Mednotes

L10 Psych Med Diabetes

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tagspsychmed, lecture
aliasesL10 Psych Med Diabetes

14 min read

Overview

This lecture covers the psychological dimensions of living with diabetes: the epidemiology of diabetes in New Zealand, the lived experience and “journey” from diagnosis through complications, Diabetes Distress as a construct distinct from depression, the behavioural burden of self-management (health literacy, eating problems), psychological barriers such as fear of hypoglycaemia and psychological insulin resistance, depression and anxiety comorbidity, modern pharmacological and technological treatments and their psychological effects, and finally a practical framework (the 7A’s model) and communication approach for supporting patients.

What is diabetes: NZ context

  • Approx 300,000+ New Zealanders live with diabetes (6-7% of the population).
  • Type 2 diabetes accounts for 90% of cases.
  • Prevalence is increasing rapidly, especially in Māori (2-3x prevalence) and Pacific peoples (highest rates in NZ), and in lower socioeconomic groups.
  • Structural determinants driving this: access to healthcare, food environments (an “obesogenic environment”), and colonisation impacts.
  • Type 1 diabetes: autoimmune disease, juvenile onset, insulin dependent.
  • Type 2 diabetes: progressive disease related to insulin resistance.
  • Basic psychological care should be an integral part of diabetes care; the emotional and physical aspects of diabetes are so intertwined that treating the emotional side as a separate “co-morbidity” is counterproductive (Fisher, Gonzalez & Polonsky).

Living with diabetes

  • A person with type 2 diabetes is typically asked to change lifelong habits (eating, exercise, weight) with rewards that are not apparent in the short term, and must make difficult or frustrating food-related decisions at every meal (resisting favourite foods, managing well-meaning but unhelpful comments from family/friends, confusing health advice).
  • Diabetes is often described as “more than a full-time job” — but with no pay, no holidays, and no guarantee the effort is rewarded.
  • Living with diabetes requires long-term self-management; successful care depends on complex daily behaviours, not just the physical condition.
  • Support from healthcare professionals, family and peers is often needed, covering: lifestyle factors, emotional wellbeing, social and family support, and medication management/blood testing (Young-Hyman et al., 2016).

The diabetes journey

Illustrated via a case study (Mr David Lee, 54-year-old delivery driver, BMI 32, diagnosed with type 2 diabetes after fatigue, excessive thirst and frequent urination; felt shocked, guilty and overwhelmed; started metformin and lifestyle changes; later experienced diabetes distress, lapses in self-care during a stressful work period, rising HbA1c, and early neuropathy at HbA1c 8.5%).

Four stages of the journey and their associated psychological challenges:

  1. Diagnosis — grief response (shock, denial, sadness, anger, frustration, sense of loss); guilt and self-blame, and depression (thinking they may have been able to prevent it); anxiety about what the diagnosis means and what comes next.
  2. Initial adjustment — understanding the condition; establishing new routines affecting family dynamics and whānau commitments; lack of motivation; struggles with identity; financial pressure from the cost of healthy food.
  3. Ongoing management — diabetes distress; lifestyle changes and limitations (recognising highs and lows, understanding blood sugar readings, attending appointments, insulin administration including needle phobia); financial and emotional burden.
  4. Complications/progression — fear of the unknown; feelings of hopelessness; increased need for social support; barriers to accessing care.

Diabetes distress

  • Psychosocial strain of managing diabetes on a daily basis.
  • A unique construct capturing the interplay between the disease and distress relating to its physical, social, financial and emotional burden.
  • Distinct from depression, which is more general.
  • Risk factors: comorbid chronic illness, low empowerment, low diabetes-specific support.
  • Associated with: sub-optimal self-management, hyper- and hypoglycaemia, impaired quality of life.
  • Having a good HbA1c (blood sugar control) does not always mean the absence of diabetes distress.
  • Measured with the Problem Areas in Diabetes (PAID) scale.
  • Diabetes distress is reported as more common in people with type 2 diabetes not on insulin than in those with type 1 diabetes or insulin-treated type 2 diabetes [slide pictogram, exact values not legible].

Behavioural burden: health literacy and eating problems

  • Managing diabetes goes beyond blood glucose control and requires identifying and managing psychosocial issues.
  • Health literacy: patients face large volumes of complex information; 40-80% of information given is forgotten (Kessels, 2003); the teach-back method may improve retention.
  • Practical issues include non-adherence to treatment and difficulties with self-management.
  • Disordered eating behaviours and eating disorders occur in people with diabetes; reported as more common in type 1 than type 2 diabetes [pictogram, exact values not legible].
  • Screening tool: the SCOFF questionnaire (a reliable and valid screening instrument):
    1. Do you make yourself Sick because you feel uncomfortably full?
    2. Do you worry you have lost Control over how much you eat?
    3. Have you recently lost more than 14 lbs (one stone) in a 3-month period?
    4. Do you believe yourself to be Fat when others say you are too thin?
    5. Would you say that Food dominates your life?
  • The mSCOFF (modified SCOFF) replaces question 5 with: “Do you ever take less insulin than you should?” — screening for intentional insulin omission for weight control.

Psychological barriers: fear of diabetes effects

  • Common fears: hypoglycaemia, hyperglycaemia, diabetes-related complications, and injections/needles.
  • Measured with the Hypoglycaemia Fear Survey-II Worry (HFS-II W) scale.
  • Illustrative burden for a person with type 1 diabetes of 40 years’ duration: approximately 58,400 finger pricks (averaging four per day), likely over 4,000 mild hypoglycaemic episodes, and 40-60 severe hypoglycaemic events; typically makes over 100 diabetes-related decisions every day; feels tired of continually thinking about diabetes and that family is continually concerned about them.

Depression and anxiety

  • Depression prevalence is 2x higher in people with diabetes.
  • Bidirectional relationship: depression worsens glycaemic control, and poor control worsens mood.
  • Emerging, clinically used concept: “diabetes burnout”.
  • Overlap between diabetes distress and depressive symptoms (proportions from a Venn diagram): diabetes distress only 6%, diabetes distress and depressive symptoms together 13%, depressive symptoms only 13%, neither 68%.
  • Depression and anxiety symptoms are both reported as more frequent in people with type 2 diabetes not on insulin than in type 1 diabetes or insulin-treated type 2 diabetes [pictograms, exact values not legible], and this pattern (type 2, no insulin, showing the highest rates) holds across diabetes distress, depression symptoms and anxiety symptoms.
  • Related measurement tool referenced: Hospital Anxiety and Depression Scale (HADS-D).

Psychological barriers to insulin use

  • Negative thoughts about insulin include: concerns about medications and side effects, anxieties about injections, lack of confidence/skills, and impact on self-perception and life.
  • Measured with the Insulin Treatment Appraisal Scale (ITAS).
  • Psychological resistance to insulin is associated with: impaired quality of life, reduced emotional wellbeing, and sub-optimal diabetes self-management and HbA1c.
  • Downstream impact: more diabetes-related complications and symptoms, less satisfaction with treatment, and increased burden/costs to the individual and the healthcare system.

Modern treatments and technology

  • Pharmacological: GLP-1 receptor agonists and SGLT2 inhibitors, widely used internationally with increasing (though still restricted) access in New Zealand via PHARMAC.
  • Psychological relevance of these medications: weight loss effects can drive identity changes; cost and access issues create inequity stress; injection burden remains relevant for some agents.
  • Technology in diabetes care: continuous glucose monitors (CGMs), insulin pumps, and apps.
  • Psychological impacts of technology are mixed: it reduces burden for some patients but increases anxiety for others through “information overload”, raising the question of when monitoring becomes hypervigilance.

Supporting patients: the 7A’s model

A circular framework for what a clinician can do:

  • Aware — be aware that people with diabetes may experience emotional and mental health problems.
  • Ask — ask about emotional and mental health problems.
  • Assess — assess for emotional and mental health problems, using a validated questionnaire where available.
  • Advise — advise about emotional and mental health problems.
  • Assist — assist with developing an achievable action plan.
  • Assign — assign to another health professional.
  • Arrange — arrange follow-up care.

Communication and referral

  • Key points: use an open, empathic communication style; “meet the person” where they are in their life, not where you think they should be; language and communication style affect engagement, disclosure, motivation and outcomes; use mutual goal setting and a collaborative approach; remember motivational interviewing (MI), especially where people struggle.
  • Refer for appropriate support to: GP-led care, diabetes nurse specialists, dietitians, and endocrinology referral pathways.
  • Situations warranting referral to a mental health provider (Diabetes Care, 2016): self-care remains impaired after tailored diabetes education despite diabetes distress; a positive screen on a validated tool for depressive symptoms; symptoms or suspicion of disordered eating behaviour or an eating disorder; intentional omission of insulin or oral medication to cause weight loss; a positive screen for anxiety or fear of hypoglycaemia; suspected serious mental illness; in youth/families, behavioural self-care difficulties, repeated hospitalisations for diabetic ketoacidosis, or significant distress; a positive screen for cognitive impairment; declining or impaired ability to perform diabetes self-care behaviours; before bariatric surgery, and after it if ongoing adjustment support is needed.

Promoting successful self-management

Three key themes that impact success (Rankin et al., 2007):

  • Understanding diabetes and one’s own involvement (thinking and beliefs about it).
  • Learning to get on with everyday life while managing diabetes.
  • Support from friends and management of psychosocial stressors.

Practical guidance for helping a person make changes (Box 2.5):

  • Convey a message of hope, empathy and understanding, while remaining factual and informative.
  • Refrain from threat- or fear-based persuasion, particularly if the person is not ready to face the reality and consequences of diabetes for their future.
  • Seek to understand why a person may not be making changes that seem “good” for them, rather than assuming unwillingness.
  • Help the person understand their own barriers to optimal self-management and ways to overcome them.
  • Create space for the person to reflect on where they are now, and their own priorities and preferences (including what they like/dislike about their current situation and a future without change).
  • Acknowledge that other issues may have greater priority for them right now; explore their own “road blocks” and how important these are to them.
  • Explore what options the person has for making changes that would benefit their health.
  • Enhance the person’s confidence to undertake specific behaviours; help them reflect on options and support realistic steps, making success more likely.
  • Successful completion of one step (e.g. walking 30 minutes once a week) increases confidence to attempt the next step (e.g. three times a week).
  • Work with the person to develop a realistic, individualised action plan and identify resources to aid change, agreeing on actions that are relatively easy with few barriers.

Self-test

  1. Give the New Zealand prevalence figures for diabetes overall and for type 2 diabetes specifically, and name the two population groups noted as having the highest rates.
  2. Distinguish type 1 from type 2 diabetes as described in this lecture.
  3. Define diabetes distress and explain how it differs from depression.
  4. What does it mean that “having a good HbA1c doesn’t always translate to absence of diabetes distress”?
  5. Describe the four stages of the diabetes “journey” and give one psychological challenge specific to each stage.
  6. What is the teach-back method and why is it relevant to diabetes care, given the Kessels (2003) finding?
  7. List the five SCOFF questions, and explain how the mSCOFF differs from the SCOFF.
  8. Name the four common diabetes-related fears assessed by the HFS-II W scale.
  9. Describe the bidirectional relationship between depression and glycaemic control, and name the related clinical concept introduced in this lecture.
  10. List the four negative thought categories underlying psychological barriers to insulin use and give one downstream consequence for self-management.
  11. Explain the psychological relevance of GLP-1 receptor agonists/SGLT2 inhibitors and of diabetes technology (CGMs, pumps, apps), including one benefit and one risk of technology.
  12. Walk through the 7A’s model in order, giving a one-line description of each step.
  13. David tells you: “I know what to do, I just don’t do it.” Using the communication principles and Box 2.5 guidance from this lecture, describe how you would respond.
  14. List three situations from the referral indicators table that would prompt referral of a person with diabetes to a mental health provider.
  15. State the three key themes that Rankin et al. (2007) identified as impacting successful self-management.

Answers

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