What is the recommended approach for managing patients with diabetes and co-existing psychiatric disorders?

Management of Patients with Diabetes and Co-existing Psychiatric Disorders

Coordinated management of diabetes and serious mental illness is essential to achieve diabetes treatment targets, requiring enhanced monitoring and support for diabetes self-management behaviors. 1

Screening and Assessment

• Conduct annual screening for depressive symptoms in all patients with diabetes, especially those with a self-reported history of depression, using age-appropriate depression screening measures 1
• Begin assessment for depression at diagnosis of complications or when significant changes in medical status occur 1
• Screen for disordered or disrupted eating using validated screening measures when hyperglycemia and weight loss are unexplained based on self-reported behaviors 1
• Monitor cognitive capacity throughout the lifespan for all individuals with diabetes, particularly in those with documented cognitive disabilities, history of severe hypoglycemia, very young children, and older adults 1
• Annually screen people who are prescribed atypical antipsychotic medications for prediabetes or diabetes 1

Management Approach for Specific Psychiatric Conditions

Depression

• Refer patients with positive depression screens to mental health providers with experience using cognitive behavioral therapy, interpersonal therapy, or other evidence-based approaches 1
• Consider that patients with recent psychiatric illness may have poorer metabolic control (higher HbA1c levels) and report more symptoms of poor metabolic control 2

Serious Mental Illness (particularly schizophrenia and thought disorders)

• Provide increased level of support through enhanced monitoring of and assistance with diabetes self-management behaviors 1
• Include a nonmedical caretaker in decision-making regarding the medical regimen when a person has a mental illness that impacts judgment and ability to establish a collaborative relationship with care providers 1
• Consider remote monitoring, facilitating health care aides, and providing diabetes training for family members and caregivers 1

Eating Disorders

• Re-evaluate the treatment regimen of people with diabetes who present with symptoms of disordered eating behavior or eating disorders 1
• Consider adjunctive medication such as glucagon-like peptide 1 receptor agonists, which may help individuals meet glycemic targets and regulate hunger and food intake 1
• Be cautious in labeling individuals with diabetes as having a diagnosable psychiatric disorder when disordered eating patterns may be associated with physiologic disruption in hunger and satiety cues 1

Medication Considerations

• If a second-generation antipsychotic medication is prescribed for adolescents or adults with diabetes, carefully monitor changes in weight, glycemic control, and cholesterol levels every 12-16 weeks 1
• Adjust treatment regimen as needed based on metabolic changes 1
• Be aware that antipsychotics with noradrenergic activity have the highest potential to cause metabolic abnormalities, with clozapine and olanzapine posing the highest risk 3

Common Pitfalls and Caveats

• Avoid mislabeling patients as "difficult" when they may be experiencing diabetes distress, which differs from psychiatric disorders like depression 4
• Recognize the bidirectional relationship between diabetes and psychiatric disorders - both influencing each other in multiple ways 5
• Be aware that the overall report of diabetes symptoms may be influenced primarily by the presence of psychiatric disorders rather than actual metabolic control 2
• Consider that patterns of maladaptive food intake may be driven by physiologic disruption rather than psychological factors 1

Integrated Care Approach

• Implement coordinated management of diabetes and psychiatric conditions through collaborative care with the patient's diabetes treatment team 1
• Incorporate active monitoring of diabetes self-care activities into treatment goals for people with diabetes and serious mental illness 1
• Consider group support, accountability, and assistance with applying diabetes knowledge as beneficial approaches for patients with both conditions 1