Assessment of Psychiatric Disorders Among Older Adults With Diabetes Mellitus
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Recent studies have suggested that certain psychiatric disorders occur with increased frequency among older adults with type 2 diabetes mellitus for several reasons.1,2 First, diabetes is considered to be one of the most psychologically and behaviorally demanding of the chronic medical illnesses. Multiple coping strategies are necessary to deal with the losses that can occur with aging. Because 95% of the management of diabetes is conducted by the patient, a diagnosis of diabetes can lead to increased levels of anxiety, depressive symptoms, and lowered self-esteem. This is often true in individuals who are predisposed to psychiatric disorders or those with limited social supports.
Further, the increased co-occurrence of diabetes and psychiatric disorders may be due to the medical consequences of diabetes—in particular, dementia and associated behavioral disturbances. Persons with certain psychiatric disorders, especially depression and schizophrenia,3,4 have higher incidence rates of diabetes than the general population. Last, some antipsychotic medications can induce or worsen type 2 diabetes.
The presence of a psychiatric disorder has been associated with poorer glycemic
control5 and, consequently, an increased risk of diabetes-related complications.6 This article reviews the evidence base linking diabetes and certain psychiatric disorders, and provides a strategy for assessment and treatment of these co-occurring conditions.
DIABETES AND DEPRESSION
The association between diabetes and depression dates back to 1674, when Dr. Thomas Willis believed that depression caused diabetes. Persons with depression are twice as likely as the general population to develop diabetes.3 The lifetime prevalence of depression among adults with diabetes is estimated to be 28.5%,1 which is almost three times the prevalence rate for the general adult population in the United States1,7 and 14 times the rate for older adults.
Depressive symptoms include sad mood, anhedonia, insomnia with early morning awakening, anorexia, helplessness, hopelessness, excessive guilt, and/or death wishes or suicidal ideas. Depressive symptoms have been significantly and consistently associated with hyperglycemia.5,8 Hypercortisolemia, often associated with depression, is known to increase blood sugar levels, and this may in part explain this finding. Alternatively, due to the degree of self-management needed, comorbid depression in diabetes may lead to poorer outcomes and increased risk of complications because of lower adherence to glucose monitoring, exercise, diet, and medication regimens.9 Depressive symptoms have been associated with decreased quality of life, and higher serum cholesterol and triglycerides10 in elderly persons with diabetes, as well as an increased risk of stroke, particularly in black men with diabetes. In fact, the lowest adherence to dietary and exercise recommendations is among older adults with the highest levels of depressive symptom severity.11,12
Diabetes is also a risk factor for cerebrovascular disease. The associated vascular cerebrocortical abnormalities preferentially occur in the frontal lobes and have been linked with a subtype of depression seen in older adults that presents with psychomotor retardation, loss of interest, paranoia at times, and executive dysfunction.13 This executive dysfunction can further interfere with adherence to diabetes self-management, because planning, sequencing, and organizing are all adversely affected.14
Identification of depression
The U.S.
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