kelingwang/causation_strength_rating huggingface dataset:
Diabetes care professionals should also ask whether there are new or different barriers to treatment and self-management, such as feeling overwhelmed or stressed by having diabetes (see diabetes distress, below), changes in finances, or competing medical demands (e.g., the diagnosis of a comorbid condition).
When psychosocial concerns are identified, referral to a qualified behavioral health professional, ideally one specializing in diabetes, should be made for comprehensive evaluation, diagnosis, and treatment (380,381,402,403).
Indications for referral may include positive screening for overall stress related to work-life balance, diabetes distress, diabetes management difficulties, depression, anxiety, disordered eating, and cognitive dysfunction (see Table 5.2  for a complete list).
It is preferable to incorporate psychosocial assessment and treatment into routine care rather than waiting for a specific problem or deterioration in metabolic or psychological status to occur (39,391).
Health care professionals should identify behavioral health professionals, knowledgeable about diabetes treatment and the psychosocial aspects of diabetes, to whom they can refer individuals.
The ADA provides a list of behavioral health professionals who have specialized expertise or who have received education about psychosocial and behavioral issues related to diabetes in the ADA Mental Health Professional Directory (professional.diabetes.org/ada-mental-health-provider-directory).
Ideally, behavioral health professionals should be embedded in diabetes care settings.
In recognition of limited behavioral health resources and to optimize availability, other health care professionals who have been trained in behavioral health interventions may also provide this specialized psychosocial care (396,399,426,427).
Although some health care professionals may not feel qualified to treat psychological problems (428), strengthening the relationship between a person with diabetes and the health care professional may increase the likelihood of the individual accepting referral for other services.
Collaborative care interventions and a team approach have demonstrated efficacy in diabetes self-management, outcomes of depression, and psychosocial functioning (5,6).
The ADA provides resources for a range of health professionals to support behavioral health in people with diabetes at professional.diabetes.org/meetings/behavioral-health-toolkit.
Diabetes distress is very common (391,439–441).
While it shares some features with depression, diabetes distress is distinct and has unique relationships with glycemic and other outcomes (440,442).
Diabetes distress refers to significant negative psychological reactions related to emotional burdens and worries specific to an individual�s experience in having to manage a severe, complicated, and demanding chronic condition such as diabetes (439,440,443).
The constant behavioral demands of diabetes self-management (medication dosing, frequency, and titration as well as monitoring of glucose, food intake, eating patterns, and physical activity) and the potential or actuality of disease progression are directly associated with reports of diabetes distress (439).
The prevalence of diabetes distress is reported to be 18–45%, with an incidence of 38–48% over 18 months in people with type 2 diabetes (443).
In the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study, significant diabetes distress was reported by 45% of the participants, but only 24% reported that their health care teams asked them how diabetes affected their lives (391).
Similar rates have been identified among adolescents with type 1 diabetes (441) and in parents of youth with type 1 diabetes.
High levels of diabetes distress significantly impact medication-taking behaviors and are linked to higher A1C, lower self-efficacy, and less optimal eating and exercise behaviors (5,439,443).
Diabetes distress is also associated with symptoms of anxiety, depression, and reduced health-related quality of life (444).
Diabetes distress should be routinely monitored (445) using diabetes-specific validated measures (1), such as those available through the ADA�s website (professional.diabetes.org/sites/default/files/media/ada_mental_health_toolkit_questionnaires.pdf).
As there are diabetes distress measures that are validated for people with type 1 and type 2 diabetes at different life stages, it is important to select a tool that is appropriate for each person or population.
If diabetes distress is identified, it should be acknowledged and addressed.
If indicated, the person should be referred for follow-up care (403).
This may include specific diabetes education to address areas of diabetes self-care causing distress and impacting clinical management and/or behavioral intervention from a qualified behavioral health professional, ideally one with expertise in diabetes, or from another trained health care professional.
Several educational and behavioral intervention strategies have demonstrated benefits for diabetes distress and, to a lesser degree, glycemic outcomes, including education, psychological therapies, such as cognitive behavioral therapy (CBT) and mindfulness-based therapies, and health behavior change approaches, such as motivational interviewing (429,430,446,447).
Data support diabetes distress interventions delivered using technology to reduce diabetes distress (437), including phone-delivered CBT combined with a smartphone application for CBT (448).
DSMES has been shown to reduce diabetes distress (5) and may also benefit A1C when combined with peer support (449).
It may be helpful to provide counseling regarding expected diabetes-related versus generalized psychological distress, both at diagnosis and when disease state or treatment changes occur (450).
A multisite RCT with adults with type 1 diabetes and elevated diabetes distress and A1C demonstrated large improvements in diabetes distress and small reductions in A1C through two 3-month intervention approaches: a diabetes education intervention with goal setting and a psychological intervention that included emotion regulation skills, motivational interviewing, and goal setting (451).
Among adults with type 2 diabetes in the Veterans Affairs system, an RCT demonstrated benefits of integrating a single session of mindfulness intervention into DSMES, followed by a booster session and mobile app-based home practice over 24 weeks, with the strongest effects on diabetes distress (452).
An RCT of CBT demonstrated positive benefits for diabetes distress, A1C, and depressive symptoms for up to 1 year among adults with type 2 diabetes and elevated symptoms of distress or depression (453).
An RCT among people with type 1 and type 2 diabetes found mindful self-compassion training increased self-compassion, reduced depression and diabetes distress, and improved A1C (454).
An RCT of a resilience-focused cognitive behavioral and social problem-solving intervention compared with diabetes education (434) in teens with type 1 diabetes showed that diabetes distress and depressive symptoms were significantly reduced for up to 3 years post-intervention, although neither A1C nor self-management behaviors improved over time.
These recent studies support that a combination of educational, behavioral, and psychological intervention approaches is needed to address distress, depression, and A1C.
As with treatment of other diabetes-associated behavioral and psychosocial factors affecting disease outcomes, there are few outcome data on long-term systematic treatment of diabetes distress integrated into routine care.
As the diabetes disease course and its management are fluid, it can be expected that related distress may fluctuate and may need different methods of remediation at different points in the life course and as disease progression occurs.
DSMES focuses on empowering individuals with diabetes by providing them with the tools to make informed self-management decisions (15).
DSMES should be person-centered; this is an approach that places the person with diabetes and their family and/or support system at the center of the care model, working in collaboration with health care professionals.
Person-centered care is respectful of and responsive to individual and cultural preferences, needs, and values.
It ensures that the values of the person with diabetes guide all decision-making (16).
Research supports diabetes care and education specialists (DCES), including nurses (registered nurses and nurse practitioners), registered dietitian nutritionists (RDNs), pharmacists, and other health professionals as providers of DSMES who can also tailor curricula to individual needs (71–73).
Members of the DSMES team should have specialized clinical knowledge of diabetes and behavior change principles.
In addition, a DCES needs to be knowledgeable about technology-enabled services and may serve as a technology champion within their practice (68).
Certification as a DCES (cbdce.org/) and/or board certification in advanced diabetes management (diabeteseducator.org/education/certification/bc_adm) demonstrates an individual�s specialized training in and understanding of diabetes management and support (56), and engagement with qualified professionals has been shown to improve diabetes-related outcomes (74).
Additionally, there is growing evidence for the role of community health workers (75,76), as well as peer (75–80) and lay leaders (81), in providing ongoing support.
Given individual needs and access to resources, a variety of culturally adapted DSMES programs need to be offered in a variety of settings.
The use of technology to facilitate access to DSMES, support self-management decisions, and decrease therapeutic inertia calls for broader adoption of these approaches (82).
Additionally, it is important to include social determinants of health (SDOH) of the target population in guiding design and delivery of DSMES.
The DSMES team should consider demographic characteristics such as race, ethnic/cultural background, sex/gender, age, geographic location, technology access, education, literacy, and numeracy (56,83).
For example, a systematic review and meta-analysis of telehealth DSMES interventions with Black and Hispanic people with diabetes showed a 0.465% decrease in A1C, demonstrating the importance of considering demographic factors in relation to DSMES interventions (53).
Anxiety symptoms and diagnosable disorders (e.g., generalized anxiety disorder, body dysmorphic disorder, obsessive compulsive disorder, specific phobias, and posttraumatic stress disorder) are common in people with diabetes (455).
The Behavioral Risk Factor Surveillance System estimated the lifetime prevalence of generalized anxiety disorder to be 19.5% in people with either type 1 or type 2 diabetes (456).
A common diabetes-specific concern is fear related to hypoglycemia (457–459), which may explain avoidance of behaviors associated with lowering glucose, such as increasing insulin doses or frequency of monitoring.
Factors related to greater fear of hypoglycemia in people with diabetes and family members include history of nocturnal hypoglycemia, presence of other psychological concerns, and sleep concerns (460).
See Section 6, �Glycemic Goals and Hypoglycemia,� for more information about impaired awareness of hypoglycemia and related fear of hypoglycemia.
Other common sources of diabetes-related anxiety include not meeting blood glucose targets (455), insulin injections or infusion (461), and onset of complications (1).
People with diabetes who exhibit excessive diabetes self-management behaviors well beyond what is prescribed or needed to achieve glycemic goals may be experiencing symptoms of obsessive-compulsive disorder (462).
General anxiety is a predictor of injection-related anxiety and is associated with fear of hypoglycemia (458,463).
Psychological and behavioral care can be helpful to address symptoms of anxiety in people with diabetes.
Among adults with type 2 diabetes and elevated depressive symptoms, an RCT of collaborative care demonstrated benefits on anxiety symptoms for up to 1 year (464).
An RCT of CBT for adults with type 2 diabetes showed a reduction in health anxiety, with CBT accounting for 77% of the reduction in health anxiety at 16 weeks of follow-up; this trial also found decreased depressive symptoms and diabetes distress (465).
Additionally, an RCT showed switching from intermittently scanned CGM without alerts to real-time CGM with alert functionality in adults with type 1 diabetes decreased hypoglycemia-related anxiety at 24 months of follow-up while reducing A1C (466).
Thus, specialized behavioral intervention from a qualified professional is needed to treat hypoglycemia-related anxiety.
History of depression, current depression, and antidepressant medication use are risk factors for the development of type 2 diabetes, especially if the individual has other risk factors, such as obesity and family history of type 2 diabetes (467–469).
Elevated depressive symptoms and depressive disorders are common among people with diabetes (385,459), affecting approximately one in four people with type 1 or type 2 diabetes (390), and among parents of youth with diabetes (470).
Thus, routine screening for depressive symptoms is indicated in this high-risk population, including people with type 1 or type 2 diabetes, gestational diabetes mellitus, and postpartum diabetes.
Regardless of diabetes type, women have significantly higher rates of depression than men (471).
Routine monitoring with age-appropriate validated measures (1) can help to identify if referral is warranted (403,410).
Multisite studies have demonstrated feasibility of implementing depressive symptom screening protocols in diabetes clinics and published practical guides for implementation (407–410,472).
Adults with a history of depressive symptoms need ongoing monitoring of depression recurrence within the context of routine care (467)
Integrating behavioral and physical health care can improve outcomes.
When a person with diabetes is receiving psychological therapy, the behavioral health professional should be incorporated into or collaborate with the diabetes treatment team (473).
As with DSMES, person-centered collaborative care approaches have been shown to improve both depression and medical outcomes (473).
Depressive symptoms may also be a manifestation of reduced quality of life secondary to disease burden (also see diabetes distress, above) and resultant changes in resource allocation impacting the person and their family.
When depressive symptoms are identified, it is important to query origins, both diabetes-specific ones and those due to other life circumstances (444,474).
Trials have shown consistent evidence of improvements in depressive symptoms and variable benefits for A1C when depression is simultaneously treated (401,473,475), whether through pharmacological treatment, group therapy, psychotherapy, or collaborative care (398,429,430,476,477).
Psychological interventions targeting depressive symptoms have shown efficacy when delivered via digital technologies (478).
A systematic review of internet-delivered CBT studies indicated benefits across chronic health conditions, including diabetes (479).
For people with diabetes, an RCT comparing internet plus telephonic CBT to usual care found moderate to large improvements in depressive symptoms at 12 months (480).
Physical activity interventions also demonstrate benefits for depressive symptoms and A1C (318).
It is important to note that the medical treatment plan should also be monitored in response to reduction in depressive symptoms.
Estimated prevalence of disordered eating behavior and diagnosable eating disorders in people with diabetes varies (481–483).
For people with type 1 diabetes, insulin omission causing glycosuria in order to lose weight is the most commonly reported disordered eating behavior (484,485); in people with type 2 diabetes, bingeing (excessive food intake with an accompanying sense of loss of control) is most commonly reported.
For people with type 2 diabetes treated with insulin, intentional omission is also frequently reported (486).
People with diabetes and diagnosable eating disorders have high rates of comorbid psychiatric disorders (487).
People with type 1 diabetes and eating disorders often have high rates of diabetes distress and fear of hypoglycemia (488).
Diabetes care professionals should monitor for disordered eating behaviors using validated measures (489).
When evaluating symptoms of disordered or disrupted eating (when the individual exhibits eating behaviors that appear maladaptive but are not volitional, such as bingeing caused by loss of satiety cues), etiology and motivation for the behavior should be evaluated (483,490).
Mixed intervention results point to the need for treatment of eating disorders and disordered eating behavior in the context of the disease and its treatment.
Given the complexities of treating disordered eating behaviors and disrupted eating patterns in people with diabetes, it is recommended that interprofessional care teams include or collaborate with a health professional trained to identify and treat eating behaviors with expertise in disordered eating and diabetes (491).
Key qualifications for such professionals include familiarity with diabetes disease physiology, weight-related and psychological risk factors for disordered eating behaviors, and treatments for diabetes and disordered eating behaviors.
More rigorous methods to identify underlying mechanisms of action that drive change in eating and treatment behaviors, as well as associated mental distress, are needed (492).
Health care teams may consider the appropriateness of technology use among people with diabetes and disordered eating behaviors, although more research on the risks and benefits is needed (493).
Caution should be taken in labeling individuals with diabetes as having a diagnosable psychiatric disorder, i.e., an eating disorder, when disordered or disrupted eating patterns are found to be associated with the disease and its treatment.
In other words, patterns of maladaptive food intake that appear to have a psychological origin may be driven by physiologic disruption in hunger and satiety cues, metabolic perturbations, and/or secondary distress because of the individual�s inability to control their hunger and satiety (483,490).
The use of incretin therapies may have potential relevance to the treatment of disrupted or disordered eating (see Section 8, �Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes�).
Incretin therapies work in the appetite and reward circuitries to modulate food intake and energy balance, reducing uncontrollable hunger, overeating, and bulimic symptoms (494), although mechanisms are not completely understood (495).
Weight loss from these medications (496) may also improve quality of life.
More research is needed about whether use of incretins and other medications affects physiologically based eating behavior in people with diabetes.
Studies of individuals with serious mental illness, particularly schizophrenia and other thought disorders, show significantly increased rates of type 2 diabetes (497).
People with schizophrenia and other thought disorders who are prescribed antipsychotics should be monitored for prediabetes and type 2 diabetes because of the known comorbidity.
Changes in body weight, glycemia, and lipids should be monitored every 12–16 weeks, unless clinically indicated sooner (498).
Disordered thinking and judgment can be expected to make it difficult to engage in behavior that reduces risk factors for type 2 diabetes, such as restrained eating for weight management.
Further, people with serious behavioral health disorders and diabetes frequently experience moderate psychological distress, suggesting pervasive intrusion of behavioral health issues into daily functioning (499).
Serious mental illness is often associated with the inability to evaluate and apply information to make judgments about treatment options.
When a person has an established diagnosis of a mental illness that impacts judgment, activities of daily living, and ability to establish a collaborative relationship with care professionals, it is helpful to include a nonmedical caretaker in decision-making regarding the medical treatment plan.
This caretaker can help improve the person�s ability to follow the agreed-upon treatment plan through both monitoring and caretaking functions (500).
Coordinated management of prediabetes or diabetes and serious mental illness is recommended to achieve diabetes treatment targets.
The diabetes care team, in collaboration with other care professionals, should work to provide an enhanced level of care and self-management support for people with diabetes and serious mental illness based on individual capacity and needs.
Such care may include remote monitoring, facilitating health care aides, and providing diabetes training for family members, community support personnel, and other caregivers.
Qualitative research suggests that educational and behavioral intervention may provide benefit via group support, accountability, and assistance with applying diabetes knowledge (501).
Cognitive capacity is generally defined as attention, memory, logic and reasoning, and auditory and visual processing, all of which are involved in diabetes self-management behavior (502).
Having diabetes (type 1 or type 2) over decades has been shown to be associated with cognitive decline (503–505).
A host of factors have been linked with cognitive impairment in people with type 1 diabetes, including diabetes-specific (e.g., younger age at diagnosis, longer disease duration, more time in glycemic extremes, recurrent diabetic ketoacidosis, higher A1C, and presence of microvascular complications), other medical (e.g., dyslipidemia, intestinal flora, and poorer sleep quality), and sociodemographic (e.g., female gender and lower educational level) factors (506).
Declines have been shown to impact executive function and information processing speed; they are not consistent between people, and evidence is lacking regarding a known course of decline (507).
Diagnosis of dementia is more prevalent among people with diabetes, both type 1 and type 2 (508).
Executive functioning is an aspect of cognitive capacity that has particular relevance to diabetes management.
Attention deficit hyperactivity disorder has been linked with twice the risk of type 2 diabetes (509).
Among youth and young adults with type 1 diabetes, lower executive functioning has been linked with more difficulties with diabetes self-management and higher A1C (510).
In contrast, higher self-regulation has been linked with better emotional and diabetes-specific functioning (511).
Thus, monitoring of cognitive capacity and skills among individuals with or at risk for diabetes is recommended, particularly regarding their ability to self-monitor and make judgments about their symptoms, physical status, and needed alterations to their self-management behaviors, all of which are mediated by executive function (508).
As with other disorders affecting mental capacity (e.g., major psychiatric disorders), the key issue is whether the person can collaborate with the care team to achieve optimal metabolic outcomes and prevent complications, both short and long term (499).
When this ability is shown to be altered, declining, or absent, a lay care professional should be introduced into the care team who serves in the capacities of a day-to-day monitor as well as a liaison with the rest of the care team (1).
Cognitive capacity also contributes to ability to benefit from diabetes education and may indicate the need for alternative teaching approaches as well as remote monitoring.
Youth will need second-party monitoring (e.g., parents and adult caregivers) until they are developmentally able to evaluate necessary information for self-management decisions and to inform resultant behavior changes.
Episodes of severe hypoglycemia are independently associated with decline as well as the more immediate symptoms of mental confusion (512).