It is also important to remain aware of socioeconomic changes—in employment, insurance coverage, and living situations, for example—which are not addressed in the screening tools.
Moderate to high diabetes distress scores, as well as individual items patients identify as “very serious” problems, represent clinical red flags that should be the focus of careful discussion during a medical visit. Patients with moderate to high distress should be referred to a therapist trained in cognitive behavioral therapy or problem-solving therapy. Physicians who lack access to such resources can incorporate cognitive behavioral and problem-solving techniques into patient discussion. (See “Directing help where it’s most needed.”) All patients should be referred to a certified diabetes educator—a key component of diabetes care.45,46
SIDEBAR
Directing help where it's most needed
CASE 1 ›
Conduct a behavioral experiment
Fred J, a 67-year-old diagnosed with type 2 diabetes 6 years ago, comes in for a diabetes check-up. He is a new patient who recently retired from his job as a contractor and was referred by a colleague. In response to a question about his diabetes management, Mr. J tells you he’s having a hard time.
“I get down on myself,” the patient says. “I take my medications every day at the exact same time, but when I test my sugar, it’s 260 or 280. I know I did this to myself. If only I weighed less, ate better, or exercised more.”
At other times, “I think, 'Why bother?'” Mr. J adds. “I feel like there’s nothing I can do to make it better.”
The DDS-2 screen you gave Mr. J bears out his high level of distress and his fear of complications. He tells you about an aunt who “had diabetes like me and had to go on dialysis, then died 2 years later.” When you ask what he fears most, Mr. J says he worries about kidney failure. “I don’t want to go on dialysis,” he insists.
You take the opportunity to point out that nephropathy is not inevitable and that he can perform self-care behaviors now that will prevent or delay kidney complications.
You also decide to try a cognitive behavioral technique in an attempt to change his thought process. You ask Mr. J to agree to a week-long behavioral experiment to examine the effect of walking for 30 minutes each day.
He agrees. You advise him to write down his predictions before he begins the experiment and then to keep a log, checking and recording his glucose levels before and after each walk. You schedule a follow-up visit to discuss the results, hoping that a reduction in blood glucose levels will convince Mr. J that exercise is beneficial to his diabetes.
CASE 2 ›
Identify the problem; brainstorm with the patient
Susan T, a 46-year-old with a husband and 2 teenage children, comes in for her 3-month diabetes check-up. At her last visit, she expressed concerns about her family’s lack of cooperation as she struggled to change her diet. This time, she appears frustrated and distraught.
Your nurse administered the PAID-5 while Ms. T was in the waiting room and entered her score—8, indicating high diabetes distress—in the electronic medical record. You ask Ms. T what’s happening, knowing that encouraging her to verbalize her feelings is a way to increase her trust and help alleviate her concerns.
You also try the following problem-solving technique:
Define the problem. Ms. T is having a hard time maintaining a healthy diet. Her husband and children refuse to eat the healthy meals she prepares and want her to cook separate dinners for them.
Identify challenges. The patient works full-time and does not have the time or energy to cook separate meals. In addition, she is upset by her family’s lack of support in her efforts to control her disease.
Brainstorm multiple solutions:
1) Ms. T can prepare all of her own meals for the work week on Sunday, then cook for the others when she returns from work.
2) Her husband and children can make their own dinner if they do not want to eat the healthier meals she prepares.
3) The patient can join a diabetes support group where she will meet, and possibly learn from, other patients who may be struggling with diabetes self-care.
4) Ms. T can ask her husband and children to come to her next diabetes check-up so they can learn about the importance of family support in diabetes management directly from you.
5) The patient’s family can receive information about a healthy diabetes diet from a certified diabetes educator.
Decide on appropriate solutions. The patient agrees to try and prepare her weekday meals on Sunday so that she is not tempted to eat less healthy options. She also agrees to bring her family to her next diabetes check-up and to diabetes education classes.
CORRESPONDENCE
Elizabeth A. Beverly, PhD, Department of Family Medicine, Ohio University Heritage College of Osteopathic Medicine, 35 W. Green Drive, Athens, OH 45701; beverle1@ohio.edu.