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Managing the psychological impact of diabetes

Jen Nash
DClinPsy BSc
Clinical Psychologist

Depression is twice as common in people with diabetes as in the general population.1 Yet, in the busy setting of the diabetes clinic, discussions about the emotional impact of a chronic condition that requires 24-hour self-management can often be overlooked. Further, diabetes professionals may feel at a loss to know how to intervene in the psychological aspect of their patient's care, particularly as there is a lack of clear referral pathways for psychological services in many areas of the UK.

Nicholson et al conducted a postal survey of the national availability of psychological services for people with diabetes.2 They received responses from 267 diabetes centres (out of 464; 58% response rate) and less than one third of centres surveyed had access to specialist psychological services.
This lack of psychological provision exists, despite recent national guidance prioritising the psychological care of people with diabetes. Standard 3 of the National Service Framework (NSF) for Diabetes states a need to develop strategies to deal with the psychological consequences diabetes within routine
clinical care.3

National Institute for Health and Clinical Excellence (NICE) guidance urges diabetes professionals to be alert to depression and anxiety, and to be able to detect and manage non-severe psychological problems.4 Nicholson et al concluded that over two-thirds of respondents to their survey had not been able to implement the majority of national guidelines in this area; and only 2.6% met all guidelines.2

The case for greater psychological provision within diabetes care is clear. While the impact of diagnosis, the ongoing behavioural demands of managing the condition, and possible metabolic disturbance, may be risk factors for individuals with diabetes developing depression, there is also growing evidence
that depression itself may be a risk factor for developing diabetes.5

Even in those patients without a formal diagnosis of depression, experiencing negative emotions, such as anger, frustration, hopelessness, fear and shame, are very prevalent among individuals with diabetes.

Risk factors
The psychological challenges faced by those recently diagnosed with diabetes can become less problematic over time and with experience of living with the condition. However, some stressors may emerge after many weeks, months or years following diagnosis. There may also be difficulties that arise upon initial diagnosis, which continue without being resolved. Some examples of psychological challenges that frequently occur among patients with diabetes are:

  • Managing overwhelming emotions, such as shame, guilt, regret, fear and anxiety, triggered by the diagnosis of a chronic health condition.
  • Implementing the lifestyle changes necessary for self-management of diabetes.
  • Informing others about one's health status (family, friends, employers).
  • Frequent experiences of frustration and stress when desired health results are not achieved.
  • Needing to rely on regular medication to stay well (insulin and/or oral medication).
  • Regular blood glucose monitoring and the constant challenge of managing blood sugar levels.
  • Anxiety about hypoglycaemia.
  • Fear of long-term complications.
  • Having difficulty communicating openly with healthcare professionals.
  • Negotiating the emergence or exacerbation of sexual problems.
  • Struggles with needle phobia.
  • Dealing with the embarrassment of injecting in public.

Symptoms of depression in patients with diabetes
The symptoms of major depression, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), are shown in Box 1.

[[Box 1 Nash]]

In the case of a co-morbid physical health problem, the DSM criteria must not simply be treated as a symptom checklist. As the NICE guidelines caution, account must be taken of the degree of associated functional impairment, eg, in social, occupational, or other important areas of functioning.4

Getting to grips with the complex interplay between psychological distress and diabetes can be a daunting task for diabetes professionals. Evidently, as the Nicholson et al survey suggested, there is a real need for greater psychological provision in diabetes teams, including dedicated referral pathways to clinical psychologists, in addition to multidisciplinary team training.2

This article aims to outline shortened depression screening questions and provide brief strategies from cognitive behavioural therapy (CBT) that health professionals can implement in their routine practice with patients with diabetes.

How to screen for psychological difficulties within the time constraints of routine clinical practice
A number of tools are available for screening for depression, including the Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory (BDI). However, in routine practice, the following two questions have been demonstrated to be effective as a starting point in screening for depression:

  • During the past month, have you been bothered by having little interest or pleasure in doing things?
  • During the past month, have you been bothered by feeling down, depressed, or hopeless?

If the answer to either of these questions is "yes," follow this up by asking the patient if they would like help with this problem. If the answer to this is also "yes," then it is very reasonable to offer treatment.

Recommended treatment for depression
The NICE guidelines for managing depression and a chronic health problem recommend that health professionals and clients collaboratively consider the use of antidepressants and/or psychological interventions based on a CBT approach.4 Section 1.4.2.1 states: "For patients with persistent sub-threshold depressive symptoms or mild-to-moderate depression and a chronic physical health problem, and for patients with sub-threshold depressive symptoms that complicate the care of the chronic physical health problem, consider offering individual guided self-help based on the principles of cognitive behaviour therapy."

Cognitive behavioural therapy
CBT was developed by the psychiatrist, Aaron Beck, in the 1960s. It proposes that there are four inter-related aspects to emotional distress:

  • Thoughts and thinking styles ("cognitions").
  • Emotions and feelings.
  • Behaviours.
  • Physical symptoms.

CBT positions our thoughts as central to our emotional experience. It encourages the client with low mood or depression to examine their thoughts in an objective way; to begin to question the validity of them; and then replace unhelpful thoughts with more functional ones (see Figure 1).

[[Fig 1 Nash]]

Unhelpful thinking in individuals with diabetes
All of us, whether or not we have diabetes, have thoughts that are sometimes unhelpful and that negatively impact on our mood. However, there are certain categories of unhelpful thinking that are more common in people with diabetes. Some of these are listed in Table 1.

[[Tab 1 Nash]]

If your patient reports that they have been feeling depressed or low, you could encourage them to become aware of the thoughts they are having when they notice their mood changing. Writing down their thoughts may feel like a lot of effort, but it can really help them to capture and explore their styles of thinking, and identify which are helpful and which are less so. Below is a five-step process that you can teach your clients to assist them in this process.

Fives steps to help your patients challenge their thoughts
Step 1: What is the situation or event?
For example, measuring my blood glucose level and it being higher than I expected; or stepping on the scales and not having lost any weight.

Step 2: What is happening in your body and what do you do?
Mood - hopeless.
Body sensations - low energy, feel sick, dry mouth.
Behaviours - snapped at my partner.

Step 3: What do you tell yourself? What are the
thoughts you notice running through your mind?
"What have I done wrong? I can't do this. I'm a failure."

Step 4: Challenge your thoughts
Ask the patients some helpful questions:
What is the evidence for and against this thought?
Is thinking this way helping you?
Are there other ways of thinking about this
situation?
If a friend told you they were thinking this way, how would you respond?
Are you thinking in "all or nothing" terms?

Step 5: Come up with an alternative,
balanced thought
Help the client think of an alternative thought:
"I have tried but just because I haven't got the result I wanted, it doesn't mean that I'm a
failure".
"If a friend was feeling this way I'd help her think about what she could do differently next time, or suggest she phone her diabetes nurse to ask for advice".
"I have persevered with other challenges in my life - this challenge is just the same".

Self-help diaries
There are thought records and diaries freely available online (go to www.PositiveDiabetes.com) that can aid both patients and health professionals with the thought-challenging process.

Summary
Educating yourself about these basic CBT-based psychological strategies confers a double benefit. First, it enables the patient to feel more supported in their experience of dealing with the daily challenges of managing the high self-care demands of diabetes. Second, it empowers you, as a health professional, to begin to address the psychological needs of your patients using communication methods that are truly person-centred.

References
1. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of co-morbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001;24(6):1069-78.
2. Nicholson T, Taylor J, Gosen C, Trigwell P, Ismail K. National guidelines for psychological care in diabetes: how mindful have we been? Diabetic Medicine 2009;26:447-50.
3. Department of Health (DH). National service framework for diabetes. London: DH; 2001.
4. National Institute for Health and Clinical Excellence (NICE). Depression in Adults with a Chronic Health Problem. London: NICE; 2009.
5. Knol M, Twisk J, Beekman A, Heine R, Snoek F, Pouwer F. Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis. Diabetologia 49:837-45.
6. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. The American Psychiatric Press Incorporated; 2004. 

Further reading
Padesky CA, Greenberger D. Mind Over Mood: Change How You Feel by Changing the Way You Think. Guilford Press; 1995.
White CA. Cognitive Behaviour Therapy for Chronic Medical Problems. London: Wiley-Blackwell; 2001.

Resource
You can access further training on cognitive behavioural therapy, motivational interviewing and other psychological strategies tailored to working with people with diabetes by visiting:
W: www.PositiveDiabetes.com