AUG 28 - Once considered the disease of only the ‘affluent community’, diabetes has become a common health issue nowadays, even in under-developed countries like Nepal. For many Nepalis, to know of people with diabetes in the family or in the neighbourhood is not unusual. Although we do not have authoritative, published data on the exact incidence and prevalence of the disease here, the ever-increasing demand for specialised health centres and professionals to treat the disease is proof of the increased problem. Even the Ministry of Health has prioritised diabetes as a prominent non-communicable disease (NCD) and has specific plans and programmes for its prevention and intervention. However, the lay people and concerned stakeholders tend to focus only on the physical effects and neglect the mental-health aspects of this chronic disease.
Diabetes is considered one of the most psychologically demanding of chronic medical illnesses and is often associated with several psychiatric disorders. The frequent co-occurrence of diabetes and psychiatric disorders has been recognised for several centuries and is thought to be related to several factors. Way back in the 17th century, Thomas Willis speculated that diabetes was caused by “long sorrow and other depressions.” In the book The Pathology of Mind, published in 1879 by Sir Henry Maudsley, the author says, “Diabetes is a disease which often shows itself in families in which insanity prevails.” Over the past few decades, this correlation has been studied more extensively with greater scientific rigour, and it is now an established fact that diabetes and psychiatric disorders share a bidirectional association, influencing each other in multiple ways:
1. When an individual is a victim of both diabetes and mental illnesses, the course of diabetes can be complicated by the emergence of psychiatric disorders. Depression, anxiety disorders and even schizophrenia are more prevalent in diabetic patients than in the general population (depression occurs at twice the rate in diabetic populations; generalised anxiety disorder at three times the rate), implying that diabetes can lead to the development of these psychiatric disorders.
2. Psychiatric disorders like depression and schizophrenia can also act as significant independent risk factors for development of diabetes: depression has a 60 percent liability, while schizophrenia possesses a 200-400 percent increased risk.
3. There could be an overlap between the clinical presentations of diabetes and psychiatric disorder (for example, decreased blood sugar and conditions such as panic attacks). Diabetes could emerge as a side effect of the medications used for psychiatric disorders as well.
Diabetes and psychiatric disorders interact in other ways as well. Heavy use of substances such as tobacco and alcohol, habits that many depressed individuals often possess, could lead to the development of diabetes. According to previously diagnosed cases, their use can alter the body’s mechanism for handling diabetic drugs and thus bring about poor treatment-outcomes. Moreover, as patients are responsible for 95 percent of disease management, the presence of disorders like depression or schizophrenia could interfere with the management of diabetes by influencing treatment adherence. Similarly, certain disorders such as a phobia of needles and injections can present difficulties with investigation and treatment processes such as blood glucose testing and insulin injection. Also, patients with psychiatric disorders are less likely to seek treatment, and such delays would postpone detection of co-occurring diabetes as well.
The co-occurring psychiatric disorders in patients with diabetes is also associated with impaired quality of life, poor blood sugar control, increased emergency room visits due to hypoglycemic delirium (brain failure due to low levels of blood sugar) or diabetic ketoacidosis (an emergency situation where the body starts to break down body fat), higher frequency of hospitalisation, and higher rates of absenteeism from work. Additionally there is an increase in the cost of medical care—twofold or even higher (depending on the treatment setting) than among the population without co-occurring psychiatric disorders.
Although a well-established fact in the West and affluent countries, the correlation between diabetes and psychiatric illnesses has received little attention in Nepal. There is a need to study these issues in the local context as attitudes and concepts vary in relation to culture. In Nepal, people tend to hide mental health issues due to the fear of the stigma that accompanies the disease. Thus diabetics with co-morbid psychiatric disorders need special attention.
Because diabetes and psychiatric disorders interact in multifaceted ways, integrated multidisciplinary approaches and interventions are needed to effectively and comprehensively serve those suffering from these diseases.
Dr Rabi Shakya is Assoc. Prof. & Head, Dept. of Psychiatry, Patan Academy of Health Sciences, Lalitpur
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