Does Identification of Diabetes Distress Improve Outcomes?

Early recognition, routine screening, and evidence-based treatments for diabetes distress can improve HbA_1c, blood pressure, cholesterol, overall health, and reduce medical costs.¹ Untreated diabetes distress may lead to diminished diabetes self-care and increase the risk of diabetes complications, including lower extremity amputations.² Eighteen to 50% of your patients with diabetes will experience diabetes distress in any given 18-month period of time.³  

Fortunately, diabetes distress is highly responsive to intervention. Screening can identify patients with diabetes distress and, with the management of diabetes distress specialists on your multidisciplinary team, potentially improve patient outcomes.

What is Diabetes Distress?

Diabetes distress refers to the worries, concerns, and fears among people with diabetes about their disease.⁴ It is the consequence of the emotional, rigorous and demanding aspects of living with diabetes and the self-care necessary to manage this chronic condition. People with diabetes can feel overwhelmed by the relentless nature of managing their disease 24 hours a day, 7 days a week, and 365 days a year with no vacation. Feelings of powerlessness, hopelessness, despair, discouragement, and frustration may leave your patients feeling that diabetes is controlling them instead of the other way around. Diabetes distress is not a complication or pathology but a recognized part of living with and managing diabetes. However, unrecognized and untreated diabetes distress can be serious, leading to diabetes burnout, apathy, and disengagement with their self-care and management.⁴

Diabetes stigma is defined as “negative attitude, judgement, discrimination or prejudice against someone because they have diabetes.”⁵ It comes from the false idea that people with diabetes have made unhealthy food or lifestyle choices, which resulted in their diagnosis.⁶ Four out of 5 adults with diabetes will experience this discrimination and that may adversely affect them.⁵ Diabetes stigma can negatively impact emotional, mental, and physical health including self-care, access to optimal health care, and social and professional opportunities.⁵ International consensus statements encourage diabetes providers to strive to bring an end to this stigma and discrimination, which have direct connections to symptoms of diabetes distress.⁵

What Are Signs and Symptoms of Diabetes Distress?

• Expressions of anger and/or feelings of shame and self-blame about obesity, dietary compliance, or diabetes complications
• Excessive worry about their diabetes with little motivation to change
• Ongoing worry about cost and quality of medical care
• Missed medical appointments
• Social isolation and lack of support from family or friends
• Fear of developing diabetes complications

In fact, fear is often the predominant emotion in patients with diabetic foot ulcers (DFU). In patients with diabetes foot complications Wukich and colleagues found the fear of infection and minor or major amputation is greater than fear of death, blindness, heart attack, stroke, or dialysis.⁷ Screening for diabetes distress will identify and guide treatment, address fears, and could potentially improve wound healing and overall well-being.

How Can a Podiatrist Assess for Diabetes Distress?

Complex screening tools can be time consuming and unrealistic in a busy clinic schedule. A quick assessment and referral of concerning patients to a diabetes distress specialist is the ideal solution. Asking a few simple questions may reveal diabetes distress in your patient and may be pivotal to their foot outcome. Consider asking either of these 2 questions; then, with compassion and empathy, actively listen to the details of their response:

• What is living with diabetes like for you?
• How is your diabetes foot problem affecting your day-to-day life?

How Do You Help Your Patients With Suspected Diabetes Distress?

The heart of diabetes distress interventions involves recognizing that how you feel affects what you do.⁴ Feelings, beliefs, and expectations about diabetes influence behaviors around diabetes management. If a patient’s responses lead you to suspect diabetes distress, begin by normalizing their feelings. Acknowledge that diabetes can be very difficult to manage and no one does it perfectly. Feelings of blame and shame are common. Consider asking patients’ permission to have a diabetes distress professional on the team help them with their feelings of distress.

Diabetes distress–trained professionals on a multidisciplinary team may include a Certified Diabetes Care and Education Specialist (CDCES) or a Board Certified-Advanced Diabetes Manager (BC-ADM). Diabetes distress specialists can assist with an in-depth diabetes distress evaluation and management approach and a complete review of your patient’s diabetes plan. A CDCES can review results of screening tests, and focus interventions that target on feelings, gaining perspective and develop a solid follow-up plan. Diabetes psychologists who engage in cognitive behavioral therapy and counseling may work with a CDCES. Recent findings at the American Diabetes Association (ADA) 2023 scientific sessions found the greatest reductions in diabetes distress occurred when concurrently addressing educational (CDCES) and emotional (psychologist) components.⁸ The targeted recommendations from your CDCES guides the multidisciplinary team to incorporate the diabetes distress plan of care and differentiate between other conditions.

Is It Diabetes Distress or Depression?

Differentiating between diabetes distress and depression can be difficult but important due to each condition’s different treatment approaches. Emotional distress is a common issue in a variety of conditions including diabetes distress, depression symptoms, subclinical depression, and major depression disorder (MDD).⁹ Diabetes distress is more common than MDD among patients with diabetes.¹⁰ Patients can manage diabetes distress through self-care skills, coping skills, change-related discomfort, and external support.¹¹ On the other hand, MDD is a medical illness that requires a gold standard clinical exam for diagnosis and usually involves therapy and/or medication for effective treatment.

Depression symptoms can mimic hyperglycemia in people with diabetes. These symptoms include emotional lability, irritability, trouble sleeping and malaise, which could distort study outcomes and lead to an overdiagnosis of depression.¹² Screening tools within the multidisciplinary team can be helpful to distinguish diabetes distress and depression.

What Screening Tools Can Help Identify Diabetes Distress?

Validated screening tools for diabetes distress and depression administered after referral are helpful for the CDCES to better understand the main issues behind the distress. The validated and standardized screening tools for diabetes distress are the Type 1 and Type 2 Diabetes Distress Assessment Scales (DDAS).¹³ Both Type 1 and Type 2 DDAS evaluate the basic emotional components and sources of specific distress. The DDAS is scored to evaluate for diabetes distress and the findings help guide discussions and targeted interventions.

Depression screening using the Patient Health Questionnaire 9 (PHQ-9) helps to identify the severity of depressive symptoms.¹⁴ In the literature, about 23% of patients have both diabetes distress and depressive symptoms.¹⁰ Consider screening using both the Type 1 or Type 2 DDAS and PHQ-9 to fully identify diabetes distress and/or depression. Tracking survey results can help with evaluation of interventions and trends over time.

CDCES services are highly underutilized among practitioners. Less than 5% of Medicare beneficiaries and only 6.8% of privately insured patients with diabetes have ever used the Diabetes Self-Management and Education Services (DSMES) of a CDCES.¹⁵ Once a patient develops a DFU, strongly consider giving the patient a CDCES referral to evaluate for diabetes distress and the overall diabetes management plan. Inpatient CDCES may gently start a diabetes distress conversation during the highly stressed hospitalization time for patients facing amputation and then facilitate outpatient referral for follow-up.

CDCES referral is recommended at 4 key times during the lives of all patients with diabetes:

• at diagnosis
• annually and/or when not meeting treatment targets
• when complicating factors develop
• when transitions in life and care occur.

Complicating factors such as DFUs and amputation are key times for referral. Current guidelines require initiation of the CDCES referral by the primary provider for their diabetes.

How to Find a DSMES Program With a CDCES

Association of Diabetes Care & Education Specialists
American Diabetes Association
DDAS Diabetes Distress Assessment Scales – T1 DDAS and T2 DDAS

Will Diabetes Distress Identification and Treatment Improve DFU Outcomes?

Likely, yes. Unfortunately, prior studies looking at physiologic and psychological effects on DFU healing used more general and non-diabetes specific measures such as the Perceived Stress Scale (PSS) and the Hospital Anxiety and Depression Scale (HADS).^16–18 Stress has been long identified as a critical factor that impacts acute wound healing.²⁰ Increasing knowledge regarding stress on chronic wounds (diabetic foot ulcers) outcomes is evolving.¹⁹ Several studies have shown expedited DFU wound healing with decreased psychological distress.¹⁷ Successful interventions have included relaxation techniques, coping styles, guided imagery, and hypnosis.^18-23 In addition, physiologic markers including vagal tone, cortisol, and matrix metalloproteinases (MMPs) measurements have shown positive effects on DFU healing with stress reduction.^20–22 Shame and guilt have been associated with tumor necrosis factor (TNF) levels slowing healing.¹⁹ Qualitative studies have shown perceived benefits in DFU healing and emotional wellbeing for both patients and caregivers.¹⁷ We need future studies using the diabetes-specific DDAS tool in evaluating trials on DFU healing.

In Conclusion

DFUs are a source of significant emotional distress including the worries and fears of amputation.²³ Ignoring this distress leaves out the emotional side of the treatment plan. Using DDAS results to provide targeted interventions promotes a focused approach to meet patients where they are.

Addressing the emotional concerns of DFU patients involved on limb preservation teams will improve overall health outcomes and likely wound healing. CDCES and/or diabetes psychologist members of the limb preservation team are valuable to identify and manage diabetes distress. Future studies using the DDAS to better understand the psychological and physiologic benefit of addressing diabetes distress will hopefully yield improved DFU healing and eliminate preventable amputations.

Dr. Griffin is a Clinical Assistant Professor in the Department of Medicine, Internal Medicine and Geriatrics at Oregon Health and Science University. He is a Fellow of the American College of Foot and Ankle Surgeons, emeritus.

References

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