Diabetes and Behavioral Health

Diabetes and Behavioral Health

Over my 30-year career, I have developed a personal and professional interest in mental health challenges and how they impact health and well-being. Mental health issues affect patients of all ages, races, and socioeconomic groups. When a patient also has a chronic physical condition, mental health issues can even further complicate care. These disorders can negatively impact patients’ ability to manage medications, avoid medication complications, and advocate and care for themselves. I would like to share some simple techniques that can help you address behavioral health issues while improving outcomes for your patients with diabetes.

We know that people with a chronic condition like diabetes have an increased incidence of depression and anxiety. Many of my patients feel depressed, sad, guilty, angry, frustrated, and overwhelmed with this diagnosis. Diabetes is part of every waking moment. They don’t get a day off. They may feel burned out. In fact, they may completely embrace denial and ignore their diabetes entirely.

Signs of depression in patients with diabetes
Frustration and fatigue can set in from the burden of monitoring and caring for themselves. This can lead to depression and anxiety in the patient as well as in their family members, such as spouses, parents or children. Patients may stop checking their blood sugar, or provide false numbers on logs or to family members. Patients may start gaining weight, engage in episodes of binge eating, or “secretly” eating unhealthy food.
Sometimes, patients just feel hopeless as they face diabetes and all the ways it impacts their health, their lifestyle, and their well-being. Screening for depression is important—and it’s important to check for these symptoms specifically:

  • Loss of interest or pleasure
  • Change in sleep patterns
  • Waking up earlier than normal
  • Change in appetite
  • Trouble concentrating
  • Loss of energy
  • Nervousness
  • Guilt
  • Morning sadness
  • Suicidal thought
  • Withdrawal from friends and activities
  • Declining school and work performance
  • Use of drugs or alcohol to cope with their feelings

Treatment begins with empathy and empowerment
How can we address behavioral health issues in our patients while trying to manage their diabetes? First, we need to validate what they may be feeling: anger, fear, sadness, and frustration. I tell my patients: “YES, life is definitely unfair and unjust. I’m so sorry you have this diagnosis. And it makes sense that you feel the way you do. I am happy you chose me to be on your path with you because we can really get this well controlled together.”

Try to build in the time for this conversation with every patient with diabetes:
1) What are you feeling?
2) How does managing diabetes fit into your life goals? What’s the hardest part about getting to these goals?
3) Empower the patient about how he or she can regain positive momentum. “Do you want type two diabetes to control you and your health, or do you want to control it?”
Point out all the positive steps they’ve taken in life, whether for diabetes or any other health issue. “I’ve noticed many challenges you have confronted and overcome in your life – can we explore the same problem-solving approaches you have before so successfully as ways to also manage diabetes?”
We family docs are often lucky enough to have long term relationships with our patients and we can rely on past problems we have watched them and their families confront. Reminding them of these successes and the tools/support they used can empower them to use these same skills to treat their disease.
4) What support system and resources do they rely on to get through tough times or solve problems? Does each of your patients have support from family, friends, their job or school? Who are the people who provide the meals, manage the medications and appointments? Make sure to include those people in the conversation.

There are patient support online resources and in-person groups that can connect them to people facing the same issues. People who can share, support or even be a great person with whom they can “vent” when needed. The local chapters of the American Diabetes Association have online support groups and local events. Check to see if your local hospital offers support groups or classes. There are Facebook groups that unite people around health conditions.

Taking control could also come in the form of advocating for research or lower insulin prices (www.t1international.com/IL), which also gives patients a voice and a place to bond with others sharing their challenges, fears and goals.

From fear to action plan
Ask “What’s your greatest fear about having type two diabetes?”
And: “What help do you need to make you less afraid of these things?”
You might need to refer them to a counselor for regular visits. Patients with behavioral health diagnoses have already faced tough challenges. Explore the same problem-solving approaches to effectively control diabetes. If the patient is already seeing a behavioral health specialist, make sure discussing diabetes is part of their plan at every visit. There are mental health professionals with specific training in working with chronic medical comorbidities. Do you have someone on your team at your practice to spend time integrating their specific diabetes management strategies in their self-care plan?
Ultimately, we want our patients to visualize a time in the near future where the diabetes is well controlled. Help them keep that visual alive; refer to it at each visit if you can.

Let me give you some evidence-based strategies that we can offer directly to our patients with mental health challenges as well as diabetes. These tactics are low-cost and have excellent outcome data.

Mindfulness: By now most people have heard of this effective and validated practice. I remind patients that research shows a mere 15 minutes a day of mindfulness can decrease anxiety and depression and improve mood and productivity. I like the app called CALM as it walks the patients through a multitude of mindfulness practices -- they are never left sitting alone “trying to meditate.”

Energy work: Tai Chi, Yoga, QiGong, and Reiki may benefit some patients with anxiety and depression. Therapeutic, peaceful movement is a good introduction to the concept of exercise that our patients need.
Here are links to more information on these concepts:

Tai-Chi and Qi-Gong
Both tai chi and qi-gong are ancient practices of flowing physical movements combined with a relaxed, focused mental state and breathing exercises. Evidence about the efficacy of tai chi and qi-gong for mental health disorders, like depression, anxiety, and stress is mixed. Differences in how the studies are done has led to trouble drawing firm conclusions about how big the effect might be. The risk of harm is small, and specific patients may find it useful. Learn more here.

Yoga may help patients feel more active, and it may be a way for some to engage regularly with a class or community group. There is some evidence that yoga practice can help patients reduce stress or anxiety related to daily evidence, although the evidence that it affects anxiety disorders or depression is not as strong.  Learn more here.

In reiki, the practitioner manipulates or directs energy fields to improve the flow of a patient’s energy, typically without touching the patient. The evidence to support reiki’s underlying mechanism of action is scant, and there are no high-quality evidence to support its use for depression or anxiety. However, it has no known harms, and individual patients may find it useful.  Learn more here.

Supplements: St. John’s Wort and S-Adenosyl-L-Methionine (SAMe) both have some evidence of benefit in depression. As with any supplement, counsel patients who choose to use supplements to buy from a reputable source, since some products may not contain the full amount of product advertised.

Evidence for other supplements for patient-oriented outcomes in depression and anxiety is mixed, and none have consistent, high-quality studies to support their use. Omega-3 fatty acids, zinc, iron, magnesium, potassium, selenium, and vitamins A, D, C, and B vitamins have been studied.

Forgiveness: One small study showed that patients with diabetes who scored higher on a forgiveness scale score score lower on depression scales and higher on quality of life scales. Forgiving might improve your life!1 
Gratitude: Expressing gratitude for three things daily also decreases anxiety and depression. Whether you do it to start the day, whenever you see an opportunity to be grateful, or in your final thoughts before bedtime, this can help everyone involved, including the support team family, friends or co-workers.

Nature: Being out in nature improves our mood. One study found that participants who spent a day in the forest compared with those who spent a day at leisure indoors had significantly less hostility and depression, and reported significantly more liveliness.2 Stress biomarkers are reduced after just 20 minutes outdoors, and the effect was seen even when walking around in an urban park, so patients don’t need a National Park Pass or a vacation to begin to benefit.3

Quick Dopamine Boosters: Need even the quickest fixes to turn around a down moment in a time of frustration? These are simple and can be done in a split second at home.
>Stimulating the senses: put on a favorite perfume , take a scented bath, or burn a soothing scented candle or essential oil diffuser. Believe it or not, even a new lipstick shade can bump up your confidence.
>Get moving: Grab some light weights and do lots of bicep curls to feel good and get the blood pumping. Turn on your favorite music and dance! Get family and friends nearby to dance and giggle with you!
>Distract your mind: Maybe challenge yourself with a Sudoku, crossword puzzles, or an old fashioned puzzle you leave out.
These are all suggestions that our patients can easily incorporate into their daily lives. Creating a plan and following up on these interventions is well worth it!

Highlight what you’ve achieved
Each session should include the positive reinforcement that we all need. “Here is why I am optimistic about our working together to control your diabetes”– and then recap all the great support that they have from family, friends, your practice, and all the resources you’ve explored together and what they have accessed and accomplished on their own. Remind them of their strong suits – determination, love for their family, joy in music or art, whatever their talents and treasures may be.

Emphasize even minimal progress: ”You lost two pounds since we last visited: that’s two pounds closer to your healthy you. How many pounds can we look forward to you getting off in the next six weeks? By your history, three pounds sounds reasonable.”
As you and your patients formulate a plan to work on diabetes and better mental health – set the goals.
Ask your patients and families to visualize the outcome. How will your daily life be better? Then revisit that same question at each visit! How is your daily life better? How is that vision of the healthy you shaping up?

Remember, your patients with diabetes may need help with the emotional and psychological impact of diabetes first, in order to take on the responsibilities of managing the medical side. Visit iafp.com/DID for resources on this week’s topic.

Diabetes and Behavioral Health
ADA: Mental Health Resources 
ADA Online Community for Type 2 
Illinois ADA website  


1 Yazla E, Karadere ME, Küçükler FK, Karşıdağ Ç, İnanç L, Kankoç E, Dönertaş M, Demir E. The effect of religious belief and forgiveness on coping with diabetes. Journal of religion and health. 2018 Jun 1;57(3):1010-9.
2 Morita E, Fukuda S, Nagano J, Hamajima N, Yamamoto H, Iwai Y, Nakashima T, Ohira H, Shirakawa TJ. Psychological effects of forest environments on healthy adults: Shinrin-yoku (forest-air bathing, walking) as a possible method of stress reduction. Public health. 2007 Jan 1;121(1):54-63.
3 Hunter MR, Gillespie BW, Chen SY. Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers. Frontiers in psychology. 2019 Apr 4;10:722.

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