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Poor mental health in diabetes: still a neglected comorbidity
Editorial
As early as the 17th century, Thomas Willis hypothesised a link between diabetes and low mood, and research has since shown the importance of managing psychiatric conditions in patients with diabetes. Comorbid diabetes and mental health disorders are often poorly managed, even in countries with strong health-care systems. Such patients generally suffer poor quality of life, severe diabetes-associated complications and, ultimately, early diabetes-associated mortality. There is thus an urgent need to address mental health disorders in patients with diabetes. Serious mental health disorders—including schizophrenia, bipolar disorder, anxiety disorders, and major depressive disorder—occur in a larger proportion of patients with diabetes than in the general population. Similarly, development of diabetes is more common in patients with serious mental health disorders. The potentially bidirectional mechanistic links between mental health disorders and diabetes are understudied but are probably numerous and complex, and might include stress from the burden of dealing with a lifelong condition, early life adversity, inflammation, or dysregulation of the hypothalamic-pituitary-adrenal axis. Additionally, many psychiatric drugs markedly increase the risk of diabetes and other metabolic disorders. In this issue, we present a Series of three papers focused on depression—the most common mental health disorder—in patients with diabetes. Although depression is at least twice as prevalent in patients with diabetes as in the general population, affecting an estimated 20% of patients with diabetes worldwide, guidance on addressing depression is missing from most diabetes treatment guidelines, and literature on the topic is still scarce. As discussed by Frank Snoek and colleagues in this issue, there has been confusion regarding the definition of depression in patients with diabetes and in differentiating it from diabetes-distress, a psychological concept related to but not interchangeable with depression. Since depression and diabetes-distress can substantially reduce adherence to lifestyle and medical management and the ability to effectively self-monitor blood glucose, mental health should be a clinical priority in patients with diabetes to minimise the risk of long-term complications. As outlined in the Series paper by Frank Petrak and colleagues in this issue, several studies—mostly in the www.thelancet.com/diabetes-endocrinology Vol 3 June 2015
USA—show that collaborative care, in which mental health is integrated into primary care, is the most clinically effective and cost-effective approach. The UK’s 2011 No Health Without Mental Health report estimated that introducing collaborative care for the treatment of depression in patients with type 2 diabetes would save the UK’s National Health Service and social care about £3·4 million (US $5·2 million) in 4 years, with a further £11·7 million ($17·2 million) of benefits to individuals owing to improved productivity. As Petrak and colleagues outline, there is weak rationale to screen for depression in patients with diabetes until strong systems for coordinated care are in place. Notably, however, the 2015 American Diabetes Association’s standards of medical care state that adults aged 65 years or older should be considered for depression screening and treatment. As opposed to high-income countries, studies of mental health disorders in patients with diabetes from lowincome and middle-income countries are almost nonexistent. In these regions, where the greatest increase in diabetes prevalence is set to take place in the next two decades, it is unlikely that the mental health needs of patients with diabetes will be met without changes to health-care systems. WHO estimated in 2011 that almost half of the world’s population lives in a country where, on average, there is just one psychiatrist for every 200 000 people, and 80% of patients in low-income and middleincome countries with serious mental health disorders do not receive the care they need. Research in these settings is urgently needed to investigate what management approaches will be most effective; opportunities for tasksharing, and training of community health workers in joint mental health and diabetes care, should be explored. Until more evidence is available to enable improved identification of patients at high risk of mental health disorders, clinicians must be vigilant in identifying early signs of poor mental health in patients with diabetes and referring patients to a mental health specialist where necessary. Most of all, clinicians must ensure that depression is recognised and treated as rigorously as the physical complications of diabetes that are generally prioritised. A shift in attitudes to treatment will help to lessen the stigma of mental health disorders and increase patients’ acceptance of mental health care. ■ The Lancet Diabetes & Endocrinology
2/John Knill/Ocean/Corbis
Poor mental health in diabetes: still a neglected comorbidity
See Series pages 450, 461, and 472 For No Health Without Mental Health see https://www.gov.uk/ government/uploads/system/.../ dh_124058.pdf For the 2015 American Diabetes Association guidelines see Diabetes Care 2015; 38 (suppl 1): S1–94 For WHO 2011 Mental Health Atlas see http://www.who.int/ entity/mental_health/ publications/mental_health_ atlas_2011/en/index.html
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As early as the 17th century, Thomas Willis hypothesised a link between diabetes and low mood, and research has since shown the importance of managing psychiatric conditions in patients with diabetes. Comorbid diabetes and mental health disorders are often poorly managed, even in countries with strong health-care systems. Such patients generally suffer poor quality of life, severe diabetes-associated complications and, ultimately, early diabetes-associated mortality. There is thus an urgent need to address mental health disorders in patients with diabetes. Serious mental health disorders—including schizophrenia, bipolar disorder, anxiety disorders, and major depressive disorder—occur in a larger proportion of patients with diabetes than in the general population. Similarly, development of diabetes is more common in patients with serious mental health disorders. The potentially bidirectional mechanistic links between mental health disorders and diabetes are understudied but are probably numerous and complex, and might include stress from the burden of dealing with a lifelong condition, early life adversity, inflammation, or dysregulation of the hypothalamic-pituitary-adrenal axis. Additionally, many psychiatric drugs markedly increase the risk of diabetes and other metabolic disorders. In this issue, we present a Series of three papers focused on depression—the most common mental health disorder—in patients with diabetes. Although depression is at least twice as prevalent in patients with diabetes as in the general population, affecting an estimated 20% of patients with diabetes worldwide, guidance on addressing depression is missing from most diabetes treatment guidelines, and literature on the topic is still scarce. As discussed by Frank Snoek and colleagues in this issue, there has been confusion regarding the definition of depression in patients with diabetes and in differentiating it from diabetes-distress, a psychological concept related to but not interchangeable with depression. Since depression and diabetes-distress can substantially reduce adherence to lifestyle and medical management and the ability to effectively self-monitor blood glucose, mental health should be a clinical priority in patients with diabetes to minimise the risk of long-term complications. As outlined in the Series paper by Frank Petrak and colleagues in this issue, several studies—mostly in the www.thelancet.com/diabetes-endocrinology Vol 3 June 2015
USA—show that collaborative care, in which mental health is integrated into primary care, is the most clinically effective and cost-effective approach. The UK’s 2011 No Health Without Mental Health report estimated that introducing collaborative care for the treatment of depression in patients with type 2 diabetes would save the UK’s National Health Service and social care about £3·4 million (US $5·2 million) in 4 years, with a further £11·7 million ($17·2 million) of benefits to individuals owing to improved productivity. As Petrak and colleagues outline, there is weak rationale to screen for depression in patients with diabetes until strong systems for coordinated care are in place. Notably, however, the 2015 American Diabetes Association’s standards of medical care state that adults aged 65 years or older should be considered for depression screening and treatment. As opposed to high-income countries, studies of mental health disorders in patients with diabetes from lowincome and middle-income countries are almost nonexistent. In these regions, where the greatest increase in diabetes prevalence is set to take place in the next two decades, it is unlikely that the mental health needs of patients with diabetes will be met without changes to health-care systems. WHO estimated in 2011 that almost half of the world’s population lives in a country where, on average, there is just one psychiatrist for every 200 000 people, and 80% of patients in low-income and middleincome countries with serious mental health disorders do not receive the care they need. Research in these settings is urgently needed to investigate what management approaches will be most effective; opportunities for tasksharing, and training of community health workers in joint mental health and diabetes care, should be explored. Until more evidence is available to enable improved identification of patients at high risk of mental health disorders, clinicians must be vigilant in identifying early signs of poor mental health in patients with diabetes and referring patients to a mental health specialist where necessary. Most of all, clinicians must ensure that depression is recognised and treated as rigorously as the physical complications of diabetes that are generally prioritised. A shift in attitudes to treatment will help to lessen the stigma of mental health disorders and increase patients’ acceptance of mental health care. ■ The Lancet Diabetes & Endocrinology
2/John Knill/Ocean/Corbis
Poor mental health in diabetes: still a neglected comorbidity
See Series pages 450, 461, and 472 For No Health Without Mental Health see https://www.gov.uk/ government/uploads/system/.../ dh_124058.pdf For the 2015 American Diabetes Association guidelines see Diabetes Care 2015; 38 (suppl 1): S1–94 For WHO 2011 Mental Health Atlas see http://www.who.int/ entity/mental_health/ publications/mental_health_ atlas_2011/en/index.html
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