The year 2016 was pivotal in the field of diabetes and psychosocial support. The American Diabetes Association (ADA) revised its annual guidelines to include a position statement on the psychosocial care for people living with diabetes.1 Regardless of the type of diabetes, lifestyle change is required for effective management. Diabetes educators’ unique training and expertise put them in a good position to help people with diabetes manage most aspects of living with the condition. Even with the best technologies and numerous resources, it is often the psychosocial barriers that keep people from initiating and sustaining behavior change.
The general considerations for psychosocial care published by the ADA include “monitoring patient performance of self-management behaviors as well as psychosocial factors impacting the person’s self-management.”
Psychosocial needs should be addressed throughout the lives of people living with diabetes. This typically occurs during the initial diagnosis phase or if a serious complication develops, but can be neglected at other times. It is important not to forget that psychosocial needs reach outside of the realm of diabetes, too. Health-care professionals can become so preoccupied with modifying medications and discussing diet and nutrition that the patient’s beliefs and behaviors are forgotten. Measuring the patient’s willingness and readiness to change is vital. This can occur with a conversation about their willingness to change and motivation to initiate change and sustain it. Finding internal motivation can help with longer-lasting behavior change.
“Consider assessment of life circumstances that can affect physical and psychological health outcomes and their incorporation into intervention strategies.”
Although managing diabetes is a 24/7 job, patients deal with other positive and negative stressors every day. Buying a house, having a family member move in, going on vacation, financial struggles and caring for a loved one can all lower the priority of managing diabetes. A physician who is a good listener can help patients prioritize steps to change. Diabetes educators often assume that diabetes self-management is the number one priority, but that is rarely the case, regardless of type of diabetes and the presence of diabetes-related complications. Other circumstances can trump managing diabetes. Knowing the appropriate time and which diabetes-related behavior to address first is important. Once patients at least somewhat improve stress management, their diabetes-related behaviors can be addressed. Be sure to consider lifestyle when helping people reach diabetes-related goals.
“Providers should consider an assessment of symptoms of diabetes distress, depression, anxiety, and disordered eating and of cognitive capacities using patient-appropriate standardized/validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. Including caregivers and family members in this assessment is recommended.
“Addressing psychosocial problems upon identification is recommended. If an intervention cannot be initiated during the visit when the problem is identified, a follow-up visit or referral to a qualified behavioral health care provider may be scheduled during that visit.”
Most diabetes educators, regardless of discipline, have a basic understanding of psychological concerns. Each phase of living with diabetes is associated with various psychological conditions. Young-Hyman et al. suggest that there is a delineation of “nonclinical/normative” behaviors and clinical symptoms at each phase of living with diabetes to include pre-diagnosis, diagnosis of diabetes, learning stage, maintenance of behavior change, life transitions affecting the sustainment of behavior change, the influence of complications and disease progression on maintenance, and the influence of aging on behavior change.1
Reactions such as sadness, nervousness, changes in sleep, worrying, hopelessness and feelings of being overwhelmed are all considered normal when a person is diagnosed with a chronic condition or upon change in health status. When the psychological reactions cross over to the clinical side of the spectrum, including a behavioral health specialist such as a psychologist or psychiatrist is recommended. Ideally, this would include a behavioral health-care provider familiar with the daily challenges of living with diabetes.
A diabetes educator should have many tools on hand to help him or her decide when to refer a client to a behavioral health-care provider. Young-Hyman et al.provide a comprehensive list of measures for assessing psychosocial variables.1 The Patient Health Questionnaire (PHQ-9) is a popular nine-item screening tool used for monitoring general depressive symptoms.2
The MacArthur Foundation Initiative developed a toolkit to help primary care physicians evaluate and determine the best treatment plan for those who score highly on the screening instruments. Although developed for physicians, it is a good resource for other health-care providers. The MacArthur Foundation Initiative also distributes patient handouts and documents on monitoring depression symptoms as well as templates for communicating with primary care physicians.3
The Child Depression Inventory (CDI-2) is an assessment tool for depression in those ages 7-17.4 The Geriatric Depression Scale (GDS) is a similar instrument for those 55-85 years old.5 For anxiety, the Beck Anxiety Inventory is empirically validated, although it must be purchased from its publisher.6
The Diabetes Distress Scale and Problem Areas in Diabetes (PAID) measure diabetes-specific distress, with PAID versions for children, teenagers, parents and adults.7,8 Measures such as these can provide great assistance in determining when a referral to a behavioral health-care provider is warranted.
Including family members and friends of diabetes patients is essential because diabetes educators rely on self-reporting in assessing psychological distress, which has flaws, including under- and over-representation of symptoms. Including others in the assessment/interview can provide a more accurate picture of what is truly going on in the lives of people living with diabetes. It is important to judge whether you can get truthful answers from a family member when the person living with diabetes is present or if a phone call or private meeting with the family member or friend will be more valid. Adequate management of psychological concerns will yield better diabetes self-management in the long run.
People living with diabetes are far from exempt from struggling with psychological/psychiatric disorders listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5), published in 2013.9 Common conditions in those living with diabetes include adjustment disorders, depressive disorders, anxiety disorders, obsessive-compulsive disorders, feeding and eating disorders, impulse control disorders and neurocognitive disorders. Symptoms of these conditions negatively influence one’s ability to monitor and manage diabetes. Noting the severity of these symptoms and the degree to which they are causing impairment in social, occupational and other important activities is essential.
Without substantial impairment, one cannot be diagnosed with a disorder listed in the DSM-5. It is important to distinguish if these conditions are present in all situations or only when there are diabetes-related concerns, such as limiting food choices due to fear of not knowing an accurate carbohydrate count or refusing to have blood glucose levels under a certain range (for example <150 mg/dL) due to an irrational fear of having a hypoglycemic-induced seizure.
The rationale and motivation for engaging in certain behaviors need to be discussed. If a person is being treated for a serious mental illness such as schizophrenia or bipolar disorder, then adequate medical management of these conditions is essential to expect one to engage in healthy diabetes self-management behaviors. The side effects of psychiatric medications, which can confound symptoms of diabetes, need to be considered when working with an individual with diabetes. It may be necessary to consult with the managing psychiatric provider, who may be a primary care physician, regarding an educator’s concerns about side effects of medications to determine if there are better alternatives that would not compromise the treatment of the psychiatric condition. If this is a psychiatric crisis, then that must be resolved before diabetes self-management can be expected.
Diabetes educators have many roles in working with people with diabetes. Incorporating the person living with diabetes and his or her loved ones in treatment planning is essential. Reinforcing positive behaviors, instead of focusing on what the individual is or is not doing, is helpful to maintain motivation and increase self-esteem and self-efficacy. Recognizing small goals and verbalizing them can help with motivation as well. Something as simple as validating how difficult switching to a sugar-free beverage must have been for the individual provides positive reinforcement.10
Establishing rapport with an individual living with diabetes is extremely important. This can set the stage for future appointments. Educators who are warm, non-threatening, caring, non-judgmental and active listeners are usually the most successful. At times, it may be necessary to refer an individual to a mental health professional. Normalizing this process and introducing the mental health professional as part of the team can help reduce stigma associated with seeing this type of provider. A mental health professional who is knowledgeable about aspects of living with diabetes is helpful when diabetes-specific behaviors are causing a lot of the psychological distress. Delegating these types of difficult conversations to another trusted professional can help to ensure that the person living with diabetes is able to get as many of these needs met as possible to enhance quality of life.
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About our expert: Nicole M. Bereolos, PhD, MPH, CDE, private practice, Dallas, Texas