Two years ago, I wrote a blog post about diabetes and anger. In that post, I explored a lot of the day to day reasons why a person with diabetes might feel anger, and frustration. In fact, there are many reasons why a person with diabetes would, indeed, become angry. Those reasons can be varied, including anger at oneself for 'failing' to prevent the disease, to anger at family for not understanding or patrolling/policing the person with diabetes' behavior, etc. These are common types of anger: the anger that results from struggling to cope with a new and changing environment, for which we might have little control. (You can check out that blog post link, above, for a more in depth look at that topic.)

However, little did I realize that I was going to get such a huge response from the public -- but not about anger in this usual, common sense -- but anger in the chronic and mental health sense. Folks from all over the country have poured out their hearts to me in sheer frustration and worry over their loved ones, from sons to spouses, to friends. From lay people, to mental health professionals as well.

I must emphasize here, that I am NOT a mental health professional. I am not a medical expert of any kind, or a scientist. I am just a person with diabetes, with a blog. A person who loves learning every day, researching my own condition, and learning how to live and cope with it. Anything I say here is information you must take to your own clinician, or consult with your own mental health professional. It is also information that anyone can research on their own: never take my word for anything. Always be a skeptic.

Now that we have gotten that out of the way, let's start with the ways in which diabetes can clinically affect our moods.

Day to Day Blood Glucose Swings

When our blood sugars are not within normal or euglycemic boundaries (i.e., between 70-120 mg/dL, or 3.9-6.7 mmol/L), our mood and emotions will be altered. In some extreme cases, a person who, for example, experiences severe low blood sugar may become angry and even combative, or violent, or may seem 'drunk.' A person who experiences high blood sugar may experience sadness and depression, inability to concentrate, fatigue, etc. The root of all these glucose related mood swings has to deal with their association with the neurotransmitters in our brains, and how those in turn, communicate messages to our nerve cells about mood, appetite, and even sleep. Dealing with these states of mind is challenging, and can be tiring for the person with diabetes, as well as bring on a short temper. To top it off, having a negative disposition may also bring on bad blood glucose numbers, creating a vicious cycle that feeds off itself.

Chronic Mood Swings

The problem with being on this persistent 'roller coaster' of high and low blood glucose swings is that it can be bring about permanent, and chronic, mental health problems. Problems such as clinical depression, anxiety, anger, and a whole host of mental health conditions, like bipolar disorder.

According to a study on "Diabetes and Psychiatric Disorders," by the Indian Journal of Endocrinology and Metabolism, "Diabetes and psychiatric disorders share a bidirectional association -- both influencing each other in multiple ways." So much so, that apparently scientists back in the late 1800s found diabetes to be a disease which had been present in families with a pronounced history of mental health problems, so that insulin shock therapy was used as a treatment for mental health disorders even as shortly as insulin was isolated for the first time.  (Yes, insulin has a role in mental health, and even in the development of such diseases as Alzheimer's.)

This study further points out that there are several ways in which both diabetes and mental health problems can show up:

• As two parallel conditions, which developed independently of each other, with no apparent connection;
• As a complication of the diabetes, or as a complication of the mental health problem: type 2 diabetes may lead to depression, as well as depression may lead to type 2 diabetes, for example;
• As a product of hypoglycemia or hyperglycemia (and ketoacidosis), such as the development of chronic anxiety;
• And as a result of taking various medications for treating mental health -- many of these medications can lead to a triggering of a type 2 diabetes diagnosis. 

In my personal and anecdotal experience, I am a person who suffers from dysthymia. Dysthymia is a type of low grade, long term depression, which can subside and be in the background, for much of one's life. It is much milder than regular depression. However, in situations in which I have had an undiagnosed, and chronic health condition, such as hypothyroidism, or type 2 diabetes -- the imbalances in health provoked episodes of severe depression. The conditions influenced my depression and worsened it. In this way, uncontrolled diabetes can worsen or complicate a mental health condition that is already present, making overcoming of both conditions a challenge. 

It could very well be that the sudden and deep mood changes many persons with diabetes have experienced were the result of these drastic, and long term changes in blood glucose influencing an already underlying mental health problem -- especially if the diabetes was left undiagnosed or untreated for an extended period of time. It is particularly difficult for a person with diabetes that is weighed down by these mood changes, to find the motivation and positive inclination to manage their health condition. Quality of life tends to be reduced, and so does optimism, which can lead to development of unsavory habits, such as uncontrolled diet, smoking and drinking -- habits which can exacerbate mental health problems and lack of control, to an already breaking point. 

How Do We Help? 

In my previous blog post on anger, I noted several ways in which we could be of support to a person who was being burdened every day by the management of their diabetes. Being a good listener, helping a person cook meals, and being empathetic, are all proper ways in which we can deal with a loved one's chronic health condition. The Behavioral Diabetes Institute provides resources for us to utilize when we are overcome by our day to day emotions when managing diabetes, and may feel burnt out, or depressed. 

However, there are situations in which we need to be more proactive in identifying the mental state of our loved ones. Understand that, outside of a rare and severe hypoglycemic event, violent and aggressive behaviors are NOT standard complications of diabetes. These are not typical or normal behaviors for a person with diabetes. (Grouchiness is.) If a person you love is experiencing warning signs of serious mental health problems, you might need to have a conversation with them about visiting a mental health professional. This is an intimidating task, and there are suggestions out there, on how to broach the subject. 

The National Alliance on Mental Illness (NAMI) has a good Resource Guide for Families Dealing with Mental Illness. In it, they address what to do for 'crisis intervention,' when a person's behavior is particularly violent, or out of control:

If the individual with mental illness is in danger of physical injury, if his or her behavior is out of control or others are in danger, it is important to know what steps to take. Plan ahead by locating available sources for help: your emergency phone number (911), police or sheriff department number, Community Mental Health crisis or emergency number, name and phone number of a mental health professional, friends or neighbors who may be of help, and the nearest NAMI affiliate. Keep these numbers posted by the telephone. 

Any behavior such as this, that falls outside of both a mental health disorder, or a severe hypoglycemic episode, is unjustified violence, and should never be tolerated. Do not put up with it. 

. . .

Mood swings can be a standard part of diabetes mellitus and its attendant blood glucose fluctuations. However, when chronically unregulated, these blood glucose fluctuations can bring about more serious mood disorders. These mood disorders are NOT a standard symptom of day to day diabetes management, and will usually not ameliorate on their own. If you are living with a person who has become unpredictable, or violent, due to a potential mental health disorder, please seek help from your local community mental health centers, a mental health professional, or from your family physician.

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His foot was black and woody; gnarled, like dirt covered ginger. I will never forget the terror in my mother's eyes as she fruitlessly tended to its bandaging, and yelled at him for letting things get to this point. It was a shocking state of affairs. My father was now blind, bedridden, undergoing dialysis, and at the verge of needing his foot amputated.

My old childhood home had changed from whatever it was in my memories and into a hospital. Dad's room was an intensive care unit; my sister's old room was storage for the massive amounts of dialysis fluid boxes he would be needing.

I knew that dad was struggling... but I didn't know the extent. I had been gone from home for far too long, I guess, where at least reality wouldn't have denied me the right to know the truth. My parents, however, were the kind of people that lie by omission -- never telling their youngest daughter whatever might have worried her, or troubled her; never keeping her up to date with issues such as this. It was their way of protecting me... but it was far less protective than the truth. On May 5th, 2003, dad passed away. I only got to spend one last weekend with him the previous March... where he couldn't see me, couldn't go on walks with me, and had the beginning stages of dementia.

For the longest time I was very angry at my dad. To be and feel desperate at the healing of the unhealable is one of the most impotent feelings a loved one can experience. You are overcome with anger at the selfishness of the 'uncompliant' diabetic, not thinking how this would impact family; not thinking of the burdens of family having to be nurses, diaper changers, dialysis providers, and well... at the other end of helplessly watching them rot.

It has taken me years to deal and cope with these feelings; to come to terms with acceptance and forgiveness, and understanding that although complications happen, they are not always due to our choices as people with diabetes. That sometimes, the long ride is just too much -- and the genetic deck is not stacked in our favor.

Except on December 20th, 2013...

A desperate message was posted in a large online community to which I belong by a young man seeking advise about his father's infected wound, how it was not healing, and asking about what all that needed to be done. Someone -- knowing about me and my advocacy -- gave him my name. Then the desperation began anew... this unreasonable feeling of 'how can I save this person's loved one?' What all can I do to turn back the hands of time? I answered as best I could... with all the information I knew.

But information is cold, and stiff. It doesn't change his lack of access to resources, to well educated medical professionals, to the state of the art facilities we enjoy here in the states. It doesn't change that he knew not much about neuropathy, how to care for poor circulation, how to effectively and diligently monitor blood glucose levels, let alone what healthy blood glucose levels were, that Indian food is not exactly diabetic friendly, and that years and years of this status quo would likely not be undone.

Every day, the young man messaged me. "What can be done?" Sometimes, a few times a day. I could see the desperation of his situation -- I could see in my mind's eye, the terror on his face. At some point, I had to say "I am sorry. I am not a medical professional. These are the best guidelines I can give you... and to urge you to seek a wound care specialist." I wish I could have done more. I felt like I was needing to save my own father all over again.

I heard little from the young man, after that... But I had my suspicions. My gut feelings. On December 31st, he wished me a Happy New Year, perhaps in the most somber of ways one could wish it. Just words on a page... not even capitalized. Then by January 5th, he finally mustered the courage to tell me that on the 2nd, his father passed away. And it all came back around, home for me...

I mustered an "I'm so sorry,"  in the best way that I knew how, never once telling him about my own pain. My own loss. "It's fine," he replied.

Perhaps not so, today... and that's just fine, as well.

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