2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S82 Psychological Aspects of Diabetes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Helen Jones RN MSN CDE, Peter Hall PhD, Barry Simon MD and Beth Mitchell PhD KEY MESSAGES • Significant behavioural demands and challenging psychosocial factors affect nearly all aspects of diabetes management and subsequent glycemic control. • All individuals with diabetes and their families should be regularly screened for symptoms of psychological distress. • Preventive interventions such as participative decisionmaking, feedback and psychological support should be incorporated into all primary care and self-management education interventions to enhance adaptation to diabetes and reduce stress. INTRODUCTION Significant behavioural demands and challenging psychosocial factors affect nearly all aspects of diabetes management and subsequent diabetes control (1,2). Psychological issues related to the diagnosis and/or self-care demands may present anywhere on a continuum from impairment in quality of life to clinically significant depressive and/or anxiety disorders. ADJUSTMENT PROBLEMS Both adults and children face challenges associated with adjustment to diabetes. Some children and/or their parents have adjustment problems soon after the diagnosis of diabetes (3,4).Those who do not solve these problems within the first year of diagnosis are at risk for poor adaptation to diabetes, including regimen adherence problems, poor glycemic control and continued psychosocial difficulties (5,6). Stress (general and diabetes-specific) (7,8), inadequate social and family interactions (9,10), inappropriate beliefs about the nature of diabetes (10), and poor coping skills (11,12) may have a negative impact on self-care behaviours and glycemic control. Adults with type 1 and 2 diabetes across many cultures report significant psychological distress related to the diagnosis of diabetes, with a negative impact on diabetes selfmanagement (13). The diagnosis of diabetes may precipitate or exacerbate existing psychological disorders (14,15). As quality of life is adversely affected by the presence of comorbid psychological disorders and health complications (14,15), the identifi- cation of potential psychiatric conditions, such as depression, anxiety and eating disorders, is critical. Depression Depressive symptoms are common in people with diabetes compared with the general population (14,16,17), and major depressive disorder is present in approximately 15% of patients with diabetes (18). Depressive disorders in adults and children are associated with poorer self-care behaviour (19,20), poorer glycemic control, health complications, decreased quality of life and psychological well-being (14,21), increased family problems, and higher healthcare costs (22-25). Anxiety Emerging evidence suggests that the prevalence of phobic disorders (24,26) and generalized anxiety disorders (3) is elevated in people with type 1 diabetes. Generalized anxiety disorder appears to be increased in individuals with diabetes compared with the general population (14 vs. 3 to 4%, respectively) (27). As many as 40% of patients have at least some anxiety symptoms (27), and fear of hypoglycemia (28,29) is not uncommon in those with diabetes. A recent meta-analysis suggested that the presence of clinically significant anxiety disorders among those with type 1 and 2 diabetes is associated with poor glycemic control (28). Eating disorders Eating disorders are frequently observed in young women and adolescent females with type 1 diabetes (30,31) and are associated with poorer glycemic control (31,32) and an increased risk of long-term complications (33). A metaanalysis of controlled studies of eating disorders and diabetes showed a higher prevalence of bulimia in girls with diabetes compared with healthy controls (34). Other studies have demonstrated prevalence rates of full syndrome and subthreshold eating disorders that are twice as high as those in peers without diabetes (30,35).Young women and adolescent females with type 1 diabetes should, therefore, be regularly screened for eating disorders with the Eating Disorders Inventory (36). Those with an identified or suspected eating disorder should be referred to a medical team or mental health professional knowledgeable in treating such disorders.
SCREENING All individuals with diabetes and their families should be regularly screened for symptoms of psychological and social distress (2,20). Healthcare professionals should actively explore psychological factors by asking empathetic but frank openended questions about stress, social support, unhealthy selfcare behaviours, health beliefs about risk of complications, treatment efficacy and the degree of interference with normal functioning (37). People with diabetes should be screened for depression and anxiety regularly, either through direct queries (e.g. “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?”) (38), or with a standardized questionnaire (e.g. Beck Depression Inventory [39], the Problem Areas in Diabetes scale [37], the Child Health Questionnaire [CHQ] [40], Behaviour Assessment System for Children [BASC] [40]). INTERVENTIONS Preventive psychological interventions should be incorporated into all primary care and self-management education interventions to enhance adaptation to diabetes and reduce stress. Educational and psychological interventions often share a theoretical basis around increasing readiness to change and self-efficacy (41,42). Effective interventions for children and adults include psychosocial support, feedback and reinforcement (20,43- 45); coping skills training (46); cognitive-behavioural therapy (CBT) (47); and family behaviour therapy (48). Approaches that increase patient participation in decisionmaking regarding care and education have been shown to be more effective than a “do as I say” approach in enhancing psychological adjustment to diabetes, and potentially preventing psychological distress (49-51). For those with suboptimal self-care or significant psychological symptoms, focused interventions using CBT or family behaviour therapy need to be considered (43,52). These issues should be addressed using psychosocial services within diabetes teams or resources in the community. In pediatric populations, intensive case management with psychoeducation may be required (43,52). In-home, multisystemic therapy can be used to reduce diabetes-related stress (53), improve glycemic control and reduce inpatient admissions for adolescents with poor glycemic control (2,54). Antidepressant medication (55) and CBT have each been shown to be specifically effective in treating depression in adults with diabetes (56). Risk of significant weight gain during extended use of selective serotonin reuptake inhibitor antidepressants may be greater for paroxetine (57); sertraline or fluoxetine may be preferred in this weight-sensitive population. RECOMMENDATIONS 1. Individuals with diabetes should be regularly screened for subclinical psychological distress and psychiatric disorders (e.g. depressive and anxiety disorders) by interview [Grade D, Consensus] or with a standardized questionnaire [Grade B, Level 2 (39)]. 2. Patients diagnosed with depression, anxiety or eating disorders should be referred to mental health professionals who are either part of the diabetes team or are in the community [Grade D, Consensus].Those diagnosed with depression should be offered treatment with CBT [Grade B, Level 2 (56)] and/or antidepressant medication [Grade A, Level 1A (55)]. 3. Multidisciplinary team members with required expertise should offer CBT-based techniques, such as stress management strategies and coping skills training [Grade A, Level 1A for type 2 diabetes (42); Grade B, Level 2, for type 1 diabetes (46)], family behaviour therapy [Grade B, Level 2 (48,53)] and case management [Grade B, Level 2 (43,53)] to improve glycemic control and/or psychological outcomes in individuals with suboptimal self-care behaviours, suboptimal glycemic control and/or psychological distress. OTHER RELEVANT GUIDELINES Organization of Diabetes Care, p. S20 Self-management Education, p.S25 Type 1 Diabetes in Children and Adolescents, p. S150 Type 2 Diabetes in Children and Adolescents, p. S162 REFERENCES 1. Delamater AM, Jacobson AM, Anderson B, et al. Psychosocial therapies in diabetes. Report of the Psychosocial Therapies Working Group. Diabetes Care. 2001;24:1286-1292. 2. Wysocki T, Buckloh LM, Lochrie AS, et al. The psychologic context of pediatric diabetes. Pediatr Clinic North Am. 2005;52: 1755-1778. 3. Kovacs M, Goldston D, Obrosky DS, et al. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care. 1997;20:36-44. 4. Landolt MA,Vollrath, Laimbacher J, et al. Prospective study of posttraumatic stress disorder in parents of children with newly diagnosed type 1 diabetes. J Am Acad Child Adolesc Psychiatry 2005;44:682-689. 5. Grey M, Cameron ME, Lipman TH, et al. Psychosocial status of children with diabetes in the first 2 years after diagnosis. Diabetes Care. 1995;18:1330-1336. 6. Jacobson AM, Hauser ST, Lavori P, et al. Family environment and glycemic control: a four-year prospective study of children and adolescents with insulin-dependent diabetes mellitus. Psychosom Med. 1994;56:401-409. 7. Lloyd CE, Dyer PH, Lancashire RJ, et al. Association between stress and glycemic control in adults with type 1 (insulindependent) diabetes. Diabetes Care. 1999;22:1278-1283. 8. Seiffge-Krenke I, Stemmler M. 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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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