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Table of Contents
Year : 2012  |  Volume : 16  |  Issue : 7  |  Page : 37-40

Neuropsychiatric screening in type 2 diabetes mellitus

1 Department of Endocrinology, Medwin Hospitals, Hyderabad, Andhra Pradesh, India
2 Department of Medicine, MKCG Medical College, Berhampur, Orissa, India
3 Department of Pharmaceutics, Roland Institute of Pharmaceutical Sciences, Berhampur, Orissa, India
4 Department of Anesthesia, Central Security Hospital, Riyadh, Saudi Arabia

Date of Web Publication24-Mar-2012

Correspondence Address:
Sunil K Kota
Department of Endocrinology, Medwin Hospitals, Chiragh Ali Lane, Nampally, Hyderabad - 500 001, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-8210.94255

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Diabetes mellitus is considered to be one of the most psychologically demanding of the chronic medical illnesses and is often associated with several psychiatric disorders. Psychiatric disorders can be a risk factor for, as well as a complication of, diabetes leading to bidirectional association between the two morbidities. Physicians caring for people with diabetes must be trained to recognize and manage comorbid psychiatric conditions that commonly occur. Our current article reviews the various screening procedures for effective evaluation of the neuropsychiatric illnesses coexisting with diabetes and other pertinent issues.

Keywords: Diabetes mellitus, psychiatric disorders, screening

How to cite this article:
Kota SK, Meher LK, Jammula S, Krishna S, Kota SK, Modi KD. Neuropsychiatric screening in type 2 diabetes mellitus. Indian J Endocr Metab 2012;16, Suppl S1:37-40

How to cite this URL:
Kota SK, Meher LK, Jammula S, Krishna S, Kota SK, Modi KD. Neuropsychiatric screening in type 2 diabetes mellitus. Indian J Endocr Metab [serial online] 2012 [cited 2021 May 13];16, Suppl S1:37-40. Available from: https://www.ijem.in/text.asp?2012/16/7/37/94255

   Introduction Top

In a chronic disorder like diabetes mellitus, treatment adherence is major challenge. Poor compliance could be due to various reasons among which neuropsychiatric problems are an important issue. Coexistent psychiatric illness in diabetes leads to impaired quality of life, [1] increased cost of care, [2] phobia of needles and injections interfering with investigations and treatment process, [3] poor treatment adherence, [4] poor glycemic control with increased admissions due to hyperglycemic emergencies and other complications, [5],[6],[7] altered pharmacokinetics of antidiabetic agents due to substance abuse involving tobacco and alcohol, [3] higher absenteeism, [7] and overlapping clinical presentation. [3] Assessing a diabetic in toto includes psychosocial status. [8] Neuropsychiatric screening should include patient's attitudes about the illness and expectations from the treating physician and hospital. Quality of life affects mood and the available financial, emotional, and social support. Neuropsychiatric issues in diabetes have a significant influence on patient outcomes and quality of life.

It is common for patients to experience emotional distress from living with diabetes and the effect of its complications. "Diabetes burnout" and "Diabetes overwhelmus" are the terms that have been used to display the distress of diabetes. [9] We have discussed the various screening modalities to define various psychiatric morbidities noted in diabetic patients.

   Schizophrenia and Diabetes Top

Schizophrenia is an independent risk factor for diabetes. Development of glucose intolerance, diabetes, and ketoacidosis is reported with atypical antipsychotics. Patients with schizophrenia are 2- to 4-fold more likely than the general population to be overweight or obese. [10] Antipsychotics contribute to weight gain. Structured weight control and exercise programs can yield good results. The "Brief Assessment of Cognition in Schizophrenia" (BACS) score includes six parameters for evaluation in 35 minutes. [11] "Repeatable Battery for the Assessment of Neuropsychological Status" (RBANS) [12] and the "Schizophrenia Cognition Rating Scale" (SCoRS) [13] are also useful tools taking less than 30 minutes for administration. Others like "Brief Cognitive Assessment Tool for Schizophrenia" (B-CATS) can be administered in <15 minutes. [14]

   Anxiety in Diabetes Top

Anxiety symptoms are considered to be significant risk factors for diabetes. Diabetes too is associated with higher prevalence of anxiety disorders (3 times), with anxiety accounting for poor glycemic control. [15] Phobia to needles and hypoglycemic episodes further worsen glycemic control. Clinical features such as anxiety, sweating, tremor, tachycardia, and confusion are present in both anxiety and hypoglycemic episodes. [3] Certain medications such as benzodiazepines, beta-blockers, and selective serotonin reuptake inhibitors interfere with glycemic control.

   Depression in Diabetes Top

Patients with diabetes and depressive symptoms have mortality rates nearly twice as high as persons with diabetes and no depression. Depression may be due to biochemical changes of diabetes, like hyperglycemia, inflammation, activation of hypothalamic-pituitary-adrenal axis, or it could be due to the lifestyle factors associated with diabetes. [16] Also, neurohormonal changes induced by depression, like hypercortisolism, can lead to insulin resistance and diabetes. Behavioral factors associated with depression, including lack of physical activity and poor diet, increase the risk of diabetes. All diabetics should be screened annually for depression. Two simple questions mentioned below help in screening the patients and it is clinically effective.

During the past month, have you often been bothered by feeling down, depressed, or hopeless?

During the past month, have you often been bothered by little interest or pleasure in doing things?
"Geriatric Depression Scale" (GDS): The 15-item GDS is used to screen for depressive symptoms in older individuals. [17] This measure is scored based on a 15-point scale, and impairment is indicated by a score of 5 or higher. "Hamilton Rating Scale for Depression" (HRSD) is also a useful tool including 21 symptoms. [18] "Hospital Anxiety and Depression Scale" (HADS) could be used further to quantify severity of anxiety and depression in this population. It has 144 items with two subscales: anxiety and depression, with each item having 4 rating scale. Scores of ≥11 are associated with significant morbidity. [19] Others like "Patient Health Questionnaire-9" (PHQ-9) [20] and "Symptom Checklist-90" (SCL-90) [21] are sensitive and time-efficient tools for both anxiety and depression.

Common side effects of antidepressants which are relevant to diabetes are sedation, weight gain, and related with an impact on cardiovascular system. Alleviating depressive symptoms in these patients has a positive impact on improving their mental and physical functioning, treatment adherence with disease self-management and medication regimens, diabetes outcomes like a better HbAlc.

   Personality Disorders in Diabetes Top

Diabetic patients have a higher prevalence of borderline personality disorders. This exposes the patients to various other psychiatric comorbidities. The splitting and sabotaging behavior renders the patient care profoundly cumbersome. [22] Others like opportunistic, alienated, oppositional, and explosive personalities are associated with higher prevalence of diabetes. [23]

   Diabetic Peripheral Neuropathy Top

All patients with diabetic peripheral neuropathy (DPN) should be screened for psychiatric comorbidities. They may be at an increased risk of committing suicide due to the co-occurrence of unrecognized psychiatric illness and inadequately managed pain. [24]

   Diabetes-Related Emotional Distress Top

One-third of the diabetics have serious concerns like "worry about the future and the possibility of diabetic complications." The "Problem Areas in Diabetes" (PAID) is a good tool to assess diabetes-related emotional distress. The PAID is a measure of diabetes-specific emotional distress, which was developed by the Joslin Diabetes Center, Boston. [25] This self-administered questionnaire consists of 20 items that cover a range of emotional problems frequently reported in type 1 and type 2 diabetes. Each item is scored from 0 to 4 ("not a problem" to "serious problem"). The sum of the 20 items is multiplied by 1.25 to yield a final score of 0-100. Psychometric reports to date on the PAID have shown it to: (i) have consistently high internal reliability (i.e. a = 0.90); (ii) have sound (r = 0.83) 2-month test-retest reliability using a sample of stable patients; (iii) correlate strongly with a wide range of theoretically related constructs such as general emotional distress, depression, diabetes self-care behaviors, diabetes coping, and health beliefs; and (iv) be a statistically significant predictor of glycemic control in a study that tracked a managed care population control for 1 year. [26]

   Cognitive Dysfunction in Diabetes Top

Elderly patients with diabetes have an increased risk of developing cognitive problems. One-third of the elderly diabetics have cognitive dysfunction and its presence is associated with poor diabetes control. [27] Cognitive functions that enable complex behaviors are particularly important for patients with diabetes. But older patients with diabetes and concomitant cognitive dysfunction may find it cumbersome to adhere to the complicated treatment regimens like multiple daily insulin injections, multiple oral medications, and various diet-related instructions. Elderly population is at an increased risk of hypoglycemia due to various reasons including omission of meals, incorrect dose or timing of insulin injections and/or oral medications, and associated renal dysfunction. Diabetes has been associated with increased incidence of functional disabilities and increased risk of falls and fractures. Executive dysfunction is correlated with inability to perform lower-extremity tasks, leading to higher risk of falls. The useful cognitive questionnaires and tests are described below.

The "Mini Mental State Examination" (MMSE) is one of the most commonly used cognitive screening measures because it is quick and easy to administer. [28] The MMSE includes specific questions related to attention, orientation, memory, calculation, and language. The measure scoring is based on 30 total points and impairment is indicated by a score of 24 or lower. This is a good tool to screen for memory function.

The "Clock-Drawing Test" (CDT) is a simple validated measure of cognitive function. [29] In this test, participants are presented with two sheets of paper: one provides written instructions and the other serves as a response sheet. The instructions direct participants to draw a clock and set the time to 10 minutes after 11. CDT scored by Mendez method uses a 20-point scale. This system of scoring has been shown to be most accurate in predicting deficit in cognitive function and correlates with MMSE.

The "Clock-in-a-Box" (CIB) test is a modified CDT aimed at screening cognitive dysfunction in the medical setting. [30] This test was developed specifically to be a fast and reliable index of executive function. In this test, as an added step, participants are asked to draw a clock in the blue box. The total score is the sum of the memory and executive function sub-scores. Total score in CIB is used to assess overall cognitive function.

Patients with diabetes need to be evaluated for barriers to safe and effective diabetes control. Screening for subtle cognitive dysfunction is important when complicated treatment regimens are used. Glycemic targets should be individualized; patients with diabetes and executive dysfunction may need special education and skills to manage their disease.

   Sexual Dysfunction and Diabetes Top

Both psychological and physiological factors can contribute to sexual dysfunction in diabetics. Sexual dysfunction can be a symptom of co-occurring psychiatric illness, a consequence of medical illness, or a side effect of concomitant medication. Several scales have been developed like the "Changes in Sexual Functioning Questionnaire" (CSFQ), which can be incorporated into a routine initial clinic visit. [31] Screening for depressive and other psychiatric symptoms like psychosis, anxiety, and substance use disorders, which may be interfering with desire and arousal, is essential.

   Substance Abuse Disorders Top

Mostly they include tobacco and alcohol abuse. Tobacco and cigarette use is associated with increased risk of diabetes and its micro- and macrovascular complications by virtue of its actions like hyperglycemia, hyperinsulinemia, endothelial dysfunction, and hypertension. [32],[33] Prevalence of alcohol abuse in diabetics is pegged at 50-60%. [34] Alcohol consumption in high amounts is associated with increased risk of diabetes. Alcohol is implicated in fasting hyperglycemia, potentiation of drug-induced hypoglycemia or reactive hypoglycemia, hypoglycemia unawareness, synergistic effect on neuropathy and retinopathy, interaction with antidiabetic agents (lactic acidosis with metformin, disulfiram like reaction with chlorpropamide, hepatopathy leading to reduction in dose). [3] "Fagerstrom Test for Nicotine Dependence" (FTND) [35] and CAGE [36] questionnaire ( Acronym of 4 questions like 1.Have you ever felt you needed to Cut down on your drinking?, 2. Have people Annoyed you by criticizing your drinking?, 3. Have you ever felt Guilty about drinking? 4. Have you ever felt you needed a drink first thing in the morning [Eye- opener] to steady your nerves or to get rid of a hangover?) are used for evaluation.

   Conclusion Top

Multipronged interaction between psychiatric illnesses and diabetes makes the management of diabetes more challenging. Increased awareness about these comorbidities and timely psychiatrist consultation would help in better care in this group of patients. The various screening tools at disposal would help in early diagnosis of such illnesses.

   Acknowledgements Top

All the authors would extend their heartfelt thanks to Dr Jagadeesh Tangudu, M Tech, MS, PhD, Sowmya Jammula, M Tech for their immense and selfless contribution towards manuscript preparation, language editing and final approval of text.

   References Top

1.Goldney RD, Phillips PJ, Fisher LJ, Wilson DH. Diabetes, depression, and quality of life: A population study. Diabetes Care 2004;27:1066-70.  Back to cited text no. 1
2.Hutter N, Schnurr A, Baumeister H. Healthcare costs in patients with diabetes mellitus and comorbid mental disorders--a systematic review. Diabetologia 2010;53:2470-9.  Back to cited text no. 2
3.Balhara YP. Diabetes and Psychiatric disorders. Indian J Endocrinol Metab 2011;15:274-83.  Back to cited text no. 3
4.Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, et al. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. Diabetes Care 2007;30:2222-7.  Back to cited text no. 4
5.Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: A meta-analytic review of the literature. Diabetes Care 2000;23:934-42.  Back to cited text no. 5
6.Bryden KS, Dunger DB, Mayou RA, Peveler RC, Neil HA. Poor prognosis of young adults with type 1 diabetes: A longitudinal study. Diabetes Care 2003;26:1052-7.  Back to cited text no. 6
7.Das-Munshi J, Stewart R, Ismail K, Bebbington PE, Jenkins R, Prince MJ. Diabetes, common mental disorders, and disability: Findings from the UK National Psychiatric Morbidity Survey. Psychosom Med 2007;69:543-50.  Back to cited text no. 7
8.Jacobson AM. Pychological care of patients with insulin dependant diabetes mellitus. N Engl J Med 1996;334:1249-53.  Back to cited text no. 8
9.Rubin RR. Counselling and psychotherapy in diabetes mellitus. ln: Snoek FJ, Skinner TJ, editors. psychology in diabetes care. New York, NY: Wiley; 2000. p. 235-63.  Back to cited text no. 9
10.Holt RIG, Bushe C, Citrome L. Diabetes and schizophrenia 2005: Are we any closer to understanding the link? J Psychopharmacol 2005;19:56-65.  Back to cited text no. 10
11.Keefe RS, Goldberg TE, Harvey PD, Gold JM, Poe MP, Coughenour L. The Brief Assessment of Cognition in Schizophrenia: Reliability, sensitivity, and comparison with a standard neurocognitive battery. Schizophr Res 2004;68:283-97.  Back to cited text no. 11
12.Gold JM, Queern C, Iannone VN, Buchanan RW. Repeatable battery for the assessment of neuropsychological status as a screening test in schizophrenia I: sensitivity, reliability, and validity. Am J Psychiatry 1999;156:1944-50.  Back to cited text no. 12
13.Keefe RS, Poe M, Walker TM, Kang JW, Harvey PD. The schizophrenia cognition rating scale: An interview-based assessment and its relationship to cognition, real-world functioning, and functional capacity. Am J Psychiatry 2006;163:426-32.  Back to cited text no. 13
14.Hurford IM, Marder SR, Keefe RS, Reise SP, Bilder RM. A brief cognitive assessment tool for schizophrenia: construction of a tool for clinicians. Schizophr Bull 2011;37:538-45.  Back to cited text no. 14
15.Engum A. The role of depression and anxiety in onset of diabetes in a large population based study. J Psychosom Res 2007;62:31-8.  Back to cited text no. 15
16.Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence and determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res 2010;132:195-200.  Back to cited text no. 16
[PUBMED]  Medknow Journal  
17.D'Ath P, Katona P, Mullan E, Evans S, Katona C. Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract 1994;11:260-6.  Back to cited text no. 17
18.Williams JB. A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry 1989;45:742-7.  Back to cited text no. 18
19.Herrmann C. International experiences with the Hospital Anxiety and Depression Scale--a review of validation data and clinical results. J Psychosom Res 1997;42:17-41.  Back to cited text no. 19
20.Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. JAMA 1999;282:1737-44.  Back to cited text no. 20
21.Buckelew SP, Burk JP, Brownelee-Duffeck M, Frank RG, DeGood D. Cognitive and Somatic aspects of Depression among a rehabilitation sample:" Reliability and Validity of SCL-90-R research subscales. Rehabil Psychol 1988;33:66-75.  Back to cited text no. 21
22.Leichter SB, Dreelin E. Borderline Personality Disorder and Diabetes: A Potentially Ominous Mix. Clin Diabetes 2005;23: 101-3.  Back to cited text no. 22
23.Lustman PJ, Frank BL, McGill JB. Relationship of personality characteristics to glucose regulation in adults with diabetes. Psychosom Med 1991;53:305-12.  Back to cited text no. 23
24.Vileikyte L, Leventhal H, Gonzalez JS, Peyrot M, Rubin RR, Ulbrecht JS, et al. Diabetic Peripheral Neuropathy and Depressive Symptoms. Diabetes Care 200;528:2378-83.  Back to cited text no. 24
25.Welch GW, Jacobson AM, Polonsky WH. The problem areas in diabetes scale. An evaluation of its clinical utility. Diabetes Care 1998:20;760-6.  Back to cited text no. 25
26.Snoek FJ, Pouwer F, Welch GW, Polonsky WH. Diabetes related emotinal distress in Dutch and US diabetes patients:cross cultural validity of the problem areas in diabetes scale. Diabetes Care 2000;23:1305-9.  Back to cited text no. 26
27.Munshi M, Capelson R, Grande L, Lin S, Hayes M, Milberg W, et al. Cognitive Dysfunction Is Associated With Poor Diabetes Control in Older Adults. Diabetes care 2006;29:1794-99.  Back to cited text no. 27
28.Folstein MF, Folstein SE, McHugh PR. „Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.  Back to cited text no. 28
29.Nishiwaki Y, Breeze E, Smeeth L, Bulpitt CJ, Peters R, Fletcher AE. Validity of the Clock-Drawing Test as a screening tool for cognitive impairment in the elderly. Am J Epidemiol 2004;160:797-807.  Back to cited text no. 29
30.Grande L, Milberg W, Rodolph J, Gaziano M, McGlinchey R. A timely screening for executive functions and memory. J Int Neuropsychol Soc 2005;11 Suppl 1:9-10.  Back to cited text no. 30
31.Clayton AH, McGarvey EL, Clavet GJ. The Changes in Sexual Functioning Questionnaire (CSFQ): development, reliability, and validity. Psychopharmacol Bull 1997;33:731-45.  Back to cited text no. 31
32.Eliasson B. Cigarette smoking and diabetes. Prog Cardiovasc Dis 2003;45:405-13.  Back to cited text no. 32
33.Frati AC, Iniestra F, Ariza CR. Acute effect of cigarette smoking on glucose tolerance and other cardiovascular risk factors. Diabetes Care 1996;19:112-8.  Back to cited text no. 33
34.Ahmed AT, Karter AJ, Liu J. Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours. Diabet Med 2006;23:795-802.  Back to cited text no. 34
35.Radzius A, Gallo JJ, Epstein DH, Gorelick DA, Cadet JL, Uhl GE, et al. A factor analysis of the Fagerström Test for Nicotine Dependence (FTND). Nicotine Tob Res 2003;5:255-40.  Back to cited text no. 35
36.Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984;252:1905-7.  Back to cited text no. 36

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