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Whether you have been living with diabetes for years or have been recently diagnosed, you realize the profound way diabetes affects every facet of your daily life. No chronic disease demands more time and energy than diabetes. Managing your diet and activity, monitoring your blood sugar levels, and taking your medications correctly can consume your waking hours, even during times when your diabetes is in control and properly managed. You may not be aware of the scope and magnitude of challenges to your mental well-being that are unique to people living with diabetes. If you have diabetes and are suffering from anxiety, depression, or other mental health issues, you are not alone. The mental health toll from both Diabetes 1 or 2 is significant but, unfortunately, largely unrecognized. Prevalence of Mental Health Issues in Diabetics If you have diabetes, you are likely to experience depression. If you are depressed, you are twice as likely to develop Type II Diabetes at some point in your life. Studies show that depression and diabetes occurring in the same individual are twice as likely as in the general population. A recent study showed that 24% of people with diabetes experience major depression, and the depression tends to linger. Adolescents with Diabetes I and II have not been researched as widely, but 9-24% are affected by depression. Only 25 to 50% of people with diabetes with depression are treated. Researchers aren’t yet clear about all the reasons depression and diabetes are so closely related, but their correlation is strong. Some of the following factors have been explored: Daily management of an unstable chronic disease is stressful. Complications from diabetes are numerous, and as the disease burden increases, the potential for depression increases. Depression diminishes the energy to make smart lifestyle choices. Exercise, healthy eating, medication adherence, and self-care take a back seat when a person is just trying to make it through the day. There is a possibility that some anti-depressants adversely affect metabolic control and weight gain, thereby leading to a greater chance of the development of diabetes. Ways to Manage Diabetes and Depression Together Diabetes self-management programs: Diabetes programs focused on behavior have helped people improve their blood sugar control, manage weight loss and develop good physical fitness habits. They can also help improve your sense of well-being and quality of life. Psychotherapy: Cognitive behavioral therapy has improved depressive symptoms and enabled patients to take better care of themselves. Medications and lifestyle changes: Medications — for both diabetes and depression — and lifestyle changes, including different types of therapy coupled with regular exercise, can improve both conditions. Depression is a serious condition that can lead to even more problems for the person suffering. Untreated depression can lead to loss of employment, substance abuse, and even suicide. Chronic depression is different from the type of sadness you feel after a break-up or the loss of a pet. It can interrupt your daily life to the point where you are barely functioning. Depression should be taken seriously and will very likely not “go away with time.” If you suspect that you or someone you care for are suffering from depression, please seek out assistance as soon as possible. Symptoms of Depression Feeling sad or empty Losing interest in favorite activities Overeating or not wanting to eat at all Not being able to sleep or sleeping too much Having trouble concentrating or making decisions Feeling very tired Feeling hopeless, irritable, anxious, or guilty Having aches or pains, headaches, cramps, or digestive problems Thoughts of suicide or death Stress and Anxiety Stress is normal. Relationships, employment, parenting, or merely watching the news can contribute to a racing heart, sweating, and fear. Add constant management of an unpredictable disease, and many will become overwhelmed. People overwhelmed by stress often ignore self-care. Stress hormones produced by your body can cause blood sugar to drop or rise quickly. Stress from illness or injuries can cause blood sugar to rise dangerously. Anxiety is a reaction to stress. Symptoms may include nervous feelings, a feeling of panic or doom, increased heart rate, hyperventilation, feeling weak or tired, or trouble concentrating. Anxiety can also feel like low blood sugar, and low blood sugar can feel like anxiety. Check your blood sugar if you suddenly feel anxious. Usually, therapy works better than medications for anxiety. Ways to lower stress A quick walk can lower stress for hours Meditation or yoga Calling a friend who understands you, not someone who causes you stress Limiting alcohol and caffeine Adequate sleep Doing something you enjoy (Paint! Read a book! Watch your favorite movie!) Diabetic Distress People living with diabetes may be experiencing multiple distressing feelings and emotions. It’s common to feel burned out, angry, frustrated, and worried from the continuous demands of managing your disease. So many diabetics experience these feelings daily, in fact, that the syndrome has been termed Diabetic Distress, which is reported by 33% to 50% of adults with diabetes during any 18-month period. This is not a medical diagnosis but a term describing an emotional state causing several distressing emotions at once. This distress makes it very difficult to take care of yourself and can cause your diabetic symptoms to worsen. Diabetic distress looks very much like depression or anxiety but may not respond to the most common treatments. What are some of the common sources of distressing feelings? Management of Diabetes: The endless activities involved with managing your diabetes include checking blood sugar, selecting healthy foods, the need to be physically active, and remembering to take your medication. Fear of hypoglycemia or low blood sugar: Low blood sugar can quickly become a medical emergency for diabetics. Blood sugar can drop quickly in the event of too much insulin, too little food, excessive exercise, or other causes. Symptoms can range from mental disorientation to seizures to death. The initial feeling of dropping blood sugar is uncomfortable and usually frightening for most people. Once a serious episode has occurred, no one wants to experience another, and it can spurn worries about future social embarrassment. Many people allow their blood sugars to exceed the recommended levels to avoid having low blood sugar. Worry about diabetes complications: From the time of diagnosis, diabetics are educated about the complications of their disease. A diabetic is twice as likely to die from heart disease, including stroke. Diabetes is the leading cause of lower limb amputation. Diabetes is also the foremost cause of kidney disease, which affects 25% of adult diabetics. High blood sugar can cause permanent vision complications. These are big (and very real) worries to be permanently burdened with. Some people with diabetes are unable to stop thinking about dire outcomes, particularly when they are diligently trying to control their disease without seeing appreciable improvement. Acceptance of Diagnosis; Denial and Uncertainty Diabetes can be a difficult diagnosis to accept in the beginning. Understanding you have a life-long condition requiring daily management is daunting. Responses can range from depression and grief to denial and avoidance. Steps you can take to help with your distress If possible, see a diabetic specialist (ideally, an endocrinologist) for your diabetes care. He will likely have more understanding of your unique challenges and be more up to date on diabetic care and new developments. Ask your doctor to refer you to a mental health counselor who specializes in chronic health conditions. See a diabetes educator, hopefully, one-on-one. They have special training and excellent skills to help their patients’ problem solve; to find solutions to seemingly insurmountable obstacles. Identify one or two goals for management and focus on them. Trying to “fix everything” at once will only lead to more feelings of overwhelm. Join a diabetes support group. Talking with a group of people who share some of your worries and challenges can be reassuring. You will likely learn from each other as well. Helping others really is an excellent means of helping yourself. Diabulimia Eating disorders are characterized by an unhealthy relationship with food. In many cases, that means obsessively counting calories or controlling every morsel that passes through one’s lips. Managing diabetes means doing just that (to some extent), and as a result, diabetes can be a high-risk factor for developing an eating disorder. “Diabulimia” specifically refers to restricting insulin in order to lose weight. Sometimes the person will already have body image issues when they are diagnosed, and the realization that restricting insulin will facilitate weight loss exacerbates a previously existing eating disorder. And other times, it goes the other way around; the person may not have body image issues to begin with, but discovering this “easy,” yet the incredibly dangerous method of losing weight quickly leads to an eating disorder. The DSM-5 (a diagnostic tool for mental health professionals) classifies the restriction of insulin as a purging behavior. One can “binge” and then restrict insulin. Hence the term “diabulimia,” or they can restrict both food and insulin, in which case they may be diagnosed with anorexia nervosa. Both conditions are incredibly dangerous and should be looked out for, especially in teenage girls and young women who are already vulnerable to the dangers of an eating disorder. The risks of this behavior are severe. In the short term, you can expect disruptions in menstruation, severe dehydration, yeast infections, and muscle atrophy. In the long term, there is a risk of kidney disease, liver disease, heart disease, coma, stroke, and eventually death. Warning Signs of Diabulimia Increasing neglect of diabetes management Secrecy about diabetes management Avoiding doctors appointments Fear that insulin “makes me fat” Extreme anxiety about body image Avoiding eating in public or around friends and family Overly strict food rules Withdrawal from friends and family Infrequently filled Treatment for Diabulimia The best-case scenario for diabulimia treatment is to see an endocrinologist as well as a mental health professional. The endocrinologist specializes in both diabetes and eating disorders, and the mental health professional can help the patient get to the root of their eating disorder, whether it’s depression, anxiety, or solely a reaction to diabetes. Diabulimia is a serious mental health condition, and stressing the dangers of diabetes complications is definitely not helpful in this case. The patient needs specialized and ongoing care in order to learn to manage their diabetes without endangering their life. You Can Live with Diabetes Diabetes is a chronic, lifelong medical condition that needs to be taken seriously. It takes time, practice, and possibly a bit of trial and error in order to learn how to manage it properly and healthily. It can be scary and overwhelming, and you are not alone if you are afraid for yourself or your loved one living with diabetes. It is not the end of the world though, even if it feels like it right now. Like any other challenging thing you’ve faced, you will feel stronger and more capable once you have acquired the tools necessary for living with diabetes. Don’t go through this alone. Lean on your loved ones for support. Talk to your doctor and mental health care provider openly and honestly. It is absolutely normal and acceptable to feel depressed, anxious, angry, or overwhelmed by your diagnosis of diabetes, but it does not have to consume your whole life. With proper assistance, support, and education you can live your absolute best and fullest life despite your diabetes; it doesn’t have to define you or control you. Resources 10 Tips for Coping with Diabetes Distress. (2021, August 10). Centers For Disease Control and Prevention. https://www.cdc.gov/diabetes/managing/diabetes-distress/ten-tips-coping-diabetes-distress.html Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2001). The prevalence of comorbid depression in adults with diabetes: A meta-analysis. Diabetes Care, 24, 1069 –1078. Castro, M.D., R. (2020, September 3). Diabetes and Depression: Coping with the two conditions. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/diabetes/expert-answers/diabetes-and-depression/faq-20057904 Dada, J. H. (2012, August 1). Understanding Diabulimia — Know the Signs and Symptoms to Better Counsel Female Patients. Today’s Dietician. https://www.todaysdietitian.com/newarchives/080112p14.shtml Felman, A. (2019, May 24). How does diabetes affect mood and relationships? Medical News Today. https://www.medicalnewstoday.com/articles/317458#diabetes-and-mood-swings Holt, R. I. G. (2014, June 14). Diabetes and Depression. National Institutes of Health (NIH). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4476048/ National Eating Disorders Association. (2018, February 21). Diabulimia. https://www.nationaleatingdisorders.org/diabulimia-5 Robinson, D. J. (2018, April 1). Diabetes and Mental Health. Canadian Journal of Diabetes. https://www.canadianjournalofdiabetes.com/article/S1499-2671(17)30841-9/fulltext Young-Hyman D, de Groot M, Hill-Briggs F, et al. Psychosocial Care for People with Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016; 39: 2126–2140.