This issue of Endocrine Today introduces the Diabetes in Real Life column, coordinated by Susan Weiner, MS, RDN, CDE, CDN. In the coming months, Weiner’s roster of diabetes education experts will discuss pressing issues and novel concepts in patient care.
In this issue, Weiner talks with clinical psychologist and diabetes educator
Beverly S. Adler, PhD, CDE, about depression, a common and complex condition associated with a diagnosis of diabetes. People with diabetes related depression often have difficulty managing self-care behaviors, including medication adherence. Health care providers need to understand the significance of this issue for our patients with diabetes.
Tell me briefly about your experience working with people with diabetes as a clinical psychologist and certified diabetes educator.
Dr. Adler: My training in clinical psychology is in cognitive behavioral therapy (CBT). Whether I am helping patients to cope with a new diagnosis or to live with long-standing diabetes, CBT is a successful strategy to deal with their adjustment issues. Not everybody goes through these emotional stages, or necessarily in this order, but CBT can address the irrational cognitions and behaviors of denial, anger, bargaining and depression before they reach the goal of diabetes acceptance.
As a certified diabetes educator, I developed my “TLC therapy” for patients with diabetes: talk, listen, counsel. I break down the therapy process into three parts: talk — teaching patients about diabetes and its management; listen — supporting patients and validating their feelings when they speak; counsel — utilizing CBT to challenge unreasonable thoughts and replace them with more reasonable thoughts and actions. My focus in therapy is to empower my patients to cope with their diabetes.
What can you tell us about the link between diabetes and depression?
Dr. Adler: Clinical depression can occur up to twice as often among diabetes patients as in the general population. Mild depressive feelings are normal as long as they are not pervasive or prolonged. According to the National Institute of Mental Health, symptoms of depression may include the following: difficulty concentrating, remembering details and making decisions; fatigue and decreased energy; feelings of guilt, worthlessness or helplessness; feelings of hopelessness or pessimism; sleep difficulties, such as insomnia, early-morning wakefulness or excessive sleeping; irritability and restlessness; loss of interest in usual activities, such as hobbies, being with people, sex; appetite changes, such as overeating, or appetite loss; persistent sad, anxious or “empty” feelings; thoughts of suicide or suicide attempts.
Being depressed is likely to interfere with diabetes self-management. Research has found that people with diabetes and depression have poorer metabolic and glycemic control. Depressed people with diabetes are less likely to adhere to diet, exercise and medication regimens.
How can symptoms of depression be treated?
Dr. Adler: Clinical depression, if unrelated to diabetes, can be treated with psychiatric medications (antidepressants) and psychotherapy — CBT is one of the most effective treatments.
When depression is related to living with diabetes, this is called diabetes-specific distress or simply diabetes distress. Diabetes distress arises from living with the stresses of diabetes, specifically regarding the emotional burden, physician-related distress, regimen-related distress and interpersonal distress. The emotional distress, within the context of diabetes self-management, does not require psychiatric medications for relief.
Diabetes distress is different from clinical depression. It is an unhealthy style of coping that develops from living with the burden of a chronic illness. Diabetes distress can be divided into four categories. Emotional burden includes feelings of shock, denial, sadness, anger, frustration, guilt, failure and low self-esteem and also worry about possible long-term complications. Physician-related distress includes not feeling confident in the doctor’s competence about diabetes, having a difficult relationship with health care providers, and fear that the physician is critical or judgmental about the patient’s self-care. Regimen-related distress includes obligations of diet, physical activity, blood glucose monitoring and taking medications. Lastly, interpersonal distress includes conflict with family or friends due to diabetes issues and feeling alone and emotionally unsupported by family and friends.
I should note that diabetes distress is not an actual diagnosis in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, “depressive disorder due to another medical condition” can be found in the DSM-5. Diabetes distress can be managed and reduced using CBT strategies to change maladaptive thoughts and behaviors thereby reducing emotional distress. The focus of treatment is to challenge irrational beliefs that cause distress. These may include a variety of emotional reactions, including anger, shame, fear, shock and guilt. By learning to recognize unreasonable thoughts, these patients with diabetes can challenge their negative thoughts and change their thinking to rational thoughts.
What is the benefit of utilizing CBT?
Dr. Adler: CBT can help improve the patient’s attitude toward diabetes as well as self-management. Patients with diabetes report reduced feelings of depression, anxiety, anger, frustration, guilt and diabetes-specific stress as a result of therapy. CBT that addresses mood and diabetes self-care can also lead to improved blood glucose control. Along with improved thoughts and actions, people with diabetes can feel empowered, instead of overwhelmed, to take control of their diabetes and not let diabetes take control of them.
Do you have any last words on this topic?
Dr. Adler: Yes. A health care provider might consider making a referral to a diabetes educator at four critical times: when diabetes is newly diagnosed, at annual assessments to review all areas of self-management, when any diabetes-related complications have been identified, and at critical transitional care stages and changes in health status. If a person exhibits symptoms of depression or diabetes distress at any time, it would be beneficial to recommend psychological treatment, if possible with a mental health clinician who provides diabetes-focused therapy. People who are engaged in their own self-care are less frustrated and more upbeat about having diabetes. Empowerment can lead to good diabetes self-management.
- Adler BS. AADE in Practice. 2014;2:34-37.
- Polonsky WH, et al. Diabetes Care. 2005;28:626-631.
- Powers MA, et al. Diabetes Care. 2015;387:1372-1382.
For more information:
- Beverly S. Adler, PhD, CDE, is a clinical psychologist and certified diabetes educator in private practice in Baldwin, New York, specializing in treating the emotional issues of people with diabetes. She is the author/editor of two diabetes self-help books: My Sweet Life: Successful Women with Diabetes and My Sweet Life: Successful Men with Diabetes. She can be reached at www.AskDrBev.com.
Susan Weiner, MS, RDN, CDE, CDN, is the 2015 AADE Diabetes Educator of the Year and author of The Complete Diabetes Organizer and Diabetes 365 Tips For Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at firstname.lastname@example.org.