Preserving Mental Health for Those Living with Diabetes

Treating those with type 1 diabetes includes paying attention to the mental and emotional well-being of patients and their families.

With Randi Streisand PhD, Jessica Pierce PhD, Maisa Feghali MD and David G. Marrero PhD

Smiling parents sitting with two younger children in their laps on the floorConsidering the care of the entire family of type 1 diabetes patients can lead to greater well-being and future self-management.

Caring for patients diagnosed with type 1 diabetes means tending not only to their medical needs but their mental health needs as well. These differ in young children, young adults, adults and pregnant adults, often with special challenges along the way.

Childhood: Get the Family On Board

"I hope I convince you we all need to pay attention to this age group and their families," says Randi Streisand PhD, professor and chief, psychology and behavioral health, Children's National Hospital and the George Washington University School of Medicine & Health Sciences. She presented this research at the 81st Scientific Sessions of the American Diabetes Association.

Among the goals of treating type 1 diabetes, she says, is keeping them physically healthy, optimizing their emotional well-being and development, as well as helping them participate in their diabetes management as they grow older.

"Most health care providers are focused on the physical aspects," she says, such as A1C, which is necessary of course but not enough. The age at diagnosis can be so young that children aren't verbal yet, she points out, and that presents challenges for the family.  It's necessary for parents to differentiate, for instance, a toddler tantrum versus a toddler with low blood sugar. Some toddlers adapt to diabetes management easily, she finds, but not all.

Then, when children enter school, parents need to spend time educating others about diabetes management—school personnel, after-school caretakers, and sports directors. Parents often describe taking care of a child with diabetes as more than a full-time job, since a full-time job typically has an ending hour. 

Recent research: Prevalence of depression in parents

In the Type One Training Study, Dr. Streisand and colleagues randomized 30 mothers of young children (1 to 6 years) with type 1 diabetes to a phone-based intervention or a physical activity. Both programs were met with satisfaction.

One of the sobering findings: nearly half of mothers had clinically significant levels of depression. "The stress parents are under is real," she says, "and it doesn't necessarily go away."

In another study, involving stepped care, Dr. Streisand’s team looked at three levels of behavioral intervention for parents of young patients, based on need. It included peer coaching, telephone-based support, and other components. Parents moved up to more intensive intervention if their distress increased or if the children didn't meet the glycemic goals. Again, she found high levels of depressive symptoms among parents in this study. 

Clinical tips for childhood type 1 diabetes treatment

The choice of language parents and physicians use when talking about diabetes is very important. Clinicians should encourage parents to use the big words—insulin, diabetes. Replace talking about ''medicine," which is usually taken temporarily to feel better, with ''insulin," for example.

Encourage families to have blood glucose checks incorporated into the family routine—set up a certain place to do injections, for instance.

Clinicians can also talk to parents about behavioral expectations, such as—house rules apply to all children, not just those without diabetes. They can give their child a choice, to a degree. Not if they want their sensor changed, but other choices that won't affect their care. A dietitian team can help families with mealtime advice.

Clinicians should also remember to remind parents to practice good self-care, seek out supportive networks, and maintain their own physical health.

Adolescence, Young Adulthood: Passing the Responsibility 

"Diabetes management during adolescence and early adulthood are extremely challenging," says Jessica Pierce PhD, research scientist at Nemours Center for Healthcare Delivery Science and associate professor, University of Central Florida College of Medicine. In general, their A1Cs ''aren't even close" to recommendations, she says.

Piling onto the usual adolescent challenges, Dr. Pierce says, adolescents and young adults with diabetes may experience depression, eating disorders and other psychological concerns. All can impact diabetes management.

She suggests that parents should be sharing diabetes self-care and transferring more responsibility to the teen as the teen demonstrates success. 

Many adolescents report difficulties disclosing they have diabetes with peers. ''We know that AYA (adolescents and young adults) with diabetes engage in risk taking behaviors to the same extent as peers," Dr. Pierce says, "but the outcomes may pose a bigger price—such as impacts on glycemic control." Diabetes distress is common during this period. 

Clinical tips for adolescent type 1 diabetes treatment

Psychosocial screening is recommended by the ADA, and clinicians should follow that, she says. Family-based procedures such as goal setting and shared responsibility can improve glycemic care and relationships. 

As teens and young adults transition to higher school levels, including college, each shift can be challenging. They must also transition from pediatric diabetes care to adult care. The goal is to identify potential distress and step in. 

Pregnancy: Gestational vs. Pre-Existing

''Diabetes in pregnancy occurs in about 7% of pregnancies," says Maisa N. Feghali MD, assistant professor of maternal-fetal medicine at the University of Pittsburgh and Magee-Womens Hospital, “of those, 6% are gestational and just 1% pre-gestational.” Diagnosis during pregnancy can include type 1 and type 2 diabetes. 

"Those numbers are expected to increase in the coming years," Dr. Feghali says. For those already diagnosed with diabetes, it is often a time of transitioning some forms of medical care from their endocrinologist, who may not feel comfortable overseeing the pregnancy, to their obstetrician.

The goals of treatment are stricter when a woman with diabetes is pregnant. The goals are an A1C less than 6%, fasting under 95 mg/dL, postprandial 2-hour or less than 120 mg/dl and CGM time in range over 70%. An increase in monitoring is necessary to maintain stricter control and insulin requirements increase.

"We ask them (women) to test blood glucose at least 7 times a day [if they are not on a CGM]," Dr. Feghali says. They also ask for weekly review of their measurements, an A1C measure at every trimester, additional visits for ultrasound, and fetal monitoring. 

“Women can feel guilty about having diabetes during pregnancy,” Dr. Feghali says. “The constant monitoring has an impact, often increasing guilt and concern about risk to their child if they don't manage the disease well.”

Clinical tips for treating gestational diabetes 

Especially as the pregnancy continues, women seek and appreciate peer support, Dr. Feghali says, as well as emotional support. 

Clinicians should provide the patient with strategies for dealing with high and low blood glucose levels—and to make sure that information is always available, especially if physicians are offline when it occurs.

Women with gestational diabetes likely have little to no knowledge about how to handle diabetes, unlike pregnant women with pre-existing diabetes. Screening is typically done at 24-28 weeks. Recommended treatment includes nutritional counseling and lifestyle modifications. If that does not work, pharmacologic treatment is initiated. 

Gestational diabetes (GDN) is sometimes thought of as a milder version compared to ''full-blown" type 2 diabetes, but the risks of GDM are still significant, she says. These include pre-eclampsia, higher risk of pre-term delivery and a higher need for C-section.

Goals of gestational diabetes management are similar to those of pre-existing. Clinicians should be aware that pregnant women sometimes downplay the risk, and they should be prepared to educate the women not to, says Dr. Feghali.

Women also report that a GDM diagnosis ''takes away some of the joy of pregnancy they are experiencing," Dr. Feghali says.

Addressing the mental health of your patients

For diabetic people of all ages, it is important to screen for diabetes distress and depression. "These two conditions look similar but are actually quite different and observed frequently in patients at all ages," says David G. Marrero PhD, director of the Center for Border Health Disparities at the University of Arizona Health Sciences. Assessing both can be done with standardized forms and can significantly contribute to better shared decision making.

Clinicians should include personnel trained in mental health to collaborate in patient management, Dr. Marrero says

He also advises clinicians to address emotional issues during each visit. Simple way to approach this is asking: "What has been the most difficult thing you have to deal with regarding your diabetes?"

Encourage patients to express themselves and let them know there are no right or wrong answers.

Continue Reading:
The Effects of Physician Communication on Emotional Burden in Diabetic Patients
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