Often we can sense that our patients are having troubles adapting to their diabetes. First they are in denial then they feel despair. It is so easy to just overlook how this affects their diabetes and just focus on the rest.
Treatment options are valuable only after your patient is willing to listen, this article begins with ways to approach someone who may be depressed and then describes very important help you can offer without being a trained Mental Health professional.
The goal is to find what would be most comfortable for your patient and for you.
A) “I’m your ________ . When I see things that might be signs of even a small amount of depression, I have to ask.”
B) Place a small sign inviting patients to ask about the connection between Diabetes and Depression in easy view of all patients. Relevant articles can be offered as well. For example:
A Kaiser Permanente study of some 1,680 subjects found that those with diabetes were more likely to have been treated for depression within six months before their diabetes diagnosis. About 84 percent of diabetics also reported a higher rate of earlier depressive episodes.
A 2004 Johns Hopkins and other centers study tracking 11,615 initially non-diabetic adults aged 48-67 over six years found that “depressive symptoms predicted incident type 2 diabetes.”
According to an evaluation of 20 studies over the past 10 years, the prevalence rate of diabetics with major depression is three to four times greater than in the general population. While depression affects maybe three or five percent of the population at any given time, the rate is between 15 and twenty percent in patients with diabetes, according to the American Diabetic Association. Women, in particular are at greater risk, according to other studies.
C) “You’ve seemed a little different, a little down, the last few times I’ve seen you. Most people don’t stop to think about it but do you think you’re getting as much pleasure (satisfaction) out of your life as you used to? Do things seem a bit more out of control than usual? Sometimes it’s hard for people to know these things but they can be important.”
D) “You seem a little depressed. Not necessarily “can’t-get-out-of-bed / suicide” depressed, depressed with a little “d”. It’s common, particularly with diabetes. Do you think it might be true of you?”
E) “What you’re saying (how you seem) reminds me of a person I knew who also…… Turned out they were depressed. Do you think that might be true of you too?”
F) “People don’t realize it but depression is a form of stress. They are often willing to treat their physical condition but won’t touch their “emotional” side. Sometimes they believe there’s nothing they can do about the emotional stuff unless major things change in their lives. What they don’t get is that their emotional and physical sides are connected. Stress will impact your blood sugar. I love to remind people that the only sure way to separate Mind and Body is with the guillotine.”
G) “With Diabetes no one is really positive about whether emotional issues contribute to physical difficulties or whether physical issues create emotional issues. Have you thought about exploring both ends?”
No matter how skillfully you Approach, chances are you’ll encounter Resistance. Denial of there being anything wrong, framing their emotional response as completely a product of circumstances that would make anyone depressed, seeing causes as beyond any useful intervention, not having the time to address the issue, not having the money to address the issue, not having the energy to address the issue and even “not being that kind of person”, are but some of the ways people resist examining and treating emotional material.
Don’t get depressed by this. There are treatment options for Resistance.
a) Patience – The common mistake is trying to “break through” the Resistance. It seems so clear that the patient would be so much better off if they listened to what you were saying and pursued appropriate treatment. So you initiate, they resist, you push harder, they push back harder……and the door closes. Though it may not seem so, they heard you. If you keep the door open with them, the next contact is a new opportunity to try again. Maybe they’ll be more able to move at that point. Maybe not. Patience.
b) Respect – For them as human beings, for the struggle that rages within them, for their pain, for their ability to continue to cope, for their potential and for their need at the moment for some defense. Once they get this respect from you, they can be less threatened and Resistance lessens.
c) Care / Concern – In combination with Respect, this is as close as it comes to creating a solvent for Resistance. It is primarily a non-verbal phenomenon, though obviously, saying you care is not a useless thing. Care / Concern is something your patient has to feel as genuine within you. It doesn’t have to go to the degree of your giving up your life for the patient; it just has to be real.
d) Value to Pt’s Significant Others – People will do things for those they love they may not do for themselves. Perhaps doing for others works because of the patients’ value system or perhaps because it makes seeking treatment something about the need of others, not a need of their own. Whatever the reasons do it for your kids/ husband / wife / parent can overcome Resistance.
e) A Different Perspective – In many ways, depression is a point of view, a way of perceiving things. Some patients realize this, particularly when they can remember that they had a different response to the same circumstances a short time ago. They may accept treatment if it’s framed as a way to get back their old perspective or as a way to get a new perspective that works better. This approach bypasses the idea of there being “something wrong” with them and makes it into finding a new idea.
OPTIONS FOR THE, AT LEAST, SOMEWHAT RECEPTIVE PATIENT
1) Referral to the Right Professional – Depressed people are not known for their ability to work diligently in the pursuit of very much, particularly towards something towards which they may have ambivalence. For you to be able to supply them with people they can trust who can talk with them (Psychotherapist), medicate them (Psychiatrist) or provide them with more natural anti-depressives (Integrative Physician) can make the difference between treatment and no treatment.
2) Assessment – The professionals named just above can also diagnose as well as treat. It may be easier to suggest to a patient that you’ve sent some people to X just to see what’s going on and that has worked out well.
3) 15 Minutes of Your Time – A few questions, a brochure and a statement of concern doesn’t get the message across as well as your willingness to give of your time. That’s beyond the role. It provides the opportunity to diminish Resistance, gives the patient someone to come back to if they’re not satisfied with the treatment of a Mental health professional and demonstrates your judgment of their value – something badly needed by someone who’s depressed.
4) A Review in X Weeks – For those not willing to go to a Mental Health professional, even for assessment, you can offer to review their progress with them in X weeks. This Review can be set up with the understanding that if it reveals insufficient progress the patient will go for further evaluation with a Mental Health professional.
5) More Detailed Information – About depression, depression and DM, on different forms of treatment…..whatever. The primary point here is you become an ally, a resource with and for the patient. The best place to get this is from a local Mental Health professional who becomes your ally. “Your” professional can be your guide to Assessing, Approaching, Overcoming Resistance and Guiding the Receptive patient. This can further benefit your patient in that she/he can be referred to someone already a bit familiar with the patients’ unique situation.
Your input to a depressed patient can provide hope. It can provide a means by which they can re-establish positive control in world they increasingly experience as beyond their abilities. You may be able to see what’s happening to them, sometimes before they recognize it in themselves. You can help them overcome the obstacles they put in front of their own progress. You can guide and support them in their use of available treatment. It will take some effort on your part but I think you’ll find it quite rewarding.
Leonard Lipson, M.A. L.M.H.C. received his Bachelors degree in Psychology from Adelphi University and his Masters in Psychology from the New School for Social Research. He received four years of post-graduate education from The American Institute for Psychotherapy and Psychoanalysis. He has been in the private practice of psychotherapy for the past 29 years, with offices in Manhattan and Suffern, NY. Mr. Lipson created the Medical Adherence Training program in 1995. The program helps people adhere to what is medically recommended. The program now serves patients throughout the U.S. and is in the process of being put into book form.
Mr. Lipson is a member of the Rockland County Psychological Society, The Society for Behavioral Medicine and The NYS Mental Health Counselors Association