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Q&A: John Zrebiec of Joslin Mental Health Services

Wednesday, June 15, 2011

“We are primarily focused on trying to understand how people feel and think about themselves in relationship to diabetes in order to improve their health and their quality of life,” says John Zrebiec, L.I.C.S.W., director of Joslin’s Mental Health Services. Here he answers seven questions about diabetes and therapy.

Why does Joslin have a mental health unit?

It may seem odd to fit a mental health group in the middle of a diabetes center, but it makes a lot of sense. You have this challenging chronic illness that has cognitive demands and lifestyle issues, with emotional ramifications not just for the people with diabetes but their family members.

What makes your patient population distinctive?

People often say to me, Life shouldn’t be any different if you have diabetes than if you didn’t have diabetes. That’s simply not true. 

If you don’t have diabetes you don’t have to wake up first thing in them morning and think about what your blood sugar, or how much insulin do you need to take and when do you need to take that, which is an abrupt reminder of one’s mortality every morning.

All these balls are in the air: Insulin, medications, food, exercise, blood sugar checking… Nobody can do it perfectly. A colleague of mine, Richard Rubin, who wrote one of my favorite books, Psyching Out Diabetes, says something that goes to the heart of diabetes: The most exhausting thing about having diabetes is having to think about it all the time.

How does that affect people?

It leads to a higher than average rate of emotional stress. 

The research says that people with diabetes suffer from depression at a rate that’s two to four times higher than people without diabetes, where the rate is about 6 percent.

Additionally, if you look at generalized anxiety disorders, the rate in the general population is about 4 percent. If you have diabetes, it’s about 14%. And 40 percent of people with diabetes report higher than average anxiety levels, even though not at a level that is clinically diagnosable. 

We also know from some newer studies that women with diabetes suffer from eating disorders at a higher rate than women without diabetes. Dr. Ann Goebel-Fabbri here is an expert on that condition. It’s a really difficult emotional problem; these are women who are willing to risk feeling horrible or even risk death in order to remain thin.

What issues are most common?

 Probably 60% of the people we see here at Joslin suffer from depression. Many of the others are suffering from some kind of anxiety disorder, and then a smaller group from eating disorders.

How often do patients come in?

A few of our patients have ongoing weekly or bi-weekly treatments but most coordinate their visits with their medical appointments. If they come once every three months to see their doctor, they may see us at the same rate. 

What events in a patient’s life are most likely to bring them in?

One is initial diagnosis. It would be ideal if everyone who is initially diagnosed with diabetes could have a mental health evaluation. I’m not saying that they all will have emotional problems, but this can help them understand how to deal with all the overwhelming emotions they have at diagnosis. 

They need to figure out how they’ll take care of themselves and the needs of their family, how they’ll integrate all these diabetes demands into their lifestyles and keep life as normal as possible. It also helps them to plan how to set realistic expectations.

The second time they may come is when something goes off track metabolically—their A1Cs or their weight is going up, or there’s a change in their treatment plan, like going from diet and exercise to medication, or from medication to insulin.

The third point is when they’re diagnosed with a complication for diabetes. That can rattle people to their core, and they’ll need to figure out how they’ll manage that situation, much as they did with their initial diagnosis.

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Page last updated: July 31, 2014