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The wide array of comorbidities and treatment variables can make diabetes a difficult disease to manage—and to live with. Providers must be equipped to address the complexities and complications that affect patients with diabetes. In December 2016, the American Diabetes Association published a position statement recognizing the psychosocial factors (environmental, social, behavioral, and emotional) that affect medical outcomes and psychological well-being in persons with diabetes. These include self-management, diabetes distress, psychological comorbidities, and life-course considerations.1
SELF-MANAGEMENT
A patient’s perception of his or her ability to self-manage diabetes is an important psychosocial factor in treatment and management outcomes. Training patients with diabetes in self-care skills and the use of technologies—at the time of diagnosis, annually, and/or when complications or transitions in care occur—can empower patients to assume an active role in their daily management. These interventions can be tailored to address specific, individualized problems that contribute to suboptimal glycemic outcomes, such as issues in numeracy or coping, food insecurity, or lack of support. Employing a nonjudgmental approach that normalizes periodic lapses in self-management may help encourage patients and minimize their resistance to self-management.
DIABETES DISTRESS
The frustration, worry, anger, guilt, and burnout imposed by diabetes and its management (via glucose monitoring, medication dosing, and insulin titration) is known as diabetes distress. With a reported prevalence of 18% to 45%, this disease burden is quite common.2 Because high levels of diabetes distress are associated with low self-efficacy, poor glycemic outcomes, and suboptimal exercise/dietary habits, referral for counseling should be considered if a patient expresses feelings of distress.
Use of validated screening tools, such as Problem Areas in Diabetes (PAID)3,4 or the Diabetes Distress Scale (DDS)5, can aid in routine monitoring for diabetes distress. (See the Table for more information.) If distress is identified in specific self-care areas, further patient education on self-management is appropriate.
PSYCHOLOGICAL COMORBIDITIES
Depression, anxiety, disordered eating, and serious mental illness (eg, schizophrenia) are known psychological comorbidities of diabetes. Screening for symptoms using patient-appropriate, standardized/validated tools should occur at initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance.
Depression
Patients with diabetes should be screened for depression when medical status worsens or when complications occur; it is recommended to include caregivers and family members in this assessment. Patients who screen positive for depression should be referred to mental health providers who have experience with cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatment approaches, and who can provide collaborative care alongside the diabetes treatment team. Once diagnosed with depression, patients should be screened annually.
Anxiety
Expression of fear, dread, or irrational thoughts, avoidant and/or repetitious behaviors, and social withdrawal are signs of anxiety that should prompt screening. Consider screening for anxiety in patients who express worry about diabetes complications, insulin injections or infusion, taking medications, and/or hypoglycemia that interferes with self-management behaviors.
Continue to: Patients with hypoglycemia unawareness...
Patients with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, can increase self-monitoring of glucose with a glucometer or continuous glucose monitor. Blood Glucose Awareness Training (or other similar evidence-based intervention) can be used to help reestablish awareness of hypoglycemia and reduce fear of hypoglycemia.6-8 Providers can deliver hypoglycemia awareness education in the clinic.
Disordered Eating
When hyperglycemia and weight loss are unexplained by self-reported medication dosing, diet, and exercise, consider screening for disordered or disrupted eating (see Table for screening tools). In addition, reviewing the medical regimen is recommended to identify potential treatment-related effects on hunger/caloric intake.
Cognitive Impairment
Since research has shown significantly increased rates of diabetes among persons with serious mental illness (eg, schizophrenia), annual screening for prediabetes and diabetes is recommended for those taking atypical antipsychotic medications. Furthermore, some of the effects of serious mental illness—such as disordered thinking and impaired judgment—make it difficult for a patient to engage in risk-reducing behaviors or (if diagnosed) to manage diabetes. Therefore, monitoring of diabetes self-care activities should be incorporated into treatment goals for persons with these comorbid conditions.
Continue to: CONCLUSION
CONCLUSION
As providers, we should be familiar with the evidence-based, validated tools available to identify the psychosocial comorbidities of diabetes. Screening and assessing patients for psychosocial/behavioral challenges should be performed at an initial visit, at periodic intervals, and whenever there is a change in disease, treatment, or life circumstances.
Health care alliances with behavioral/mental health providers who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes are key. Patient-centered care is essential to promote optimal medical outcomes and psychological well-being. As members of the health care team, we must be respectful and responsive to patient preferences, needs, and values; clinical decisions should be guided by patient values. If A1C is not at goal despite maximized medication therapy and lifestyle modification, consider identifying and addressing any psychosocial factors that may be involved.
1. Young-Hyman D, de Groot M, Hill-Briggs F, et al. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(12):2126-2140.
2. Aikens JE. Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care. 2012;35(12):2472-2478.
3. Polonsky WH, Anderson BJ, Lohrer PA, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18(6):754-760.
4. Welch G, Weinger K, Anderson B, Polonsky WH. Responsiveness of the Problem Areas in Diabetes (PAID) questionnaire. Diabet Med. 2003;20(1):69-72.
5. Polonsky WH, Fisher L, Earles J, et al. Assessing psychosocial stress in diabetes: development of the Diabetes Distress Scale. Diabetes Care. 2005;28(3):626-631.
6. Cox DJ, Gonder-Frederick L, Polonsky W, et al. Blood Glucose Awareness Training (BGAT-2). Diabetes Care. 2001;24(4):637-642.
7. Fisher L, Hessler DM, Polonsky WH, Mullan J. When is diabetes distress clinically meaningful? Establishing cut points for the Diabetes Distress Scale. Diabetes Care. 2012;35(2):259-264.
8. Gonder-Frederick LA, Schmidt KM, Vajda KA, et al. Psychometric properties of the Hypoglycemia Fear Survey-II for adults with type 1 diabetes. Diabetes Care. 2011;34(4):801-806.
Clinician Reviews in partnership with
Amy Butts, Billy Collins, and Joy Dugan are members of the American Diabetes Association's Primary Care Advisory Group. Amy Butts is in private practice in Weirton, West Virginia. Billy Collins is a Health Services Officer for the Indian Health Service on the Alabama-Coushatta Tribe of Texas reservation in Polk County. Joy Dugan is an Adjunct Assistant Professor in the Joint Master of Physician Assistant and Master of Public Health Program at Touro University California in Vallejo.
Amy Butts serves on the speakers' bureau for Janssen Pharmaceuticals. Billy Collins and Joy Dugan have no potential conflicts of interest to report.
Clinician Reviews in partnership with
Amy Butts, Billy Collins, and Joy Dugan are members of the American Diabetes Association's Primary Care Advisory Group. Amy Butts is in private practice in Weirton, West Virginia. Billy Collins is a Health Services Officer for the Indian Health Service on the Alabama-Coushatta Tribe of Texas reservation in Polk County. Joy Dugan is an Adjunct Assistant Professor in the Joint Master of Physician Assistant and Master of Public Health Program at Touro University California in Vallejo.
Amy Butts serves on the speakers' bureau for Janssen Pharmaceuticals. Billy Collins and Joy Dugan have no potential conflicts of interest to report.
Clinician Reviews in partnership with
Amy Butts, Billy Collins, and Joy Dugan are members of the American Diabetes Association's Primary Care Advisory Group. Amy Butts is in private practice in Weirton, West Virginia. Billy Collins is a Health Services Officer for the Indian Health Service on the Alabama-Coushatta Tribe of Texas reservation in Polk County. Joy Dugan is an Adjunct Assistant Professor in the Joint Master of Physician Assistant and Master of Public Health Program at Touro University California in Vallejo.
Amy Butts serves on the speakers' bureau for Janssen Pharmaceuticals. Billy Collins and Joy Dugan have no potential conflicts of interest to report.
The wide array of comorbidities and treatment variables can make diabetes a difficult disease to manage—and to live with. Providers must be equipped to address the complexities and complications that affect patients with diabetes. In December 2016, the American Diabetes Association published a position statement recognizing the psychosocial factors (environmental, social, behavioral, and emotional) that affect medical outcomes and psychological well-being in persons with diabetes. These include self-management, diabetes distress, psychological comorbidities, and life-course considerations.1
SELF-MANAGEMENT
A patient’s perception of his or her ability to self-manage diabetes is an important psychosocial factor in treatment and management outcomes. Training patients with diabetes in self-care skills and the use of technologies—at the time of diagnosis, annually, and/or when complications or transitions in care occur—can empower patients to assume an active role in their daily management. These interventions can be tailored to address specific, individualized problems that contribute to suboptimal glycemic outcomes, such as issues in numeracy or coping, food insecurity, or lack of support. Employing a nonjudgmental approach that normalizes periodic lapses in self-management may help encourage patients and minimize their resistance to self-management.
DIABETES DISTRESS
The frustration, worry, anger, guilt, and burnout imposed by diabetes and its management (via glucose monitoring, medication dosing, and insulin titration) is known as diabetes distress. With a reported prevalence of 18% to 45%, this disease burden is quite common.2 Because high levels of diabetes distress are associated with low self-efficacy, poor glycemic outcomes, and suboptimal exercise/dietary habits, referral for counseling should be considered if a patient expresses feelings of distress.
Use of validated screening tools, such as Problem Areas in Diabetes (PAID)3,4 or the Diabetes Distress Scale (DDS)5, can aid in routine monitoring for diabetes distress. (See the Table for more information.) If distress is identified in specific self-care areas, further patient education on self-management is appropriate.
PSYCHOLOGICAL COMORBIDITIES
Depression, anxiety, disordered eating, and serious mental illness (eg, schizophrenia) are known psychological comorbidities of diabetes. Screening for symptoms using patient-appropriate, standardized/validated tools should occur at initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance.
Depression
Patients with diabetes should be screened for depression when medical status worsens or when complications occur; it is recommended to include caregivers and family members in this assessment. Patients who screen positive for depression should be referred to mental health providers who have experience with cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatment approaches, and who can provide collaborative care alongside the diabetes treatment team. Once diagnosed with depression, patients should be screened annually.
Anxiety
Expression of fear, dread, or irrational thoughts, avoidant and/or repetitious behaviors, and social withdrawal are signs of anxiety that should prompt screening. Consider screening for anxiety in patients who express worry about diabetes complications, insulin injections or infusion, taking medications, and/or hypoglycemia that interferes with self-management behaviors.
Continue to: Patients with hypoglycemia unawareness...
Patients with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, can increase self-monitoring of glucose with a glucometer or continuous glucose monitor. Blood Glucose Awareness Training (or other similar evidence-based intervention) can be used to help reestablish awareness of hypoglycemia and reduce fear of hypoglycemia.6-8 Providers can deliver hypoglycemia awareness education in the clinic.
Disordered Eating
When hyperglycemia and weight loss are unexplained by self-reported medication dosing, diet, and exercise, consider screening for disordered or disrupted eating (see Table for screening tools). In addition, reviewing the medical regimen is recommended to identify potential treatment-related effects on hunger/caloric intake.
Cognitive Impairment
Since research has shown significantly increased rates of diabetes among persons with serious mental illness (eg, schizophrenia), annual screening for prediabetes and diabetes is recommended for those taking atypical antipsychotic medications. Furthermore, some of the effects of serious mental illness—such as disordered thinking and impaired judgment—make it difficult for a patient to engage in risk-reducing behaviors or (if diagnosed) to manage diabetes. Therefore, monitoring of diabetes self-care activities should be incorporated into treatment goals for persons with these comorbid conditions.
Continue to: CONCLUSION
CONCLUSION
As providers, we should be familiar with the evidence-based, validated tools available to identify the psychosocial comorbidities of diabetes. Screening and assessing patients for psychosocial/behavioral challenges should be performed at an initial visit, at periodic intervals, and whenever there is a change in disease, treatment, or life circumstances.
Health care alliances with behavioral/mental health providers who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes are key. Patient-centered care is essential to promote optimal medical outcomes and psychological well-being. As members of the health care team, we must be respectful and responsive to patient preferences, needs, and values; clinical decisions should be guided by patient values. If A1C is not at goal despite maximized medication therapy and lifestyle modification, consider identifying and addressing any psychosocial factors that may be involved.
The wide array of comorbidities and treatment variables can make diabetes a difficult disease to manage—and to live with. Providers must be equipped to address the complexities and complications that affect patients with diabetes. In December 2016, the American Diabetes Association published a position statement recognizing the psychosocial factors (environmental, social, behavioral, and emotional) that affect medical outcomes and psychological well-being in persons with diabetes. These include self-management, diabetes distress, psychological comorbidities, and life-course considerations.1
SELF-MANAGEMENT
A patient’s perception of his or her ability to self-manage diabetes is an important psychosocial factor in treatment and management outcomes. Training patients with diabetes in self-care skills and the use of technologies—at the time of diagnosis, annually, and/or when complications or transitions in care occur—can empower patients to assume an active role in their daily management. These interventions can be tailored to address specific, individualized problems that contribute to suboptimal glycemic outcomes, such as issues in numeracy or coping, food insecurity, or lack of support. Employing a nonjudgmental approach that normalizes periodic lapses in self-management may help encourage patients and minimize their resistance to self-management.
DIABETES DISTRESS
The frustration, worry, anger, guilt, and burnout imposed by diabetes and its management (via glucose monitoring, medication dosing, and insulin titration) is known as diabetes distress. With a reported prevalence of 18% to 45%, this disease burden is quite common.2 Because high levels of diabetes distress are associated with low self-efficacy, poor glycemic outcomes, and suboptimal exercise/dietary habits, referral for counseling should be considered if a patient expresses feelings of distress.
Use of validated screening tools, such as Problem Areas in Diabetes (PAID)3,4 or the Diabetes Distress Scale (DDS)5, can aid in routine monitoring for diabetes distress. (See the Table for more information.) If distress is identified in specific self-care areas, further patient education on self-management is appropriate.
PSYCHOLOGICAL COMORBIDITIES
Depression, anxiety, disordered eating, and serious mental illness (eg, schizophrenia) are known psychological comorbidities of diabetes. Screening for symptoms using patient-appropriate, standardized/validated tools should occur at initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance.
Depression
Patients with diabetes should be screened for depression when medical status worsens or when complications occur; it is recommended to include caregivers and family members in this assessment. Patients who screen positive for depression should be referred to mental health providers who have experience with cognitive behavioral therapy, interpersonal therapy, or other evidence-based treatment approaches, and who can provide collaborative care alongside the diabetes treatment team. Once diagnosed with depression, patients should be screened annually.
Anxiety
Expression of fear, dread, or irrational thoughts, avoidant and/or repetitious behaviors, and social withdrawal are signs of anxiety that should prompt screening. Consider screening for anxiety in patients who express worry about diabetes complications, insulin injections or infusion, taking medications, and/or hypoglycemia that interferes with self-management behaviors.
Continue to: Patients with hypoglycemia unawareness...
Patients with hypoglycemia unawareness, which can co-occur with fear of hypoglycemia, can increase self-monitoring of glucose with a glucometer or continuous glucose monitor. Blood Glucose Awareness Training (or other similar evidence-based intervention) can be used to help reestablish awareness of hypoglycemia and reduce fear of hypoglycemia.6-8 Providers can deliver hypoglycemia awareness education in the clinic.
Disordered Eating
When hyperglycemia and weight loss are unexplained by self-reported medication dosing, diet, and exercise, consider screening for disordered or disrupted eating (see Table for screening tools). In addition, reviewing the medical regimen is recommended to identify potential treatment-related effects on hunger/caloric intake.
Cognitive Impairment
Since research has shown significantly increased rates of diabetes among persons with serious mental illness (eg, schizophrenia), annual screening for prediabetes and diabetes is recommended for those taking atypical antipsychotic medications. Furthermore, some of the effects of serious mental illness—such as disordered thinking and impaired judgment—make it difficult for a patient to engage in risk-reducing behaviors or (if diagnosed) to manage diabetes. Therefore, monitoring of diabetes self-care activities should be incorporated into treatment goals for persons with these comorbid conditions.
Continue to: CONCLUSION
CONCLUSION
As providers, we should be familiar with the evidence-based, validated tools available to identify the psychosocial comorbidities of diabetes. Screening and assessing patients for psychosocial/behavioral challenges should be performed at an initial visit, at periodic intervals, and whenever there is a change in disease, treatment, or life circumstances.
Health care alliances with behavioral/mental health providers who are knowledgeable about diabetes treatment and the psychosocial aspects of diabetes are key. Patient-centered care is essential to promote optimal medical outcomes and psychological well-being. As members of the health care team, we must be respectful and responsive to patient preferences, needs, and values; clinical decisions should be guided by patient values. If A1C is not at goal despite maximized medication therapy and lifestyle modification, consider identifying and addressing any psychosocial factors that may be involved.
1. Young-Hyman D, de Groot M, Hill-Briggs F, et al. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(12):2126-2140.
2. Aikens JE. Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care. 2012;35(12):2472-2478.
3. Polonsky WH, Anderson BJ, Lohrer PA, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18(6):754-760.
4. Welch G, Weinger K, Anderson B, Polonsky WH. Responsiveness of the Problem Areas in Diabetes (PAID) questionnaire. Diabet Med. 2003;20(1):69-72.
5. Polonsky WH, Fisher L, Earles J, et al. Assessing psychosocial stress in diabetes: development of the Diabetes Distress Scale. Diabetes Care. 2005;28(3):626-631.
6. Cox DJ, Gonder-Frederick L, Polonsky W, et al. Blood Glucose Awareness Training (BGAT-2). Diabetes Care. 2001;24(4):637-642.
7. Fisher L, Hessler DM, Polonsky WH, Mullan J. When is diabetes distress clinically meaningful? Establishing cut points for the Diabetes Distress Scale. Diabetes Care. 2012;35(2):259-264.
8. Gonder-Frederick LA, Schmidt KM, Vajda KA, et al. Psychometric properties of the Hypoglycemia Fear Survey-II for adults with type 1 diabetes. Diabetes Care. 2011;34(4):801-806.
1. Young-Hyman D, de Groot M, Hill-Briggs F, et al. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(12):2126-2140.
2. Aikens JE. Prospective associations between emotional distress and poor outcomes in type 2 diabetes. Diabetes Care. 2012;35(12):2472-2478.
3. Polonsky WH, Anderson BJ, Lohrer PA, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18(6):754-760.
4. Welch G, Weinger K, Anderson B, Polonsky WH. Responsiveness of the Problem Areas in Diabetes (PAID) questionnaire. Diabet Med. 2003;20(1):69-72.
5. Polonsky WH, Fisher L, Earles J, et al. Assessing psychosocial stress in diabetes: development of the Diabetes Distress Scale. Diabetes Care. 2005;28(3):626-631.
6. Cox DJ, Gonder-Frederick L, Polonsky W, et al. Blood Glucose Awareness Training (BGAT-2). Diabetes Care. 2001;24(4):637-642.
7. Fisher L, Hessler DM, Polonsky WH, Mullan J. When is diabetes distress clinically meaningful? Establishing cut points for the Diabetes Distress Scale. Diabetes Care. 2012;35(2):259-264.
8. Gonder-Frederick LA, Schmidt KM, Vajda KA, et al. Psychometric properties of the Hypoglycemia Fear Survey-II for adults with type 1 diabetes. Diabetes Care. 2011;34(4):801-806.
