by Carol E. Watkins, M.D.
[Spring 1999; Vol.26 No. 1]
In the past few years, more patients have been coming to us asking for treatment of their "chemical imbalance." On the positive side, some use this as a way to destigmatize their reasons for visiting us. On the other hand, it may indicate a desire to oversimplify the complexities of mental illness.
Diabetes Mellitus is one of the best models to show the complex interface between emotional conflicts and a "chemical imbalance." It can also show the importance of having psychiatrists involved at all levels in the treatment of such a condition. As we get better at measuring glucose control, it is quite clear that emotional issues are critical in maintaining good diabetic control. I have found this to be the case in the management of my own diabetes.
Using various home monitoring devices, I can measure glucose levels minute-to-minute (regular home glucose monitor), measure the average glucose level over two weeks (home fructosamine monitor) and go to the lab for an average of my blood glucose levels over the past three months.(Hemoglobin A1c) Certain types of situations and issues raise or lower my glucose significantly. Some of the things I learned back when I was in analysis have certainly helped. Few of us completely resolve all of our internal conflicts. Certain people and situations tend to reactivate my own conflicts. If I have insight into this, I can anticipate it, check my sugars more frequently and adjust my insulin accordingly. A few unexpectedly high sugars may alert me to watch out for emotional tension, or simply to check whether I am getting enough sleep.
When I am treating patients with diabetes and depression, the pharmacological part is important too. Different classes of antidepressants can have significantly different effects on blood glucose. However, most treatments that successfully resolve a depression result in significant improvement in diabetic control. When I was telling my endocrinologist about this, she took notes.
It is conceivable that some day we will have home monitors to determine the status of a particular neurotransmitter on a daily basis. Even so, the person looking at the number on his or her home monitor will still have internal and external conflicts.
Diabetes shows us an apparently simple "chemical imbalance" (insulin deficiency and/or insulin resistance) rapidly becomes a much more complex issue. New technology makes it easier to quantify the relationship between diabetic control and emotional states, but the concept of psychosomatics is not new. As our knowledge of neurochemistry increases, we should avoid falling into the simplistic trap of dealing only with a "chemical imbalance." Instead, we should take advantage of the increased data to help us better understand our patients in both intrapsychic and social contexts.