Euthymia in Diabetes.

Euthymia, or optimal mood, is an integral part of health. A diagnosis of diabetes poses multiple challenges to mental and emotional health and may lead to psychological and psychiatric dysfunction. Such conditions influence glycaemic control negatively and may act as barriers to achievement of desired biomedical outcomes. This article describes the concept of euthymia in diabetes and calls for euthymia to be accepted as a target, as well as a tool, in modern diabetes care.

Diabetes is a heterogeneous metabolic syndrome characterised by the wide diversity of biomedical and psychosocial features. While the acute and chronic medical complications of diabetes have been recognised for a long time, the psychological and psychiatric aspects of diabetes have garnered attention only in the recent years.[1]

Mental health and diabetes

Disorders such as anxiety, depression and schizophrenia have been found to occur with greater frequency in people with diabetes.[2] Additionally, unique to diabetes is a syndrome-specific condition known as diabetes distress. Perhaps better termed as diabetes adjustment disorder, diabetes distress is defined as a perceived inability to cope with the demands and challenges of living with diabetes.[3] A call has also been made to recognise a drug-specific condition known as insulin distress. Insulin distress is a response or adjustment disorder which may occur in people who are prescribed insulin.[4] All these contribute to an unacceptably high burden of mental health dysfunction in people with diabetes. Such dysfunction has a bidirectional relationship with hyperglycaemia: diabetes is linked with a higher burden of psychiatric morbidity, while depression and anxiety are worsened by the presence of hyperglycaemia.[5] Thus, it becomes important to measure distress, depression and anxiety, along with glycaemic levels, if optimal outcomes are to be achieved.

While biomedical targets such as euglycaemia, eulipidemia and normotension are clearly delineated in diabetes care, similar targets are not utilised for the psychological domain of health. One reason for this may be lack of familiarity with psychiatric nosology and diagnostic tools as used in the classification of psychiatric disorders (ICD-10 and DSM-5) among diabetes care professionals.[6,7]

The concept of euthymia

The word euthymia (′eu′ = well + ′thymos′= soul/emotion) was first defined by the Greek scholar Democritus as follows: one is satisfied with what is present and available, taking little heed of people who are envied and admired and observing the lives of those who suffer and yet endure.[8] This definition is uncannily similar to the concept of equanimity or balance found in the ancient Indian text, the Bhagavad Gita.[9,10] It is also reflected in the concept of positive mental health,[11] eustress,[12] and psychological well-being.[13] Psychological flexibility, conceptualised as the ability to recognise and adapt to various situational demands; to change one’s paradigms when these strategies compromise personal or social functioning; to maintain balance among important life domains; and to display consistency in one’s behaviour and deeply held values, adds to the understanding of euthymia as a dynamic entity.[14]

Euthymia – a tool and a target

We propose euthymia as a tool, as well as a target, for diabetes care. The term conveys a sense of healthy life, and healthy coping, with diabetes. Euthymia implies not only an absence of psychiatric illness, but also lack of diabetes distress. This is extremely important, as communication impacts diabetes care in many ways.

Euthymia, defined as a state of optimal mood, or mental wellbeing, can be measured objectively by validated tools including the WHO-5.[15] Fava and Bech list the following characteristics of a euthymic state: lack of mood disturbances that meet diagnostic criteria of disease, a feeling of cheerfulness with refreshing/restorative sleep, and psychological flexibility with resistance to stress (resilience and anxiety/frustration tolerance).[16] A 10 item euthymia scale has been proposed as a clinometric tool for euthymia assessment.[16] The Acceptance and Action Questionnaire (AAQ-II) has been designed to measure psychological flexibility.[17]

The case for euthymia

Euthymic diabetes, or diabetic euthymia (as some may wish to call this) conveys a positive connotation and can be used as a counterfoil to the term ‘diabetes distress’. Thus, patient-provider communication may revolve around the need to achieve diabetes euthymia, rather than avoid diabetes distress. It reinforces the importance of the biopsychosocial model of health, as opposed to a purely glucocentric or biomedical approach.[18]

It reminds healthcare professionals of the need to assess patient-reported outcomes and psychological measures as a part of routine diabetes care.[19] Once incorporated into daily practice, it will facilitate ‘eulexithymia’ in diabetes care professionals themselves.[20]