Recognising and treating psychological issues in people with diabetes mellitus
Intended for healthcare professionals
Evidence and practice    

Recognising and treating psychological issues in people with diabetes mellitus

Sheila Hardy Practice nurse educator, Charlie Waller Trust, Thatcham, England, and post-doctoral researcher, University of Hull, Hull, England

Why you should read this article:
  • To recognise the importance of considering psychological well-being as part of the holistic care of people with diabetes mellitus

  • To enhance your knowledge of the psychological issues that people with diabetes may experience, including depression, distress and guilt

  • To consider the interventions you could implement in your practice to treat psychological issues in people with diabetes

Diabetes mellitus is a long-term condition that can lead to complications such as diabetic ketoacidosis, retinopathy and cardiovascular disease as a result of uncontrolled high blood glucose levels. In addition to these physical health complications, people with diabetes are more likely to experience psychological issues such as guilt, distress and depression compared with the general population. These issues can negatively affect an individual’s ability to effectively monitor and self-manage their condition; however, they are often an overlooked aspect of diabetes care. This article explains how nurses can prevent, recognise and treat some of the psychological issues that people with diabetes commonly experience.

Nursing Standard. doi: 10.7748/ns.2021.e11682

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

sheila.hardy@charliewaller.org

Conflict of interest

None declared

Hardy S (2021) Recognising and treating psychological issues in people with diabetes mellitus. Nursing Standard. doi: 10.7748/ns.2021.e11682

Published online: 10 May 2021

Diabetes mellitus is a common long-term condition characterised by high blood glucose levels, which occur as a result of impaired insulin secretion and/or insulin action. It has been estimated that up to 4.7 million people in the UK are living with diabetes (Whicher et al 2020). Around 8% of people diagnosed with diabetes will have type 1 diabetes, which is caused by the autoimmune destruction of the insulin-producing beta cells in the endocrine pancreas (Paschou et al 2014, Whicher et al 2020). In type 1 diabetes, the pancreas produces little or no insulin, so individuals with this condition will require life-long insulin injections.

Around 90% of people diagnosed with diabetes will have type 2 diabetes (Whicher et al 2020), in which the body is unable to produce sufficient insulin or the insulin it produces does not work effectively. Type 2 diabetes is associated with a variety of risk factors, such as obesity, hypertension, hypercholesterolaemia, having a family member with the condition, and a history of gestational diabetes (a type of diabetes that women can develop during pregnancy, but which usually resolves after birth) (Khardori 2021). The management of type 2 diabetes typically involves lifestyle changes such as a person adapting their diet and increasing their physical activity levels, as well as the administration of medicines and/or insulin (National Institute for Health and Care Excellence (NICE) 2020).

People with diabetes are at risk of long-term microvascular complications such as neuropathy, nephropathy and retinopathy, as well as macrovascular complications such as cardiovascular disease, stroke and peripheral artery disease (Deshpande et al 2008, Papatheodorou et al 2018). One systematic review identified that cardiovascular disease is a major cause of comorbidity and death among people with type 2 diabetes (Einarson et al 2018). Other complications of diabetes include dental conditions, reduced resistance to infections, and birth complications among pregnant women with diabetes (Deshpande et al 2008).

In addition to these physical health complications, people with diabetes may experience various psychological issues. However, it has been identified that psychological health and well-being is a frequently overlooked aspect of diabetes care (Chew et al 2014, Holt et al 2014), with one Diabetes UK (2019) report finding that only around 25% of people with diabetes who felt they required specialist mental health support could access it. This article outlines some of the psychological issues that people with diabetes commonly experience, and explains how nurses can prevent, recognise and treat such issues as part of providing holistic care for this patient group.

Key points

  • People with type 2 diabetes are more likely to experience psychological issues such as guilt, distress and depression compared with the general population

  • Experiencing psychological issues can negatively affect diabetes outcomes, for example leading to suboptimal control of blood glucose levels

  • Nurses can assist in preventing and recognising the development of psychological issues by using a motivational interviewing approach, which involves expressing empathy, emphasising self-efficacy and using open-ended questions and reflection

  • Interventions for treating psychological issues in people with diabetes include patient education, psychological support and antidepressant medicines

Diabetes and psychological issues

Psychological issues that are commonly experienced by people with diabetes include depression, diabetes distress and guilt. It is essential that nurses caring for people with diabetes have the knowledge and skills to alleviate emotions such as guilt in these individuals, and are able to prevent, recognise and treat depression and distress.

Depression

Khaledi et al’s (2019) systematic review and meta-analysis demonstrated that almost one in four adults with type 2 diabetes experienced depression. This presents a major clinical challenge because the outcomes of diabetes are negatively affected by depression, and vice versa (Holt et al 2014). Having comorbid diabetes and depression can lead to significant adverse effects on people’s health outcomes and a lower quality of life compared with the general population (Naylor et al 2012). In addition, people with comorbid diabetes and depression are more likely to have suboptimal control of their blood glucose levels and are less likely to consume a healthy diet, undertake adequate exercise and take their prescribed medicines compared with people who have diabetes but not depression (Bogner et al 2013, Rotella and Mannucci 2013). People with comorbid type 2 diabetes and depression are also at increased risk of developing complications associated with diabetes (Mezuk et al 2008).

Several studies have found that the prevalence of subthreshold depression is higher in adults with diabetes than in those without diabetes (Shrestha et al 2020). People with subthreshold depression are defined as those who have experienced more than two but less than five depressive symptoms – for example feeling ‘down’, worthless or hopeless, and being unable to take pleasure in normally enjoyable activities – for a duration of at least two weeks (Rodríguez et al 2012). It has been estimated that 8% of people with subthreshold depression will progress to major depression within two years of developing symptoms (Lee et al 2018).

Diabetes distress

Diabetes distress is an emotional state characterised by concerns about the burden of diabetes and its treatment, as well as the social effects of the condition (Young-Hyman et al 2016). It causes significant emotional harm and can negatively affect health outcomes (Kreider 2017). Diabetes distress has a reported prevalence of between 18% and 45% (Young-Hyman et al 2016), and those experiencing it may feel frustrated, ‘defeated’ and overwhelmed by the physical and mental effort involved in managing their condition.

Guilt

Guilt is commonly experienced by people diagnosed with type 2 diabetes, who may feel that their lifestyle choices and dietary habits have contributed to the development of their condition, or that they have deviated from the lifestyle and medical advice they have been given by healthcare professionals. In some cases, this excessive guilt can lead to increased substance misuse, suicidal tendencies and isolation (Diabetes.co.uk 2019).

Preventing psychological issues

The approach that nurses use to provide lifestyle advice to a person with diabetes can influence whether that person develops psychological issues. For example, inappropriate advice or criticism can lead to some people experiencing a sense of guilt and viewing themselves, rather than elements of their behaviour, negatively (Tangney et al 2005). Similarly, if a person perceives that a nurse is passing judgement on their weight, for example, regardless of the nurse’s actual intentions, this can lead to increased distress (Darby et al 2014). NHS England (2018) have developed guidance which provides practical examples of language that will encourage positive interactions with people who have diabetes and can subsequently lead to positive outcomes.

One framework that was designed to assist healthcare professionals in identifying and managing diabetes distress is the 7 As model (Diabetes UK 2021a). This is a seven-step process that can be used as part of a person-centred approach during consultations with patients who have diabetes. The process includes three steps to identify diabetes distress – be aware, ask and assess – and four steps to support a person who experiences diabetes distress – advise, assist, assign and arrange (Diabetes UK 2021a).

Motivational interviewing approach

Nurses can use a motivational interviewing approach to assist them in preventing and recognising the development of psychological issues in people with diabetes. This approach involves expressing empathy, emphasising self-efficacy and using open-ended questions and reflection, all of which can enable individuals to reach their own conclusions about any unhealthy lifestyle behaviours and the need to change these (Miller 2010). Because the motivational interviewing approach is focused on the person’s behaviour rather than criticising the person themselves, they are less likely to develop psychological issues such as guilt, and are more likely to engage with lifestyle changes (Darby et al 2014).

Part of this motivational interviewing approach involves the nurse identifying a person’s readiness to make lifestyle changes and responding accordingly. Box 1 details two potential nurse responses to a patient with type 2 diabetes who has stopped exercising due to depression.

Box 1.

Two potential nurse responses to a patient with type 2 diabetes who has stopped exercising due to depression

Michael is a 52-year-old man who has been diagnosed with type 2 diabetes. Since his last diabetes review, he has gained weight and his glycated haemoglobin (HbA1c) level has increased. Previously, Michael was walking for one hour every day, but he stopped doing so around two months ago

First nurse response

  • Nurse: ‘It looks like stopping walking may have increased your blood glucose levels. You could start walking again, or we can increase your medicines now.’

  • Michael: I can’t start walking again. I’m so tired and I really can’t be bothered.’

  • Nurse: ‘That’s a shame. Okay, we’ll increase your medicines. Perhaps you will feel less tired when your blood glucose level has gone down.’

Second nurse response

  • Nurse: ‘I’m interested to hear what changed two months ago to make you stop walking. Can you tell me about that?’

  • Michael: ‘Yes, I started to feel a bit low, and my sleep wasn’t good, so I was tired. Since then, everything has seemed like an effort.’

  • Nurse: ‘Sometimes people with diabetes do feel low and this can affect them in various ways, including their motivation to exercise. It would be worth checking your mood, because this can be treated. This just involves answering a few questions.’

In Box 1, it can be seen that the first nurse response provided a limited choice that focused on a pharmaceutical approach, had the potential to induce feelings of guilt in the patient about their lack of exercise, and did not identify that the patient may have an underlying psychological issue. Conversely, the second nurse response was empathic and encouraged the patient to discuss their feelings. Using this motivational interviewing approach would be more likely to encourage patients to engage with the nurse and any subsequent treatment (Darby et al 2014).

Problem-solving and setting goals

Motivating people with diabetes by engaging them in problem-solving can reduce the emotional burden associated with the daily demands of diabetes self-management, and may assist in preventing the development of psychological issues such as diabetes distress. One problem-solving technique that nurses can use with patients involves the identification of SMART (specific, measurable, achievable, relevant and time-based) goals. For example, a person with diabetes who wanted to begin exercising might have an initial goal of walking three times per week for 20 minutes, which could subsequently be increased. Goal setting in this way is likely to be more beneficial than setting ambitious goals that the person may not be able to achieve and could negatively affect their self-esteem as a result (Powers et al 2016).

Diabetes education and monitoring well-being

Providing education about diabetes is another method that nurses can use to prevent the development of psychological issues in people with diabetes. Such education can address misconceptions concerning diabetes, for example that it is dangerous for people with diabetes to drive or that they can only eat certain foods (Chowdhury et al 2018).

One randomised controlled trial suggested that monitoring people’s well-being at diabetes check-ups could prevent the development of depression (Pibernik-Okanovic et al 2009). While there is no specific guidance for nurses on measuring the well-being of people in their care, there are some tools that could contribute to a well-being assessment. For example, the Warwick-Edinburgh Mental Wellbeing Scale (Tennant et al 2007) is a 14-item tool that is often used by scientists and psychologists to measure well-being. A shorter, seven-item version of this tool is also available.

Recognising underlying psychological issues

It is important for nurses to remember that people with diabetes may present with physical symptoms that can obscure any underlying psychological issues. These physical symptoms may include increased tiredness, bowel issues, sleep difficulties, headaches or changes in appetite. Individuals may also report an increase in smoking, alcohol or drug use. To ensure that psychological issues such as distress and depression are identified in people with diabetes, guidance from The King’s Fund and Centre for Mental Health (Naylor et al 2012) recommends asking about the person’s emotional well-being and normalising the discussion of mental and emotional aspects of physical health conditions as part of any assessment.

Nurses can also use validated screening tools to recognise distress and depression in people with diabetes (Holt et al 2014). For example, Whooley et al (1997) detailed two screening questions that can be used to ascertain whether someone is experiencing depression, and which are advocated by NICE (2009):

  • During the last month, have you often been bothered by feeling down, depressed or hopeless?

  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

An answer of ‘no’ to these questions indicates that the person is unlikely to have depression. Conversely, if the patient answers ‘yes’ to either of the two questions, then a more detailed assessment should be undertaken, for example using the Patient Health Questionnaire-9 (PHQ-9) (Spitzer et al 1999). The PHQ-9 is a nine-question self-administered diagnostic tool used to screen for depression. It focuses on parameters such as sleep, appetite, mood, self-esteem and concentration, which are each scored from 0 (not at all) to 3 (nearly every day). The PHQ-9 cut-off score for moderate-to-severe depression is ≥10 points, but it has been suggested that this should be increased to ≥12 points in people with diabetes to improve the distinction between diabetes-related symptoms and depressive symptoms (van Steenbergen-Weijenburg et al 2010). If a nurse has a consultation with a patient who reports that they are feeling ‘down’ or depressed, they can assess the patient using the PHQ-9 without the need to first ask any screening questions.

Another tool that nurses can use to assess the psychological issues in people with type 2 diabetes is the Diabetic Distress Scale-2 (DDS2) (Fisher et al 2008). In this tool, the patient scores two statements using a six-point Likert scale, with a score of 1 indicating ‘not a problem’ and a score of 6 indicating a ‘severe problem’. The two statements are:

  • Feeling overwhelmed by the demands of living with diabetes.

  • Feeling that I am often failing with my diabetes regimen.

If the person’s mean score is ≥3 across the two questions, or a total score of ≥6, it is recommended that the Diabetic Distress Scale-17 (DDS) (Polonsky et al 2005) should be used. The DDS is a self-administered questionnaire comprising 17 items on potentially challenging areas for people with diabetes, such as: feeling that diabetes is taking up too much mental and physical energy; feeling that friends or family are not supportive; and feeling overwhelmed by the demands of living with diabetes.

One study by Schmitt et al (2015) compared tools that can be used to assess people’s levels of diabetes distress, identifying that the DDS is a useful self-report measure, particularly for assessing any challenges related to the self-management of diabetes experienced by individuals. However, the researchers also reported that the tool did not cover all the psychological issues that a person with diabetes might experience, nor did it demonstrate a sufficient focus on food-related issues and complications (Schmitt et al 2015).

The Distress Thermometer (Roth et al 1998) is another tool that can be used to screen people for distress. It comprises an 11-point scale presented visually in the form of a thermometer, which an individual uses to self-report how distressed they have felt over the previous week, ranging from 0 (no distress) to 10 (extreme distress). The Distress Thermometer was originally developed for use in people with cancer, and research has demonstrated that it can be useful in various long-term conditions (Gillespie and Cadden 2013). However, no specific evidence for its efficacy in people with diabetes has been identified.

Treating psychological issues

A range of interventions are available for treating psychological issues in people with diabetes, including patient education, psychological support and antidepressant medicines. One systematic review found that treating depression in people with diabetes with psychotherapeutic interventions or medicines was effective, but that the optimal response occurred with a combination of patient education in diabetes self-management skills and psychological support (van der Feltz-Cornelis et al 2010).

Patient education

NICE (2020) guidelines recommend offering structured education to adults with type 2 diabetes and/or their family members or carers at the time of diagnosis, with annual reviews. This education should be evidence based, suit the needs of the person, and be delivered by trained educators (NICE 2020). Diabetes education often includes a psychological component, where in addition to learning about diabetes and its self-management, patients have the opportunity to express how they feel about their condition (Holt et al 2014).

Psychological support

In general practice and community settings, nurses often have more regular contact with people who have diabetes compared with other healthcare professionals, and because nurses are trusted to support patients’ physical health, they are often also considered the optimal source of psychological support (Dowling 2018).

Nurses can use various methods and strategies to provide psychological support to patients with diabetes. For example, they can use Diabetes UK’s (2021b) ‘information prescription’ on diabetes and mood as a basis for discussing psychological issues. This document aims to enable a person with type 2 diabetes to discuss their feelings, manage their diabetes effectively and identify practical methods to feel increasingly positive about living with their condition, for example talking to other people who have diabetes, consuming a balanced diet and increasing their physical activity levels.

Mindfulness and meditation-based strategies are simple, and easy to understand and practice, and do not incur additional costs to patients or healthcare organisations because a range of high-quality free resources are available. Meditation-based strategies may offer immediate positive benefits such as improved self-care behaviour, self-reliance and self-control for people with type 2 diabetes, including among those who are not able to engage in moderate-to-vigorous physical activity. These strategies have also demonstrated some improvements in body weight, glycaemic control and blood pressure levels (Priya and Kalra 2018). Hardy (2015) stated that nurses can offer mindfulness as an appropriate intervention for patients to assist them in self-managing their diabetes.

Intervention and observational studies have found that exposure to nature is associated with numerous health benefits, including stress reduction (Twohig-Bennett and Jones 2018), so encouraging people with diabetes to spend time in green spaces could be beneficial to their mental well-being and diabetes self-management. Research has also shown that moderate-intensity physical activity interventions involving supervised aerobic exercise can reduce symptoms of depression (Stanton and Reaburn 2014) and may improve glycaemic control (Harmer and Elkins 2015).

Behavioural activation is an evidence-based treatment for depression that seeks to reduce a person’s symptoms and improve their mood through behavioural tasks related to reducing avoidance, activity scheduling, and enhancing positively reinforced behaviours (NICE 2011). Stigma is often a barrier to psychological treatments for depression, and many people with diabetes find exercise challenging. Therefore, incorporating strategies from behavioural activation into a structured exercise programme can provide a less stigmatising method of addressing depression and supporting exercise in people with diabetes (Schneider et al 2016). However, although behavioural activation is recommended by NICE (2011), it is not commonly available in the UK at present.

In 2008, Improving Access to Psychological Therapies services were established in England to provide evidence-based psychological therapies such as cognitive behavioural therapy, interpersonal therapy and psychodynamic therapy for people with common mental health conditions such as anxiety and depression (NICE 2011). It has been recommended that this type of specialist mental healthcare should be provided to people with long-term conditions such as diabetes to manage mental health issues (James 2019).

Antidepressant medicines

Antidepressant medicines may be appropriate for people with moderate-to-severe depression (NICE 2011), which could include individuals with comorbid diabetes. Selective serotonin reuptake inhibitors (SSRIs) are the most frequently used type of antidepressant medicines; however, Meng et al (2019) identified that although some SSRIs may have a beneficial effect on glycaemic control, others may induce hyperglycaemia or hypoglycaemia.

Before antidepressants are prescribed for a person with diabetes, healthcare professionals should consider the side effects of the antidepressant, since these may affect the individual’s diabetes management, for example in terms of glycaemic control. It is also important that they consider the potential interactions with any of the medicines the person with diabetes may be prescribed. There is no evidence to support the use of specific antidepressants for people with long-term physical health conditions such as type 2 diabetes (NICE 2009).

Conclusion

People with diabetes are more likely to experience psychological issues such as guilt, distress or depression compared with the general population. If left untreated, these issues can negatively affect diabetes outcomes, for example leading to suboptimal control of blood glucose levels. By using a motivational interviewing approach to prevent and recognise psychological issues, nurses can empower people with diabetes to improve their self-management of the condition. Various interventions may also be beneficial, for example patient education, mindfulness and meditation-based strategies, antidepressant medicines and specialist mental healthcare.

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