Heart attack, stroke, nerve damage.

These are just some of the complications for which millions of Americans with diabetes are at a higher risk.

According to a study led by the University of Michigan, individuals with chronic diabetes complications are more likely to have a mental health disorder, and vice versa.

Having a mental health condition also increases the risk of developing chronic complications of diabetes, meaning the relationship goes both ways.

“We wanted to determine whether chronic diabetes complications led to mental health disorders or if mental health disorders led to those diabetes complications. However, we found that both relationships are true,” said Brian Callaghan, M.D., M.S., senior author and Eva L. Feldman, M.D., Ph.D., Professor of Neurology at U-M Medical School.

“The findings highlight the importance of actively screening for mental health disorders in diabetes patients, in addition to screening for chronic complications, which is the recommended standard of care in diabetes.”

Three-times greater risk

The research team, led by Michigan Medicine and the Department of Biostatistics at the U-M School of Public Health, examined insurance claims data from over 500,000 individuals with type 1 or type 2 diabetes and 350,000 people without diabetes.

Results published in Diabetes Care indicate that individuals with chronic diabetes complications face an increased risk of experiencing a mental health condition such as anxiety or depression, with the risk rising as they age.

Those with mental health disorders were up to 2.5 times more likely to experience sustained diabetes complications.

In individuals under 60 years old, type 1 diabetes showed a stronger link to chronic complications, while type 2 diabetes was more associated with mental health challenges.

A possible reason for this bidirectional relationship, researchers say, may be that having a diabetes complication or mental health condition has direct effects on developing the other complication.

“For instance, a stroke causes detrimental effects on the brain, which may directly lead to depression,” Callaghan said. 

“And having a mental health condition and diabetes may affect a person’s self-management of their condition — like poor glycemic control or not taking medications — which, in turn, may increase their risk of diabetes complications.”

Common risk factors

The relationship may not always be straightforward. Diabetes complications and mental health conditions have common risk factors; obesity, glycemic control issues, and social determinants of health can all increase the likelihood of developing both comorbidities.

“First author Maya Watanabe, M.S., a biostatistician at the Harvard T.H. Chan School of Public Health and former graduate student research assistant at U-M, mentioned that the association we are seeing is most likely driven by a combination of direct and indirect effects as well as shared risk factors.”

Diabetes care providers can possibly prevent multiple complications by addressing shared risk factors simultaneously.

In an 18-month period, as many as 50% of individuals with diabetes may experience distress related to their condition, according to the CDC.

Several national diabetes centers have implemented screening for depression and distress in their patients, but there is no standardized mental health screening process in diabetes care.

The researchers point out that additional resources will be necessary to screen and manage mental health conditions, as many clinicians who manage diabetes lack specific training to accurately identify and treat them.

Mental health care

“The U.S. Preventive Services Task Force emphasizes that patients who screen positive for mental health conditions should receive appropriate diagnosis and evidence-based treatment, or be referred to a facility that can provide the necessary care.”

“Primary care providers and endocrinologists are already overworked. Therefore, systems of care need to be in place to help provide mental health care when needed,” said Dr. Eva Feldman, co-author of the statement. Dr. Feldman is the Director of the ALS Center of Excellence and James W. Albers Distinguished University Professor at U-M.

“These systems should include mental health screening, easily accessible insurance coverage for mental health services, and physician and patient education programs. Action is needed, and our new research further proves that this action must occur now.”