Episode 8: Coping with Diabetes Part 1: Psychosocial Considerations

EPISODE 8: Coping with Diabetes Part 1: Psychosocial Considerations

Dr. Rita Kalyani:          Welcome to Diabetes Deconstructed, a podcast for people interested in learning more about diabetes.  I’m your host, Dr. Rita Kalyani, at Johns Hopkins.  We developed this podcast as a companion to our Patient Guide to Diabetes website.  If you want a trusted and easy to understand resource for diabetes, or to listen to previous podcasts, please visit Hopkins Diabetes Info dot org.

Today, we are pleased to welcome Dr. Marissa Alert. Dr. Alert is a licensed clinical psychologist, speaker, and consultant who is committed to helping people improve their mental health and lifestyle habits. Dr. Alert specializes in teaching individuals to manage stress, cope with anxiety and depression, lose weight and overcome barriers to making healthy changes. She has driven to help people move from where they are to where they want to be and to live a life in line with their values. She currently serves as the Director of Clinical innovation for TadHealth. Welcome, Dr. Alert.

Dr. Marissa Alert:        Thanks, Rita. It’s really great to be here. I’m excited to talk more about diabetes management and some really effective tools and information to help people out there with diabetes.

RK:                  Well, thanks. We’re so glad to have you here today, too. And I wonder if you could start off by telling us a little bit about… what are psychosocial diseases and why are they important to recognize in people with diabetes?

MA:                  Yeah, so when we think about psychosocial factors, or conditions that can affect diabetes management, they’re primarily three that I like to focus on, because they’re the most common. And we know based on research and just clinical experience, that these really affect how people manage their diabetes. And those three conditions are depression, anxiety, and also diabetes distress. And in terms of depression and anxiety, I know people are quite familiar with experiencing those symptoms, feeling down, feeling worried. But in terms of… and prediabetes distress as well. It’s just feeling this sense of overwhelm for managing their diabetes, it feels like they’re taking on a lot. And all three of those conditions affect diabetes management because they really get in the way of how well people take care of their diabetes, how well they take their medications, and how often they do so, as well as checking their blood sugar, feeling like they have the energy and desire to eat healthy and be active. And we know that all these self-care behaviors really play an important role in controlling blood sugar levels. 

RK:                  For sure, diabetes is such a self-management disease that having psychosocial factors to consider in addition can make the management more complex and challenging. How common is depression in diabetes?

MA:                  In terms of actual ranges, we know that perhaps up to 25% of people with diabetes can eventually develop depression. In terms of anxiety, the rates are a little bit lower for that. And in terms of diabetes distress, there’s a wide range as well in terms of how many people experience that and some of the challenges in measuring that, um, in terms of you know, whether or not patients with diabetes are being assessed at visits. But we know that just from reports, there’s a lot of them at some point in their diabetes journey where they experience diabetes distress. And again, some of the symptoms there may include things such as again, feeling really overwhelmed, feeling as if taken on diabetes has become too difficult, and also they may be anxious about it. They may find themselves being really concerned about managing their blood sugar levels to the point where, you know, they’re constantly worrying about ‘Are my blood sugar levels too high?’ ‘Is it being well taken care of?’ And again, the longer people have diabetes, the more likely it is for them to experience and report feeling distressed and overwhelmed by having the condition.

RK:                  So it sounds like diabetes distress is more common, would you say, than depression and anxiety, is that right? 

MA:                  It can certainly be more common. And in terms of how frequent or the prevalence of it, we know that it’s certainly going to be diabetes distress, then comes depression and also anxiety would be the other one that follows after depression.

RK:                  You know, I think diabetes distress is, at least recently, something that has become increasingly recognized and maybe just wasn’t something that had been acknowledged in the management of people with diabetes. How does the provider distinguish between diabetes distress versus depression? And how would a patient know if they have it?

MA:                  A lot of the symptoms of diabetes distress actually overlap with depression. In order for a clinician or patient to determine whether or not it’s diabetes distress or major depressive disorder, a couple of things can be considered. For one, diabetes distress is diagnosed in people with diabetes; it’s not considered a psychiatric disorder, it’s a lot more common. And even though there are similar symptoms, the criteria for major depression helps to rule that out. And so in order for someone to be diagnosed with depression, they need to be experiencing a significant decline in their mood. So meaning that they’re feeling really down or are sad and not just for like one day, but it has to be persistent in that it has to occur for at least two weeks. In addition to that, they need to also feel like a loss of desire to do things that they typically enjoy. And so for instance, if they felt they were really outgoing, they loved being outdoors, or they loved going out and meeting up with friends and all of a sudden they’re not feeling like doing those things anymore, that’s also another sign of depression. In addition to that, there’s also difficulty concentrating, there could be changes in their sleep as well, in their eating patterns. So maybe eating too much, or eating too little, sleeping too much, or sleeping too little. In addition to that, there may be thoughts of suicide as well. And so because of that, these are things that should be taken into consideration when someone is determining especially a condition whether or not it is diabetes, or whether or not it’s diabetes distress, or whether or not it is depression.

RK:                  So if someone is concerned that a loved one or themselves may have depression, what would be the next steps for them?

MA:                  You know, recognizing the change in that person’s mood, how they typically engage is great. Oftentimes, people may, you know, just discard it and think it’s just a normal part of having diabetes, or they should be able to manage. So I think when a loved one or even that person recognizes that things have changed in terms of how well they’re able to function, how well they’re able to carry on daily activities, then seeking professional help as soon as possible is really important. And I would encourage people to err on the side of seeking professional help – whether that’s talking to the primary care physician, or getting in touch with a mental health professional. It could be that they’re just having a really tough time and even if that’s the case, and it’s not major depressive disorder, they can still get support. And that support is important because coming back to our point about how psychosocial factors affect diabetes self-care, even if they’re really stressed out, and it’s not a clinical condition, that that stress can also affect their blood sugar levels, as well as how well they take care of themselves. Another thing I want to add is, especially given the current climate with COVID-19 and the added stress of that has brought on to a lot of people, including those with diabetes, it can be really difficult for them to find a mental health provider. Oftentimes, you know, starting with a primary care physician who might be able to make a referral to them can be really helpful. In terms of navigating, trying to figure out if someone’s health insurance is going to cover it, if they can find someone that they actually like and want to work with that’s in network, we know that all those things can pose as a challenge to getting care and getting care as soon as possible. If people aren’t able to get in touch with their clinician, calling up their health insurance company just to see what’s available, you’re getting a sense of who’s in network. And the thing about mental health treatment is that some clinicians actually provide services on a sliding scale fee. And so if there’s someone that’s not in network, or they haven’t found someone that they do connect with, there are some providers that based on, you know, the client’s circumstances, are willing to shift how much they charge based on that client circumstance. 

RK:                  Thanks for bringing up all those resources. You know, I’ve definitely found also during the pandemic, it is hard to find people you can refer to. Mental health professionals are definitely a shortage. And having a provider or primary care doctor help you navigate that is, for sure, very important. I wonder if you could speak to the individual who might be hesitant to make that step. It’s not a small step, is it, to seek mental health and the stigma that some might feel in doing that? What would you say to that person?

MA:                  You know, I really appreciate that question. Because it’s often a common concern that people raise when it comes to getting, you know, professional help. There’s a lot of stigma attached to it in terms of what does it mean that I’m having to talk to a professional about my mental health? Am I crazy? how are people going to think about me? Are they going to think that I’m not able to function? Are they going to think that I’m not capable. And the thing that’s important to keep in mind is everyone struggles at some point. Everyone needs help at some point. And the way I like to see it is that the same way if someone isn’t feeling well, and they go to see their doctor. Same thing when we’re not able to cope with the challenges, whether that’s a result of too much stress, or diabetes distress, or anxiety or depression, you’re reaching out to get support so that you can better function. And the goal there is not to make sure you’re not crazy; it is to help you recognize that you are functioning at this level prior to experiencing these symptoms, and you’re simply working with someone to help you get back to that level. Because we know that if you’re overwhelmed, you’re stressed, you’re anxious, you’re depressed, you’re not able to function as you typically did. And while there are some people who are able to kind of push through, people can’t really tell that they are struggling. They still are, and so the whole thing is even if you’re able to fake it until you make it, eventually you know that those people tend to implode or explode. Things eventually come to the surface. And so while it is really difficult, I think shifting your mindset as to how you view therapy. And I’m not saying it’s something that’s easy, but I think recognizing what the end goal is, instead of focusing on what the perception of seeking help is. And clinicians are bound to confidentiality, so if someone comes to see me it’s not as it comes in a post it on Facebook or LinkedIn saying, Hey, everyone, you know, take note. And so the important thing is that your clinician and whoever you works with, they want to make sure that they can provide you with the best help. And if someone comes to me, and they’re struggling in a way that I’m not able to help them, I’m bound by my ethics code, which tells me that I should refer that person to someone who’s going to be better able to meet their needs, and treat them if that option is available. Given a lot of the challenges that you know, the pandemic has brought to light, so many people are struggling with mental health, including people who never had a mental health condition before, who currently find themselves dealing with a lot of stress, either from working at home or vaccination, or working with employees or having to take care of their children and manage their job as well. And so a lot of these stressors, you know, are really affecting people. It’s important to know that it’s okay to get help, that there are people out there, you’re not struggling alone, in terms of when we look at the rates of anxiety and depression, like those are two very common mental health conditions. At some point, you’re going to know someone who’s either been struggling with those conditions or sought treatment for them. So I say all that to just normalize the process of seeking mental health treatment that is normal, it doesn’t mean that you’re crazy or something is wrong with you, or something is wrong with all of us. What it means is that you’re simply allowing yourself to function as best as you can. And we know that especially a lot of people with diabetes, they may be caregivers as well. And so I firmly believe that if we’re able to better care for ourselves, then we’re able to continue to support and be there for other people.

RK:                  And I really like what you said about really optimizing function and health. It’s is not just physical health, but mental health and they’re really very closely tied together. And especially for the individual with diabetes, where especially with the new diagnosis, getting used to checking your finger sticks for glucose multiple times a day, and maybe taking insulin, if you need to take that injection multiple times a day, adjusting your diet, adjusting your habits, they can be overwhelming. And learning how to cope and adapt certainly is part of what enables someone to be successful in the long-term. I wonder if you could give some examples of how having some of these psychosocial factors can impact diabetes management.

MA:                  Yeah, so I can start with diabetes distress and depression since there’s a lot of overlap there in terms of some of those symptoms. Let’s say that I’m really feeling overwhelmed. I’ve had diabetes for the past 10 years. I haven’t really been able to keep my blood sugar levels under control or managed in a way that, you know, my physicians are happy with. And I feel like I’m doing everything that I can. On top of that, I just lost my job, so I’m dealing with a lot of stress. And I’m starting to now think that ‘you know, I’m getting older… who’s gonna want to employ me?’ so I start to feel really down. I no longer want to go out and meet up with friends or you know, take walks outside, which I loved doing. So my mood is down, I don’t want to engage in things that I typically love. And because I’m consumed by these things, I find it hard to concentrate on finding things that I like doing: finding a job, reaching out for support. In addition to that, with my difficulty concentrating, I’m more stressed out. I’m finding it difficult to sleep so my energy during the day is really low. And because of that, when it comes to managing my diabetes, it’s a struggle. I don’t want to even get out of bed and much less stick my finger to see what my blood sugar levels are. In addition to that, I don’t really want to take the time to figure out what I’m going to eat. Like it’s easier for me to, you know, get on DoorDash or Uber Eats or go to the drive-thru and pick something up. And so I’m not checking my blood sugar levels and I’m not eating healthy. And on top of that my energy is low; my mood is really down. So I’m certainly not thinking about exercising or being active. And what does that look like? Perhaps I’m spending a lot more time on my phone or watching television or, you know, on Netflix. What this looks like is eventually as the symptoms of depression persists, feeling of overwhelm persists, I’m taking less and less care of my diabetes because the mere presence of those symptoms makes it difficult for me to want to engage or have the energy to do what I regularly do.

RK:                  And makes it challenging, as you say, to really focus on optimal diabetes management. So clinically for us and diabetes clinic, we then see higher blood glucose levels, difficult to maintain eating habits, maybe fluctuations in times when diabetes is managed really well on times and diabetes is not managed so well. It can definitely become a challenge. And just prescribing medication for diabetes management is not enough if the motivation is not there. I wanted to touch briefly upon something you said about stress before we move on to different treatments. How is stress related to diabetes management? Can having stress impact your blood glucose levels?

MA:                  Yeah, absolutely. We know that people who are feeling stressed, that can also increase their blood sugar levels. We’ve known that from studies on stress management, patients with diabetes who undergo stress management training see changes in their blood sugar levels – meaning that those levels tend to decrease with training. And so stress is certainly something important to keep in mind and to manage because like diabetes distress, like depression, like anxiety, we know that stress also affects how people take care of their diabetes as well. And so it can make it a lot more difficult, again, for people to stay on top of what they’re eating, how active they are. It can make them forget to check their blood sugar levels or take their medications. I think if we just pause to think about, you know, feeling highly stressed… brains on survival mode, and that survival mode typically does not include ‘did I take my diabetes medication?‘ Recognizing when we’re stressed I think is really important. And a lot of people find it challenging to even know when they’re stressed, or how they’re affected when they are stressed. And so one important thing that I encourage people to do is check in with themselves often. ‘How am I feeling?’ ‘How am I doing?’ And simply doing that helps them to increase their awareness of whether or not they are stressed, or how they’re feeling in the moment- whether that’s their content, or they’re happy, they’re sad, they’re frustrated. And these are clues to then help them get into problem-solving mode. ‘What’s causing me to feel this way?’ ‘What’s causing me to feel stressed or down?’ ‘And is this something that I can change?’ ‘Or do something about?’ ‘Or do I have to find other ways to cope with this feeling that I’m experiencing?’

RK:                  I really liked that question. Just those brief words, ‘How am I feeling today?’ you know, to really give insight into your current mood and how that might be impacting your diabetes management. Now moving on to treatment… you know, once we’ve identified or once you’ve identified in your practice, that someone might have one of these psychosocial factors or conditions – whether it’s diabetes distress, depression, anxiety, or even stress. Could you share with us what kind of strategies do you use in your practice? Or what kind of strategies are commonly used to manage these conditions to ultimately, in our context, help with diabetes management as well?

MA:                  One of the most well-researched approaches to treating depression, as well as anxiety is cognitive behavioral therapy, known shorthand as CBT. And it’s been shown through numerous studies that this is an effective approach for helping people to improve their mood and their well-being and also better deal with anxiety. In CBT, what a patient or participant can expect is that that therapist is going to help them pay attention to how they’re thinking, because we know that how we think affects how we feel and how we behave. And so to give an example of just a simple connection between our thoughts or behaviors and our feelings, I usually have people, especially those with pets, think about you know, having a pet that’s pretty rambunctious and likes to jump on top of counters. And so let’s say that it’s 10 o’clock at night, you’re in bed, lights are out, and you hear something fall on the floor, like a big thud. If your first thought is ‘That cat jumping on the counters again’. That response and action that you take after having that thought is gonna be very different than if you think ‘Oh, no, is someone breaking in?’ Right? Thinking someone’s breaking in is gonna get you into survival mode, you’re going to feel a lot more stressed, you’re going to get into thinking, you know, ‘Should I call 911?’, maybe you have your partner go check and see, you know, what’s going on there versus if you think it’s the cat, you’re probably just going to, you know, I’ll deal with that in the morning. So you’re not likely to take action if you have one thought versus thinking someone’s breaking in. When we translate that to diabetes management, or even just someone who’s feeling down, the way that they perceive their current situation, meaning how you look at themselves, how they look at the world, how they view their current problems… that really affects the actions that they take, and how they feel in the moment.

And so with CBT, the goal there is to help people recognize what we call “errors in thinking” or cognitive distortions, and really helping people to think about, you know, ‘Is what I’m thinking helpful or not helpful?’ So an example of that might be… I’m never going to be able to deal with my diabetes. Nothing I do is ever going to work. One error noted there is with fortune-telling, right? You’re predicting into the future that you’re never going to be able to deal with your diabetes or manage it well. So if you think that you’re never going to be able to manage it well, then are you really going to keep taking your medication? Are you really going to keep checking your blood sugar levels? Are you going to keep eating healthy? By helping people recognize how they think, we can help them also recognize, you know, what’s problematic or counterproductive with the way they’re thinking and helping them to reframe that thinking or restructure their thoughts. And so if I can help someone moved from ‘You know what, I’ll never be able to <inaudible> my diabetes, what’s the point?’ to ‘You know, there gonna be some days when things are hard, but I have the tools to help me figure it out. I have the support to help me work through my challenges’. Then, they’re going to be a lot more likely to take action if they’re able to recognize that you know, thinking, ‘I’m never going to be able to change things’ is not helpful and it’s going to keep me stuck and not, you know, allow me to better manage my blood sugar versus if they have a more healthy or helpful way of thinking about their diabetes and their thoughts. And same thing applies to anxiety as well.

And in addition to helping people reframe their thinking, it also teaches them a number of coping skills as well. And so I like to think about equipping patients with a lot of tools in their toolbox – recognizing that, you know, there isn’t just a one size fits all, when it comes to dealing with symptoms of depression and dealing with symptoms of anxiety. As a clinician, I have to remember that everyone’s different. I can easily recommend deep breathing and meditation to some folks and their other people like, ‘No, that’s not going to work, my mind keeps going and I’m not willing to do that.’ And if they’re really, really feel strongly about not trying something, the goal is for me to not add to their stress, if I’m trying to help them manage it, or cope with depression and anxiety, but to really meet them where they are. Let’s explore other things that you can try to help you deal with stress. And the idea is that if you love taking baths, you can’t do that during a stressful call so how else can you cope? Coming back to my point that I made earlier with the goal of therapy, helping people to get back to a level of functioning where they were before, when I think about therapy and equipping patients with these different coping strategies is to help them once they finish therapy, to use those different tools in their toolbox to ensure that they maintain that level of functioning.

RK:                  So in essence, it sounds like you’re helping people retrain how they think, reframe how they approach potentially challenging situations to perhaps a more productive and specific way of dealing with it in the future – not only to help with your mental health, but really with the mind and body being so connected to also help with your your physical health as well… The diabetes management too. You mentioned fortune-telling is one of the pitfalls and thinking… Are there others that you’ve commonly seen in patients that you’ve managed? 

MA:                  Yeah, and so there are a number of what we call like cognitive distortions or unhelpful thinking styles. There are a number of ways in which people refer to them. And those include, as I mentioned, like fortune-telling, there’s also things that are called black-and white thinking. And so for instance, if I’m not first and last, like there is no in-between, it’s either my diabetes is well-managed, or it’s not. And so for someone who’s really adherent, they’re really militant about it, and they can’t miss a day. It could be one week, and you know, they didn’t check their blood sugar once when they were supposed to. And their thinking is like, ‘Oh, I can’t manage my blood sugar, I’m the worst.’ There is no recognition that, ‘Hey, I’ve been doing pretty well all these other days. And just this one time, I haven’t been able to.’ So in addition to black-and-white thinking, we also have what we call mental filter, where people only pay attention to certain types of evidence. And so they kind of block out all of the positives that happen. And then they simply just focus on the negatives. Another one is mind reading, imagining what other people are thinking. Let’s say that my labs don’t look that great. And I’m sitting there with my doctor, and I’m thinking that ‘They’re thinking I’m really horrible, because I can’t seem to manage my diabetes. I can’t seem to exercise. And so they’re judging.’ ‘I know, that’s what they’re thinking.’ You know, everyone doesn’t do these things. Because everyone does at some point, right? We believe that we know what other people are thinking. We have black-and-white thinking when it comes to certain situations. It’s just that when we’re stressed out, or when we’re dealing with challenges, these types of thinking tend to come to the surface, and we do them a lot more often. And again, if I’m thinking that my doctor, in that moment, you know, hates me or thinks I’m terrible, I may not come back to see them or go to my next checkup. And so things continue to go downhill because I’m not taking the necessary steps to ensure that my diabetes is consistently managed. Another one is labeling, where people you know, call themselves name. ‘Because I didn’t check my blood sugar, I’m such an idiot… like, why can I figure this out? This is really simple. Sharon over here, like she’s talking about how well she’s managing and how great her numbers are. And I’m such a loser like I can’t do this.’ And other one is… should-or-must statements using critical words: like should, must, maybe, always. These are things that really help to keep people stuck because there’s no room… no kind of wiggle room or no room to kind of go outside the lines. ‘I should always check my blood sugar.’ ‘I should always get eight hours of sleep.’ ‘I ought to do this’ and not just having these feelings for ourselves but for other people as well. And so if I’m feeling that my doctor should always smile when I come in the office, or my doctor should always do this or needs to always do this… if that doesn’t happen, then let’s say that my doctor doesn’t smile at me and I read that like, ‘Well, they didn’t smile.’ ‘They should plus I’m doing really well… maybe I’m not doing so well… maybe you know I need to do more’ and then we can see that person then spiraling into a lot of worry and anxiety, which we know can then affect their treatment. And so they’re a number of different thinking styles and people tend to gravitate towards a few of them. So maybe they’re, they’re filled with black-and-white thinking or all-or-nothing thinking, or they’re really, you know, about labeling, so calling themselves names, putting themselves down. And so again, therapy is just about raising awareness and helping people to see patterns, help them figure out what’s working, what’s not working, and also to provide them with solutions that makes sense for them and actually fit into their life.

RK:                  Well, it sounds like there’s many different strategies depending on the individual that could be employed to really retrain the mind to adopt healthier ways of thinking. And thanks for sharing those examples. I know that I’ve heard many of them in my practice, and will likely resonate with many of our listeners as well in terms of some of the thinking that occurs, especially during times of stress, or when times are more difficult. I know that we talked about cognitive behavioral therapy, but I wonder if you could briefly touch upon when might medication being needed for these conditions. 

MA:                  In terms of medication management, that can depend on participants’ preference. There’s some people who… they’re like, ‘No, I don’t want medication. I’m not interested in it.’ And there’s some folks that come in and they’re like, ‘Look, I can’t afford to see you every week. I don’t have the time. It’s just too much. I’d like some medication to help me with managing it.’ The other option too, is that depending on the person’s severity level, we know that as depression, anxiety becomes more severe, then to help facilitate what’s happening in therapy – coupling that with medication management can help to ensure that that person is able to cope and manage their symptoms a lot better. And so it comes down to a number of factors: people’s preferences, how they’re presenting, how they’re being affected, the severity of their condition, as well. And those are just a few that are taken into consideration. In terms of types of medication, there are different lines of treatment that physicians may go to, or psychiatrists may go to in terms of prescribing these medications. And that can also be a result of the person’s family history, their medical conditions – if they have any health risks that may make it more likely for them to experience side effects on one medication. And so when your physician is figuring out or psychiatrist is figuring out what medication, the dosage, the frequency, they kind of look at the whole picture, your current symptoms, and your diagnosis, your medical history, as well as your mental health history. 

RK:                  Thanks so much, Dr. Alert, for being with us today. I know that I’ve learned a lot about psychosocial factors and how they contribute to diabetes. I really appreciate your insights. Thanks again.

MA:                  Yeah, thank you. I was really excited to be here. And I hope from this discussion that patients with diabetes are encouraged to think more about their mental health, recognize the effect it has on their ability to take care of themselves, and to know that treatment is available and is able to help them and it works.

RK:                  I’m Dr. Rita Kalyani, and you’ve been listening to Diabetes Deconstructed.  We developed this podcast as a companion to our Patient Guide to Diabetes website.  Our vision is to provide a trusted and reliable resource, based on the latest evidence, that people affected by diabetes can use to live healthier lives.  For more information, visit Hopkins diabetes info dot org.

We love to hear from our listeners.  The email address is Hopkins Diabetes Info at JHMI dot edu. Thanks for listening.  Be well, and see you next time