EXECUTIVE SUMMARY

Case managers should screen patients with diabetes for depression, as the condition is prevalent and often undiagnosed.

  • Case managers could ask patients open-ended questions about any problems with diabetes.
  • If patients are experiencing problems with sleep or other issues, case managers can follow up with more questions to pinpoint whether these issues could be related to depression.
  • Every facility should implement protocols for depression screening.

Case managers should expect a large segment of patients with diabetes also to present with depression, and possibly distress or anxiety related to diabetes. These mental health issues are common among people with the chronic illness, according to government statistics.1

The key is to open the door for people to share information about their struggles and feelings, says Mark Peyrot, PhD, professor emeritus of sociology at Loyola University Maryland.

Screening is not a treatment for depression, but it is vital to identifying people who are at risk of depression, says Mary de Groot, PhD, associate professor of medicine and acting director of the diabetes translational research center at Indiana University School of Medicine.

“The next preferred step is to connect people with resources so they can make choices,” she says. “People need to be screened annually for depression. They should be screened at any time there is a change in medical status, or a change that might include the onset of diabetes complications, or when there’s a major life stressor that puts people at risk for clinical depression.”

Case managers can play a major role in connecting patients with community resources and support, depending on what patients want, de Groot says.

There is no one method for assessing whether a patient is experiencing psychological difficulties, but case managers can ask simple questions. “Ask more open-ended questions that allow them to tell their story of what it’s been like living with diabetes,” Peyrot says.

Examples include:

  • Are you experiencing any problems with your diabetes?
  • Is there anything you would like to talk about regarding your diabetes?
  • Is there anything else that concerns you about your diabetes?

“If you ask a general question, you might get an answer of, ‘I had hypoglycemia,’ or ‘My blood sugar went really high, and I can’t get it down,’” Peyrot says. “Or, someone might say, ‘I am getting frustrated with my diabetes.’”

When patients share their feelings, problems with sleep or anxiety, or other issues that indicate a mental health component, the case manager can ask follow-up questions and identify a possible problem to be assessed by the patient’s primary care provider, diabetes specialist, and/or a mental health professional.

“Cast your net more broadly to include things that no one has diagnosed and that maybe no one else has asked about,” Peyrot says. “A person who is struggling with diabetes may feel helpless because they think nothing works, and they don’t see this as a mental illness. They just think diabetes is horrible to live with.”

That could indicate subclinical depression, where the person experiences feelings that have not met the technical criteria for a depression diagnosis, Peyrot explains.

If general questions do not elicit much information, case managers could ask questions that focus on patients’ emotional reaction to diabetes, such as:

  • Do you feel overwhelmed with managing your diabetes?
  • How do you feel about how your management regimen?
  • What kind of support do you receive? Is it adequate?

If the patient appears to harbor some emotional distress, the case manager could inform the provider and suggest the patient might need treatment or more support. “Everyone in the chain of treatment and referral has a role to play,” Peyrot adds.

For example, patients’ case management and diabetes teams could view this as not just the ABCs of diabetes care (A stands for A1c, B stands for blood pressure, and C is for cholesterol), but as the ABCDs, with D standing for depression. “You have to assess for depression, just like the other three,” Peyrot says.

The big issue after asking patients about their emotional health is to know what to say when they acknowledge depressive feelings or suicidal ideation. The solution is for institutions to create protocols for handling mental health issues among their patients with chronic illnesses.

“We need to address it, and we need to have protocols in place for screening for depression,” de Groot explains. “Case managers can get to know those protocols so when they’re screening for depression, they’ll feel comfortable and supported. When they’re doing that, they’re doing a great service for their patients.”

When suggesting mental healthcare to patients, case managers and providers could think in terms of making a sale. They will see greater success in achieving buy-in with patients if they try a persuasive approach, Peyrot says. In sales, that usually means making the sales pitch with a closing line asking the person if they could put them down for the purchase.

The closing line for patients with diabetes could be to say, “Would you like some support or help with this? Would you like to do something about this to make the situation better?” he suggests.

It is a burden when providers expect the patient to volunteer his or her interest in counseling or some other solution. “Give them an opportunity to say, ‘Yes, that’s an issue for me,’ and ‘I could use some help dealing with it,’ and so on,” Peyrot says.

REFERENCE

  1. Centers for Disease Control and Prevention. Diabetes and mental health. Page last reviewed Aug. 6, 2018.