Hi-R-Ed Online

Diabetes Distress - Unscreened Killer in Diabetes!

Mental health decline and excessive stress can lead to diabetes distress.

Avoiding clinical contact

Avoiding Monitoring

Missing work

Increase in A1C/marked decrease

Increase in Co-occurring symptoms

Depression

Anger

Loss of Hope

Increase in risk taking behaviors

Secondary stressor (relational, financial, physical stressors)

I often remind patients that people with diabetes who have resources and education are less likely to suffer serious complications from their disease. However, diabetes stress can still reach these people. The stress of life with diabetes can build up and lead to a break in one’s selfcare abilities.

We often see this characterized in patients who manifest the following symptoms:

they begin avoiding clinical contact by repeatedly rescheduling or cancelling appointments,

they frequently discontinue blood sugar monitoring, show an increase or marked decrease in A1C,

they have more episodes of severe hypoglycemia,

they have an increase in comorbid symptoms like headaches, blurry vision, neuropathy, yeast infections in women, or signs of depression.

These are all signs of diabetes distress. Depression doesn’t necessarily mean that someone is going to neglect their diabetes management, but if the depression is triggered by their diabetes management, it certainly could.

If the patients seems overwhelmed by the events in their life, such as expressing a loss of hope that they’re never going to reach their clinical goals, or that they are discouraged about there not being a "cure" for diabetes yet, these could all be signs of diabetes distress. An increase in risk-taking behaviors could mean the patient is having an increase in hypoglycemic events (or repeated, severe hypoglycemic events). Behaviors such as reporting having exercised without checking blood sugar first, or showing an increase in risk-taking events in the rest of their life (like binge drinking, run-ins with the law, or having suddenly taken on other activities that put them in harm’s way), all could indicate the onset of diabetes distress. And if these are combined with a secondary stressor (relationship change, death of a family member, conflict with a friend or partner, or a financial stressor), or a physical stressor such as a new secondary diagnosis or injury, this is going to compound their stress and may lead to a break in their ability to self-manage their diabetes.

Let's take a closer look at the ADA’s 7 A’s model. This model emphasizes the role healthcare professionals play in the diagnosis and management of diabetes distress. It helps clinicians to identify symptoms by asking patients how they are doing, assessing the patient for risks related to diabetes distress, advising them through education on what diabetes distress is, and awareness of the various resources and supports available to them. Patients can then be assisted in finding support and/or assigned to a clinician for follow-up.

The ADA's Standards of Care Screening Tools

The ADA’s 2022 and 2023 standards of care list screening for psychosocial problems (such as depression, diabetes related distress, anxiety, eating disorders, and cognitive impairment) in their standards of care. However, they don’t indicate how often to screen, and they don’t necessarily tell us how. I strongly recommend using electronic portals for periodic mental health questionnaires for anxiety and stress, asking patients if they are having trouble meeting financial goals, and similar questions. An idea I’ve found useful is to have patients complete an assessment questionnaire as part of their appointment intake, then rotating the anxiety questionnaire and the financial stability questionnaire so that they fill each out at different appointments.

At first this may appear to be overbearing, but from the patient’s side it can also demonstrate that our clinicians and insurance providers really care about the whole person, not just their physical being.

(click on the images below to make them larger)

The middle assessment shown above is called the PAID assessment, or ‘Problem Areas in Diabetes Scale’, and is a fantastic tool that touches on many areas of mental health and resource security. It can be updated routinely. This can be done at visits or between them via email or an online portal. This slide and the last in this presentation are from the ADA’s Mental Health Workbook, which is a fantastic resource for screening tools, as well as education and patient support.