Diabetes Psychosocial Care Addressed by ADA in First Published Recommendations

To combat depression and anxiety disorders, the authors recommend annual screening of all patients, particularly those with a history of anxiety or depression, either self-reported or documented in medical records. A directive to promptly refer all patients who meet clinical criteria for a diagnosis of depression to a mental or behavioral health professional received an “A” grade. Similarly, patients who meet criteria for an anxiety disorder should be referred for treatment. In both cases, assessment of self-management behaviors is recommended since both depression and anxiety can effect adherence. Patients who have anxiety secondary to episodes of severe hypoglycemia should be evaluated for hypoglycemia unawareness and treated using Blood Glucose Awareness Training or a similar, evidence-based intervention (“A” grade).

Clinical and Subclinical Disordered Eating

Diagnosable eating disorders are associated with high rates of comorbid psychiatric conditions in people with diabetes.¹⁰ Unhealthy behaviors — including omitting insulin injections in order to lose weight and binge eating — are common in both type 1 and type 2 diabetes. ^11-13 When assessing disordered eating behavior clinicians should examine patients’ motivation and intentions to help determine if medication or treatment regimen changes are appropriate. 

To manage disordered eating behaviors, the authors gave “B” grades to 2 recommendations: consider evaluating treatment regimen when a patient presents with symptoms of either disordered eating or disrupted patterns of eating associated with treatment or disease processes, and use validated screening measures to identify potential disordered eating behavior when weight loss and hyperglycemia are present and unexplained by self-reported changes in medication, meal planning, or physical activity.  

Other Issues in Psychosocial Care

In addition to recommendations focused on specific comorbidities, the statement authors offered an overview of “life course considerations,” noting that patients with diabetes are being diagnosed with the condition earlier and living longer.^1,14

“At each point in the life course, providers should consider which resources and accommodations are needed to maximize disease outcomes and well-being,” the authors wrote, noting that disease management cannot be successful without the consideration of the patient’s lifestyle and emotional status.

“Social determinants of health such as poverty and culture were mentioned because they are important but not focused on because there is not a clear path for practitioners to [have an impact on] these factors,” added Dr Young-Hyman.

Psychosocial Care Delivery

According to Dr Young-Hyman, the greatest challenge currently facing diabetes clinicians is capacity: more mental health clinicians with knowledge about living with and managing diabetes are needed. “The [ADA] and the American Psychological Association are concurrently developing training curriculum aimed at doing just that: offering continuing education to licensed psychologists to better prepare them to perform…as part of a care team.” The first of these programs is scheduled to launch at the ADA’s annual Scientific Sessions and the APA’s 2017 Annual Convention.

“While medical providers are trained to help people manage the medical aspects of their disease, they are not always taught to understand the impact that psychosocial factors have on people living with diabetes,” said Alicia McAuliffe-Fogarty, PhD, clinical health psychologist and vice president of the lifestyle management team at the ADA, in a press release.²

“If clinicians don’t inquire, monitor, and assess, psychosocial factors will impact care, often contributing to frustration for both providers and patients,” Dr Young-Hyman added. “When providers recognize these needs, [both] patients and providers benefit by identifying needed resources, potential behavior change strategies, and the need for diabetes-specific ongoing support to maximize care outcomes.”

Disclosures

Dr Hill-Briggs is a member of the Board of Directors of the American Diabetes Association. Dr Hood has served as a consultant to Bigfoot Biomedical and Johnson & Johnson Diabetes Institute, and reports receiving research support from Dexcom. Dr Peyrot reports receiving research grants from Bristol-Myers Squibb, Genentech, and Novo Nordisk, as well as consulting fees from AstraZeneca, Calibra, Genentech, Eli Lilly, and Novo Nordisk. Dr Peyrot has also received speaking honoraria from Novo Nordisk and has participated in advisory panels for GlaxoSmithKline, Eli Lilly, and Novo Nordisk. 

References

1. Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39:2126-2140. doi: 10.2337/dc16-2053
2. The American Diabetes Association® releases psychosocial recommendations for medical providers [news release]. Arlington, VA: American Diabetes Association; November 22, 2016. http://www.diabetes.org/newsroom/press-releases/2016/ada-releases-psychosocial-recommendations-for-medical-providers.html?referrer=https://www.google.com/  Accessed December 12, 2016.
3. De Groot M, Crick KA, Long M, Saha C, Shubrook JH. Lifetime duration of depressive disorders in patients with type 2 diabetes. Diabetes Care. 2016;39:2174-2181. doi: 10.2337/dc16-1145  
4. Holt RIG, de Groot M, Lucki I, Hunter CM, Sartorius N, Golden SH. NIDDK international conference report on diabetes and depression: current understanding and future directions. Diabetes Care. 2014;37:2067-2077. doi: 10.2337/dc13-2134
5. Li C, Barker L, Ford ES, Zhang X, Strine TW, Mokdad AH. Diabetes and anxiety in US adults: findings from the 2006 Behavioral Risk Factor Surveillance System. Diabetic Med. 2008;25(7):878-881. doi: 10.1111/j.1464-5491.2008.02477.x
6. Smith KJ, Beland M, Clyde M, et al. Association of diabetes with anxiety: a systematic review and meta-analysis. J Psychosom Res. 2013;74(2):88-89. doi: 10.1016/j.jpsychores.2012.11.013
7. Cox DJ, Irvine A, Gonder-Frederick L, Nowacek G, Butterfield J. Fear of hypoglycemia: quantification, validation, and utilization. Diabetes Care. 1987 Sept-Oct;10(5):617-621
8. Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L. A critical review of the literature on fear of hypoglycemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns. 2007;68(1):10-15. doi: 10.1016/j.pec.2007.05.003
9. Zambanini A, Newson RB, Maisey M, Feher MD. Injection related anxiety in insulin-treated diabetes. Diabetes Res Clin Pr. 1999;46(3):239-246. doi: 10.1016/S0168-8227(99)00099-6
10. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC. The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;61(3):348-358. doi: 10.1016/j.biopsych.2006.03.040
11. Phinas-Hamiel O, Hamiel U, Greenfield Y, et al. Detecting intentional insulin omission for weight loss in girls with type 1 diabetes mellitus. Int J Eat Disord. 2013;46(8):819-825. doi: 10.1002/eat.22138 
12. Goebel-Fabbri AE, Fikkan J, Franko DL, Pearson K, Anderson BJ, Weinger K. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31(3):415-419. doi: 10.2337/dc07-2026
13. Weinger K, Beverly EA. Barriers to achieving glycemic targets: who omits insulin and why? Diabetes Care. 2010;33(2):450-452. doi: 10.2337/dc09-2132
14. McIntyre RS, Konarski JZ, Misener VL, Kennedy SH. Bipolar disorder and diabetes mellitus: epidemiology, etiology, and treatment implications. Ann Clin Psychiatry. 2005;17(20):83-93. doi: 10.1080/10401230590932380