The ADA psychosocial position statement, published in December 2016 in Diabetes Care, is the ADA’s first attempt to offer guidance on the subject to healthcare practitioners working with patients with diabetes. It was 10 years in the making and is, in the words of one of the authors, Mary de Groot (Indiana University School of Medicine, Indianapolis, USA), “a position statement whose time has come.”
The guiding principle of the statement is that psychosocial care should be provided to all patients with diabetes, as part of integrated, collaborative, patient-centered care. Its general recommendations also call for assessment of several key psychosocial factors:
- Diabetes distress
- Depression
- Anxiety
- Disordered eating
- Cognitive capability
These should be assessed at diagnosis, routinely thereafter, and any time there are important changes in disease status and in patients’ personal situations. The statement also offers advice on when patients should be referred to a specialist mental health provider. Ideally, it says, such providers should be integrated within diabetes care; however, it also encourages practitioners to identify and build alliances with behavioral/mental health specialists.
In addition to its general recommendations, the statement covers specific areas, one of which is psychosocial issues that can affect self-management. It takes issue with the term “noncompliance,” saying that the term, which implies passive, unthinking adherence to the doctor’s orders, is at odds with the active evaluation, anticipation, planning, and problem-solving required of patients to manage their diabetes. Practitioners should therefore be wary of attributing suboptimal glycemic control to noncompliance, and should ensure that they assess patients’ self-management abilities and any psychosocial and medical issues that may affect it.
Diabetes distress is another highlighted condition, with the statement noting that it is distinct from a psychological disorder, instead being a reaction to the burden of diabetes management and the worry of disease progression. This problem can arise at any age, with around a third of children affected, and can also occur in parents of children with type 1 diabetes.
The statement also advises on who and when to screen for some specific psychological comorbidities:
- Depression
- Anxiety disorders
- Disordered eating behavior
- Serious mental illness
Additionally, the statement lists appropriate assessment and diagnostic tools for all mentioned psychosocial issues, chosen “on the basis of the scientific rigor used in their development and the availability of norms for clinical use.”
The statement also considers how the psychosocial problems related to diabetes can change over patients’ lives, including, for example, family involvement, issues of consent, and counseling about fertility for youths with diabetes; and screening for early detection of cognitive decline in older patients. Finally, it outlines recommendations for patients two special populations: patients with complications or functional limitations, in whom monitoring for chronic pain is advised; and patients undergoing bariatric surgery, who may need mental health support both before and after the procedure.
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