Diabetes, Depression and Anxiety – When Too Sweet is Too Bitter

According to Dr. Darius Schneider, a Scripps Affiliated Medical Groups Endocrinologist, 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.

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. Clinicians have been conditioned to emphasize 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 decrease stigma and increase access to appropriate and effective behavioral health care for people with diabetes in the near future.

Large studies have repeatedly shown, that people with diabetes are disproportionately highly represented within those vulnerable subgroups where the excessive inflammation associated with severe COVID-19 can lead to respiratory failure, septic shock, and ultimately, death.

“Malglycemia,” the hallmark of insufficient diabetes control defined as a combination of hyperglycemia, hypoglycemia, and increased glycemic variability, is associated with increased inflammatory immune responses and likely higher mortality from COVID-19. Additionally, recent studies have shown a potential link between COVID-19 infection and the onset or worsening of autoimmunity in people susceptible for Type 1 Diabetes.

It is therefore absolutely critical for people with diabetes to closely monitor their blood glucose levels and stay in close touch with their endocrinologists to make necessary therapy adjustments and mitigate the risk for a complicated COVID-19 course. Most endocrinology offices offer video call visits, so there is no reason to postpone essential care.