In his recent post, Are Clinicians Missing Part of their Patients’ Story?, Garry Welch, Ph.D. described why it is important for clinicians who provide care for people with diabetes to understand what diabetes distress is and how it differs from depression.
If depression has been identified properly through a screening tool, clinicians in non—provider roles such as diabetes educators and health coaches, should offer referrals to appropriate behavioral health services for treatment. It is not the responsibility of these health professionals – nor do we have the training or authority – to dispense treatment for depression such as pharmacotherapy or cognitive behavior therapy. Providing help for diabetes distress, however, is within the purview of allied health professionals with training in diabetes care. That is because diabetes distress is directly related to the daily burdens of managing the disease. Once properly identified as diabetes distress (rather than depression), the goal is to explore what is causing distress and then assist the patient in finding ways to lower their anxiety.
The 7 A’s Model of responding to diabetes distress suggests a series of actions clinicians can take when working with patients. The first three steps focus on determining the existence and extent of the problem and supply a jumping-off point for conversation aimed at addressing the causes of distress. Steps 1-3 are: 1) Aware – realize that diabetes distress is a frequent problem; 2) Ask – ask the patient how they are feeling about diabetes; and 3) Assess – use a validated tool to identify and parse diabetes distress.
There are a variety of ways of determining whether patients are suffering from diabetes distress. The simplest way is to ask. When patients are seen for routine clinical care, practitioners should routinely inquire how they are feeling about living with diabetes, if there are any areas of self-care the patient finds difficult, and if or how diabetes is impacting other parts of their life. Although diabetes distress is typically associated with higher A1C levels and less engagement in self-care behaviors, people with excellent diabetes control can still be deeply anxious and stressed. Frequent blood glucose checking or keeping food and exercise records, while often vital to glucose control, can be tiresome and divert time and energy from other important daily tasks. Sometimes, learning that complications from diabetes will require an even greater focus on self-management can increase anxiety, even while improving the patient’s quality of life in the future.
In conjunction with the 7 A’s Model, screening tools such as the PAID (Problem Areas in Diabetes) or DDS (Diabetes Distress Scale) can be used to identify diabetes distress and pinpoint areas to explore in conversation with the patient. The Type 2 Diabetes program on Silver Fern’s Behavior Diagnostic Platform features a module specifically designed to assess diabetes distress, helping clinicians quickly evaluate the degree to which a patient is experiencing distress and identify the specific factors that are troubling the patient and may be preventing them from being fully engaged in their care.
After diabetes distress has been identified, the last three steps of the 7 A’s Model aim to support the patient with treatment and further action. They are 4) Advise; 5) Assist or Assign; and 6) and Arrange. Advise refers to explaining the concept of diabetes distress to the patient and its possible consequences for health and self-care, acknowledging how difficult it is to manage diabetes and how negative feelings are perfectly reasonable. Clinicians should not be surprised if a patient feels some level of diabetes distress during their lifetime. The complexity and chronicity of disease management paired with societal influences that might not support a healthy lifestyle can make it more difficult for patients to feel in control of their health. Sometimes, giving patients time to express their feelings about the disease, including its effects, its treatment, and the way its chronicity encumbers their life, and validating the patient’s feelings, is sufficient to relieve some of their emotional fatigue. Patients can feel alone with their disease and knowing that their fears, anger, and resentment are normal can go a long way to alleviating their distress.
The next step is to Assist or Assign, depending on whether the issue is within the clinician’s scope of practice. There are often concrete adjustments that can be made to the self-management plan that can make it less burdensome for the patient. For example, a patient with type 2 diabetes taking oral non-hypoglycemic agents, who finds fingersticks painful, and is currently checking twice per day, may not need to check their blood glucose more than a few times a week. Perhaps a patient thinks they can never have their favorite foods again because they contain too much carbohydrate and they are now feeling deprived. Offering recipe adaptations that maintain the essence of the original recipe can increase the patient’s satisfaction with their meal plan and help them to think about strategies for adopting healthier behaviors without triggering feelings of depravation.
A useful feature of Silver Fern’s Diabetes Emotional Distress module is that it provides clinicians with suggested actions and resources to support the patient with the challenges illuminated by the assessment. These actions and treatment referrals are research based and have been shown to be effective at alleviating diabetes distress in clinical practice. Consider this powerful story about a patient’s progress after learning about his diabetes distress, told my Wendy P., Health Coach in the EmblemHealth Gold Program.
Assign – When a problem exceeds the scope of practice or the practitioner is not knowledgeable in the particular area where the patient needs treatment support, it is appropriate to refer the patient to another provider, such as a support group, a certified diabetes educator, or a member of the behavioral healthcare team. Finally, the Arrange step focuses on follow-up care. Just as diabetes is a chronic disease requiring lifelong interventions, patients’ feelings of distress are likely to fluctuate depending on how their diabetes is changing and other stressors in their life. Frequent re-evaluation of patients experiencing diabetes distress, as well as asking all patients how they are doing managing their disease, must become part of routine care for patients with diabetes.
Providing support for patients’ emotional health is essential to supporting their efforts to take their medication, eat healthfully, and engage in physical activity. Emotional health gives patients a solid base to engage in effective self-care.
To learn more about diabetes emotional distress and how it differs from depression, visit Are Clinicians Missing Part of their Patients’ Story? written by Garry Welch, Ph.D.
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Nora Saul is a Registered Dietitian and Certified Diabetes Care and Education Specialist. Nora has more than 25 years of experience in the field of diabetes education, consulting for the Joslin Diabetes Center and other industry partners. Nora leads content development for Silver Fern’s diabetes products and training.