ADA Standards 2020: Psychosocial issues and smoking.

PSYCHOSOCIAL ISSUES

Introduction 

• Psychosocial screening should include:
• Attitudes towards diabetes and treatment
• Mood
• General and diabetes-related QoL
• Financial, social and emotional resources
• Psychiatric history
• Standarized and validated tools should be used to detect: diabetes distress, anxiety, depression, disordered eating, and cognitive capacities. 
• Patients >=65 can be screened for depression and cognitive impairment.
  

Diabetes distress

• Dfn: negative psychological reactions related to having to manage diabetes. It's mostly related to burdens of diabetes management, disease progression and complications.
  
• Affects about 45% of patients
• Should be screened with "validated tools" like PAID (problem Areas in Diabetes) or DDS (Diabetes Distress Scale), see diabetesdistress.org
  
• If positive, referred to a DSMES provider, given the fact that DSMES improves it
• If DD negatively affects diabetes management, to a mental health specialist with knowledge in diabetes.
  

Anxiety

• Screen for anxiety disorders AD in people who show symptoms of anxiety including hypoglycemia unawareness with fear of hypoglycemia
• Refer to mental health if positive screening.
• AD affect 19.5% of people with diabetes. The most common causes are hypoglycemia, not meeting glycemic targets, injections, and diabetes complications.
• Obsessive-compulsive disorder should be suspected in cases off attitudes toward self-management that go far beyond the usual care. 
• Structured programs of Blood Glucose Awareness Training (BGAT) help improving glycemic control and hypoglycemia en cases of fear of hypoglycemia and hypo unawareness. BGAT are usually 8 weekly sessions in groups of 5-15 subjects.
  

Depression

• It affects 25% of type 1 or type 2 diabetes. It should be yearly screened with validated measures
• If positive screening, refer to a MH provider, its treatment improves diabetic outcomes. 
• If depression improves, reconsider therapy, previously rejected measures like physical activity or intensive insulin regimes can be accepted now.
  

Disordered eating behaviour

• The most DEBs are insulin omission in type 1 diabetes and binge eating in type 2 diabetes. 
• Suspect DEB in cases of unexplained worsening of glycemic control and weight lose
• Certaing drugs like GLP-1 RA may help reducing hunger in binge-eaters.
  

Serious mental illness

• Schizophrenia and other serious mental illness increase the risk for diabetes and it should be routinely monitored
• Atypical or second-generation antopsychotic drugs like olanzapine particularly raise diabetes risk 
• Because of difficulties in self-management, a caretaker must be included in the decision-making process and diabetes treatment plan. 

SMOKING AND DIABETES

• Advise all smokers with diabetes not to smoke or use e-cigarettes. Evedence suggests short advice against smoking is effective. In motivated patients, pharmachologic treatment is also beneficial. E-cigarettes are also harmful and not advisable.