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Diabetes, Depression and Anxiety – when too sweet is too bitter

Diabetes is a chronic condition that affects millions of people worldwide. It impacts every aspect of health and wellbeing and is highly unpredictable. Further, it leads to other chronic conditions creating yet new unpredictable circumstances. It is not surprising that diabetes and mental health go hand in hand: the sense of burden or defeat that oftentimes punctuates life with diabetes leads to diabetes distress, anxiety and depression – and, reciprocally, these conditions worsen diabetes. Additionally, the modern technology with a constant overload of information that has to be processed and acted upon while being able to improve glycemic control and reduce hypoglycemia with consistent use also leads to increased anxiety and depression symptoms, especially in youth.

There is strong evidence that depression is often unrecognized and, if diagnosed, undertreated in people with diabetes. Perhaps this is because diabetes is such a complex disorder and the time allocated to clinicians does not allow for addressing both the physical and the psychological needs of their patients or, maybe, because we, clinicians, have been conditioned to overemphasize glycemic control and, sometimes, forget the human being behind those “hard metrics”.

Recently, researchers at Rice University found a mechanistic link between emotional stress and diabetes, with roots in the brain’s ability to control anxiety: a metabolic chain reaction that starts with low inhibitory signals leading to more frequent anxiety and higher levels of pro-inflammatory cytokines, including interleukin-6 (IL-6), could provide a fertile soil for development and worsening of diabetes. Further, a newly described protein, FKBP51, is thought to be at the intersection of a shared pathway between diabetes and anxiety.

Since individuals who are anxious are more likely to avoid treatment and use maladaptive strategies that worsen glycemic control, this may represent a vicious closed loop.

It wasn’t until 2016, however, that the American Diabetes Association (ADA) published a position statement on psychosocial care in diabetes, with evidence-based guidelines for psychosocial assessment and care of individuals with diabetes – hence acknowledging that psychosocial struggles are just as important as glycemic management issues.

The field of health psychology overall is relatively new and, thus far, only very few diabetes care providers have attended to these issues as part of routine care, and we are still lacking standardized screening and assessment methods.

Tools like the recently described Diabetes Anxiety Depression Scale (DADS) will hopefully transfer to decreased stigma and increased access to appropriate and effective behavioral health care for people with diabetes in the near future.

In the end, the very success of modern technology depends heavily on the feelings that these technologies elicit in those who are poised to be constantly surrounded by them.

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