Psychosocial Care for People with Diabetes. Deborah Young-Hyman
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studies and theory-based conceptualization demonstrate how access to resources (see Chapter 9 on exercise), responsibility taking (see Chapter 7 on adherence), and structured interventions (see Chapter 8 on nutrition) impact adoption and maintenance of self-care behaviors, thereby improving or inhibiting treatment success. This section underscores the need for multidisciplinary screening and care, and should help the clinician identify appropriate resources for nonmedical aspects of care.
The chapters in the Implementation of Treatment Technology section present what is known about prescribing and implementing advances in intensive treatment technologies such as use of insulin pumps (see Chapter 10), aids for improving adherence such as continuous glucose monitoring (CGM) and intensification of regimens (see Chapter 11), and bariatric surgery (see Chapter 12), proven to ameliorate type 2 diabetes in obese individuals. These technologies are relatively new in our treatment armamentarium, and therefore long-term outcome data is not yet available. However, the chapters present recommendations for screening, use, and monitoring of psychosocial issues related to technology implementation. Although these advanced treatment technologies are potentially available to all individuals with diabetes, systematic protocols for screening regarding patient suitability and psychosocial monitoring of their use are not broadly disseminated or standardized. Inclusion of these chapters is meant to facilitate clinicians’ choice of psychosocial criteria to consider when implementing intensive treatment regimens, and to suggest psychological processes and developments that need monitoring.
The final section, Life Course Issues, contains chapters that address both the life course of the patient and psychosocial issues inherent in the life course of the disease. With the exception of diabetes remission via bariatric surgery or transplantation (the latter technology still in the experimental stage), the disease is chronic and progressive. Therefore there are predictable times when disease management becomes more difficult, distress can be expected, and more resources are needed (see Chapter 13). It is unclear how often this treatment perspective, anticipatory guidance regarding expected difficulties, is implemented in clinical care. Complicating expected disease progression is the idiosyncratic life course of the individual. Three chapters focus on how care can be enhanced for the specific needs of these populations at particular stages of life: childhood and adolescence (Chapter 14), adulthood (Chapter 15), and when disability occurs—often in later life (Chapter 16). The intersection between the life course of the individual and the progression of the disease becomes of greater concern as more children are diagnosed with type 2 diabetes, and as treatment for all types of diabetes improves so that patients can be expected to live longer with the disease.
It is hoped that these recommendations will serve to inform and influence public policy for guiding diabetes care and research, as well as the reimbursement policies of the various insurers and managed care organizations. In addition to being a clinical resource, the systematic presentation of this body of information should serve to enhance the likelihood that adequate resources are available to respond effectively to the psychosocial needs of patients with diabetes. Recent pharmacologic and technical advances have made available increasingly complex treatment regimens that can improve medical outcomes. In the final analysis, however, adoption of effective treatment is based on the knowledge, beliefs, attitudes, and behaviors of patients, caretakers, and health care providers about how psychosocial barriers can be overcome to improve the health and quality of life of people with diabetes and their families.
Chapter 1 Depression and Diabetes
Mary de Groot, PhD
Assessment and Diagnosis of Depression
Depression refers to a spectrum of disorders and cluster of symptoms that involve sad or blue mood or anhedonia, neurovegetative symptoms (e.g., changes in appetite, sleep), and cognitive impairments occurring during a discrete period of time. Major depressive disorder (MDD) is defined as a cluster of five or more of the following symptoms occurring two weeks or longer: depressed or sad mood, loss of pleasure or interest in routine activities, changes in weight or appetite, hyper- or hyposomnia, fatigue, psychomotor agitation or retardation, worthlessness or excessive guilt, decreases in concentration, and/or suicidal ideation or attempt (American Psychiatric Association [APA] 2000). Episodes may be recurrent or single events.
Subsyndromal depression or minor depressive disorders include dysthymia (low-grade depression lasting more than half of the time during a two-year period), adjustment disorder with depressed mood (a period of depression lasting no more than 6 months in response to an identifiable psychosocial stressor such as a major life event or medical event), and depressive disorder not otherwise specified (a period of depressive symptoms resulting in impairment in social or occupational functioning that does not meet criteria for other diagnostic categories) (APA 2000).
Diabetes-related distress is distinguished from depression spectrum disorders in that concerns are directly related to diabetes management and/or social support (e.g., interactions with relatives pertaining to self-care behaviors) (Fisher 2007). Distress is specifically associated with the experience of living and managing diabetes. Diabetes-related distress may coincide with or exist separately from depressive symptoms or episodes (Fisher 2007). Although diabetes-related distress is an appropriate target for psychosocial interventions, it is not currently designated as a psychiatric diagnosis.
Analyses of several national surveys have identified demographic and psychosocial correlates of MDD or depressive symptoms in individuals with diabetes that include: female sex, younger age, BMI >30 kg/m2, high school education, poverty, smoking, treatment with insulin, higher A1C, single marital status, poor health status perception, and increased number of complications (Egede 2003, Jones 2004, Katon 2004b, Nichols 2007). The onset of symptoms may be gradual or correspond closely to an external event that is readily identifiable by the patient.
Differential Diagnoses
The diagnosis of MDD is excluded in the presence of primary psychotic disorders (e.g., schizophrenia, schizoaffective disorder, delusional disorders) or the presence of manic or hypomanic periods resulting in the diagnosis of bipolar disorder I or II, respectively (APA 2000). Anxiety spectrum disorders (e.g., panic disorder, agoraphobia, specific phobia, social phobia, obsessive compulsive disorder, generalized anxiety disorder) may co-occur with the diagnosis of a depression spectrum disorder (APA 2000) (Table 1.1).
Table 1.1. DSM-IV Criteria for a Major Depressive Episode
A. Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure
1. depressed mood most of the day, nearly every day, as indicated by either subjective reports or observation made by others
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
3. significant weight losses when not dieting or weight gain, or decrease or increase in appetite nearly every day
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day