How Depression and Anxiety Affect Diabetes Management
By Cheryl Alkon
Managing diabetes is a full-time juggling act, and doing so while living with anxiety and depression can make it even harder. Hear from people with diabetes and healthcare providers about strategies to manage mental health.
In the four decades since she was diagnosed with type 1 diabetes, Bethany Rose has seen first hand how mental health and diabetes are inextricably linked.
“When I have acute anxiety, the cortisol in my body spikes my blood sugar and makes it very stubborn about coming down,” said Rose, who lives in Winnipeg, Manitoba, Canada. “I have significant insulin resistance during anxiety. It’s a double hit when it happens, because I feel like crap from the anxiety and then also from the high blood sugar. It doesn’t help that some of the symptoms are similar, like pasty mouth and nausea.”
The combination of blood sugar stress and anxiety can send Rose into what she calls a downward spiral because the added stress of feeling she is doing a poor job of managing her diabetes produces more anxiety, marked by feeling of helplessness and weakness. “Suddenly, I’m feeling down about myself because I can’t control either issue,” she said. “It’s super frustrating.”
Managing diabetes is already a juggling act but doing so while also living with clinical anxiety and/or depression can make it even harder. Being able to manage blood glucose, medication timing and dosing, thinking closely about what to eat and counting carbohydrate grams already takes up a lot of brain space.
Trying to do all that while dealing with anxiety (about diabetes itself or other issues) or depression, which can sap your energy with feelings of hopelessness, can mean that diabetes management drops off or sits on the back burner while your focus is elsewhere.
Recognizing what’s what
Susan Guzman, clinical psychologist and co-founder and director of clinical education at the Behavioral Diabetes Institute in San Diego, California, noted that there are different ways to think about mental health issues and diabetes. They include diabetes distress as well as depression, anxiety, and other mental health diagnoses such as substance abuse or eating disorders.
Diabetes distress, which Guzman said affects about 40 percent of people who live with diabetes, is moderate to high levels of distress over the worries, thoughts, fears, and concerns about living with diabetes.
For people with diabetes, “having tough thoughts about a tough disease is normal; it is not a pathology,” or a separate diagnosis the same way depression or anxiety would be, she said. With diabetes management challenges and diabetes burnout, “you feel like there is this big job that is diabetes management, and you don’t have the energy to want to take it on,” she said.
Diabetes distress isn’t the same as depression necessarily, said Guzman. Instead, she explained, “having depression is like your ‘give-a-damn’ is broken.” People with depression may have ongoing sadness, what is described as a blue mood, numbness, or nothing at all. Other symptoms of depression include difficulty concentrating, changes in appetite, or having a hard time sleeping.
“The symptoms of depression can overlap with the tasks of the job of managing diabetes and can become an additional obstacle,” she said.
Anxiety, which is having intense, excessive, and persistent worry and fear about everyday situations, according to the Mayo Clinic, can elicit a fast heart rate, rapid breathing, sweating and feeling tired. For people who are newly diagnosed, it’s common to experience a heightened level of anxiety, said Marjorie Madikoto, a family nurse practitioner and diabetes educator with the Diabetes SelfCare Management Institute in New Carlton, Maryland.
People often think, “What does this diagnosis mean, how will I cope? Early recognition of feelings of anxiety is important,” she said.
The link between these mental health issues and diabetes can last long after diagnosis, said Allision Nimlos, a licensed marriage and family therapist and the owner of Greater Than Counseling and Coaching, a practice in the St. Paul, Minnesota area. She is also the co-founder of the Diabetes + Mental Health Conference and has lived with type 1 diabetes for 28 years.
“The relationship between anxiety and depression and diabetes management can often act like a feedback loop, with one causing the other and then exacerbating the first,” Nimlos said.
Someone with social anxiety might avoid checking their blood glucose or taking insulin at a dinner party because they worry how others may perceive them, or they feel like a burden or intrusion. Fear of hypoglycemia (low blood sugar) is another example of the feedback loop: a low blood sugar episode can create intense anxiety or even a trauma response, which then prompts a person to mismanage their insulin to avoid low blood sugars.
“This actually exacerbates the anxiety, which then continues the cycle of avoidance,” Nimlos said.
Advice from providers
Mental health issues such as anxiety and depression “are all highly treatable and manageable conditions,” said Nimlos. “With the right help and guidance, you can live a wonderful, meaningful and joyful life.”
The key thing is to get needed support as soon as possible.
“Anxiety and depressive disorders do not magically go away over time,” Nimlos said. “In fact, they often become worse without proper therapeutic support and skills in managing emotions. One thing I tell my clients is that anxiety and depression are champion liars. They tell us that we can’t handle hard things or that nothing matters. They are very believable voices and they are wrong. It does matter and you can do hard things. You are worth it.”
Finding such guidance often means finding a therapist, either in person or through a virtual relationship.
“It can be hard to find a mental health specialist with expertise in diabetes, but that doesn’t mean you can’t be helped by one who doesn’t have it,” said Guzman.
She said you have to ask for help, which some people, particularly men or in some cultures, can have a hard time doing. Speaking with your healthcare provider may be one way to find a therapist to talk to. Other ways of finding help can be through referrals to mental health providers in online diabetes communities, or by searching the databases listed at the end of this story to find a provider near you who may be available for in-person or virtual visits for mental health.
Also, finding a therapist you are comfortable with, and who accepts your health insurance or is otherwise offering a smooth process to access care, is important.
It can take some time, but “finding a good therapist is like finding a good pair of jeans,” said Madikoto. “If you put it on, it should fit. You and your therapist should be able to bond, and the therapist should be able to extrapolate from you the information they need to get you to where you need to get to. It’s a very personal thing, and you’re the only one who will know if the jeans will fit. That’s how you need to be with your therapist.”
Ways to deal from people with diabetes
Those who live with diabetes and depression and/or anxiety share their insights about what works best for them.
“The most impactful advice I can give is to do today what will make you feel better tomorrow,” said Deanna Glick, who lives in Leesburg, Virginia. She has lived with type 1 diabetes for 30 years and was diagnosed with anxiety and depression 23 years ago. “I learned this from my current therapist. This way, each decision can be made with that goal in mind. It doesn’t always work perfectly and not every day is managed perfectly, but I come back to that concept, and it helps.”
That can mean going to sleep and not staying up later to watch another episode of a TV show, drinking water, eating a vegetable, going for a walk, or meditating when it is time to make a choice about what to do with your time.
“I prioritize mental health care so that I am capable of physical health care and operate based on the understanding that physical health care impacts mental health,” she said.
Being able to recognize the emotions that come with living with diabetes, and finding a supportive space to talk through them, can be helpful for some.
“This disease is hella burdensome on all those involved, and we need to take it in stride,” said Christine Brown, who has lived with type 1 diabetes for 20 years and lives with generalized anxiety disorder as well as an eating disorder triggered by diabetes. “We need a space to feel crappy about it sometimes and dwell in the difficulties, especially when times are tough, without people saying, ‘it’s going to be okay,’ because it isn’t. It’s forever and that’s a hard pill to swallow. Burnout is going to come and go and we need a supportive space to feel the negative emotions and to talk through them, even if there isn’t a nice, easy answer.”
Brown said her husband has been great because “he lets me rant and complain when things are really hard,” she said. “He just listens and tries to help me problem-solve blood sugar drama even though he may not fully understand.”
Glick agreed that having someone to listen to you is essential. “It’s not helpful for friends to advise you to ‘stay positive.’ That is not how it works,” she said. “I’ve found following social media groups, even if I don’t engage, is helpful to see relatable comments. My therapists—I’ve had four in my life so far—have been the key to everything. The one I was seeing when I was diagnosed with depression and anxiety in my 20s and still trying to do too much personally and professionally, told me very bluntly one day, ‘You are going to have to live your life differently.’ She was right and I’ve come a long way in resolving a lot of issues that contributed to my anxiety and depression.”
For Rose, “I firmly believe that mental health care for people with diabetes is as important as physical health care,” she said. “There is no shame in wanting to take steps to manage your mental health in order to improve your physical health and your quality of life.”
Resources for finding a mental health provider
American Diabetes Association’s searchable database for therapists who work with adults and/or children, searchable by zip code and telehealth providers.
Database from Psychology Today with searchable database by zip code and type of provider. Can also search for therapists who list diabetes in their business name, as well as therapists near you who specialize in chronic illness issues.
Behavioral Diabetes Institute – A California-based nonprofit focused on tools to face the psychological demands of diabetes.
988 National Suicide & Crisis Hotline that sends callers to the National Suicide Prevention Hotline in the United States.