Diabetes: A Medical Disease with a Behavioral Treatment!

Let's take a look at the psychological costs of diabetes.

On top of the financial burden endured by people with diabetes, there are huge losses in their mental health world. We don’t have statistics on the increased rates for missed work, divorce, and relationship conflict which are directly related to diabetes management… but we do have study data showing that people with diabetes are likely to suffer from higher rates of depression. Those rates are 2-3 times higher than their counterparts who do not have diabetes, and 4 times the national average for rates of anxiety. They’re also three times higher than the national rates for disordered eating and eating disorder diagnosis. In fact, research found that 55% of respondents with type 1 diabetes experienced clinically diagnosable levels of anxiety, and 46% experienced symptoms that could be diagnosed as acute depression. 50% experienced increased fatigue to the point where they were unable to fulfill activities of daily living at some point during their diagnosis. While at the same time less than 25% of respondents reported ever having sought treatment for mental health needs.

But there is no reason that diabetes has to be a disease with crippling mental health struggles.

So let’s take a look at these specific struggles and how we can help.

Stages of Grieving

Grieving is the first thing we experience after a diabetes diagnosis. It’s life altering--we receive a diagnosis which begins a lifelong commitment to specific lifestyle changes, and a disease that could be terminal if not treated.

So, just like someone who gets a cancer diagnosis or is told they need an immediate life-saving limb amputation, people with diabetes also experience the stages of grieving. They may be grieving their perceived self (as someone they thought of as healthy) who they now perceive as less than healthy. They may also be grieving what they fear may happen to their career, relationships, athletic pursuits, or other dreams or goals. They may be fearing stigma or what they saw happen to someone else in their life who was given a diabetes diagnosis.

The five stages of grieving are comprised of:

Denial

Denial is where patients will often not admit to having diabetes because they don’t have any of ‘those’ symptoms, or maybe the lab got their blood work mixed up with someone else’s, or they have excuses like, “I had a really high sugar snack the night before I had that blood work done--so let me get it redone and then we’ll see”.

 In someone who has had a diabetes diagnosis for a while they may think, “I don’t need to take my medication or insulin because I feel great without it”.

As a clinician who specializes in type 1 diabetes, and one who has had it for over 15 years, every now and again when I’m disconnected from my pump for several hours and my blood sugar doesn’t elevate as much as I expect, a little voice in the back of my head will start to whisper that maybe I don’t have diabetes, after all. And this is common and happens at all stages of treatment. Another form of denial might be someone who just goes and exercises without taking any rapid acting carbs with them--as if they didn’t have diabetes and then they have a hypoglycemic episode. Or someone who continues to drink high sugar sodas because they’re in denial of the impact that those will have on their wellness long-term.

Anger

Anger during the grieving stage is often turned at clinicians early on. Most clinicians have heard a patient bluster “You don’t understand, or “that’s easy for you to say” or “you’re just a pill pusher!” By the way, many clinicians don’t get it, are overly judgmental, and do push meds in the wrong ways, but anger is also often aimed at ourselves. You can imagine it happening in this way. An episode of disordered eating occurs and the person will fast to atone for eating a bad meal that raised blood sugars, or leave blood sugars running high because “I earned feeling bad because I caused this”, It may also be directed at loved ones for being the food police and questioning food decisions, It can also often be directed at our devices themselves and blaming those devices for not working properly. I know I personally have sent more than one glucometer flying across the room in a fit of diabetes-related angst.

Bargaining

Bargaining may be internalized. Many people have been known to promise any number of greater powers and that they will do any number of good deeds if only their diabetes gets taken away. In a more practical sense, it often looks like patients asking their doctor, “if I eat right and exercise can we please take away my medications?” Or someone saying, “I’m going to keep my blood sugar really tight today because I’m going out for my birthday this weekend and my blood sugar is going to be through the roof!”

Depression

Depression is the other phase of grieving that we definitely think of the most. The classic tearful presentation on diagnosis, or the patient who is hopeless that they’re ever going to reach their clinical goals. But it can be far more insidious, leading to breakdowns in relationships, an inability to manage other disease states, a loss of ability to perform academically, athletically, or professionally, or just a loss of joy, emotional depth, increased fatigue, and others.

None of the stages above is bad in and of itself. It is the scope and duration that we need to assess. It’s okay to get mad. It’s not okay to scream at your wife. It’s okay to bargain one weekend, it’s not okay for that to be your only way of dealing with your blood sugars. It’s okay to take a day and ease back on management and eat like you don’t have diabetes. It’s not okay to drive your car with a low blood sugar and wrap it around a tree. Context, scope, and duration are the keys here.

Acceptance