointestinal symptoms

  • Patients with repeated vomiting

• For the early detection of eating disorders in a general medical setting, the following two questions should be considered first:

  • “Do you have eating issues?”

  • “Are you concerned about your weight or diet?”

• The Diab-Ess offers a specific, validated screening tool for eating disorders in patients with diabetes.

• Various standardized questionnaires (e. g. Eating Disorder Inventory EDI, EDI-2, Eating Behavior Questionnaire [Fragebogen zum Essverhalten – FEV], Eating Disorder Examination-Questionnaire [EDE-Q]) help screen for an eating disorder based on the information provided by the patient. It should be noted, however, that some of the items in these questionnaires refer to eating habits that are considered pathological in healthy individuals but are considered adequate in people with diabetes (e. g., constant monitoring of food intake). This ultimately carries the risk of false positive results.

Diagnostics

• The comorbidity of diabetes and anorexia nervosa is extremely rare and usually easy to diagnose due to the cachectic nutritional status of the anorexic patient.

• In every patient with inadequate metabolic control and with significant fluctuations in blood glucose levels and weight – especially in girls in adolescence and young women – a bulimia nervosa with or without insulin purging should be considered and differentially diagnosed at an early stage.

• For the diagnosis of an eating disorder, a detailed biographical history is often necessary. Patients have the tendency to deny eating disorders for years and this anamnesis can help the patient overcome feelings of shame and summon the courage to face the disorders.

Therapy

• Psychotherapeutic interventions to treat eating disorders are effective. There are no contraindications for use in patients with diabetes. The treatment of eating disorder patients with type 1 diabetes should therefore be carried out according to the current S3 guideline “Diagnosis and treatment of eating disorders”.

• The first choice of therapy is psychotherapy.

• The treatment can be disorder-oriented and take into account the physical aspects of the disease.

• Professional psychotherapeutic treatment of these patients is recommended because of health risks caused by the eating disorder and the increased risk of mortality, especially of anorexia nervosa, the frequently encountered comorbid depressive disorder and the negative impact on diabetes therapy.

• The therapy of eating disorders in people with diabetes should be carried out by therapists with psychodiabetological knowledge, if possible.

• Outpatient, semi-inpatient and inpatient treatment can take place in institutions or with medical or psychological psychotherapists who have expertise in the treatment of eating disorders and who provide disorder-oriented therapy elements.

• It should be taken into account that the healing process usually takes many months of treatment.

• In bulimia nervosa, SSRIs are the drug therapy of choice. Only fluoxetine is approved in Germany in combination with psychotherapy for adults with bulimia nervosa.

• Psychoeducative approaches alone are not sufficient or appropriate.

• Successful psychotherapy requires an understanding of the life situation of the patient in general and especially of the patient with diabetes. This requires particular knowledge on the part of the treating psychotherapist regarding the therapy regime and its possible connections with eating behavior/eating disorders (e. g. hypoglycemia, physical activity, etc.).

• Type 2 diabetes patients with eating disorders usually suffer from binge eating and obesity, so considerations regarding all three disease entities should be included in the treatment. A multimodal treatment concept with psychotherapy and weight management as integral components is therefore appropriate.

• Close cooperation between the diabetological and medical/psychological-psychotherapeutic treatment team is necessary in the inpatient area.

Psychological or behavioral factors in diabetes

Chronic stress, interpersonal problems, lack of social support and problems in coping with the disease can have significant relevance for the quality of life and metabolic regulation in people with diabetes.

If these or other factors are important for the start of, but especially for the progression of diabetes, they can be classified according to the corresponding history under diagnosis F54 (ICD 10) (“Mental factors or behavioral influences in diseases classified elsewhere”).

Thus, these factors can also provide cause and justification for a psychological intervention regardless of the presence of a mental disorder.

Interaction between chronic stress, interpersonal problems, or problems coping with the illness and diabetes

• Chronic stress (e. g. emotional stress in work and private life) can promote the manifestation of type 2 diabetes.

• In manifested diabetes, metabolic control and quality of life can also be negatively affected.

• Lack of social support or interpersonal problems can also be a barrier to a good quality of life and proper metabolic control. Here, a distinction must be made between an actual lack of social support (e. g. after the loss of a partner) and dysfunctional support where, for example, overprotectiveness hinders the patient from taking on necessary personal responsibility.

• In addition, interpersonal problems such as chronic conflicts can largely block any potential for social support within the framework of a relationship. How the patient (subjectively) perceives support received by third parties is a more suitable measure for estimating actual social support than the mere availability of persons.

• Emotional and cognitive problems coping with the demands of the disease often occur during the course of the disease and can negatively influence the therapeutic behavior and glycemic control.

• Patients with diabetes complications are at particularly high risk of experiencing problems in coping with the disease.

Screening

• If there is evidence of diabetes-related stress, a validated questionnaire (e. g. Problem Areas In Diabetes [PAID]) can be used.

Diagnostics

Psychological or behavioral problems in diabetes do not justify assignment to another category in Chapter V (ICD-10). An additional code should be used to identify the physical disorder (e. g. diabetes).

Interventions

• Positive effects of various psychological interventions for F 54 disorders on glycemic control and quality of life have been documented. The effects were generally detectable independently of any diabetes education that may have been conducted at the same time.

• Interventions to reduce stress should be offered to patients with severe stress, inadequate glycemic control and/or reduced quality of life.

• Targeted psychotherapeutic interventions may be considered for patients with serious interpersonal problems and/or low social support that have a negative impact on diabetes therapy.

• Psychological interventions to promote disease management should also be offered – independent of training - to patients with serious problems managing the disease.

• If there are psychological or behavioral influences that have a serious effect on the disease, therapy F54 should be carried out by therapists with psychodiabetological knowledge if possible.

German Diabetes Association: Clinical Practice Guidelines
This is a translation of the DDG clinical practice guideline published in Diabetologie 2022; 17 (Suppl 2): S394–S410 DOI 10.1055/a-1916-2171

Conflict of Interest

The authors declare that they have no conflict of interest.

Publication History

Article published online:
02 February 2023