Diabetes Linked to Increased Suicide, Alcohol-Related Deaths

People with diabetes show higher rates of death related to suicide, alcohol, and accidents compared with the general population, with the risk particularly high among those treated with insulin, according to new results from a large Finnish study.

"The findings from this large nationwide cohort indicate higher mortality attributable to suicide, alcohol-related causes, and accidents among diabetic patients than among the nondiabetic population," write the authors of the research published in the European Journal of Endocrinology.

"The results emphasize the importance of effective psychosocial interventions among high-risk diabetic patients," they stress.

Alcohol-Related Deaths Up to 10 Times Higher in Diabetes

With diabetes known to be associated with higher mortality rates from illnesses including cancer and cardiovascular disease, Leo Niskanen, MD, PhD, of Helsinki University Hospital, Finland, and colleagues sought to investigate the lesser known effects of mental illness.

They analyzed population data on 434,629 individuals in Finland among whom about half (208,148) had diabetes, determined according to the purchase of or reimbursement for at least one insulin prescription and/or one oral antidiabetic drug prescription between January 1997 and December 2010.

Of the patients with diabetes, most (76%) were treated only with oral antidiabetic drugs and not insulin.

The researchers found that, of 2832 alcohol-related deaths, 1981 were among patients with diabetes, 3187 deaths from accidents included 1707 patients with diabetes, and 853 deaths from suicide included 499 patients with diabetes, over a mean follow-up of 7.1 years.

Mortality rates among those with diabetes were increased for nearly all endpoints, but those treated with insulin had notably higher rates.

For men with diabetes treated with new oral drugs, the mortality risk ratio (MRR) for an alcohol-related death was 1.7, whereas the rate was as high as 6.9 for those taking insulin, compared with those without diabetes.

For women with diabetes, the risk of mortality from alcohol-related causes was even higher, at an MRR of 2.1 among those treated only with oral glucose-lowering drugs and an MRR of 10.6 for those taking insulin.

"Male diabetic subjects and those treated with insulin were at the highest risk [of alcohol-related death], but in the case of alcohol-related deaths, female subjects with diabetes showed excess mortality regardless of treatment modality," the authors note.

The most common alcohol-related cause of mortality was alcoholic cirrhosis of the liver, accounting for 45% of all deaths.

Accident-Related, Suicide Mortalities Also Higher

In terms of accident-related deaths, the most common of which was falling (36%), mortality rates were also higher among those treated with insulin, including among men (MRR, 2.1) and women (MRR, 1.5).

Mortality rates from suicide were greater among men treated with insulin (MRR, 2.1) compared to those without diabetes, but for women, the risk was only higher among those treated with new oral drugs (MRR, 1.6).

The findings on suicide are consistent with a recent meta-analysis of 54 studies (Eur J Endocrinol. 2017;177:R169-R181), which concluded that diabetes, particularly type 1 diabetes, was significantly associated with an increased risk of suicide.

But the authors note that the suicide risk may in fact be even greater than realized, because of apparent misclassification of intoxication and drug poisoning in people with diabetes.

"[Because of the problem], suicide risk among diabetes patients is probably underestimated, and more large-scale population-based studies are needed," they say.

Insulin Treatment: A Heavy Mental Health Burden

The authors underscore that the need for insulin treatment places a unique burden on people with diabetes, with the very high stakes adding even more stress to the responsibility of treatment compliance.

"Diabetic patients treated with daily injections of insulin have a heavy, unremitting burden: how they eat, move, and sleep affects plasma glucose levels," they explain.

"Miscalculation or omission in terms of self-care exposes the patient to hypoglycemia, and consequent neuroglycopenic symptoms up to the loss of consciousness may increase the risk of accidental death."

As a result, mental health issues including depression are common in patients with diabetes, and the known link between depression and alcohol abuse can further exacerbate diabetes care.

"Not only does excessive alcohol consumption negatively affect diabetes self-care adherence, it also affects the course of the illness and increases the risk of severe hypoglycemia via multiple mechanisms," Niskanen and coauthors point out.

Psychological Needs in Diabetes Inadequately Addressed

More awareness of the psychological needs of people with diabetes is required among clinicians, and such issues should be considered in their everyday medical care, Niskanen said in a press statement.

"This study has highlighted that there is a need for effective psychological support for people with diabetes," he stresses.

"If they feel like they are under a heavy mental burden or consider that their use of alcohol is excessive, they should not hesitate to discuss these issues with their primary care physician. There are many ways that these problems can be managed, provided they are communicated."

Study limitations include the inability to assess factors such as antidepressant use, but the researchers note that ongoing studies will further probe these factors and other mechanisms behind the mortality risks.

The authors have reported no relevant financial relationships.

Eur J Endocrinol. 2018;179:299-306. Full text

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