Jeff Susman, MD

September 11, 2001. I first learned the news during our departmental leadership meeting. Like the day President Kennedy was assassinated, this date and the images of the horrific assaults in New York, Washington, and Pennsylvania are burned into the American psyche. The subsequent spread of anthrax-laden letters heightened concerns that our health system was ill-equipped to deal with new global challenges to the public’s wellbeing. And most recently, a worldwide outbreak of a new respiratory illness, SARS, has shown the potential for rapid spread of a potentially fatal infectious disease.

Most physicians don’t need to be convinced that public health is of increasing importance to society. In addition to our daily battles with sexually transmitted disease, tuberculosis, and counseling vacation-goers preparing for a cruise, we are challenged to keep up with the latest immunization guidelines, preventive services recommendations, and even the definition of hypertension.

Against this backdrop, The journal of family practice is initiating a new feature—Practice Alert (“New JFP series on timely clinical issues,” pages 526–527 and “SARS: Lessons learned thus far,” pages 528–530)—that will address the intersection between medicine and public health. I trust this feature will be both practical and thought-provoking. As always, your feedback is greatly appreciated.

September 11, 2001. I first learned the news during our departmental leadership meeting. Like the day President Kennedy was assassinated, this date and the images of the horrific assaults in New York, Washington, and Pennsylvania are burned into the American psyche. The subsequent spread of anthrax-laden letters heightened concerns that our health system was ill-equipped to deal with new global challenges to the public’s wellbeing. And most recently, a worldwide outbreak of a new respiratory illness, SARS, has shown the potential for rapid spread of a potentially fatal infectious disease.

Most physicians don’t need to be convinced that public health is of increasing importance to society. In addition to our daily battles with sexually transmitted disease, tuberculosis, and counseling vacation-goers preparing for a cruise, we are challenged to keep up with the latest immunization guidelines, preventive services recommendations, and even the definition of hypertension.

Against this backdrop, The journal of family practice is initiating a new feature—Practice Alert (“New JFP series on timely clinical issues,” pages 526–527 and “SARS: Lessons learned thus far,” pages 528–530)—that will address the intersection between medicine and public health. I trust this feature will be both practical and thought-provoking. As always, your feedback is greatly appreciated.

September 11, 2001. I first learned the news during our departmental leadership meeting. Like the day President Kennedy was assassinated, this date and the images of the horrific assaults in New York, Washington, and Pennsylvania are burned into the American psyche. The subsequent spread of anthrax-laden letters heightened concerns that our health system was ill-equipped to deal with new global challenges to the public’s wellbeing. And most recently, a worldwide outbreak of a new respiratory illness, SARS, has shown the potential for rapid spread of a potentially fatal infectious disease.

Most physicians don’t need to be convinced that public health is of increasing importance to society. In addition to our daily battles with sexually transmitted disease, tuberculosis, and counseling vacation-goers preparing for a cruise, we are challenged to keep up with the latest immunization guidelines, preventive services recommendations, and even the definition of hypertension.

Against this backdrop, The journal of family practice is initiating a new feature—Practice Alert (“New JFP series on timely clinical issues,” pages 526–527 and “SARS: Lessons learned thus far,” pages 528–530)—that will address the intersection between medicine and public health. I trust this feature will be both practical and thought-provoking. As always, your feedback is greatly appreciated.

Imagine you are Rip Van Winkle, MD, waking from a 20-year sleep to hear that the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has released its 7th report.¹ You wouldn’t be surprised to learn that diuretics are first-line therapy for hypertension, a systolic blood pressure of >140 mm Hg is a more important risk factor than elevated diastolic blood pressure, and that patients will achieve goal blood pressure only if they are motivated.

Moreover, you probably wouldn’t be surprised to learn that hypertension has now been characterized as a “lifestyle syndrome”² associated with our insatiable appetites for too many calories, too much alcohol, too much salt, too much fat, too much tobacco—simply too much!

Speaking of excess, JNC VII informs us that people who are normotensive at age 55 have a 90% lifetime risk for developing hypertension, and that those with a blood pressure of 120–139 mm Hg systolic or 80–89 mm Hg diastolic blood pressure are now “prehypertensive” and should adopt lifestyle modifications. Such figures are downright depressing. I have a hard enough time getting patients to lose weight, reduce dietary sodium, and engage in physical activity when they have a disease, let alone a “predisease.”

Commenting on JNC VII in JAMA, Dr Thomas Kottke and colleagues state that “technologies are available to detect, treat, and control hypertension … delivery systems are also available. What is unclear is the degree of the will to succeed.…” I hope they are correct: that hypertension control is simply a “problem of technology transfer.” I remain suspicious, however, about such blithe pronouncements. Sure, interventions in North Karelia, Finland, and Olmstead County, Minnesota, where a managed care environment prevails, can be successful. I just wish I felt more optimistic about replicating these outcomes in the typical family practice while seeing 6 patients hourly.

Perhaps as Dr Kottke suggests, it’s simply a matter of “the will to succeed, which requires devoting the resources, organizing the treatment systems, and creating the environments that allow patients and clinicians to cross the hypertension quality chasm.”

And your next thought as Dr Van Winkle, just before you curl up for another 20 years, might be “I’ve heard this all before.”

Imagine you are Rip Van Winkle, MD, waking from a 20-year sleep to hear that the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has released its 7th report.¹ You wouldn’t be surprised to learn that diuretics are first-line therapy for hypertension, a systolic blood pressure of >140 mm Hg is a more important risk factor than elevated diastolic blood pressure, and that patients will achieve goal blood pressure only if they are motivated.

Moreover, you probably wouldn’t be surprised to learn that hypertension has now been characterized as a “lifestyle syndrome”² associated with our insatiable appetites for too many calories, too much alcohol, too much salt, too much fat, too much tobacco—simply too much!

Speaking of excess, JNC VII informs us that people who are normotensive at age 55 have a 90% lifetime risk for developing hypertension, and that those with a blood pressure of 120–139 mm Hg systolic or 80–89 mm Hg diastolic blood pressure are now “prehypertensive” and should adopt lifestyle modifications. Such figures are downright depressing. I have a hard enough time getting patients to lose weight, reduce dietary sodium, and engage in physical activity when they have a disease, let alone a “predisease.”

Commenting on JNC VII in JAMA, Dr Thomas Kottke and colleagues state that “technologies are available to detect, treat, and control hypertension … delivery systems are also available. What is unclear is the degree of the will to succeed.…” I hope they are correct: that hypertension control is simply a “problem of technology transfer.” I remain suspicious, however, about such blithe pronouncements. Sure, interventions in North Karelia, Finland, and Olmstead County, Minnesota, where a managed care environment prevails, can be successful. I just wish I felt more optimistic about replicating these outcomes in the typical family practice while seeing 6 patients hourly.

Perhaps as Dr Kottke suggests, it’s simply a matter of “the will to succeed, which requires devoting the resources, organizing the treatment systems, and creating the environments that allow patients and clinicians to cross the hypertension quality chasm.”

And your next thought as Dr Van Winkle, just before you curl up for another 20 years, might be “I’ve heard this all before.”

Imagine you are Rip Van Winkle, MD, waking from a 20-year sleep to hear that the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has released its 7th report.¹ You wouldn’t be surprised to learn that diuretics are first-line therapy for hypertension, a systolic blood pressure of >140 mm Hg is a more important risk factor than elevated diastolic blood pressure, and that patients will achieve goal blood pressure only if they are motivated.

Moreover, you probably wouldn’t be surprised to learn that hypertension has now been characterized as a “lifestyle syndrome”² associated with our insatiable appetites for too many calories, too much alcohol, too much salt, too much fat, too much tobacco—simply too much!

Speaking of excess, JNC VII informs us that people who are normotensive at age 55 have a 90% lifetime risk for developing hypertension, and that those with a blood pressure of 120–139 mm Hg systolic or 80–89 mm Hg diastolic blood pressure are now “prehypertensive” and should adopt lifestyle modifications. Such figures are downright depressing. I have a hard enough time getting patients to lose weight, reduce dietary sodium, and engage in physical activity when they have a disease, let alone a “predisease.”

Commenting on JNC VII in JAMA, Dr Thomas Kottke and colleagues state that “technologies are available to detect, treat, and control hypertension … delivery systems are also available. What is unclear is the degree of the will to succeed.…” I hope they are correct: that hypertension control is simply a “problem of technology transfer.” I remain suspicious, however, about such blithe pronouncements. Sure, interventions in North Karelia, Finland, and Olmstead County, Minnesota, where a managed care environment prevails, can be successful. I just wish I felt more optimistic about replicating these outcomes in the typical family practice while seeing 6 patients hourly.

Perhaps as Dr Kottke suggests, it’s simply a matter of “the will to succeed, which requires devoting the resources, organizing the treatment systems, and creating the environments that allow patients and clinicians to cross the hypertension quality chasm.”

And your next thought as Dr Van Winkle, just before you curl up for another 20 years, might be “I’ve heard this all before.”

On page 380 of this issue of The journal of family practice, Dr. William Cayley highlights one of the major challenges of evidence-based medicine: translating evidence for patients in a way that is not unduly influenced by our own values, biases, and expectations. We face this challenge every day.

Recently I saw a patient with uncomplicated low back pain who wanted me to prescribe a muscle relaxant. Another person, after experiencing a first episode of major depressive disorder, requested lifelong antidepressant therapy. An older woman wanted advice about treatment for shingles.

The difficulty I encountered lay neither with the availability of authoritative, explicit evidence-based summaries on these topics, nor with my knowledge of the evidence in these areas. The dilemma was that most studies, I suspect, were of patients unlike the 3 individuals in my care, and that I had little more than anecdotal information about the potential harms the interventions might cause these patients. Moreover, in such instances, how much should patients’ preferences count?

Should I divulge that trials of muscle relaxants are equivocal at best, and share my belief that muscle relaxants do little more than make a person sleepy?¹ How should I frame the current recommendation that maintenance therapy for depression be considered after the second or third episode of major depressive disorder?² And, for the woman with herpes zoster, what to make of the tradeoffs of various therapies versus watchful waiting?³

All this information to convey to my patients, and I was running late for a meeting with the Dean. If you are like me, many days the practice of evidence-based medicine feels like the holey grail.

No, I haven’t become disillusioned with evidence-based medicine—just comfortable that there will always be a need for family physicians to translate the best evidence to our patients, as biased and value-laden as our recommendations may be.

What are your observations about actually practicing evidence-based medicine? Drop me an e-mail at jfp@fammed.uc.edu, and I will share the results in an upcoming issue.

On page 380 of this issue of The journal of family practice, Dr. William Cayley highlights one of the major challenges of evidence-based medicine: translating evidence for patients in a way that is not unduly influenced by our own values, biases, and expectations. We face this challenge every day.

Recently I saw a patient with uncomplicated low back pain who wanted me to prescribe a muscle relaxant. Another person, after experiencing a first episode of major depressive disorder, requested lifelong antidepressant therapy. An older woman wanted advice about treatment for shingles.

The difficulty I encountered lay neither with the availability of authoritative, explicit evidence-based summaries on these topics, nor with my knowledge of the evidence in these areas. The dilemma was that most studies, I suspect, were of patients unlike the 3 individuals in my care, and that I had little more than anecdotal information about the potential harms the interventions might cause these patients. Moreover, in such instances, how much should patients’ preferences count?

Should I divulge that trials of muscle relaxants are equivocal at best, and share my belief that muscle relaxants do little more than make a person sleepy?¹ How should I frame the current recommendation that maintenance therapy for depression be considered after the second or third episode of major depressive disorder?² And, for the woman with herpes zoster, what to make of the tradeoffs of various therapies versus watchful waiting?³

All this information to convey to my patients, and I was running late for a meeting with the Dean. If you are like me, many days the practice of evidence-based medicine feels like the holey grail.

No, I haven’t become disillusioned with evidence-based medicine—just comfortable that there will always be a need for family physicians to translate the best evidence to our patients, as biased and value-laden as our recommendations may be.

What are your observations about actually practicing evidence-based medicine? Drop me an e-mail at jfp@fammed.uc.edu, and I will share the results in an upcoming issue.

On page 380 of this issue of The journal of family practice, Dr. William Cayley highlights one of the major challenges of evidence-based medicine: translating evidence for patients in a way that is not unduly influenced by our own values, biases, and expectations. We face this challenge every day.

Recently I saw a patient with uncomplicated low back pain who wanted me to prescribe a muscle relaxant. Another person, after experiencing a first episode of major depressive disorder, requested lifelong antidepressant therapy. An older woman wanted advice about treatment for shingles.

The difficulty I encountered lay neither with the availability of authoritative, explicit evidence-based summaries on these topics, nor with my knowledge of the evidence in these areas. The dilemma was that most studies, I suspect, were of patients unlike the 3 individuals in my care, and that I had little more than anecdotal information about the potential harms the interventions might cause these patients. Moreover, in such instances, how much should patients’ preferences count?

Should I divulge that trials of muscle relaxants are equivocal at best, and share my belief that muscle relaxants do little more than make a person sleepy?¹ How should I frame the current recommendation that maintenance therapy for depression be considered after the second or third episode of major depressive disorder?² And, for the woman with herpes zoster, what to make of the tradeoffs of various therapies versus watchful waiting?³

All this information to convey to my patients, and I was running late for a meeting with the Dean. If you are like me, many days the practice of evidence-based medicine feels like the holey grail.

No, I haven’t become disillusioned with evidence-based medicine—just comfortable that there will always be a need for family physicians to translate the best evidence to our patients, as biased and value-laden as our recommendations may be.

What are your observations about actually practicing evidence-based medicine? Drop me an e-mail at jfp@fammed.uc.edu, and I will share the results in an upcoming issue.

From its beginnings in the late 1950s, telemedicine has grown to encompass services ranging from remote psychotherapy to teleradiology.¹ Despite increasing penetration of telemedicine services, a recent Cochrane Review of the relative effects and costs of telemedicine versus face-to-face care suggests that more studies are warranted before policymakers fully embrace this technology.²

In this issue of the Journal of Family Practice, Ferris and colleagues demonstrate the feasibility and efficacy of telecolposcopy, providing another demonstration of telemedicine services to remote and rural populations.³ Of note, telecolposcopy performed better than cervicography and almost as well as on-site colposcopy, with no significant difference in sensitivity or specificity, and similar likelihood ratios for detecting all degrees of cervical intraepithelial neoplasia. What are we to make of such data?

Given the increasing burden on physicians serving rural communities and populations at risk, such findings are great news. While satisfaction with telemedicine is generally high, the initial cost of capitalization, reimbursement, and licensing challenges, as well as the threat of malpractice, continue to be substantial barriers to the diffusion of this technology.¹

While informatics continues to advance and reimbursement policies change, access to specialized teleservices remains a challenge for many patients.⁴ Ferris and colleagues are to be commended for providing further evidence that telemedicine is feasible and results in high-quality care.

From its beginnings in the late 1950s, telemedicine has grown to encompass services ranging from remote psychotherapy to teleradiology.¹ Despite increasing penetration of telemedicine services, a recent Cochrane Review of the relative effects and costs of telemedicine versus face-to-face care suggests that more studies are warranted before policymakers fully embrace this technology.²

In this issue of the Journal of Family Practice, Ferris and colleagues demonstrate the feasibility and efficacy of telecolposcopy, providing another demonstration of telemedicine services to remote and rural populations.³ Of note, telecolposcopy performed better than cervicography and almost as well as on-site colposcopy, with no significant difference in sensitivity or specificity, and similar likelihood ratios for detecting all degrees of cervical intraepithelial neoplasia. What are we to make of such data?

Given the increasing burden on physicians serving rural communities and populations at risk, such findings are great news. While satisfaction with telemedicine is generally high, the initial cost of capitalization, reimbursement, and licensing challenges, as well as the threat of malpractice, continue to be substantial barriers to the diffusion of this technology.¹

While informatics continues to advance and reimbursement policies change, access to specialized teleservices remains a challenge for many patients.⁴ Ferris and colleagues are to be commended for providing further evidence that telemedicine is feasible and results in high-quality care.

From its beginnings in the late 1950s, telemedicine has grown to encompass services ranging from remote psychotherapy to teleradiology.¹ Despite increasing penetration of telemedicine services, a recent Cochrane Review of the relative effects and costs of telemedicine versus face-to-face care suggests that more studies are warranted before policymakers fully embrace this technology.²

In this issue of the Journal of Family Practice, Ferris and colleagues demonstrate the feasibility and efficacy of telecolposcopy, providing another demonstration of telemedicine services to remote and rural populations.³ Of note, telecolposcopy performed better than cervicography and almost as well as on-site colposcopy, with no significant difference in sensitivity or specificity, and similar likelihood ratios for detecting all degrees of cervical intraepithelial neoplasia. What are we to make of such data?

Given the increasing burden on physicians serving rural communities and populations at risk, such findings are great news. While satisfaction with telemedicine is generally high, the initial cost of capitalization, reimbursement, and licensing challenges, as well as the threat of malpractice, continue to be substantial barriers to the diffusion of this technology.¹

While informatics continues to advance and reimbursement policies change, access to specialized teleservices remains a challenge for many patients.⁴ Ferris and colleagues are to be commended for providing further evidence that telemedicine is feasible and results in high-quality care.

When we asked for reader feedback to The Journal of Family Practice January 2003 issue, I had assumed family physicians would be too busy to respond, even if enthusiastic. I was wrong! The response has been astounding.

More than 100 of you have volunteered for our “Virtual Editorial Board,” to provide focused opinion on a regular basis. Many more have told us what you like best about JFP, and have shared your thoughts on how we can improve.

Praise has been overwhelming for the changes introduced with the January 2003 issue, such as the larger typeface and reader-friendly organization of editorial elements. Practicality, readability, and ease-of-comprehension are ideas repeated in your letters and e-mails:

“I really enjoyed the new JFP issue! ... very innovative and much more useful ... at-a-glance reader friendly!”

“Wow! Terrific 1st new issue. Chock full of easy to read, clinically relevant stuff. Congratulations.”

“The January issue is particularly striking—read this one from cover to cover. It is very good.”

Of course, a few of you find the larger typeface “less scholarly,” and some lament the diminished number of original research papers in the journal. As the Chair of a department of family medicine, I understand this concern. As an educator, however, I also understand that medical education must be made meaningful to a broader audience of practicing clinicians. The goal of JFP is to offer readers the best evidence on clinical issues, and we remain committed to publishing research of a practical and immediately relevant nature. Research lacking these qualities will not be read by anyone. And what is not read cannot have an impact on practice. Have no doubt: JFP will maintain the highest level of scholarship.

Evidence-based medicine terms explained in every issue

One reader had the following to say:

“I like the new format. The authors do more of the work for me on evaluating the literature and drawing evidenced based conclusions.”This reader is referring to the strength-of-recommendation and level-of-evidence ratings throughout JFP. On that note, let me direct your attention to a new standing feature of JFP—a table of evidence-based terms (on page 239).

Evidence-based medicine has increasingly informed the character of medicine worldwide. But as EBM principles have been adopted, terminology, definitions, and rating systems have varied.

We in family medicine are working to make the EBM rating system a meaningful, consistent “language” across the discipline. For now, The Journal of Family Practice is using a simplified system derived from the Oxford Centre for Evidence-based Medicine. (More detailed definitions may be found at its website: http://minerva. minervation.com/cebm/.)

As always, I want to hear your comments and suggestions.

When we asked for reader feedback to The Journal of Family Practice January 2003 issue, I had assumed family physicians would be too busy to respond, even if enthusiastic. I was wrong! The response has been astounding.

More than 100 of you have volunteered for our “Virtual Editorial Board,” to provide focused opinion on a regular basis. Many more have told us what you like best about JFP, and have shared your thoughts on how we can improve.

Praise has been overwhelming for the changes introduced with the January 2003 issue, such as the larger typeface and reader-friendly organization of editorial elements. Practicality, readability, and ease-of-comprehension are ideas repeated in your letters and e-mails:

“I really enjoyed the new JFP issue! ... very innovative and much more useful ... at-a-glance reader friendly!”

“Wow! Terrific 1st new issue. Chock full of easy to read, clinically relevant stuff. Congratulations.”

“The January issue is particularly striking—read this one from cover to cover. It is very good.”

Of course, a few of you find the larger typeface “less scholarly,” and some lament the diminished number of original research papers in the journal. As the Chair of a department of family medicine, I understand this concern. As an educator, however, I also understand that medical education must be made meaningful to a broader audience of practicing clinicians. The goal of JFP is to offer readers the best evidence on clinical issues, and we remain committed to publishing research of a practical and immediately relevant nature. Research lacking these qualities will not be read by anyone. And what is not read cannot have an impact on practice. Have no doubt: JFP will maintain the highest level of scholarship.

Evidence-based medicine terms explained in every issue

One reader had the following to say:

“I like the new format. The authors do more of the work for me on evaluating the literature and drawing evidenced based conclusions.”This reader is referring to the strength-of-recommendation and level-of-evidence ratings throughout JFP. On that note, let me direct your attention to a new standing feature of JFP—a table of evidence-based terms (on page 239).

Evidence-based medicine has increasingly informed the character of medicine worldwide. But as EBM principles have been adopted, terminology, definitions, and rating systems have varied.

We in family medicine are working to make the EBM rating system a meaningful, consistent “language” across the discipline. For now, The Journal of Family Practice is using a simplified system derived from the Oxford Centre for Evidence-based Medicine. (More detailed definitions may be found at its website: http://minerva. minervation.com/cebm/.)

As always, I want to hear your comments and suggestions.

When we asked for reader feedback to The Journal of Family Practice January 2003 issue, I had assumed family physicians would be too busy to respond, even if enthusiastic. I was wrong! The response has been astounding.

More than 100 of you have volunteered for our “Virtual Editorial Board,” to provide focused opinion on a regular basis. Many more have told us what you like best about JFP, and have shared your thoughts on how we can improve.

Praise has been overwhelming for the changes introduced with the January 2003 issue, such as the larger typeface and reader-friendly organization of editorial elements. Practicality, readability, and ease-of-comprehension are ideas repeated in your letters and e-mails:

“I really enjoyed the new JFP issue! ... very innovative and much more useful ... at-a-glance reader friendly!”

“Wow! Terrific 1st new issue. Chock full of easy to read, clinically relevant stuff. Congratulations.”

“The January issue is particularly striking—read this one from cover to cover. It is very good.”

Of course, a few of you find the larger typeface “less scholarly,” and some lament the diminished number of original research papers in the journal. As the Chair of a department of family medicine, I understand this concern. As an educator, however, I also understand that medical education must be made meaningful to a broader audience of practicing clinicians. The goal of JFP is to offer readers the best evidence on clinical issues, and we remain committed to publishing research of a practical and immediately relevant nature. Research lacking these qualities will not be read by anyone. And what is not read cannot have an impact on practice. Have no doubt: JFP will maintain the highest level of scholarship.

Evidence-based medicine terms explained in every issue

One reader had the following to say:

“I like the new format. The authors do more of the work for me on evaluating the literature and drawing evidenced based conclusions.”This reader is referring to the strength-of-recommendation and level-of-evidence ratings throughout JFP. On that note, let me direct your attention to a new standing feature of JFP—a table of evidence-based terms (on page 239).

Evidence-based medicine has increasingly informed the character of medicine worldwide. But as EBM principles have been adopted, terminology, definitions, and rating systems have varied.

We in family medicine are working to make the EBM rating system a meaningful, consistent “language” across the discipline. For now, The Journal of Family Practice is using a simplified system derived from the Oxford Centre for Evidence-based Medicine. (More detailed definitions may be found at its website: http://minerva. minervation.com/cebm/.)

As always, I want to hear your comments and suggestions.

Type 2 diabetes mellitus is one of the most common and costly chronic diseases, afflicting 16 million people nationwide. According to American Diabetes Association statistics, the disease each year costs the United States more than $100 billion in health-care expenses and lost productivity.

Diabetes is associated with many psychiatric conditions, yet psychiatrists may not be aware that patients under treatment for mental disorders are suffering from diabetes or have problems related to their psychopharmacologic therapy. With changing criteria for the diagnosis of diabetes, new evidence about the prevention and treatment of this disease, and a growing link between diabetes and psychiatric issues, the practicing psychiatrist should be knowledgeable about such possible interactions.

The following three cases illustrate these challenges and offer pearls for patient management.

Case 1: Diabetes and depression

L.S., age 54, has a five-year history of type 2 diabetes. On referral, he presents with increasing lethargy, difficulty concentrating, and irritability. His mental status examination discloses anhedonia, moderate irritability, depressed mood, loss of appetite, and overall lethargy. He emphatically denies suicidal thoughts, but feels “overwhelmed with life.” His referring physician notes that he also suffers from hyperlipidemia and hypertension, and continues to smoke one pack per day. His current medications include atorvastatin, enalapril, glucophage, and one baby aspirin per day. His weight is 247 pounds. Other than mild background retinopathy and mild peripheral neuropathy, his last physical examination was normal. His last HbA1c was 8.8%, and his creatinine was 1.7.

How do you manage this patient?

The challenge Type 2 diabetes mellitus affects more than one in 17 persons in the U.S., and physicians diagnose approximately 800,000 cases yearly. Yet one third of individuals with diabetes are undiagnosed, and multiple studies suggest we are falling short of accepted guidelines for care. Diabetes remains the leading cause of blindness, renal failure, and non-traumatic amputation in adults. While care for patients with diabetes will largely fall to primary care physicians (it is the third most common problem seen by family physicians) and endocrinologists, psychiatrists will often also see these patients.

Case 1 concluded While this patient’s history clearly suggests major depressive disorder, the possibility of other medical complications (e.g., worsening renal function or lactic acidosis from metformin therapy) should be entertained. A serum lactate level was normal and a metabolic panel, including renal function, was stable. The patient responded well to the addition of a selective serotonin reuptake inhibitor (SSRI) for his major depressive disorder.

Comment Many patients with diabetes will present with symptoms and signs suggestive of depression and anxiety. Patients with diabetes are more likely to develop depression, a disorder that worsens the outcomes for such individuals. These patients are likely to take multiple medications and have many medical comorbidities. Therapy of psychiatric disorders in patients with diabetes may be complicated by drug-drug and drug-disease interactions. When patients with diabetes present with symptoms of a mental disorder, a careful assessment is essential.

Case 2: A patient on risperidone who develops diabetes

G.L., 47, has a longstanding history of schizophrenia. She has been on risperidone for one year and has done well, but has gained 14 pounds and now weighs 212 pounds. G.L. complains of difficulty seeing and returns for assessment. What next?

Psychiatric drug use and diabetes The incidence of mental health problems is increased in individuals with diabetes and psychiatric disorders may increase diabetic morbidity. Certain medications commonly used by psychiatrists may trigger diabetic complications and some hypoglycemic agents may be associated with potential drug-drug interactions or other difficulties (Tables 1 and 2).

Approximately 40% of patients with type 2 diabetes remain undiagnosed. It is estimated that diagnosis is delayed by 4 to 7 years after the development of their disease, and patients frequently present with established retinopathy, renal disease, or macrovascular disease. As the diagnostic criteria have changed and more patients are obese and lead sedentary lifestyles, the prevalence of recognized diabetes is increasing.

Table 1

Therapeutic options for type 2 diabetes treatment

Table 2

Selected psychiatric drugs that interact with diabetes agents and patients with diabetes

The growing association of impaired glucose tolerance with progression to diabetes, the availability of effective interventions, and the high burden of morbidity for unrecognized diabetes suggest that more aggressive screening may be warranted.

Case 2 concluded Weight gain associated with atypical antipsychotic agents is all too common, and will often tip a patient “over the edge” from impaired glucose tolerance to type 2 diabetes. G.L. was referred to her primary care physician for assessment. Her fasting blood glucose Commonly used psychiatric medications may cause weight gain that exacerbates or precipitates type 2 diabetes was 312. Repeat FBG was 299. An ophthalmologic evaluation disclosed background changes consistent with diabetic retinopathy. Type 2 diabetes was diagnosed.

This patient deserves aggressive attention to modifiable risk factors, and warrants therapy for diabetes. Appropriate modification of diet, exercise, smoking and other risk factors—and medical comanagement—are critical. This includes attention to the psychotropic drugs she is taking.

Comment Medications commonly used by psychiatrists (e.g., atypical antipsychotics) may be associated with weight gain that exacerbates or precipitates type 2 diabetes.

The psychiatrist also must be aware of other potential medical comorbidities of treatment. Drug-drug interactions may occur with agents that are hepatic metabolized, including commonly used therapies for bipolar disorder (Table 2).

Metglitinides are metabolized by the CYP-3A4 system and drugs such as barbiturates and carbamazepine may induce this enzyme and reduce effectiveness. MAO inhibitors are associated with hypoglycemia with a number of agents, including sulfonylureas, and highly protein-bound agents such as the MAO inhibitors may displace repaglinide and increase its hypoglycemic activity. Fluoxetine and other SSRIs may cause hypoglycemic unawareness. Oral hypoglycemia agents themselves can be associated with hypoglycemia, and the onset may be confused with anxiety or panic attacks. The older sulfonylureas may cause inappropriate ADH (SIADH). Biguanides are occasionally associated with potentially catastrophic lactic acidosis.

Case 3: Disordered eating in an adolescent with type 1 diabetes

B.C., a 17-year-old with type 1 diabetes mellitus, is referred to a psychiatrist for a possible eating disorder. She was diagnosed with diabetes when she was 4. Over the past year her diabetes self-care has become increasingly erratic. B.C.’s mother notes that the patient often skips her insulin altogether, is preoccupied with her weight, and consumes large amounts of junk food. B.C. also admits to purging when she has been particularly lax with her diet.

Interaction between psychiatric and endocrine disorders Disordered eating appears to be frequent in adolescent girls and women with diabetes. Conscious underdosing of insulin and irregular eating habits may occur when patients are concerned about their body image, feel a stigma about using insulin, or fear they won’t fit in with friends.

It also appears that depression may be associated with diabetes, perhaps through an intervening effect on diet and exercise. The incidence of depression in patients with diabetes is up to 28%, and women with diabetes appear to have a greater risk for depression than men. Patients with diabetes who are depressed are less likely to adhere to their diabetes program and more likely to have worse glycemic control and increasing risk of complications.

Case 3 concluded B.C. is concerned about weight gain, her friends making fun of her need for injections, and hypoglycemic reactions while playing varsity volleyball. Her concerns are explored and intensive counseling is undertaken. At the same time, she is referred to an endocrinologist for further evaluation, and the diabetes care team initiates therapy with an insulin pump.

After an initial rocky period, B.C.’s therapy is stabilized and her hypoglycemic episodes reduced. B.C. discusses her concerns with other teens in a diabetes support group and is introduced at the local college to a star volleyball player (who also suffers from diabetes). As B.C. graduates, she is offered a scholarship at a top university. Her HbA1c is at normal levels.

Comment Younger individuals with diabetes face substantial challenges in adjusting to their disease. The incidence of disordered eating, depression, anxiety, and adjustment disorders is increased.

What’s more, diabetes in children and adolescents affects the whole family. Parents and siblings are often stressed over the patient’s care needs and mood swings, and may also present with mental disorders.

Related resources Oriented to mental health issues

• Wirshing DA. Adverse effects of atypical antipschotics. J Clin Psych. 2001;62:(suppl 21)7-10.
• Goodnick PJ, Henry JH, Buki VMV. Treatment of depression in patients with diabetes mellitus. J Clin Psych. 1995;56:4,128-136.
• Carney C. Diabetes mellitus and major depressive disorder: an overview of prevalence, complications, and treatment. Depression Anxiety. 1998;7:149-157.
• Jacobson AM. The psychological care of patients with insulin-dependent diabetes mellitus. N Engl J Med. 1996;334(19), 1249-53.
• Glasgow RE, Fisher EB, Anderson BJ, et al. Behavioral science in diabetes. Contribution and opportunities. Diabetes Care. 1999;22(5):832-43.
• Hoffman RP. Eating disorders in adolescents with type 1 diabetes. Postgrad Med. 2001;109(4)67-74.
• Talbot F, Nouwen A. A review of the relationship between depression and diabetes in adults: is there a link? Diabetes Care. 2000;23(10):1556-62.
• Rubin RR, Peyrot M. Psychological issues and treatments for people with diabetes. J Clin Psychol. 2001;57(4):457-78.
• Golden MP. Special problems with children and adolescents with diabetes. Primary Care Clin. 1999; 26(4):885-94.

Drug brand names

• Alprazolam • Xanax
• Atorvastatin • Lipitor
• Bupropion • Wellbutrin
• Buspirone • Buspar
• Carbamazepine • Tegretol, Epitol, Atretol
• Enalapril • Vasotec
• Fluoxetine • Prozac
• Nefazodone • Serzone
• Phenytoin • Dilantin
• Risperidone • Risperdal
• Triazolam • Halcion
• Valproate • Depacon

Disclosure

The author reports that he has been a speaker or consultant for SmithKline Beecham, Organon, Wyeth-Ayerst Pharmaceuticals, and Pfizer.

Type 2 diabetes mellitus is one of the most common and costly chronic diseases, afflicting 16 million people nationwide. According to American Diabetes Association statistics, the disease each year costs the United States more than $100 billion in health-care expenses and lost productivity.

Diabetes is associated with many psychiatric conditions, yet psychiatrists may not be aware that patients under treatment for mental disorders are suffering from diabetes or have problems related to their psychopharmacologic therapy. With changing criteria for the diagnosis of diabetes, new evidence about the prevention and treatment of this disease, and a growing link between diabetes and psychiatric issues, the practicing psychiatrist should be knowledgeable about such possible interactions.

The following three cases illustrate these challenges and offer pearls for patient management.

Case 1: Diabetes and depression

L.S., age 54, has a five-year history of type 2 diabetes. On referral, he presents with increasing lethargy, difficulty concentrating, and irritability. His mental status examination discloses anhedonia, moderate irritability, depressed mood, loss of appetite, and overall lethargy. He emphatically denies suicidal thoughts, but feels “overwhelmed with life.” His referring physician notes that he also suffers from hyperlipidemia and hypertension, and continues to smoke one pack per day. His current medications include atorvastatin, enalapril, glucophage, and one baby aspirin per day. His weight is 247 pounds. Other than mild background retinopathy and mild peripheral neuropathy, his last physical examination was normal. His last HbA1c was 8.8%, and his creatinine was 1.7.

How do you manage this patient?

The challenge Type 2 diabetes mellitus affects more than one in 17 persons in the U.S., and physicians diagnose approximately 800,000 cases yearly. Yet one third of individuals with diabetes are undiagnosed, and multiple studies suggest we are falling short of accepted guidelines for care. Diabetes remains the leading cause of blindness, renal failure, and non-traumatic amputation in adults. While care for patients with diabetes will largely fall to primary care physicians (it is the third most common problem seen by family physicians) and endocrinologists, psychiatrists will often also see these patients.

Case 1 concluded While this patient’s history clearly suggests major depressive disorder, the possibility of other medical complications (e.g., worsening renal function or lactic acidosis from metformin therapy) should be entertained. A serum lactate level was normal and a metabolic panel, including renal function, was stable. The patient responded well to the addition of a selective serotonin reuptake inhibitor (SSRI) for his major depressive disorder.

Comment Many patients with diabetes will present with symptoms and signs suggestive of depression and anxiety. Patients with diabetes are more likely to develop depression, a disorder that worsens the outcomes for such individuals. These patients are likely to take multiple medications and have many medical comorbidities. Therapy of psychiatric disorders in patients with diabetes may be complicated by drug-drug and drug-disease interactions. When patients with diabetes present with symptoms of a mental disorder, a careful assessment is essential.

Case 2: A patient on risperidone who develops diabetes

G.L., 47, has a longstanding history of schizophrenia. She has been on risperidone for one year and has done well, but has gained 14 pounds and now weighs 212 pounds. G.L. complains of difficulty seeing and returns for assessment. What next?

Psychiatric drug use and diabetes The incidence of mental health problems is increased in individuals with diabetes and psychiatric disorders may increase diabetic morbidity. Certain medications commonly used by psychiatrists may trigger diabetic complications and some hypoglycemic agents may be associated with potential drug-drug interactions or other difficulties (Tables 1 and 2).

Approximately 40% of patients with type 2 diabetes remain undiagnosed. It is estimated that diagnosis is delayed by 4 to 7 years after the development of their disease, and patients frequently present with established retinopathy, renal disease, or macrovascular disease. As the diagnostic criteria have changed and more patients are obese and lead sedentary lifestyles, the prevalence of recognized diabetes is increasing.

Table 1

Therapeutic options for type 2 diabetes treatment

Table 2

Selected psychiatric drugs that interact with diabetes agents and patients with diabetes

The growing association of impaired glucose tolerance with progression to diabetes, the availability of effective interventions, and the high burden of morbidity for unrecognized diabetes suggest that more aggressive screening may be warranted.

Case 2 concluded Weight gain associated with atypical antipsychotic agents is all too common, and will often tip a patient “over the edge” from impaired glucose tolerance to type 2 diabetes. G.L. was referred to her primary care physician for assessment. Her fasting blood glucose Commonly used psychiatric medications may cause weight gain that exacerbates or precipitates type 2 diabetes was 312. Repeat FBG was 299. An ophthalmologic evaluation disclosed background changes consistent with diabetic retinopathy. Type 2 diabetes was diagnosed.

This patient deserves aggressive attention to modifiable risk factors, and warrants therapy for diabetes. Appropriate modification of diet, exercise, smoking and other risk factors—and medical comanagement—are critical. This includes attention to the psychotropic drugs she is taking.

Comment Medications commonly used by psychiatrists (e.g., atypical antipsychotics) may be associated with weight gain that exacerbates or precipitates type 2 diabetes.

The psychiatrist also must be aware of other potential medical comorbidities of treatment. Drug-drug interactions may occur with agents that are hepatic metabolized, including commonly used therapies for bipolar disorder (Table 2).

Metglitinides are metabolized by the CYP-3A4 system and drugs such as barbiturates and carbamazepine may induce this enzyme and reduce effectiveness. MAO inhibitors are associated with hypoglycemia with a number of agents, including sulfonylureas, and highly protein-bound agents such as the MAO inhibitors may displace repaglinide and increase its hypoglycemic activity. Fluoxetine and other SSRIs may cause hypoglycemic unawareness. Oral hypoglycemia agents themselves can be associated with hypoglycemia, and the onset may be confused with anxiety or panic attacks. The older sulfonylureas may cause inappropriate ADH (SIADH). Biguanides are occasionally associated with potentially catastrophic lactic acidosis.

Case 3: Disordered eating in an adolescent with type 1 diabetes

B.C., a 17-year-old with type 1 diabetes mellitus, is referred to a psychiatrist for a possible eating disorder. She was diagnosed with diabetes when she was 4. Over the past year her diabetes self-care has become increasingly erratic. B.C.’s mother notes that the patient often skips her insulin altogether, is preoccupied with her weight, and consumes large amounts of junk food. B.C. also admits to purging when she has been particularly lax with her diet.

Interaction between psychiatric and endocrine disorders Disordered eating appears to be frequent in adolescent girls and women with diabetes. Conscious underdosing of insulin and irregular eating habits may occur when patients are concerned about their body image, feel a stigma about using insulin, or fear they won’t fit in with friends.

It also appears that depression may be associated with diabetes, perhaps through an intervening effect on diet and exercise. The incidence of depression in patients with diabetes is up to 28%, and women with diabetes appear to have a greater risk for depression than men. Patients with diabetes who are depressed are less likely to adhere to their diabetes program and more likely to have worse glycemic control and increasing risk of complications.

Case 3 concluded B.C. is concerned about weight gain, her friends making fun of her need for injections, and hypoglycemic reactions while playing varsity volleyball. Her concerns are explored and intensive counseling is undertaken. At the same time, she is referred to an endocrinologist for further evaluation, and the diabetes care team initiates therapy with an insulin pump.

After an initial rocky period, B.C.’s therapy is stabilized and her hypoglycemic episodes reduced. B.C. discusses her concerns with other teens in a diabetes support group and is introduced at the local college to a star volleyball player (who also suffers from diabetes). As B.C. graduates, she is offered a scholarship at a top university. Her HbA1c is at normal levels.

Comment Younger individuals with diabetes face substantial challenges in adjusting to their disease. The incidence of disordered eating, depression, anxiety, and adjustment disorders is increased.

What’s more, diabetes in children and adolescents affects the whole family. Parents and siblings are often stressed over the patient’s care needs and mood swings, and may also present with mental disorders.

Related resources Oriented to mental health issues

• Wirshing DA. Adverse effects of atypical antipschotics. J Clin Psych. 2001;62:(suppl 21)7-10.
• Goodnick PJ, Henry JH, Buki VMV. Treatment of depression in patients with diabetes mellitus. J Clin Psych. 1995;56:4,128-136.
• Carney C. Diabetes mellitus and major depressive disorder: an overview of prevalence, complications, and treatment. Depression Anxiety. 1998;7:149-157.
• Jacobson AM. The psychological care of patients with insulin-dependent diabetes mellitus. N Engl J Med. 1996;334(19), 1249-53.
• Glasgow RE, Fisher EB, Anderson BJ, et al. Behavioral science in diabetes. Contribution and opportunities. Diabetes Care. 1999;22(5):832-43.
• Hoffman RP. Eating disorders in adolescents with type 1 diabetes. Postgrad Med. 2001;109(4)67-74.
• Talbot F, Nouwen A. A review of the relationship between depression and diabetes in adults: is there a link? Diabetes Care. 2000;23(10):1556-62.
• Rubin RR, Peyrot M. Psychological issues and treatments for people with diabetes. J Clin Psychol. 2001;57(4):457-78.
• Golden MP. Special problems with children and adolescents with diabetes. Primary Care Clin. 1999; 26(4):885-94.

Drug brand names

• Alprazolam • Xanax
• Atorvastatin • Lipitor
• Bupropion • Wellbutrin
• Buspirone • Buspar
• Carbamazepine • Tegretol, Epitol, Atretol
• Enalapril • Vasotec
• Fluoxetine • Prozac
• Nefazodone • Serzone
• Phenytoin • Dilantin
• Risperidone • Risperdal
• Triazolam • Halcion
• Valproate • Depacon

Disclosure

The author reports that he has been a speaker or consultant for SmithKline Beecham, Organon, Wyeth-Ayerst Pharmaceuticals, and Pfizer.

Type 2 diabetes mellitus is one of the most common and costly chronic diseases, afflicting 16 million people nationwide. According to American Diabetes Association statistics, the disease each year costs the United States more than $100 billion in health-care expenses and lost productivity.

Diabetes is associated with many psychiatric conditions, yet psychiatrists may not be aware that patients under treatment for mental disorders are suffering from diabetes or have problems related to their psychopharmacologic therapy. With changing criteria for the diagnosis of diabetes, new evidence about the prevention and treatment of this disease, and a growing link between diabetes and psychiatric issues, the practicing psychiatrist should be knowledgeable about such possible interactions.

The following three cases illustrate these challenges and offer pearls for patient management.

Case 1: Diabetes and depression

L.S., age 54, has a five-year history of type 2 diabetes. On referral, he presents with increasing lethargy, difficulty concentrating, and irritability. His mental status examination discloses anhedonia, moderate irritability, depressed mood, loss of appetite, and overall lethargy. He emphatically denies suicidal thoughts, but feels “overwhelmed with life.” His referring physician notes that he also suffers from hyperlipidemia and hypertension, and continues to smoke one pack per day. His current medications include atorvastatin, enalapril, glucophage, and one baby aspirin per day. His weight is 247 pounds. Other than mild background retinopathy and mild peripheral neuropathy, his last physical examination was normal. His last HbA1c was 8.8%, and his creatinine was 1.7.

How do you manage this patient?

The challenge Type 2 diabetes mellitus affects more than one in 17 persons in the U.S., and physicians diagnose approximately 800,000 cases yearly. Yet one third of individuals with diabetes are undiagnosed, and multiple studies suggest we are falling short of accepted guidelines for care. Diabetes remains the leading cause of blindness, renal failure, and non-traumatic amputation in adults. While care for patients with diabetes will largely fall to primary care physicians (it is the third most common problem seen by family physicians) and endocrinologists, psychiatrists will often also see these patients.

Case 1 concluded While this patient’s history clearly suggests major depressive disorder, the possibility of other medical complications (e.g., worsening renal function or lactic acidosis from metformin therapy) should be entertained. A serum lactate level was normal and a metabolic panel, including renal function, was stable. The patient responded well to the addition of a selective serotonin reuptake inhibitor (SSRI) for his major depressive disorder.

Comment Many patients with diabetes will present with symptoms and signs suggestive of depression and anxiety. Patients with diabetes are more likely to develop depression, a disorder that worsens the outcomes for such individuals. These patients are likely to take multiple medications and have many medical comorbidities. Therapy of psychiatric disorders in patients with diabetes may be complicated by drug-drug and drug-disease interactions. When patients with diabetes present with symptoms of a mental disorder, a careful assessment is essential.

Case 2: A patient on risperidone who develops diabetes

G.L., 47, has a longstanding history of schizophrenia. She has been on risperidone for one year and has done well, but has gained 14 pounds and now weighs 212 pounds. G.L. complains of difficulty seeing and returns for assessment. What next?

Psychiatric drug use and diabetes The incidence of mental health problems is increased in individuals with diabetes and psychiatric disorders may increase diabetic morbidity. Certain medications commonly used by psychiatrists may trigger diabetic complications and some hypoglycemic agents may be associated with potential drug-drug interactions or other difficulties (Tables 1 and 2).

Approximately 40% of patients with type 2 diabetes remain undiagnosed. It is estimated that diagnosis is delayed by 4 to 7 years after the development of their disease, and patients frequently present with established retinopathy, renal disease, or macrovascular disease. As the diagnostic criteria have changed and more patients are obese and lead sedentary lifestyles, the prevalence of recognized diabetes is increasing.

Table 1

Therapeutic options for type 2 diabetes treatment

Table 2

Selected psychiatric drugs that interact with diabetes agents and patients with diabetes

The growing association of impaired glucose tolerance with progression to diabetes, the availability of effective interventions, and the high burden of morbidity for unrecognized diabetes suggest that more aggressive screening may be warranted.

Case 2 concluded Weight gain associated with atypical antipsychotic agents is all too common, and will often tip a patient “over the edge” from impaired glucose tolerance to type 2 diabetes. G.L. was referred to her primary care physician for assessment. Her fasting blood glucose Commonly used psychiatric medications may cause weight gain that exacerbates or precipitates type 2 diabetes was 312. Repeat FBG was 299. An ophthalmologic evaluation disclosed background changes consistent with diabetic retinopathy. Type 2 diabetes was diagnosed.

This patient deserves aggressive attention to modifiable risk factors, and warrants therapy for diabetes. Appropriate modification of diet, exercise, smoking and other risk factors—and medical comanagement—are critical. This includes attention to the psychotropic drugs she is taking.

Comment Medications commonly used by psychiatrists (e.g., atypical antipsychotics) may be associated with weight gain that exacerbates or precipitates type 2 diabetes.

The psychiatrist also must be aware of other potential medical comorbidities of treatment. Drug-drug interactions may occur with agents that are hepatic metabolized, including commonly used therapies for bipolar disorder (Table 2).

Metglitinides are metabolized by the CYP-3A4 system and drugs such as barbiturates and carbamazepine may induce this enzyme and reduce effectiveness. MAO inhibitors are associated with hypoglycemia with a number of agents, including sulfonylureas, and highly protein-bound agents such as the MAO inhibitors may displace repaglinide and increase its hypoglycemic activity. Fluoxetine and other SSRIs may cause hypoglycemic unawareness. Oral hypoglycemia agents themselves can be associated with hypoglycemia, and the onset may be confused with anxiety or panic attacks. The older sulfonylureas may cause inappropriate ADH (SIADH). Biguanides are occasionally associated with potentially catastrophic lactic acidosis.

Case 3: Disordered eating in an adolescent with type 1 diabetes

B.C., a 17-year-old with type 1 diabetes mellitus, is referred to a psychiatrist for a possible eating disorder. She was diagnosed with diabetes when she was 4. Over the past year her diabetes self-care has become increasingly erratic. B.C.’s mother notes that the patient often skips her insulin altogether, is preoccupied with her weight, and consumes large amounts of junk food. B.C. also admits to purging when she has been particularly lax with her diet.

Interaction between psychiatric and endocrine disorders Disordered eating appears to be frequent in adolescent girls and women with diabetes. Conscious underdosing of insulin and irregular eating habits may occur when patients are concerned about their body image, feel a stigma about using insulin, or fear they won’t fit in with friends.

It also appears that depression may be associated with diabetes, perhaps through an intervening effect on diet and exercise. The incidence of depression in patients with diabetes is up to 28%, and women with diabetes appear to have a greater risk for depression than men. Patients with diabetes who are depressed are less likely to adhere to their diabetes program and more likely to have worse glycemic control and increasing risk of complications.

Case 3 concluded B.C. is concerned about weight gain, her friends making fun of her need for injections, and hypoglycemic reactions while playing varsity volleyball. Her concerns are explored and intensive counseling is undertaken. At the same time, she is referred to an endocrinologist for further evaluation, and the diabetes care team initiates therapy with an insulin pump.

After an initial rocky period, B.C.’s therapy is stabilized and her hypoglycemic episodes reduced. B.C. discusses her concerns with other teens in a diabetes support group and is introduced at the local college to a star volleyball player (who also suffers from diabetes). As B.C. graduates, she is offered a scholarship at a top university. Her HbA1c is at normal levels.

Comment Younger individuals with diabetes face substantial challenges in adjusting to their disease. The incidence of disordered eating, depression, anxiety, and adjustment disorders is increased.

What’s more, diabetes in children and adolescents affects the whole family. Parents and siblings are often stressed over the patient’s care needs and mood swings, and may also present with mental disorders.

Related resources Oriented to mental health issues

• Wirshing DA. Adverse effects of atypical antipschotics. J Clin Psych. 2001;62:(suppl 21)7-10.
• Goodnick PJ, Henry JH, Buki VMV. Treatment of depression in patients with diabetes mellitus. J Clin Psych. 1995;56:4,128-136.
• Carney C. Diabetes mellitus and major depressive disorder: an overview of prevalence, complications, and treatment. Depression Anxiety. 1998;7:149-157.
• Jacobson AM. The psychological care of patients with insulin-dependent diabetes mellitus. N Engl J Med. 1996;334(19), 1249-53.
• Glasgow RE, Fisher EB, Anderson BJ, et al. Behavioral science in diabetes. Contribution and opportunities. Diabetes Care. 1999;22(5):832-43.
• Hoffman RP. Eating disorders in adolescents with type 1 diabetes. Postgrad Med. 2001;109(4)67-74.
• Talbot F, Nouwen A. A review of the relationship between depression and diabetes in adults: is there a link? Diabetes Care. 2000;23(10):1556-62.
• Rubin RR, Peyrot M. Psychological issues and treatments for people with diabetes. J Clin Psychol. 2001;57(4):457-78.
• Golden MP. Special problems with children and adolescents with diabetes. Primary Care Clin. 1999; 26(4):885-94.

Drug brand names

• Alprazolam • Xanax
• Atorvastatin • Lipitor
• Bupropion • Wellbutrin
• Buspirone • Buspar
• Carbamazepine • Tegretol, Epitol, Atretol
• Enalapril • Vasotec
• Fluoxetine • Prozac
• Nefazodone • Serzone
• Phenytoin • Dilantin
• Risperidone • Risperdal
• Triazolam • Halcion
• Valproate • Depacon

Disclosure

The author reports that he has been a speaker or consultant for SmithKline Beecham, Organon, Wyeth-Ayerst Pharmaceuticals, and Pfizer.