Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover

ADVISORY

Fall 2013 • Volume 12 • Issue 1

Diabetes Care for Clients in Behavioral 

Health Treatment

People with mental illness, substance use disorders 

(SUDs), or both are at increased risk for developing 

diabetes, a chronic metabolic disease with numerous 

long-term health consequences. Untreated behavioral 

health disorders can exacerbate diabetes symptoms 

and complications. In addition, companion features of 

behavioral health disorders—such as poor self-care, 

improper nutrition, reduced physical activity, and 

increased barriers to preventive or primary 

health care—can adversely affect management of 

co-occurring diabetes.

This Advisory provides a brief overview of diabetes 

and an introduction to the reciprocal relationship 

between diabetes and behavioral health disorders. 

It also discusses ways in which behavioral health 

treatment providers can help minimize consequences 

of diabetes for their clients by screening for the 

disease, providing referrals to care as needed, and 

coordinating care with other providers. Counselors 

also can play an important role supporting clients 

to simultaneously manage their diabetes and their 

recovery from mental illness or an SUD.

What Is Diabetes?

Diabetes is a chronic disease characterized by elevated 

blood glucose levels. It occurs when glucose digested 

from food is unable to enter the body’s cells to be used 

for energy. The hormone insulin is necessary for the 

cells to absorb glucose. In type 1 diabetes, the pancreas 

does not make enough insulin or stops making insulin 

completely; glucose remains in the bloodstream rather 

than transferring into the cells. A person with type 1 

diabetes must be given insulin to live. This form of 

diabetes most often begins early in life and appears to 

have both genetic and environmental causes.

Type 2 diabetes is far more common than type 1.1

 In 

the individual with type 2 diabetes, insulin becomes 

less effective at helping transport blood glucose into 

cells. If the disease is untreated, over a period of 

years the cells become progressively more resistant 

to insulin, even as the pancreas makes increasingly 

larger amounts of the hormone to compensate. The 

overworked pancreas can deteriorate to the point 

where it stops producing insulin altogether.

A family history of diabetes is a significant risk 

factor for type 2 diabetes, suggesting a strong genetic 

component. Other risk factors for type 2 diabetes 

include being overweight, having had gestational 

diabetes (diabetes that is diagnosed for the first time 

during pregnancy), lack of physical activity, and being 

a member of certain races/ethnicities including African 

American, Hispanic/Latino American, American 

Indian, and some Asian American and Native 

Hawaiian or other Pacific Islander groups.1

 Taking 

atypical antipsychotic medications is another known 

risk factor for type 2 diabetes.2,3

In previous decades, type 2 diabetes primarily affected 

people who were middle-aged or older. However, as 

obesity, poor diet, and lack of physical activity have 

become more common, the type 2 diabetes rate has 

soared for all age groups. Between 1980 and 2011, the 

percentage of the population with diagnosed diabetes 

increased 167 percent for people ages 44 and younger 

and between 118 percent and 140 percent for those in 

other age groups.4

In the United States, diabetes now affects 11.3 percent 

of the population ages 20 and older—nearly 26 million 

people1 (see Exhibit 1). Another 35 percent have 

prediabetes (approximately 79 million adults).1

 This 

is a condition in which blood glucose levels are higher 

than normal but not yet high enough for a diagnosis of 

diabetes. Prediabetes increases the risk for type 2 diabetes.
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 

ADVISORY

 

Exhibit 1. Diabetes Prevalence Among People Ages 20 and Older, United States, 20101 

Demographic Number of People Percent of Population 

Age ≥ 20 years 25.6 million 11.3% 

Age ≥ 65 years 10.9 million 26.9% 

Men ≥ 20 years 13.0 million 11.8% 

Women ≥ 20 years 12.6 million 10.8% 

Non-Hispanic Whites ≥ 20 years 15.7 million 10.2% 

Non-Hispanic Blacks* ≥ 20 years 4.9 million 18.7% 

*Sufficient data are not available to estimate the total prevalence of diabetes for other U.S. racial/ethnic minority populations. 

What Are the Signs and 

Symptoms of Diabetes? 

The signs and symptoms of type 1 diabetes include:5 

● Frequent urination. 

● Unusual thirst. 

● Extreme hunger. 

● Unusual weight loss. 

● Extreme fatigue and irritability. 

Many people with type 2 diabetes have no symptoms of 

the disease, or symptoms can be very mild.5

 If symptoms 

do occur, they can include: 

● Any of the type 1 diabetes symptoms. 

● Frequent infections. 

● Blurred vision. 

● Cuts and bruises that are slow to heal. 

● Tingling or numbness in the hands or feet. 

● Recurring skin, gum, or bladder infections. 

If left undiagnosed or untreated, over time diabetes can 

damage nerves and blood vessels, leading to serious 

problems such as cardiovascular disease, kidney disease, 

nerve damage, blindness, hearing loss, gum disease, 

impaired circulation that can sometimes result in lowerlimb amputations (most often of feet and toes), and 

erectile dysfunction. In addition, diabetes can trigger acute 

symptoms that can be mistaken for intoxication but that 

can be life-threatening if immediate medical attention is 

not received (see Exhibit 2). 

How Is Diabetes Diagnosed 

and Managed? 

The tests recommended to diagnose diabetes all involve 

a blood draw, and the sample is sent to a laboratory for 

analysis (see Exhibit 3). The most convenient test is the 

A1C (also called the hemoglobin A1c, the HbA1c, or the 

glycohemoglobin test). The A1C test does not require the 

patient to fast before testing, and it can be administered at 

any time of day; however, depending on which analysis 

method is used, results can be unreliable for certain 

persons such as those with chronic kidney disease, liver 

disease, or anemia. The most commonly used test, the 

fasting plasma glucose (FPG) test, requires fasting for a 

minimum of 8 hours and is most accurate when given in 

the morning. A third test is the oral glucose tolerance test 

(OGTT), which also requires fasting; it is more sensitive 

than FPG, but it is also slightly less convenient and more 

expensive. When OGTT indicates high blood glucose 

levels, a confirmatory test is necessary, unless the patient 

has obvious symptoms of diabetes.6 

An important part of disease management for type 1 and 

type 2 diabetes is glycemic control. This means keeping 

blood glucose levels within a targeted range, which is 

individually determined based on when the diabetes 

was diagnosed, the patient’s age and life expectancy, 

and whether the patient has a comorbid condition such 

as cardiovascular disease. Glycemic control is achieved 

through a diet that regulates carbohydrate intake (type 

and amount), physical activity, and frequent checking 

of blood glucose levels using a blood glucose monitor. 

2 
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Diabetes Care for Clients in Behavioral Health Treatment

Fall 2013, Volume 12, Issue 1

Management also may involve use of medications taken 

via pills, insulin injections, or insulin pumps.11 People 

with type 1 diabetes must take insulin daily; people with 

type 2 diabetes may be prescribed insulin if the disease 

cannot be managed by other means. In people who have 

prediabetes and are overweight, onset of type 2 diabetes 

and its progression may be prevented or delayed through 

modest weight loss achieved by dietary changes and 

increased physical activity, treatment with an oral diabetes 

medication, or both.12

Exhibit 2. Acute Diabetes Symptoms

Hypoglycemic episodes: Hypoglycemia results 

when blood glucose levels are too low; it is the most 

common complication of insulin therapy.7 Hypoglycemia 

also may be triggered by extended binge drinking* 

with little food consumption.8 Initial symptoms include 

headache, excessive perspiration, rapid heartbeat, 

lightheadedness, dizziness, and confusion. Symptoms 

usually recede with the ingestion of sugar (e.g., candy, 

juice, glucose tablets). If symptoms do not resolve 

quickly, immediate medical attention is required, 

because untreated hypoglycemia can lead to diabetic 

seizures, coma, and death.7,8

Hyperglycemic episodes: Episodes of very high blood 

glucose levels can occur for many reasons, such as 

when diabetes is undiagnosed or unmanaged, as a 

result of infection, or when triggered by substance use 

(including alcohol consumption). They also occasionally 

occur despite good efforts at control.

Hyperglycemic episodes can lead to a serious condition 

called ketoacidosis. It occurs when the blood contains 

high levels of ketones, which are substances produced 

when cells break down fat for energy because they 

cannot obtain glucose. High levels of ketones can be 

toxic. People with type 1 diabetes are at particular risk 

for ketoacidosis. Signs and symptoms include those 

described in the main text for type 1 diabetes as well 

as fruity-smelling breath, nausea, vomiting, abdominal 

pain, rapid heartbeat, and difficulty breathing. Confusion, 

lethargy, and coma (sometimes leading to death) also 

may occur.7,9 This condition, which can be mistaken for 

inebriation, calls for immediate medical attention.

*Binge drinking—drinking so much within about 2 hours that the level 

of blood alcohol concentration increases to 0.08g/dL. Typically, this 

may occur after four drinks for women and after fives drinks for men.10

Exhibit 3. Blood Test Levels for Diagnosis of 

Diabetes and Prediabetes6,13

A1C

(percent)

Fasting Plasma

Glucose

(mg/dL)

Oral Glucose

Tolerance Test

(mg/dL)

Diabetes 6.5 or above 126 or above 200 or above

Prediabetes 5.7 to 6.4 100 to 125 140 to 199

Normal About 5 99 or below 139 or below

Definitions: mg = milligram, dL = deciliter

For all three tests, within the prediabetes range, the higher the test result, the 

greater the risk of diabetes.

How Is Diabetes Linked to 

Mental Illness?

Diabetes has a complex and reciprocal relationship 

with mental illness and shares metabolic features with 

certain mental disorders. For example, insulin resistance 

and impaired glucose regulation, which are features of 

diabetes, have been separately observed in patients with 

mental disorders such as schizophrenia14 and depression.15

Mental illness reduces the likelihood that a person with 

diabetes will be properly treated, just as mental illness is 

associated with other disparities in care.16

Rates of severe psychological distress are twice as high in 

people with diabetes compared with the rates among those 

without the disease.17 In addition, severe psychological 

distress is negatively associated with processes of diabetes 

care (e.g., access to prevention services) and outcomes.18

For young people with type 1 diabetes, previous psychiatric 

referral is a significant risk factor for death from acute

diabetes-related events such as hypoglycemia or coma.19

Relationships between diabetes and some specific mental 

illnesses are described below.
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ADVISORY

Depression 

Diabetes increases risk for depression and depressive 

symptoms.20 CDC reports that people with diabetes have 

roughly a doubled risk of also having depression compared 

with those who do not have diabetes. Similarly, a person 

with depression faces a 60-percent increase in risk for type 

2 diabetes.1 A depressive disorder typically precedes a type 

1 diagnosis and follows a type 2 diagnosis.15 Long-term 

use of antidepressant medications has been implicated in 

higher risk for type 2 diabetes,21,22 although these findings 

remain controversial.23 

Among all people with depression, recurrence and longer 

episodes are more common in people with diabetes than in 

those without the disease.24 Even at mild levels, depression 

can adversely affect glycemic control and a person’s 

ability to perform diabetes self-care.24 

Anxiety disorders 

People with diabetes have an elevated risk for anxiety 

disorders compared with the general population.24 

Anxieties may be triggered by the burdens of having a 

chronic disease and by diabetes-specific factors such as 

having to inject insulin and living with the threat of acute 

diabetic symptoms and long-term complications. Such 

stressors may trigger generalized anxiety, obsessivecompulsive behavior, or phobic avoidance of activities 

necessary to managing diabetes such as checking blood 

glucose levels or injecting insulin.24 

Schizophrenia 

People with schizophrenia have higher rates of 

hyperglycemia and type 2 diabetes than the general 

population, and diabetes is a leading cause of illness 

and death for people affected by schizophrenia-related 

disorders.25 Antipsychotic medications used to treat 

schizophrenia and, increasingly, nonpsychotic emotional 

disorders, are associated with increased risk for type 2 

diabetes.3,25 

Deficits in learning, attention, memory, and other cognitive 

functions have been detected in type 1 and type 2 diabetes 

patients through neurocognitive testing.26 Deficits may 

result from a variety of factors, including hypoglycemia, 

hyperglycemia, and insulin resistance. These cognitive 

effects can be exacerbated in people who also have 

schizophrenia, which presents its own risks to cognition.27 

Eating disorders 

Compared with the general public, people with diabetes 

are more likely to develop eating disorders, which are 

more likely to occur in young women.24 Eating disorders 

increase the risk for poor glycemic control and resulting 

acute diabetes symptoms. 

How Is Diabetes Linked 

to Stress? 

Stress, which can be experienced without a diagnosis of a 

mental disorder, increases risk for diabetes symptoms and 

complications. Hormones that are activated in response 

to stress (e.g., epinephrine, norepinephrine, cortisol, 

growth hormone) cause blood glucose levels to increase. 

Substantial evidence exists that stress can adversely affect 

the course of diabetes (whether it also can trigger the onset 

of diabetes is not established).24 Stress also can interfere 

with diabetes self-management, although the effects may 

depend on how the stress is perceived (that is, as positive 

or negative) and whether psychosocial or psychological 

support is available.28 

How Is Diabetes Linked to 

Substance Use Disorders? 

Some substances of abuse (e.g., nicotine, amphetamine) 

induce a chemical process in the body, advanced 

glycation end-product reaction, that contributes to the 

development of diseases such as diabetes.29 Certain 

substances (e.g., methylenedioxymethamphetamine 

[MDMA, “ecstasy”], ketamine, cocaine) have immediate 

metabolic effects that can trigger acute diabetes 

symptoms in people with the disease.30 
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Diabetes Care for Clients in Behavioral Health Treatment

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Increased insulin resistance is associated with heroin 

use among men ages 49 and older.31 In a prospective 

study of women with or at risk for HIV, past or current 

heroin or methadone use was associated with increased 

risk of diabetes. The risk was independent of potential 

confounders such as HIV status, infection with hepatitis C, 

or treatment with antiretroviral medications for HIV.32 

A decreased prevalence of type 2 diabetes is associated 

with marijuana use, possibly due to its anti-inflammatory 

properties, according to an analysis of cross-sectional data 

from the National Health and Nutrition Examination Survey 

III. The association is stronger for light use (one to four 

times per month) compared with heavy use (five or more 

times per month).33 However, use of marijuana—as with use 

of any illicit substance—can impair judgment, which can 

cause patients not to seek or participate in routine care. 

Substance use also can impede personal diabetes 

management (e.g., causing patients to fail to check blood 

glucose levels, forgo insulin injections, skip meals or, 

alternatively, consume sugary snacks).30,34 An individual 

with diabetes and a co-occurring SUD may have a 

reduced likelihood of receiving laboratory tests or clinical 

examinations for monitoring the disease.35 Previous 

substance use has been identified as a significant risk 

factor in young people with type 1 diabetes who die from 

acute diabetes-related symptoms.19 

Substance use can indirectly affect risk of diabetes. 

For example, people who have injected drugs are at an 

increased risk of contracting hepatitis C.36 The hepatitis 

C virus may induce insulin resistance, which is a 

predisposing factor for developing type 2 diabetes.37 

Substance use and having diabetes both increase risk 

for certain conditions. For example, heavy alcohol use 

increases risk of liver injury, such as fatty liver, alcoholic 

hepatitis, and cirrhosis.38 People with diabetes also are at 

heightened risk for these liver conditions.39 

Relationships between diabetes and two substances of 

abuse are described below. 

Alcohol 

Available research suggests a U-shaped relationship 

between alcohol consumption and risk of type 2 diabetes. 

According to a meta-analysis of 20 cohort studies, the 

protective effect of alcohol is greatest at 24 grams per 

day for women and 22 grams per day for men, while 

deleterious effects emerge at just under 50 grams per day 

for women and at about 60 grams per day for men.40 

(A standard U.S. drink contains about 14 grams of 

alcohol.41 ) 

However, observational studies such as those that 

contributed to the above findings are subject to significant 

limitations, including unmeasured confounding variables 

and problems with generalizability. There are no 

randomized clinical trials documenting the potential 

benefits of moderate alcohol consumption for reducing the 

risk of new-onset diabetes. 

According to the 2010 U.S. Dietary Guidelines, “It is not 

recommended that anyone begin drinking or drink more 

frequently on the basis of potential health benefits because 

moderate alcohol intake also is associated with increased 

risk of breast cancer, violence, drowning, and injuries 

from falls and motor vehicle crashes.”42 For the person 

with diabetes, the potentially protective effects of modest 

alcohol consumption may be outweighed by other negative 

effects that can compound health problems.40 

Clients With Alcohol Use Disorders and 

Diabetes Face Particular Risks 

•	 Based on the 2006 to 2010 National Surveys 

on Drug Use and Health, more than one-third 

of people with diabetes ages 18 to 25 engage 

in past-month binge drinking,43 which puts 

them at risk for acute and long-term diabetes 

complications. 

•	 In a study of nearly 66,000 adults with diabetes, 

adherence to diabetes self-care behaviors was 

inversely correlated with alcohol consumption; 

rates of nonadherence among people who drink 

increased starting at just one drink per day, 

compared with the rates for people who do not 

drink or have stopped drinking.44 
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ADVISORY

Long-term alcohol use in the person with diabetes can 

worsen blood glucose control. Nonadherence with diabetic 

diet and medication regimens, resulting from drinking, 

can lead to uncontrolled blood glucose levels. Combined 

alcohol and food consumption can elevate blood glucose 

levels, leading to hyperglycemia. Conversely, drinking 

without eating (such as during a binge episode) can 

depress blood glucose levels, leading to hypoglycemia. 

Recovery to healthy blood glucose levels may take longer 

for people with diabetes who experience hypoglycemia 

following drinking. Heavy drinking, especially for people 

with diabetes, can lead to ketoacidosis. In addition, 

heavy alcohol consumption can worsen diabetes-related 

complications, such as cardiovascular disease and 

neuropathy.

45 

Long-term alcohol abuse can trigger pancreatitis, a 

potentially fatal inflammation of the pancreas that can 

present acutely or chronically.46 Pancreatitis adversely 

affects blood glucose levels and therefore plays a role in the 

development of type 2 diabetes. People with an alcohol use 

disorder and type 2 diabetes are at heightened risk for acute 

pancreatitis, although diabetes medications reduce risk.47 

Nicotine 

Smoking is associated with an increased incidence of 

diabetes.48 The association is dose-related: heavy smokers 

are at a greater risk for diabetes compared with lighter 

smokers, and current smokers are at a greater risk than 

former smokers. Further research is needed to determine 

whether the relationship is causal (e.g., smoking may 

interfere with insulin function) or due to shared risk factors 

(e.g., lack of physical activity, lower socioeconomic status, 

stress). Smoking is a major cause of heart disease and 

impaired circulation, making both of these complications 

more likely and more severe in the person with diabetes 

who smokes. Quitting smoking may reduce risk for 

developing type 2 diabetes; risk decreases over time until 

it becomes similar to that for nonsmokers.49 

How Can Diabetes Care Be 

Integrated Into Behavioral 

Health Treatment? 

Some clients entering behavioral health treatment may 

already know they have diabetes; their need to manage 

the disease may be a factor prompting them to seek help. 

However, other clients may have prediabetes or diabetes 

but not know it—their entry into recovery presents an 

opportunity to address their whole health. To support 

diabetes care for all clients, behavioral health treatment 

programs can consider several service-level adaptations, 

described below. 

Screen for diabetes and refer 

Treatment programs that conduct physical evaluations 

at intake and perform routine physical monitoring can 

consider adding diabetes screening to these activities. 

Clients identified with prediabetes or diabetes may need 

assistance from the treatment program in accessing 

medical care. They will need to see a healthcare provider 

on a regular basis for assessment of the diabetes treatment 

plan, medication monitoring, blood checks, and assessment 

for complications. 

Educate staff about diabetes 

People with hypoglycemia may appear to be under the 

influence of alcohol, even when they have had nothing 

to drink. Similarly, some of the signs of hyperglycemia 

also may be confused with intoxication, drug toxicity, or 

withdrawal. Inservice trainings can be used to provide 

staff with information on how to recognize acute diabetes 

symptoms and emergencies. Staff also can be provided 

with information on how mental illness and SUDs are each 

linked with diabetes and on how to help clients integrate 

management of their diabetes into their behavioral health 

recovery. The American Association of Diabetes Educators 

provides online resources for locating diabetes educators 

and diabetes education programs (see the Resources 

section of this publication). 
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Diabetes Care for Clients in Behavioral Health Treatment

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Support clients who inject insulin 

Inpatient treatment centers can consider adopting 

procedures that allow clients private space for blood 

glucose testing, insulin injections, refrigerated storage of 

their insulin, storage of syringes, and disposal of syringes 

after use. Clients with a history of injection drug use may 

need extra support to overcome relapse triggers associated 

with needle use. 

Arrange for mutual support 

Programs may want to coordinate with local chapters of 

mutual-help organizations to establish groups specifically 

for people in recovery who have diabetes. Programs also 

can refer clients to educational and support activities 

sponsored by local diabetes organizations. The American 

Diabetes Association Web site has a searchable feature, “In 

My Community,” to find local activities (see Resources). 

Coordinate with providers of 

diabetes care 

A diabetes care team typically includes at minimum 

a primary care provider and a diabetes educator (e.g., 

registered nurse, registered dietician, certified diabetes 

educator). To monitor for and treat complications of 

diabetes, the diabetes team also may include specialists 

such as an ophthalmologist, podiatrist, or nephrologist. The 

various professionals may operate as a collaborative care 

team, which includes a care manager who is a physician 

or under physician supervision; such teaming has been 

found to improve outcomes and quality of life for patients 

with depression who have a co-occurring condition such 

as diabetes.50 With the client’s permission, the behavioral 

health treatment provider can participate in a client’s 

diabetes care team to: 

●		Explain that injecting insulin and having needles is a 

risk factor for relapse for the client with an SUD that 

has involved drug injection. The patient may need an 

insulin pump or other considerations. 

●		Contribute information about the challenges the client 

faces managing both diabetes and his or her specific 

behavioral health disorder. 

●		Advise the other care providers on how they can 

support the client’s maintenance of recovery, which is 

crucial to diabetes management. 

●		Increase awareness of the impact of substance use on 

diabetes, including the fact that for clients who have 

poor glycemic control or acute diabetes symptoms, 

relapse to substance use (e.g., use of MDMA, 

ketamine, cocaine) may be an undisclosed but 

underlying factor. 

●		Coordinate treatment sessions and mutual-help 

meetings.
 

●		Ensure that prescribing professionals are aware of 

medications the client is taking for SUDs or mental 

disorders, to prevent any adverse drug actions or 

interactions.
 

How Can Counselors Support 

Clients With Diabetes? 

A survey of 201 people with type 2 diabetes and cooccurring serious mental illness found low levels of 

knowledge regarding diabetes, especially regarding diet; 

a follow-up survey completed 5 years later by 95 of those 

original respondents found no improvement in diabetes 

knowledge.51 Given this lack of knowledge, behavioral 

health treatment counselors can play an important role in 

conveying diabetes information and reinforcing diabetes 

management behaviors. Some clients may have cognitive 

difficulties stemming from their behavioral health disorder, 

diabetes, or both. Such clients can benefit from repeated 

instruction offered in a calm and structured setting, free 

of distractions and offered in a variety of formats (e.g., 

discussion, print and mobile products, video). 

Actions counselors can take include the following: 

●		Learn about diabetes (e.g., from other members of the 

care team for a client with diabetes or from diabetes 

organizations and educators) so as to be able to talk 

with clients in an informed manner about diabetes 

prevention, screening, diagnosis, and management 

(see Resources). 

●		Include diabetes management in the treatment plan for 

any client with diabetes, to keep it as an ongoing topic 
Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 

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ADVISORY

during the course of treatment for mental illness or an 

SUD. 

●		Reinforce with clients who have diabetes the 

importance of steady adherence to their diabetes 

treatment plan (in terms of monitoring blood glucose 

levels, taking medications and insulin, and engaging 

in physical activity), to avoid triggering acute diabetes 

symptoms. Motivational interviewing and cognitive– 

behavioral therapy may help clients enhance their 

diabetes self-management skills. 

●		Emphasize to clients the importance of eating 

according to their diabetic meal plan at regular 

times and choosing healthy foods to manage weight, 

maintain glycemic control, and reduce the risk of 

diabetes complications while also supporting recovery 

(see Resources for diabetic diet information). Confer 

with a nutritionist to determine how to help clients 

starting antipsychotic medications avoid weight gain, 

which can be a significant side effect. 

●		Reinforce education regarding the potentially adverse 

effects of alcohol use, especially binge drinking, 

on blood glucose levels. Help clients think through 

strategies to decrease risks of life-threatening diabetes 

symptoms if a relapse occurs (e.g., frequent blood 

glucose monitoring before and after the substance 

use, eating during relapse to keep blood glucose 

levels steady, letting friends know they have diabetes, 

wearing a medical alert bracelet).52 

●		Coach clients to address the psychosocial issues 

related to living with diabetes by using problemfocused coping (identifying a specific source of 

stress and determining ways to reduce or eliminate 

it). Remind them that controlling stress can help 

them improve their glucose control and advance their 

recovery from behavioral health disorders. 

Resources 

Academy of Nutrition and Dietetics 

http://www.eatright.org/ 

American Association of Diabetes Educators 

http://www.diabeteseducator.org/ 

American Diabetes Association 

http://www.diabetes.org 

Centers for Disease Control and Prevention, 

Diabetes Public Health Resource 

http://www.cdc.gov/diabetes/ 

National Diabetes Education Program 

http://www.ndep.nih.gov 

National Diabetes Information Clearinghouse 

http://diabetes.niddk.nih.gov 

National Institute of Mental Health 

http://www.nimh.nih.gov 

Notes 

1

Centers for Disease Control and Prevention. (2011). 

National diabetes fact sheet: National estimates and 

general information on diabetes and prediabetes 

in the United States, 2011. Atlanta, GA: U.S. 

Department of Health and Human Services, Centers 

for Disease Control and Prevention. 

2

American Diabetes Association, American Psychiatric 

Association, American Association of Clinical 

Endocrinologists, & North American Association 

for the Study of Obesity. (2004). Consensus 

development conference on antipsychotic drugs 

and obesity and diabetes [Consensus statement]. 

Diabetes Care, 27(2), 596–601. 

3

U.S. Food and Drug Administration. (2004, June). 

Warning about hyperglycemia and atypical 

antipsychotic drugs. FDA Patient Safety News. Silver 

Spring, MD: Author. 
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Diabetes Care for Clients in Behavioral Health Treatment

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4

Centers for Disease Control and Prevention. (2013). 

Percentage of civilian, noninstitutionalized 

population with diagnosed diabetes, by age, United 

States, 1980–2011. Retrieved September 3, 2013, 

from http://www.cdc.gov/diabetes/statistics/prev/ 

national/figbyage.htm 

5

American Diabetes Association. (n.d.). Diabetes basics: 

Symptoms. Retrieved September 3, 2013, from 

http://www.diabetes.org/diabetes-basics/symptoms 

6

National Institute of Diabetes and Digestive and 

Kidney Diseases. (2012). Diagnosis of diabetes 

and prediabetes. NIH Publication No. 12–4642. 

Rockville, MD: National Institutes of Health. 

7

Porter, R. S., & Kaplan, J. L. (Eds). (2011). Diabetes 

mellitus and disorders of carbohydrate metabolism. 

The Merck manual of diagnosis and therapy (19th 

ed., pp. 866–888). Whitehouse Station, NJ: Merck 

Research Laboratories. 

8

Cryer, P. E., & Davis, S. N. (2012). Hypoglycemia. In 

D. L. Longo, A. S. Fauci, D. L. Kasper, S. L. Hauser, 

J. L. Jameson, & J. Loscalzo (Eds.), Harrison’s 

principles of internal medicine (18th ed., pp. 3003– 

3009). New York: McGraw Hill Medical. 

9

American Diabetes Association. (n.d.). Living with 

diabetes: Ketoacidosis. Retrieved September 3, 2013, 

from http://www.diabetes.org/living-with-diabetes/ 

complications/ketoacidosis-dka.html 

10National Institute on Alcohol Abuse and Alcoholism. 

(n.d.). Overview of alcohol consumption: Moderate 

& binge drinking. Retrieved September 3, 2013, from 

http://www.niaaa.nih.gov/alcohol-health/overviewalcohol-consumption/moderate-binge-drinking 

11American Diabetes Association. (2012). Standards 

of medical care in diabetes—2012. Diabetes Care, 

35(Suppl. 1), S11–S63. 

12American Diabetes Association. (n.d.). Living with 

diabetes: Tight diabetes control. Retrieved 

September 3, 2013, from http://www.diabetes.org/ 

living-with-diabetes/treatment-and-care/bloodglucose-control/tight-diabetes-control.html 

13Diabetes Prevention Program Research Group. (2002). 

Reduction in the incidence of type 2 diabetes with 

lifestyle intervention or metformin. The New England 

Journal of Medicine, 346(6), 393–403. 

14Beary, M., Hodgson, R., & Wildgust, H. J. (2012). A 

critical review of major mortality risk factors for 

all-cause mortality in first-episode schizophrenia: 

Clinical and research implications. Journal of 

Psychopharmacology, 26(5 Suppl.), 52–61. 

15Talbot, F., & Nouwen, A. (2000). A review of the 

relationship between depression and diabetes in 

adults: Is there a link? Diabetes Care, 23(10), 1556– 

1562. 

16Frayne, S. M., Halanych, J. H., Miller, D. R., Wang, 

F., Lin, H., Pogach, L., et al. (2005). Disparities in 

diabetes care: Impact of mental illness. Archives of 

Internal Medicine, 165, 2631–2638. 

17Centers for Disease Control and Prevention. (2004, 

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ADVISORY

SAMHSA Advisory

This Advisory was written and produced under contract number 270-09-0307 by the Knowledge Application 

Program, a Joint Venture of JBS International, Inc., and The CDM Group, Inc., for the Substance Abuse and 

Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS). 

Christina Currier served as the Contracting Officer’s Representative.

Disclaimer: The views, opinions, and content of this publication are those of the author and do not necessarily 

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Recommended Citation: Substance Abuse and Mental Health Services Administration. (2013). Diabetes Care for 

Clients in Behavioral Health Treatment. Advisory, Volume 12, Issue 1.

Originating Office: Quality Improvement and Workforce Development Branch, Division of Services 

Improvement, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857.

SAMHSA Advisory

Diabetes Care for Clients in Behavioral Health Treatment

HHS Publication No. (SMA) 13-4780

Printed 2013