, but some question whether endocrinologists and others are up to the task of providing the extensive mental health services called for in the document.
Although the American Diabetes Association has often addressed the specific psychosocial concerns of persons with diabetes, the ADA’s first-ever position statement on the subject reflects a state-of-the-art approach to delivering integrated mental health and specialty services to this patient population. That alone makes the document a milestone in diabetes care, according to Yehuda Handelsman, MD, , medical director of the Metabolic Institute of America in Tarzana, Calif., and chair of the American College of Endocrinology 2011 Comprehensive Diabetes Guidelines. “It raises the importance of the psychological being in diabetes. This has been mentioned before in guidelines, but it has never been the focus. In that respect, this [document] is very important,” Dr. Handelsman said in an interview.
Dr. Yehuda Handelsman
The guidelines detail the most common psychological factors facing persons with diabetes throughout the life span, including diabetes distress, depression, anxiety, eating disorders, and diabetes-related cognitive dysfunction later in life. There is also a section addressing considerations such as mental and emotional preparation before and after bariatric surgery. Clinicians are urged to practice preventive care by assessing patients’ mental states regularly. A list of age-appropriate resources for screens and other measurement tools is included in the guidelines.
Despite the guidelines’ thoroughness, Dr. Handelsman said he is not optimistic they will change much in the way of practice. “The people who wrote this are psychologists and other mental health professionals. This is what they do. When we endocrinologists see patients, we don’t have these [skills]. It’s not so easy to incorporate these suggestions into daily practice,” Dr. Handelsman, said.
Dr. Deborah Young-Hyman
“The paper addresses all service providers who help care for people with diabetes. That presumes a starting point of primary care physicians, but includes specialists and team members such as certified diabetes educators, registered nurses, nutritionists, behavioral practitioners, and so on.”
Plenty of integrated care models for diabetes care [are] already in existence, said Dr. Young-Hyman, who is also a certified diabetes educator.
One such clinic is operated by Richard Hellman, MD, , a past president of the American Association of Clinical Endocrinologists. His North Kansas City diabetes specialty clinic has offered psychosocial services to patients for much of its 30 years. The clinic’s focus is not on primary care, but many of his patients’ health needs are met by approaching their chronic illness care in a comprehensive way, according to Dr. Hellman. The clinic’s multidisciplinary team includes certified diabetes educators, nurse practitioners, physician assistants, dietitians, a clinical psychologist, and registered nurses.
Dr. Richard Hellman
Since passage of the Affordable Care Act, the zeitgeist has been a move away from fee for service care provided by a single clinician, to collaborative models. While talk of the incoming U.S. president and Congress dismantling the law has caused some uncertainty over how physician reimbursements will be structured in the future, pressure from health insurers to keep in place value-based care models – particularly for chronic illness management – may remain regardless of the ACA’s ultimate fate.
“The evidence is that when people with diabetes who also have stress or mood disorders get the care they need, they are more productive and healthier, and both insurers and employers save money,” Dr. Hellman said.
It is what might happen should primary care physicians find themselves facing either having to meet standards of care for a number of chronic illnesses or forfeit reimbursements. Such a scenario should concern policymakers dealing with the delivery of chronic illness care, according to Dr. Hellman, who has experience relevant to these issues as a member of the Physician Consortium for Performance Improvement since 2000 and the National Quality Forum Diabetes/Metabolism Technical Advisory Panel from 2009 to 2012.
“Payment strategies to force change are a blunt tool that often don’t work well. There is so much complexity. People often have kidney or heart disease. It’s hard to write policy with so much variation going on,” he said.
Adding mental health screening and referrals likely works well for all models of chronic illness care, according to Victor L. Roberts, MD, MBA, a clinical endocrinologist in Winter Park, Fla.
However, “I don’t see how a primary care doctor will have the time to [follow all the guidelines] and determine what is going on with the patient’s mental health,” observed Dr. Roberts, who works with many central Florida primary care clinics.
“But they can tell if someone is mildly or moderately depressed, and they can refer the patient for evaluation just like you would refer them for an EKG, a blood test, or a consultation to an endocrinologist,” he added. “Look at depression as a comorbidity.”
Not treating depression and anxiety as medical conditions means patient outcomes are almost guaranteed to be poor, he said.
“If someone is depressed, they are not listening. They’re worried, they’re not paying attention, their ability to incorporate new information is impaired,” Dr. Roberts added. That leads to less facility for self care and can contribute to a bidirectional conundrum of depression and worsening health, particularly in diabetes.
An embrace of value-based care as envisioned by the guidelines’ authors is irrelevant, however, if qualified mental health specialists – particularly those trained specifically in the psychosocial needs of people with diabetes – are nowhere to be found. “I [practice] in the middle of Los Angeles, and I can tell you that in a 30-mile radius, there is not a psychologist anywhere that I can refer a diabetes patient to,” Dr. Handelsman said.
To that end, the ADA has developed a partnership with the American Psychological Association to educate psychologists about the kinds of mental health challenges specific to patients with diabetes. The curriculum will be introduced later this year during the ADA’s scientific sessions meeting. At present, none of the classes are accredited, but Dr. Young-Hyman said her “pie-in-the-sky dream” would be to expand the program and continuing medical education units.
“We see the capacity issues and want to address them,” Dr. Young-Hyman said. That alone may not be enough to change practice in the specialty setting where integrated care, as provided by Dr. Hellman’s clinic, currently is the exception, according to Dr. Handelsman.
Although he said it was likely that guidelines issued by ACE will be expanded to incorporate the ADA’s recommendations, he challenged the ADA to advocate directly to endocrinology societies to educate them on the practical application of their recommendations.
“Take the guidelines and make us use them,” he said in the interview. Otherwise, because most clinical endocrinologists are not trained to address psychosocial concerns, unless a specialist already has an interest in mental health, Dr. Handelsman said that specialist largely will ignore this document. “Some in the field will read it ... but we will not take it to the streets.”
Despite his “guarded optimism,” neither does Dr. Roberts see how practice for primary care physicians will change much – at least, not in the near future, given what he called the already “bone crushing” constraints on their time.
Yet, he warned that not dealing with mental health issues means not delivering complete care.
“Depression is a complication of diabetes, in my expert opinion,” Dr. Roberts cautioned.
“Primary care physicians need to not sidestep this. They need to make it clear to their patients that dealing with depression is part and parcel of dealing with their chronic disease. The position statement can at least be a clarion call to consider mental health a medical condition that we can address in a matter-of-fact way.”
The American Diabetes Association’s recommendations for psychosocial care in diabetes are as follows:
• Integrate psychosocial care with collaborative, patient-centered medical care, and provide psychosocial care to all people with diabetes, with the goals of optimizing health outcomes and health-related quality of life. (Evidence level A.)
• Consider assessing symptoms of diabetes distress, depression, anxiety, and disordered eating and of cognitive capacities using patient-appropriate standardized/validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. Include caregivers and family members in this assessment. (Evidence level B.)
• Consider monitoring patient performance of self-management behaviors as well as psychosocial factors impacting the person’s self-management. (Evidence level E.)
• Consider assessing life circumstances that can affect physical and psychological health outcomes and their incorporation into intervention strategies. (Evidence level E.)
• Address psychosocial problems upon identification. If an intervention cannot be initiated during the visit when the problem is identified, a follow-up visit or referral to a qualified behavioral health care provider may be scheduled during that visit. (Evidence level E.)
Dr. Handelsman chaired the American College of Endocrinology 2011 Comprehensive Diabetes Guidelines committee and is the immediate past president of ACE. Dr. Hellman is an editorial board member of Diabetes Care. Dr. Young-Hyman had no relevant disclosures.
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