Is Diabetes Distress on Your Radar Screen?
Diabetes distress, which affects almost half of those with diabetes, contributes to worsening glycemic control. Recognizing and responding to it is essential.
HOW TO RESPOND TO DIABETES DISTRESS
Diabetes distress is easier to identify than to successfully treat. Few validated treatments for diabetes distress exist and, to our knowledge, only two studies have assessed interventions aimed at reduction of such distress.31,32
The REDEEM trial recruited adults with type 2 diabetes and diabetes distress to participate in a 12-month randomized controlled trial (RCT).31 The trial had three arms, comparing the effectiveness of a computer-assisted self-management (CASM) program alone, a CASM program plus in-person diabetes distress–specific problem-solving therapy, and a computer-assisted minimally supportive intervention. The main outcomes included diabetes distress (using the DDS scale and subscales), self-management behaviors, and A1C.
Participants in all three arms showed significant reductions in total diabetes distress and improvements in self-management behaviors, with no significant differences among the groups. No differences in A1C were found. However, those in the CASM program plus distress-specific therapy arm showed a larger reduction in regimen distress compared with the other two groups.31
The DIAMOS trial recruited adults who had type 1 or type 2 diabetes, diabetes distress, and subclinical depressive symptoms for a two-arm RCT.32 One group underwent cognitive behavioral interventions, while the controls had standard group-based diabetes education. The main outcomes included diabetes distress (measured via the PAID scale), depressive symptoms, well-being, diabetes self-care, diabetes acceptance, satisfaction with diabetes treatment, A1C, and subclinical inflammation.
The intervention group showed greater improvement in diabetes distress and depressive symptoms compared with the control group, but no differences in well-being, self-care, treatment satisfaction, A1C, or subclinical inflammation were observed.32
Both studies support the use of problem-solving therapy and cognitive behavioral interventions for patients with diabetes distress. Future research should evaluate the effectiveness of these interventions in the primary care setting.
What else to offer when challenges mount?
Diabetes is a progressive disease, and most patients experience multiple challenges over time. These typically include complications and comorbidities, physical limitations, polypharmacy, hypoglycemia, and cognitive impairment, as well as changes in everything from medication and lifestyle to insurance coverage and social support.33,34 All increase the risk for diabetes distress, as well as related psychiatric conditions.
Aging and diabetes are independent risk factors for cognitive impairment, for example, and the presence of both increases this risk.35 What’s more, diabetes alone is associated with poorer executive function, the higher-level cognitive processes that allow individuals to engage in independent, purposeful, and flexible goal-related behaviors.36-38 Both poor cognitive function and impaired executive function interfere with the ability to perform self-care behaviors such as adjusting insulin doses, drawing insulin into a syringe, or dialing an insulin dose with an insulin pen.39 This in turn can lead to frustration and increase the likelihood of moderate to high diabetes distress.
Assessing diabetes distress in patients with cognitive impairment, poor executive functioning, or other psychological limitations is particularly difficult, however, as no diabetes distress measures take such deficits into account. Thus, primary care providers without expertise in neuropsychology should consider referring patients with such problems to specialists for assessment.
The progressive nature of diabetes also highlights the need for primary care providers to periodically screen for diabetes distress and engage in ongoing discussions about what type of care is best for individual patients, and why. When developing or updating treatment plans and making recommendations, it is crucial to consider the impact the treatment would likely have on the patient’s physical and mental health and to explicitly inquire about and acknowledge his or her values and preferences for care.40-44
It is also important to remain aware of socioeconomic changes—in employment, insurance coverage, and living situations, for example—which are not addressed in the screening tools.
Moderate to high diabetes distress scores, as well as individual items patients identify as “very serious” problems, represent clinical red flags that should be the focus of careful discussion during a medical visit. Patients with moderate to high distress should be referred to a therapist trained in cognitive behavioral therapy or problem-solving therapy. Clinicians who lack access to such resources can incorporate cognitive behavioral and problem-solving techniques into patient discussions. (See “Directing Help Where It’s Most Needed.”) All patients should be referred to a certified diabetes educator—a key component of diabetes care.45,46
