Mental Health Practice Exam: Diabetes Chapter 18 (2023)

Mental health is integral to diabetes care. The 2023 Guidelines highlight the bidirectional relationship between diabetes and psychiatric disorders, emphasizing that psychological well-being is a critical predictor of successful self-management and metabolic outcomes.

This practice exam tests your ability to identify, screen for, and manage the psychosocial challenges commonly faced by individuals living with diabetes, ranging from diagnosis-related distress to severe mental illness.

Key Concepts Covered in This Exam:

Diabetes Distress vs. Depression: Distinguishing between the emotional burden of living with diabetes (distress) and Major Depressive Disorder, and knowing when to refer for specialized care.
Screening Protocols: Understanding the recommendation to routinely screen for diabetes distress, anxiety disorders, and depressive symptoms using validated tools.
Eating Disorders: Recognizing “diabulimia” (insulin omission for weight loss) in Type 1 diabetes and Binge Eating Disorder in Type 2 diabetes as critical barriers to glycemic control.
Serious Mental Illness: Managing the metabolic risks associated with schizophrenia and bipolar disorder, including the impact of antipsychotic medications on weight and insulin resistance.
Psychosocial Interventions: Identifying evidence-based interventions such as Cognitive Behavioural Therapy (CBT) and motivational interviewing to improve adherence and quality of life.

1. According to the guidelines, what is the recommended treatment approach for depression in people with diabetes?

Cognitive behaviour therapy (CBT), antidepressant medication, or both
No treatment is effective for depression in diabetes
Psychotherapy alone
Antidepressants alone

2. A diabetes educator is counselling a patient who reports experiencing discrimination due to their diabetes and body weight. According to the guidelines, what are the potential consequences of this stigma?

Improved motivation to manage diabetes
Worsening distress, diminished quality of life, and decreased diabetes self-management behaviours
No significant health consequences
Stigma only affects psychological well-being, not diabetes outcomes

3. What term describes the strong negative response from people with type 2 diabetes to the recommendation to add insulin to their regimen?

Psychological insulin resistance
Fear of hypoglycemia
Treatment non-adherence
Diabetes distress

4. Case: A 28-year-old woman with type 1 diabetes maintains her blood glucose at 10-12 mmol/L because she is terrified of experiencing hypoglycemia, especially at night. What is this behaviour called?

Psychological insulin resistance
Treatment non-adherence
Compensatory hyperglycemia due to fear of hypoglycemia
Diabetes distress

5. According to the guidelines, what A1C level change is associated with depression treatment using antidepressant medication in people with diabetes and MDD?

1.3% lower than placebo
0.32% lower than placebo
0.54% lower than placebo
No change in A1C

6. What is the appropriate action when screening a patient with diabetes using the PHQ-9 and obtaining a score of 12?

Further assessment is indicated
Immediately start antidepressant medication
Rescreen in 6 months
No action needed as this is within normal range

7. According to the guidelines, cannabis use in adults with type 1 diabetes is associated with what increased risk?

2.5-fold greater risk for diabetic ketoacidosis
No increased risk
Improved glycemic control
Decreased risk of hypoglycemia

8. Case: A patient with diabetes and comorbid mental health concerns reports thoughts of self-harm. According to the guidelines, what is the recommended approach?

Inquiries about thoughts or plans for self-harm should be assessed regularly, and necessary steps should be taken to ensure safety
This is outside the scope of diabetes education
Refer to psychiatry and take no further action
Document the concern and address it at the next visit

9. Case: A 45-year-old woman with type 2 diabetes presents feeling overwhelmed by daily self-care tasks, worried about complications, and experiencing strained family relationships related to her diabetes. Her PHQ-9 score is 6. What is the most likely diagnosis?

Major depressive disorder
Generalized anxiety disorder
Diabetes distress
Adjustment disorder

10. The “5As” brief intervention for smoking cessation includes which components?

Ask, Acknowledge, Advise, Assist, Arrange
Assess, Advise, Agree, Assist, Arrange
Ask, Advise, Assess, Assist, Arrange
Assess, Acknowledge, Agree, Assist, Arrange

11. Case: A 55-year-old man with type 2 diabetes smokes 20 cigarettes per day. What is the most accurate statement about his cardiovascular risk compared to a non-smoker with diabetes?

His risk is the same as a non-smoker
His relative risk for early mortality is approximately 5 times higher
His relative risk of early mortality is similar to a non-smoker
His relative risk for coronary heart disease is approximately 1.5 times higher

12. What is the recommended maximum number of standard alcoholic drinks per week associated with causing the least potential for harm according to recent Canadian guidelines?

7 standard drinks
2 standard drinks
4 standard drinks
0 standard drinks

13. The prevalence of type 2 diabetes in people with schizophrenia is approximately how much higher than in the general population?

10-fold higher
1.5-fold higher
4- to 5-fold higher
2- to 3-fold higher

14. Case: A 17-year-old female with type 1 diabetes has recurrent DKA episodes, unexplained weight loss, and an A1C of 12%. She admits to sometimes “forgetting” her insulin. What condition should be suspected?

Type 2 diabetes misdiagnosis
Depression
Substance use disorder
Disordered eating with insulin omission (diabulimia)

15. According to the Health Belief Model, which factors should be assessed when evaluating treatment acceptance?

Blood glucose levels, A1C, and blood pressure
Disease susceptibility, severity, benefits of action, barriers, self-efficacy, and cues to action
Age, gender, and socioeconomic status
Family history, medication history, and comorbidities

16. Case: A 40-year-old woman with type 2 diabetes and depression is started on a tricyclic antidepressant. What metabolic effect should be monitored?

Weight gain and potential worsening of glycemic levels
No metabolic effects are expected
Weight loss
Hypoglycemia

17. Case: A pregnant woman with gestational diabetes is experiencing high anxiety since her diagnosis. When should mental health screening occur?

Only during the postpartum period
Only if symptoms become severe
At each prenatal visit following the GDM diagnosis and postpartum
Only at the first prenatal visit

18. Case: A patient with diabetes asks about the relationship between sleep duration and diabetes risk. According to the guidelines, what sleep durations are associated with increased risk of developing type 2 diabetes?

Sleep duration does not affect diabetes risk
Only sleeping less than 8 hours
Both short sleep (<6 hours) and long sleep (>9 hours)
Only sleeping more than 10 hours

19. People with serious mental illness (SMI) generally have a life expectancy how much shorter than the general population?

5-10 years shorter
2-5 years shorter
25-30 years shorter
10-20 years shorter

20. What is the prevalence of binge eating disorder (BED) in people with type 2 diabetes compared to the general population (2-3.5%)?

Up to 10%
The same as the general population
Up to 25%
Less than the general population

21. Which antipsychotic medications have the highest risk for causing glucose dysregulation and weight gain?

Lurasidone and cariprazine
Haloperidol and ziprasidone
Olanzapine and clozapine
Aripiprazole and brexpiprazole

22. Case: A patient with type 1 diabetes reports heavy alcohol use on weekends. What is the primary concern regarding their diabetes management?

Weight gain only
No significant concerns
Delayed hypoglycemia and reduced hypoglycemia awareness
Hyperglycemia only

23. Case: A diabetes educator is working with a patient who has type 2 diabetes and is having difficulty accepting their diagnosis. The patient keeps stating that diabetes is “not that serious” since they feel fine. Based on the Health Belief Model, what perception should be addressed?

Benefits of action
Self-efficacy
Barriers to action
Perceived disease severity

24. Case: A 35-year-old patient with type 2 diabetes and bipolar disorder is being considered for medication changes. The psychiatrist asks about the relationship between insulin resistance and bipolar disorder. What should the diabetes educator share?

Insulin resistance is associated with a less favourable course of bipolar illness and poorer response to lithium
There is no relationship between insulin resistance and bipolar disorder
Insulin resistance improves bipolar symptoms
Only type 1 diabetes affects bipolar disorder

25. Case: A 62-year-old man with type 2 diabetes refuses to start insulin despite inadequate glycemic control. He believes needing insulin means he has “failed” at managing his diabetes. What approach should the diabetes educator take?

Refer immediately to a psychiatrist for evaluation
Insist on insulin initiation and explain the consequences of poor control
Explore his beliefs and reframe insulin as related to the pathophysiology of diabetes, not personal failure
Continue with oral medications only until he is ready

26. Case: Parents of a 10-year-old child with type 1 diabetes report significant anxiety about their child’s blood glucose management and frequent nighttime checking. What should be addressed?

Refer immediately to child protective services
Only the child’s diabetes management
The parents are overreacting and should reduce monitoring
Parental/caregiver distress and fear of hypoglycemia, as these can impact the child’s outcomes

27. Case: A 70-year-old man with type 2 diabetes presents with depressive symptoms. According to the guidelines, what is a key concern in this population?

Depressive symptoms are normal in older adults and do not require treatment
Antidepressants should be used very cautiously in this age group
Screening is not recommended for older adults
Depressive symptoms are an important risk factor for cognitive impairment and increased mortality

28. Case: An adolescent with type 2 diabetes has a BMI of 35 kg/m² and reports feeling judged by healthcare providers about their weight. What concept does this describe?

Normal patient-provider interaction
Weight-based stigma in healthcare settings
Fear of hypoglycemia
Diabetes distress

29. Case: A patient taking olanzapine for bipolar disorder is gaining weight rapidly. At what time point does weight gain typically plateau with antipsychotic medications?

6-8 weeks
Weight gain continues indefinitely
2-4 weeks
Within 1 year

30. Which screening tool is recommended for assessing diabetes-specific emotional distress?

GAD-7
PHQ-9
Diabetes Distress Scale (DDS)
Beck Depression Inventory

31. Case: A diabetes care team is developing a screening protocol for mental health issues. According to the guidelines, when should individuals with diabetes be screened for diabetes-related psychological distress?

Every 5 years
Only when patients report symptoms
When newly diagnosed, as well as regularly afterwards
At diagnosis only

32. What percentage of people with diabetes are affected by diabetes distress?

Approximately 12%
Approximately 24%
Approximately 36%
Approximately 58%

33. What is the prevalence of major depressive disorder (MDD) among people with diabetes compared to the general population?

Five times higher than the general population
Approximately triple the general population
Approximately double the general population
The same as the general population

34. According to the guidelines, which psychosocial intervention has Grade A, Level 1A evidence for improving adaptation to living with diabetes?

Psychoanalysis
Art therapy
Motivational interviewing
Group counselling

35. Case: A patient with diabetes is being started on a second-generation antipsychotic. When should metabolic monitoring for weight be performed according to the guidelines?

At baseline and preferably at every visit
Only if the patient reports weight gain
Annually only
After 1 year of treatment

36. Case: A patient with diabetes and MDD has been treated with an antidepressant for 3 months. The depression has improved significantly, but A1C remains elevated. Based on the evidence, what is the most accurate interpretation?

The antidepressant is not working
Depression treatment should be discontinued
The patient needs a different class of antidepressant
Treating depressive symptoms more reliably improves mood than glycemic stability

37.

A patient with schizophrenia and diabetes is being started on an antipsychotic. Based on the guidelines, which medication would have the lowest metabolic risk?

Clozapine
Olanzapine
Aripiprazole
Quetiapine

38. Case: A diabetes educator is discussing costs of diabetes care with a patient who admits to rationing insulin due to expenses. According to the guidelines, what should occur?

Suggest the patient switch to oral medications only
Health-care providers should regularly assess, counsel, and offer resources to help reduce costs
This is a personal financial matter and should not be addressed
Refer to a social worker without further discussion

39. Case: A 11-year-old with type 1 diabetes is transitioning to adolescence. According to the guidelines, when should transition planning for adult diabetes care begin?

At age 16
At around 12 years of age
At age 18
Only when the patient requests it

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