Libby Dowling with advice on helping patients with the mental side of diabetes management
Both type 1 and type 2 diabetes can have a profound impact on a patient’s emotional and psychological wellbeing due to the self-care and motivation required to stick with treatment.
These psychological and emotional needs can range from mild difficulties to severe emotional or psychological distress when coping with the condition. Different levels of need can emerge at different points in life, and life changes – such as transition from child to adult services, pregnancy or the development of complications – can intensify need.
It is estimated that around 40% of people with diabetes experience poor psychological wellbeing at any one time.1 Poor emotional and psychological wellbeing is associated with poorer quality of life,2 and poorer diabetes management.3 Depression is twice as common in people with diabetes as in the general population.4
Eating disorders are also more common in people with diabetes, and it is suggested that 60% of women with type 1 will experience a ‘clinically significant’ eating disorder by the time they are 25 years old.5 Specific to type 1 is diabulimia – a term coined for deliberately and regularly reducing the amount of insulin taken due to concerns over body weight or shape. It is estimated to affect 40% of women aged 15-30 with type 1 diabetes.6
There are other specific psychological conditions relating to diabetes. Diabetes distress is commonly mistaken for depression, but is a different issue. Depression affects an individual’s feelings about life in general, whereas diabetes distress relates solely to diabetes – the emotional response to the burden of relentless daily self-management, and the concern about potential complications. It affects around 40% of adults with type 1 diabetes7 and around 30% of adults with type 2 diabetes.8 Diabetes distress can lead to complete burnout, where the overwhelming distress causes disengagement with diabetes management. To the clinician, the individual appears ‘non-compliant’ or ’unmotivated’.
While severe needle phobia – where even the sight of a needle causes anxiety, increased heart rate, hypotension and nausea – is rare, a fear of needles, self-injecting or finger pricking can also lead to poor diabetes management, subsequent complications9 and impaired emotional wellbeing.
Clinicians may be reluctant to address the emotional and psychological needs of people living with diabetes for a number of valid reasons, such as a lack of time or confidence to address issues raised, or lack of local services to refer on to. However, caring for the emotional needs of people with diabetes is of equal importance to caring for their physical needs. The two exist together and must be managed together, and emotional and psychological support should be seen as part of the remit of the whole diabetes team.
In general practice and community healthcare, it is often the nurse who has the most regular contact with the individual with diabetes. As they are trusted to support physical health, they are often also considered the best source of emotional support too.
There are a number of factors that can assist you to support the emotional needs of people with diabetes:
- Recognise that it may be sufficient to simply acknowledge an individual’s emotional needs.
- Asking open-ended questions demonstrates interest and can encourage the individual to respond with their own experience, feelings or thoughts.
- Normalising feelings helps people to feel that their experience is common, and lessens their anxieties in raising it.
- Consider how best to use the time available to you – spending time on emotional issues rather than physical
- ones may be of more benefit.
- Consider where the person is in their life and with their diabetes and relate to them there rather than where you want them to be.
- Generally, for an effective consultation, the person with diabetes should be doing most of the talking.
- Show that you are listening – consider your body language, clarify and paraphrase what you are hearing.
- Consider the consultation environment – will it encourage conversation? Avoid interruptions and be clear on how much time you have.
- Be aware of your language as poor use of language can increase stigma and lead to shame and resentment.
- Access what training is available to improve your communication skills.
- Be aware the emotional, psychological and support services you are able to refer to.
- Using Diabetes UK’s mood information prescription can help you talk about emotional issues in a more structured way and improve your confidence in the support you are giving your patient.
Libby Dowling is a paediatric diabetes specialist nurse and senior clinical adviser at Diabetes UK