Diabetes center offers patients psychiatric care
Diabetes center offers patients psychiatric care
Expert offers screening steps for common problems
You wouldn’t think of letting office visits with diabetes patients go by without asking what they’re eating, what type of exercise they’re doing, and whether they’re staying on top of their blood sugar levels. But have you asked your patients lately if they feel depressed or frightened or angry? New research indicates that you should make psychological evaluation a routine part of checkups with diabetes patients, says Alan Jacobson, MD, director of the Joslin Diabetes Center in Boston and professor of psychiatry at Harvard Medical School. Psychological status, he says, is just as important to the success of treatment as anything else you do for your diabetic patients.
Studies have shown that patients with poor glycemic control who of course have the highest risk of complications have a higher prevalence of psychiatric illnesses such as depression and eating disorders, are more likely to live in high-conflict families, and miss more appointments than others, Jacobson says. A history of depression is associated with substantially worse glycemic control and more serious retinopathy. Patients with eating disorders may try to lose weight by skipping or reducing insulin injections. Put any of those factors on top of the sheer magnitude of information patients must learn in order to manage their condition, and you’ve got a recipe for treatment failure.
Learning to cope with the disease
"Diabetes is a chronic condition that is extraordinarily demanding," Jacobson says. "It requires extensive learning and significant adaptations to lifestyle, and it also incorporates both present and future threats to your medical status that are frightening and disabling and even life-endangering."
When patients first learn they have diabetes, they frequently experience a sense of loss and even grief. They may feel lonely, irritable, apprehensive, or pessimistic. Children and adolescents especially may fear testing, feel that complications are time bombs waiting to go off, or think the disease will cause them to lose friends. Any of those issues can seriously affect compliance with doctors’ orders.
"The combination of chronicity, complexity, and seriousness means that it’s a major adjustment for patients and their families," Jacobson says. "Patient and family behavior is the centerpiece for success. It really becomes the patient’s decision-making, behavior, and motivations that determine the outcome."
At the Joslin Diabetes Center, a multidisciplinary treatment team includes psychiatric professionals, and the treatment approach incorporates an understanding of the social, psychological, and psychiatric ramifications of diabetes. Examples of psychosocial issues that should be considered include:
• patients’ and family members’ expectations, attitudes, and goals for treatment;
• past experience with illness in general and diabetes in particular;
• current affective state;
• extent of grief or acceptance of the diagnosis;
• readiness to learn and make behavioral changes;
• extent and sources of current stress;
• emotional reactions to key issues related to diabetes (ideals for weight, intolerance of regularity, fear of needles, fear of complications);
• psychiatric illness, especially depression and eating disorders;
• reactions to and relationships with members of the health care team;
• cultural factors affecting the perception of the meaning of illness and its treatment;
• financial issues, especially insurance coverage.
Jacobson recommends an incremental approach to treatment for newly diagnosed patients, starting with key information and support for the grief process. Once patients are familiar with the skills they need to manage the disease and have made an emotional adjustment, more in-depth education is appropriate. Patients should be taught that they can lessen the risk of complications through self-care and that having diabetes does not mean they can’t lead healthy, happy lives.
Establish strong patient-physician relationship
Working with patients in this manner can easily be accomplished through regular office visits, Jacobson says. The key is to establish a strong relationship between physician and patient that allows the patient to participate actively in the treatment process. Jacobson suggests physicians do the following:
• Incorporate into the regular patient history a few key questions relating to psychological status, such as whether the patient has any concerns about the disease and how the disease is affecting quality of life.
• Develop listening skills; be non-judgmental, and let patients know it’s acceptable to bring up their fears and concerns. Try to ask open-ended questions. Start with something like "Some of my patients have concerns about" a certain issue. Wait a moment after asking a question to see if the patient will continue to talk before you jump to the next question.
• Make screening measures for common psychiatric problems such as depression and eating disorders a part of patients’ regular assessments.
• Focus on one or two common psychiatric problems such as depression. Learn to initiate treatment or refer patients more rapidly to specialists who can help with that issue.
It may seem at the outset that this attention to psychological issues will take too much time and effort. But Jacobson says physicians can actually save time in the long run by identifying these problems early and developing a treatment plan with which the patient is likely to comply. It’s true that patients may desire longer appointments to address these issues, but a team approach to care can easily solve the time crunch. In addition, patients treated in this manner generally are more satisfied with their care and tend to miss fewer appointments.
[For more information about using psychological principles in diabetes treatment, contact Alan Jacobson, MD, medical director, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215. Telephone: 617-732-2400.]
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