LY

2018 Clinical Practice Guidelines

N O
S E
Diabetes and Mental L U Health
N A
SO
Chapter 18 PE R
David J. Robinson MD FRCPC FCPA DFAPA,
Michael Coons PhD CPsych CBSM,
Heidi Haensel MD FRCPC,
Michael Vallis PhD RPsych
Jean-Francois Yale MD CSPQ FRCPC
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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

2018
Key Changes
Reinforcement of
• the increased prevalence of diabetes with an
expanding range of psychiatricN LY
disorders,
O
including: major depressiveEdisorder, bipolar and
U S
related disorders, schizophrenia spectrum and
AL
O N
other psychotic disorders, anxiety disorders,
sleep disorders,
R Sfeeding and eating disorders,
PE trauma-related disorders
and stress- and
• regular screening of metabolic parameters in
individuals taking psychiatric medications,
particularly (but not limited to) atypical
antipsychotics

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

The interplay between diabetes, major depressive

disorder and other psychiatric conditions

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Mental illness increases risk of

diabetes and diabetic complications

Mental LY Type 2
O N
Illness US E Diabetes
• Non-adherence toN AL
medication and self-care
SO
R
• Functional impairment
E
P Major Depressive
• Risk of complications Disorder
• Healthcare costs increases the risk
• Risk of early mortality of Type 2
diabetes by 60%!

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Depressive symptoms are

present in 30% of people with
diabetes
• Major depressive disorder (also called
Y clinical
depression) occurs in 10% of O NL with Type 2
people
SE rate in the general
diabetes, which is doubleUthe
population AL N
O
RS
PE
• Co-morbid depression worsens clinical outcomes
in type 2 diabetes, possible explanations are:
• Lower levels of physical fitness
• Reduces medication adherence

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Diabetes Distress

• Despondency and emotional turmoil specifically

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related to caring for diabetes, the need for
monitoring and treatment, E
Spreoccupation with
L U
complications, and theN Aeffects on various
SO
relationships ER
P
• Related to poorer diabetic outcomes

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Diabetes Distress vs. Major Depressive Disorder

Diabetes Distress Major Depressive Disorder

Assessment Diabetes Distress Scale (17 Patient Health Questionnaire for

Instrument items) Depression: PHQ-9 (9 items)

Format Self-report using ratings scored Self-report using ratings from 0 to 3

LY
from 1 to 6 based on feelings
and experiences over the past O N
based on feelings and experiences
over the past 2 weeks
week E
S Vegetative symptoms, such as sleep,
Features Emotional Burden Subscale
L U
(5 items)
N A appetite and energy level changes

S O
E R Distress
Physician-Related Emotional symptoms, such as low
Subscale P mood and reduced enjoyment of
(4 items) usual activities

Regimen-Related Distress Behavioural symptoms, such as

Subscale agitation or slowing of movements
(5 items)
Cognitive symptoms, such as poor
Diabetes-Related Interpersonal memory or reduced concentration or
Distress Subscale feelings of guilt; thoughts of self-harm
(3 items) PERSONAL USE ONLY
2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Screening for depressive and anxious

symptoms is important in patients with
diabetes
Purpose Screening Tools
Diabetes-specific LY (PAID) Scale
• Problem Areas in Diabetes
O N (DDS)
S E
• Diabetes Distress Scale
• WHO-5 L U
Quality of Life
N A
Depression/Anxiety SO Anxiety and Depression Scale
• Hospital
P ER(HADS)
• Patient Health Questionnaire (PHQ-9)
• Beck Depression Inventory (BDI)
Websites with psychological / psychiatric scales:
[Link]
[Link]/scales_library.php.

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Treatment Options
• Cognitive-Behavioural Therapy (CBT)
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• Other types of psychotherapy
S
L U
O NA
S
• Antidepressant medication
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PE

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Features of CBT that can be applied to diabetes

treatment
Cognitive Component Behavioural Component

Record keeping to identify Strategies to help get the person

distressing automatic thoughts LY
moving (behavioural activation)
O N
S E
Understanding the link between
U
Scheduling pleasant and meaningful
Levents. Learning assertive and
thoughts and feelings
A
N effective communication skills
SO
R
PE (e.g., Focusing on feelings of mastery and
Learning the common “thinking
errors” that mediate distress
all-or-nothing thinking, accomplishment
personalization, magnification,
minimization, etc.) Learning problem-solving strategies

Analyzing negative thoughts and Exposure to new experiences

promoting more functional ones

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Other Psychiatric Associations

• Mood Disorders
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• Anxiety Disorders E
US
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N
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• Feeding and Eating
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• Schizophrenia and other psychotic disorders

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Psychoactive Medications May
Predispose to Diabetes
• Especially atypical antipsychotics (particularly
olanzapine and clozapine, but N LY can be
others
problematic as well) E O
US
AL
• Lifestyle factors alsoNcontribute
SO
• Co-morbid mentalE R illness often worsens
P
diabetes control and causes earlier and more
serious complications

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

People taking high-risk psychiatric

medications need regular metabolic screening
Parameter Base- 1 mo 2 mos 3 mos Every 3-6 Annually
line mos
Weight (BMI) X X X X LY X
OX N
Waist circumference X
S E X
L U
Blood pressure X
N A X X

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Fasting plasma X
R X X
glucose and/or A1C PE
Lipid profile X X X
Personal history of
alcohol, tobacco, X X X
recreational drug
use
Family history X X
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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Recommendation 1
1. Individuals with diabetes should be regularly
screened for diabetes-related psychological
LY
distress (e.g., diabetes distress, psychological
O N
insulin resistance, fear of hypoglycemia, etc.)
E
S depression,
and psychiatric disordersU(e.g.,
anxiety disorders) by A L
validated self-report
N
questionnaire R orSO
clinical interview [Grade D,
PE for self harm should be asked
Consensus]. Plans
about regularly as well [Grade C, Level 3]

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Recommendation 2
2. The following groups of people with diabetes
should be referred for specialized mental
Y the following]:
healthcare [Grade D, Consensus for allLof
O N
• S to diabetes
Significant distress related E
L U
management A
• ONhypoglycemia
Persistent fearSof
E R
• P insulin resistance
Psychological
• Psychiatric disorders (i.e., depression, anxiety,
eating disorders, etc.)

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

2018
Recommendation 3
3. Collaborative care by interprofessional teams
should be provided for individualsLY with diabetes
and depression to improve: ON
S E
• Depressive symptoms U [Grade A, Level 1]
AL
O N
• Adherence to antidepressant and non-insulin
R S
antihyperglycemic medications [Grade A, Level 1]
P E
• Glycemic control [Grade A, Level 1]

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Recommendation 4
4. Psychosocial interventions should be integrated
into diabetes care plans, including:Y
N L
E O
• U S [Grade D, Consensus]
Motivational interventions
Stress management ALstrategies [Grade C, Level 3]
• N
• SO
Coping skillsRtraining [Grade A, Level 1A for type 2
PE B, Level 2 for type 1 diabetes]
diabetes; Grade
• Family therapy [Grade A, Level 1B]
• Case management [Grade B, Level 2]

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Recommendation 5
5. Antidepressant medication should be used to
treat acute depression in peopleLwith Y diabetes
O N
[Grade A, Level 1] and for maintenance treatment
S E
to prevent recurrence of depression
U [Grade A, Level
L therapy (CBT) can be
1A]. Cognitive behavioural
N A
SO
used to treat depression in individuals with
R
PE [Grade B, Level 2] or in combination
depression alone
with antidepressant medication [Grade A, Level 1]

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Recommendation 6
6. Because of the risk of adverse metabolic effects of
many antipsychotic medicationsLY(especially
O N
atypical/second- and third-generation) [Grade A,
Level 1], regular metabolic S E
monitoring should be
U
AL and without diabetes
performed in peopleNwith
SO these medications [Grade D,
who are treatedRwith
Consensus] PE

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

2018
Recommendation 7
7. Children and adolescents with diabetes should be
screened at diagnosis for major depressive
LY
disorder [Grade D, Consensus] and regularly for
N
Odistress or mental
psychosocial difficulties, family
E
health disorders [Grade D, U S An expert in
AL Consensus].
mental health and/orNpsychosocial issues should
SO
R when required. This individual
provide intervention
E
may be part ofP the pediatric diabetes healthcare
team or enlisted by referral [Grade D, Consensus].
Individual and family educational interventions
should be included to address stress or diabetes-
related conflict when indicated [Grade D, Consensus]

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

2018
Recommendation 8
8. Adolescents with type 1 diabetes should be
Y
regularly screened using non-judgmental
L
O
questions about weight and body N image
concerns, dieting, binge U SE and insulin
eating
AL [Grade D, Level 2]
omission for weightNloss
SO
R
PE

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages
• The experience of living with diabetes is often
Y illness and
associated with concerns specific toLthe
O N distress,
can cause conditions such as diabetes
S E and the persistent
psychological insulin resistance
L U
A
fear of hypoglycemicNepisodes
S O
• People living with
E R
diabetes and depressive
P increased risk for earlier all cause
disorders are at
mortality compared to people living with diabetes
without a history of depression

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages
• All individuals with diabetes should be regularly
screened for the presence of diabetes distress, as
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O N
well as symptoms of common psychiatric disorders
S E
L U
• Compared to those withAdiabetes only, individuals
O N health concerns have
with diabetes and mental
R S
PE
decreased participation in diabetes self-care, a
decreased quality of life, increased functional
impairment, increased risk of complications
associated with diabetes, and increased health
care costs

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages
• Cognitive behavioural therapy, patient-centered
approaches (e.g. motivational interviewing), stress
management, coping skills training, LYfamily
N
therapy and collaborative caseOmanagement
S E
should be incorporated intoUprimary care
AL
N
SO educational interventions
• Self-managementRskills,
that facilitate P E
adaptation to diabetes, addressing
co-occurring mental health issues, reducing
diabetes-related distress, fear of hypoglycemia,
and psychological insulin resistance are all helpful
in successfully managing diabetes

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages
• Individuals taking psychiatric medications,
Y
particularly (but not limited to) atypical
L
O
antipsychotics, benefit from regular N screening of
metabolic parameters to U SE glucose
identify
AL hypertension and
dysregulation, dyslipidemia,
O N
S the course of the illness so
weight gain throughout
R
that appropriatePEinterventions can be instituted

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages for People with

Diabetes
• Living with diabetes can be burdensome LY and anxiety
provoking, with constant care E ON
demands taking a
U
psychological toll. As a result,Smany people
AL
O N
experience distress, decreased mood and disabling
R S
levels of anxiety. Diabetes is often associated with a
P E
significant emotional burden, distress over the self-
care regimen and stress in relationships (with family
and friends as well as with health-care providers)

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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages for People with

Diabetes
• It is important to acknowledge your emotional
L Y
responses and talk to your friends, family and
members of your diabetes healthcareO N team about
how you are feeling. Your team S E can help you to learn
L U
A direct you to support
effective coping skills and
N
S
services that can makeO a difference for you
E R
P
• Mood and anxiety disorders are particularly common
in people with diabetes. Eating, sleeping and stress-
related disorders are also common. Speak to your
health-care providers about any concerns you have if
you think you may be developing any of these
problems
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2018 Diabetes Canada CPG – Chapter 18. Diabetes and Mental Health

Key Messages for People with

Diabetes
Y ability to
• Mental health disorders can affect your
L
O N It is just as
cope with and care for your diabetes.
SE
important to look after yourUmental health as it is
your physical health! AL
O N
RS
PE with serious mental illnesses, such
• People diagnosed
as major depressive disorder, bipolar disorder and
schizophrenia have a higher risk of developing Type
2 diabetes than the general population

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Visit [Link]

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Or download the App

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Diabetes Canada Clinical
Practice Guidelines

LY health-care
[Link] –Nfor
providers E O
U S
L
O NA
S
1-800-BANTING (226-8464)
R
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[Link] – for people with diabetes

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