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October 27, 2016
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The Tip of the Iceberg

Just as hyperglycemia is but the tip of the iceberg when discussing the physical ravages of diabetes, depression is but the most visible diagnosis of how diabetes affects our minds.


I'm not talking about the temporary states of anxiety or paranoia, lassitude or somnolescence, that accompany our glycemic highs and lows, but the long-term, "you should get psychological help for this" effects of living with chronic disease in general, and diabetes in particular.


That people living with chronic diseases suffer higher rates of depression than the general population should come as no surprise to anyone even remotely familiar with social psychology and public health: we are living with the knowledge that, unlike the colds and sore throats everyone suffers from time to time, we will not "get better" in a week's, a month's, or even a year's time. Instead, we know that at some point in time, our conditions will deteriorate, and we can expect shorter remaining lifespans than our peers without those conditions. Along with this, our incomes are depressed in part because of the increased expense of medical care, and in part because of the additional time we must take off work for healthcare appointments, the unexpected overtime we can't work (because it would interfere with our medication schedules or because we have to plan our meals ahead of time), and the time we must take off because our chronic medical condition has made it impossible to get to work safely, or to be able to perform our jobs properly. We may be afraid to "come out of the insulin closet" to others, or unable to participate in social activities for want of appropriate food or interference with a meal or medication schedule. This further isolates us, a key factor in the development of depression.


While diabetes doesn't have the sort of periodic attacks and episodes that can have someone with lupus or rheumatoid arthritis out of commission for weeks, we do have the fear of overnight lows killing us in our sleep. These issues, because of their unpredictability, breed chronic anxiety another mental health issue.


Then there's the amount of measuring and logging we are expected to do whether it's the tracking of our blood glucose, food, or medication, the calculation and time-distribution of insulin doses, the juggling of medical appointments and medication-and-supply refills, or the analytical trend information we are expected to understand at a glance, the management of diabetes is said to require two hours per day. That's a lot of (arguably-unpaid) labor, eating up a lot of (what for others would be) free time, just to stay alive.


So, "properly" (or "optimally") managing our diabetes requires an obsessive attention to detail. That obsession can become a mental health issue in itself, growing into the inability to do anything other than log, worry, and research to the point of (arguable) cyberchondria. The diets we follow are prescribed and proscribed to the gram of food, the hundredth-unit of insulin, and blood glucose levels to the tens of milligrams per deciliter. In anyone without a chronic disease, this is considered a form of disordered eating known as "orthorexia". "Disordered eating" is the introductory chapter of eating disorders most of whose clinical diagnostic criteria prevent people from getting help until significant physical damage has resulted.


Orthorexia is hardly the only form of disordered eating associated with diabetes. Our society's obsession with weight causes many "well-padded" consumers of Novalog, Lantus, NPH, and so on to dial back their insulin dosage as a method of making their bodies "purge" the calories they've ingested. (This is the classical behavior of "diabulimia".) Others have been taught never to eat unless their blood glucose drops below certain strict set points which can be elevated by as little as a sip of sugar-free electrolyte fluid causing them to consume as few calories as someone living with anorexia nervosa. Then again, our prediagnosis preferences for foods generally considered unhealthy or dangerous for people with diabetes may cause us to binge on them, leading to binge eating disorders and their associated glycemic spikes and dips.


This obsessive, intense attention we must direct towards simply staying alive is simply more than the human brain was wired to do. As a result, we grow tired of logging, saying no, being isolated, being short of funds, and not being able to eat, drink, and exercise "like normal people" that we suffer burnout which looks very much like a subset of depressive behaviors.


Fear and anxiety, burnout and depression, obsession, and disordered eating all of these are mental health issues associated with having diabetes. I would argue they are less a result of the physical and hormonal effects of diabetes than of the psychological effects of managing diabetes.


This post was written for World Mental Health Day, October 10, 2011.

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