Daniel Sher discusses the common forms of mental illness that people with diabetes may encounter, why diabetes and mental illness are linked, and pointers for getting help.

As people with diabetes, we’re well aware that we risk running into medical complications later down the line, if we don’t get the right support for our condition. We’ve all heard about retinopathy, foot damage, kidney issues and so on. Why then, are we not talking about the impact that this condition can have on the brain?

Common culprits

As people with diabetes (Type 1 or Type 2), we are more likely to develop certain forms of mental illness. Why is this the case? Well, quite simply, diabetes is a hugely challenging condition to live with. If we don’t have the right support, we can become overwhelmed by the burden of this condition.

At the same time, though, we are vulnerable to mental illness because of the way in which blood glucose fluctuations affect the parts of our brain that are responsible for mood and cognition. As a result, many people with diabetes will encounter struggles with the following:

Clinical Depression (or Major Depressive Disorder)

Depression involves a deep and unrelenting fog of sadness. Other symptoms include a loss of pleasure in previously enjoyable activities, concentration difficulties, fatigue, low sex drive, insomnia, shifts in appetite and significant changes in body weight. Research suggests that people with diabetes are two to three times more likely to develop depression.

Anxiety Disorders

We’ve all felt stressed out from time-to-time. But if your stress levels are extreme and you are feeling this way all or most of the time, you may have an anxiety disorder. People with anxiety struggle immensely to stop themselves from worrying. In some cases, they may experience panic attacks: brief episodes of intense fear and physical reactions that seem to come out of nowhere.

How common are anxiety disorders in people with diabetes? Research suggests that 14% of us have a diagnosed anxiety disorder. Anxiety has a negative impact on glucose control due to the release of stress hormones and the fact that anxiety stops us from engaging in healthy behaviours.

Eating Disorders

Given how much emphasis is placed on our dietary intake, it’s no surprise that we risk developing disordered relationships to food and eating. We are constantly exposed to reminders that we need to watch what we eat, which leads some to feel that their value as a person is linked to their diet and blood glucose levels.

We also encounter so much stigma, blame and judgment when it comes to our dietary choices, which results in huge doses of shame – an emotion which often drives eating disorders. People with diabetes, therefore, are at risk of developing conditions, such as anorexia, diabulimia (intentional insulin restriction for weight loss) and binge-eating disorder.

What about sugar addiction?

Is food addiction real? Although this has not yet been recognised as a formal psychiatric disorder (more research is needed), there is a good body of evidence to suggest that certain foods release dopamine in a way that can hijack the brain’s reward centres, mirroring the effect that drugs and alcohol have on our brain.

For people with diabetes, an unhealthy relationship with food can set you up to experience some serious difficulties, both in terms of your mental health and your diabetes management.

Signs of sugar addiction include intense cravings, binge-eating, emotional eating, feelings of withdrawal and a sense of being completely out of control with regards to your diet.

In particular, foods that are high in sugar are more likely to affect the brain in this way, because of the rush that they provide. Remember, high sugar foods do not always taste sweet: starchy complex carbs, such as white rice, bread, pap, potatoes and pasta are all culprits here.

Is diabetes burnout a mental illness?

No: diabetes burnout is a natural response to living with a hugely challenging condition. People with diabetes burnout tend to feel overwhelmed and powerless when it comes to their diabetes management and lifestyle. They may find themselves skipping doctor’s appointments or intentionally avoiding glucose monitoring.

Although diabetes burnout is not a psychological disorder, it can cause massive blood glucose fluctuations which render a person’s brain that much more vulnerable to depression and anxiety.

Can mental illness cause diabetes?

The answer is yes: having a psychiatric disorder puts you at risk for Type 2 diabetes. Why? Medications which people take for certain conditions (like bipolar or psychosis) can trigger the development of diabetes.

At the same time, people who are struggling with a mental illness may find it harder to engage in behaviours that reduce the risk of developing Type 2 diabetes, such as frequent exercise, abstaining from drugs, cigarettes and alcohol, and making healthy food choices.

Finally, having a psychiatric disorder can change the way that your body and brain metabolise food for energy. This can make a diabetes diagnosis more likely.

How to get help

Do you feel like your emotional difficulties are stopping you from looking after your physical health? Do you often feel alone and overwhelmed? Are you mentally uncomfortable, despite your efforts at changing your lifestyle and mindset? Have you ever contemplated suicide?

If you answered yes to any of these questions, it’s advisable to get some support. Start by reaching out to your general practitioner or diabetes specialist, so that you can ask for a referral to a clinical psychologist and, if needed, a psychiatrist.

How can psychology sessions help?

If you have diabetes and an additional psychological disorder, there are various ways in which talk therapy can help. In my own practice, I use Diabetes Focused Psychotherapy,which is an individualised treatment plan designed around the specific diabetes and mental health needs of each client that I work with.

Diabetes Focused Psychotherapy draws on several other therapy approaches, including:

Motivational Interviewing helps people to change their behaviour by resolving their ambivalence and generating motivation.

Cognitive-Behavioural Therapy empowers you to take control of unhelpful thinking patterns which lead to unpleasant emotions (like hopelessness or frustration) and unhelpful behaviours (like binge-eating and avoiding testing).

Mindfulness-Based Stress Reduction involves using mindfulness meditation techniques to help improve psychological resilience.

Psychoanalytic Psychotherapy helps you to understand how past experiences and unconscious dynamics impact your life in the present. This involves helping a person to understand and take ownership of diabetes in relation to their identity, while also addressing patterns of unhelpful behaviour, such as self-sabotage and denial.  

Play Therapy and Family Therapy are useful approaches for helping children or adolescents to cope with diabetes.

Dialectical Behaviour Therapy is an approach which helps people to regulate their emotions and overcome eating disorders and/or other forms of self-harm.

Summing up

As people with diabetes, we have a higher risk for developing certain forms of mental illness. Managing a psychological disorder in addition to diabetes is never easy. Furthermore, suffering through such a condition can take a serious toll on your diabetes management and physical health. For these reasons, we need to keep an eye out for the signs of psychological distress; and we need to reach out for support when necessary. Know this: all of the disorders discussed in this article can be treated. With the right support, you can find a way to thrive with diabetes.

References

• Ali, S., Stone, M. A., Peters, J. L., Davies, M. J., & Khunti, K. (2006). The prevalence of co‐morbid depression in adults with Type 2 diabetes: a systematic review and meta‐analysis. Diabetic medicine, 23(11), 1165-1173.
• Gearhardt, A. N., Yokum, S., Orr, P. T., Stice, E., Corbin, W. R & Brownell, K. D. (2011). Neural correlates of food addiction. Archives of general psychiatry, 68(8), 808-816.
• Grigsby, A. B., Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2002). Prevalence of anxiety in adults with diabetes: a systematic review. Journal of psychosomatic research, 53(6), 1053-1060.
• McIntyre, R. S., Kenna, H. A., Nguyen, H. T., Law, C. W., Sultan, F., Woldeyohannes, H. O., … & Rasgon, N. L. (2010). Brain volume abnormalities and neurocognitive deficits in diabetes mellitus: points of pathophysiological commonality with mood disorders? Advances in therapy, 27(2), 63-80.
• Polonsky, W. H., Fisher, L., Earles, J., Dudl, R. J., Lees, J., Mullan, J., & Jackson, R. A. (2005). Assessing psychosocial distress in diabetes: development of the diabetes distress scale. Diabetes care, 28(3), 626-631.

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Lynette Lacock explains how cannabis has been used as medication in the past and the use of it for treatment of peripheral neuropathy today.

Brief history of cannabis as a medication

As far back as I can remember, cannabis was something to avoid if you were a law abiding citizen. It was illegal for most of my lifetime and considered a gateway drug, leading to all sorts of problems for those that used it.

Now all you read about these days is how cannabis helps this and that. So, how did it go from zero to hero in what seems like a relatively short period of time? Believe it or not, throughout history cannabis was more often the hero. The first documented use of cannabis for medicinal purposes was in Asia in 2800 BC by Emperor Shen Nung, the patriarch of Chinese medicine.

From that period onward it was also used for medicinal purposes by the Greeks, Romans, Indians and the British, just to name a few.  The Khoisan people were using it long before Europeans landed on the shores of Africa. It was even rumoured to have been used by Queen Victoria for menstrual cramps.

Labelled a dangerous drug

Eventually in the early 1900s it was labelled a dangerous drug and became heavily taxed, regulated and eventually outlawed in some Western countries.

In 1921, it was outlawed in South Africa under the Customs and Excise Duty Act. Some of the many reasons for this were due to an increase in recreational use, its link to crime and pressure from political and religious groups to have it banned.

Continued research

After the introduction of stronger pain medication, such as aspirin and opioids, cannabis was deemed no longer useful as a medicine and it was removed from most pharmacopeia.

Scientists still continued their research into the possible uses for cannabis. They isolated the compound cannabidiol (CBD) in the 1940s and tetrahydrocannabinol (THC) in 1964. It wasn’t until the 1980s that they discovered receptors for both of these in the human body. Finally, they were able to start to determine some of the effects these two substances had on humans.

Various Acts passed

In 1996 the Compassionate Use Act was passed in California (US) permitting medicinal use of cannabis for epilepsy unresponsive to other medications. Since that time the list of conditions it can be used for has grown along with the number of States that conceded to the Act.

In 2016 the Adult Use of Marijuana Act was passed in California.  Again other States followed suite. Many other countries around the world have also decriminalised it or legalised the use of cannabis for medicinal purposes.

It wasn’t until 2018 that South Africa legalised the private cultivation, possession and personal use of cannabis under the Cannabis for Private Use bill. Parliament’s Justice and Constitutional Development committee are tasked with amending the act to legalise and regulate the cultivation of medicinal cannabis with consideration of legalising it for recreational use by the end of 2022. This is a potential R28 billion a year industry for the country, not to mention the much-needed jobs this could create.

Unfortunately, at this point in time you can only get a license to cultivate cannabis for medicinal purposes and require special permission to obtain it for medical use.

Research continues to shows that CBD and THC can have a therapeutic effect on many different ailments, such as how it can help reduce symptoms associated with peripheral neuropathies.

Peripheral neuropathy in people with diabetes

A neuropathy is a damaged nerve or group of nerves causing numbness, weakness and/or pain. Peripheral means something on the periphery, such as your feet, legs, hands and arms. Unfortunately, 60-70% of people with diabetes will develop some form of peripheral neuropathy.

Neuropathy symptoms can vary from a burning sensation, numbness, weakness, sensitivity to touch, decreased ability to feel temperature or shooting pain. Annoyingly, symptoms can become worse at night when you’re trying to sleep.

This nerve damage can happen after a prolonged period of time with high and uncontrolled blood glucose levels. The damage can be made worse if a person also has high cholesterol and high blood pressure because this can further compromise blood flow to the nerves.

The best way to avoid peripheral neuropathies is to monitor your chronic conditions and maintain a normal blood glucose level. Once a nerve is damaged it can’t be repaired and you’re only able to treat your present symptoms while trying to prevent them from getting worse.

Finding the right cannabis for your neuropathy pain

There have been multiple studies conducted that have shown cannabis can be effective in reducing the symptoms of peripheral neuropathies. Most studies were done with combination of prescription strength (Schedule 6) CBD and THC.

The general conclusions have been that it helps with pain relief and inflammation while the THC can decrease anxiety and alter the perception of pain. This is good news for those neuropathy sufferers that haven’t had relief with conventional medication.

At this time, over-the-counter products containing maximum 600 mg CBD with maximum 20 mg daily dose per pack and 10 parts per million or <0.001% of THC are available to the general public in South Africa.

You can find these products at pharmacies or health shops and you won’t need a prescription to buy them. They come in different forms such as creams, drops or sprays. You can approach your pharmacist for assistance in finding which one would work best for you. This is regulated by the South African Health Products Regulatory Authority (SAHPRA).

Obtaining prescription strength cannabis

However, if you find these products are not effective enough you can get your doctor to apply to SAHPRA requesting permission to obtain prescription strength cannabis.

With a Section 21 application, your doctor can request unregistered medication if you qualify. Medicinal cannabis approval is usually granted by SAHPRA for the following four diagnoses: HIV/AIDS, anxiety, cancer and chronic pain.

Once you receive approval under Section 21, you’re issued with a medical card and are able to fill your prescription.

Since all of these laws and regulations are fairly new, not all doctors are aware of how to go about this process. It was only in September 2021 that the first person in the country received approval for medicinal strength cannabis.

You can go into the following link to find a doctor near you that is aware of how to apply for a Section 21 application for you and then prescribe Schedule 6 cannabis once your application is approved.

If this seems like too much trouble, you may want to wait and see what happens later this year. Hopefully in the not-too-distant future, you will be able to go to your local GP for a prescription then have it filled at your local pharmacy.

References

• https://mg.co.za/news/2022-03-08-massive-breakthrough-in-cannabis-bill/
• Massive breakthrough in cannabis bill. (2022, March 8). The Mail & Guardian.
• https://www.sciencedirect.com/science/article/pii/S0925443920301162
• Maayah, Z. H., Takahara, S., Ferdaoussi, M., & Dyck, J. R. B. (2020). The molecular mechanisms that underpin the biological benefits of full-spectrum cannabis extract in the treatment of neuropathic pain and inflammation. Biochimica et Biophysica Acta (BBA) – Molecular Basis of Disease, 1866(7), 165771.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1760722/#__ffn_sectitle
• Pertwee, R. G. (2006). Cannabinoid pharmacology: The first 66 years. British Journal of Pharmacology, 147(Suppl 1), S163–S171. 
• https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/nerve-damage-diabetic-neuropathies
• Diabetic neuropathy | niddk. (n.d.). National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved May 9, 2022, from
• https://www.ccjm.org/content/85/12/943#:~:text=Small%20clinical%20studies%20have%20found,symptoms%20refractory%20to%20standard%20therapies.
• Modesto-Lowe, V., Bojka, R., & Alvarado, C. (2018). Cannabis for peripheral neuropathy: The good, the bad, and the unknown. Cleveland Clinic Journal of Medicine, 85(12), 943–949. 
• https://www.thesouthafrican.com/news/south-africa-has-legal-marijuana-prescription/

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