Freed: This is Steve Freed and we’re here at the American Diabetes Association 78th Scientific Sessions. And we’re doing interviews and we have a special interview today with a nurse, a professor who teaches a lot of other medical professionals. And maybe we can start off with, because diabetes is one of your specialties, tell us a little bit about your practice.
Kreider: Sure, my name is Kathryn Kreider. I’m an assistant professor at Duke University School of Nursing. I’m also a nurse practitioner in adult endocrinology at Duke University Medical Center. And I’m the Director of Advanced Practice Providers for our division. So, I primarily treat diabetes, I would say 70% to 80% of my patient population has diabetes and then I treat other general endocrine conditions as well.
Freed: So, you’re doing a presentation on diabetes distress, a person who’s diagnosed with diabetes all of a sudden needs to be concerned with their food, with their physical activity, with their blood sugars, with their hypertension, all these different things. So, I would think that it becomes a part of becoming a diabetic is the distress immediately. So, what was your presentation about and what can medical professionals learn from what you discovered, and the best way to deal with patients? Because I have to assume that all diabetics in the beginning get stressed just by virtue of being diagnosed.
Kreider: You’re absolutely right. So, diabetes distress, we think of it as being a normal reaction to being diagnosed with diabetes, to developing complications, things that come up along the way. Diabetes distress is defined as a negative emotional reaction to life with diabetes. And so, it is not a psychiatric condition; it’s a very expected response, as you already mentioned, to having diabetes. The literature shows that several interventions can be helpful for patients with diabetes distress, so diabetes self-management education can be helpful so people can feel empowered and feel like they have more control over their diabetes and they know how to problem solve. The other thing that’s been helpful based on the literature is psychoeducation, which is education involving mood and motivation, and problem solving, and coping techniques. And that’s a really important part as well, because just think about how complicated life can be with diabetes and all the things you have to think about on a daily basis and problem solve. And a lot of times patients don’t feel equipped to do that. And so, that training is also very important.
Freed: So, diabetes distress, what do you look for in a patient? Assuming that everybody has it, but I’m sure there are certain elements that you can look for. Some people can deal with it, some people can’t deal with it. What do you look for when a patient comes in who’s been diagnosed prior, so that you can see what you need to do for that patient?
Kreider: Yeah, great question. So, diabetes distress, the different emotions that patients will report, are things like feeling burned out. They feel overwhelmed. They might feel guilty. They might feel afraid. So, there’s all kinds of — there’s a range of things that they could tell you. Those are some examples of things they might say. In contrast, they may not verbalize that to you. They might demonstrate lack of self-care behaviors or lack of adherence to medications and those actions can also be signs of diabetes distress. So, it’s important to ask patients an open-ended questions about how they’re doing with diabetes and how they’re managing day to day, so that you can gauge their level of potential distress related to diagnosis or complications or management.
Freed: Do you see that distress plays an important role in outcomes, specially their A1C?
Kreider: Absolutely. So, there’s a good amount of literature that shows a significant positive co-relation between high diabetes distress levels and high A1C. And this has also been shown to be malleable over time, so that patients who reduce their diabetes distress may then reduce their A1C, so that’s a very important clinical outcome that’s associated with diabetes distress. Also, other studies have shown poor quality of life related to high diabetes distress, poor self-management behavior such as less exercise, poor diet choices, those kinds of things that are related to high diabetes distress.
Freed: Do you see more distress, serious distress, [in] type 1 or type 2?
Kreider: That’s a great question. We don’t know exactly the answer to that. So, most of the studies have been done primarily in type 2 patients. There are also studies in type 1. Type 1 does not necessarily demonstrate higher distress. They both have about the same incidents and prevalence so far based on what we know. We do need more literature and studies that show differences potentially in symptomatology in type 1 and type 2 patients and also in treatment options for diabetes distress.
Freed: And how do you determine whether, or at least how much, distress they’re under? Is there a written exam that you provide them to get the results?
Kreider: So, there are several options for inventories that assess diabetes distress. And there are also several options that are very short and would be very easy to use in clinical practice. One of them is called the Diabetes Distress Scale, the DDS. There is a longer option, but there’s also one that’s only two questions that’s a great screening tool for diabetes distress. There’s another option called Problem Areas in Diabetes, the PAID scale, which has both a one question and a five-question screening. So, as clinicians we worry about time in clinic and so that’s a really easy thing to potentially implement to screen patients for diabetes distress.
Freed: What are the two questions?
Kreider: I can’t remember the wording specifically. I could show you that later. But it asks about how well basically you’re managing with diabetes and how much distress you’re under because of your diabetes.
Freed: And how do you treat it?
Kreider: So, more studies are needed for treating diabetes distress. The first thing would be making sure that patients have appropriate diabetes self-management education. So, the DAWN 2 trial was a very large trial. Over 17 countries, over 8,000 patients showed that over half of patients had never had formal diabetes self-management education and that’s a really crucial part for making sure that patients are well equipped to manage diabetes. The second step from that would be the psychoeducation part and that might require referral to mental health providers to help with coping strategies, to help with problem solving in diabetes. We don’t have great pragmatic interventions for that right now, which is a need for this population. Those are really the two key treatment options and paths at this point.
Freed: Can you associate depression with distress?
Kreider: That’s a great question. So, there’s a lot of overlap between the two. Depression and distress are not the same. They’re independent constructs. But there definitely is a subgroup of patients that have both major depressive disorder and diabetes distress. And so, that’s another layer that needs to be screened as well to make sure that patients don’t have both conditions because the treatment is different. Depression is often treated with medication therapy, pharmacotherapy, whereas diabetes distress should not be treated with pharmacotherapy. And so, the differentiation between the two is important.
Freed: And what are some practical things you can do in the clinic to help patients who are showing signs of distress?
Kreider: So, what we’re recommending right now, first of all, is to assess using one of those easy tools that you can do, so you can gauge where your patients are. And then the second thing as a clinician would be to open lines of communication, so asking basic questions like, “How are you dealing with diabetes on a daily basis? How are you feeling about managing your diabetes? Do you feel supported in your diabetes care?” And allowing patients to start talking and to open up that door of communication, because a lot of times patients report they don’t feel comfortable talking to their clinicians about how they’re doing and how they’re managing. So, those are really the first two easy steps that you can take. It shouldn’t take too much time and it really can help build bonds with your patient and help with communication lines.
Freed: Timing– as far as showing a patient is under distress, they first get diagnosed with diabetes. Just the word alone brings shivers, plus they associate losing a limb. It’s just that’s way diabetes is with patients. So, before you see distress because they’re not distressed the first day although they’re emotionally — it’s an issue, because you’re telling them all these new things that they have to do; monitor their blood sugars, take medications, et cetera, et cetera. At what point do you usually find distress or when should you be looking to find distress with the patient? Is it three months down the road or six months down the road, every visit?
Kreider: We recommend in the standards of care, actually from the ADA, recommends that you screen patients regularly, routinely. So, that is — that could mean as often as every time as you see them and it should at least be on your radar that this could be a possibility, because we know that the incidence of diabetes distress over 18 months is over 45%. It’s very high. I think it’s about 48% — up to 48%. So, it really should be something we’re thinking about at diagnosis as well as at different intervals including when new complications arise, when there’s issues about quality of life, anything that could mean a change for the patient or present a barrier.
Freed: So, what recommendations would you give to a medical professional? Not an expert, just a medical professional, family practitioner. When it comes to distress, what advice would you give them as far as what they should do for their patients?
Kreider: Yes. So, kind of back to what we talked about. The first thing again would be assess them using reliable valid tools. I already mentioned the DDS or the PAID scale. And then secondly, start talking to them about what specifically they are concerned about and what presents the biggest challenge for them as a patient, and how can we as providers help them to reduce the barriers and reduce the anxiety related to diabetes. There’s a few things that come up often such as the idea of regimen distress. Patients feel very overwhelmed with what they have to do for medication, for diet, for activity. So, really helping them with concrete goals and doing step-wise goals that are one goal at a time and meeting that goal, and then moving on can be a very useful tool for motivational interviewing.
Freed: Sometimes with technology, we see new things that can change the way we treat patients. For example, the CGM is fairly new. Do you see that as, because it’s providing more information — if you normally check three times a day, now you get readings every three minutes, and people relate to that in different ways- – so, do you find that technology has increased distress or decreased it?
Kreider: That is very patient dependent in my experience, because some patients feel more empowered when they have more information and some feel more overwhelmed. And so, I think the patient really has to understand the implications of the technology and what it can ultimately do for them, but we have to balance individuality with that, knowing that that might not be the best option for every patient, especially if they’re very anxious. And so, sort of thinking about them holistically in deciding whether or not that’s the best approach is really important.
Freed: And that’s interesting because I just spoke to a physician who refers patients, type 2. He uses a blinded CGM at first, so that it doesn’t overwhelm the patient. And then he switches them to the un-blinded CGM. What are your thoughts about using that type of concept for a type 2 patient or even a type 1?
Kreider: Sure. I think it’s interesting. I haven’t heard of that outside of a research study before, but I think it could be an interesting approach so that people can warm up to it. A lot of them are not used to wearing a device all of the time, so that’s very new concept. So, getting used to actually wearing it before you start seeing the data and the implications could be very valuable. I think that’s really interesting.
Freed: I think if you used an un-blinded device on a type 2 who checks their blood sugar once a week and all of a sudden they have all these readings for having the type of food and activity and emotional situation that they’re in, that to me would be overwhelming and causing distress in itself.
Kreider: Yes, and I think that that point about technology impact has shown up certainly in the type 1 literature related to diabetes distress, because they are more likely to use technology at this point. And it can cause a great deal of distress, because it’s actually more difficult to wear a pump than it is to give injections and things like that. So, we really have to consider that as providers, what the impact of that would be.