Many lower extremity practitioners are not aware of the risks of distress, depression, and cognitive impairment in patients with diabetes. But screening for mental health issues and adjusting patient management accordingly can significantly improve diabetic foot care outcomes.
By Larry Hand
Studies have shown that patients with diabetes have twice the risk of depressive disorder compared to people who don’t have diabetes. However, more serious is the prevalence for high diabetes distress, which could be as high as 40%. The resulting spiral, in which diabetes can lead to distress and distress can lead to poor management, can significantly hamper foot self-care among those affected.
“They’ve got complications, their feet hurt, it’s awkward, it’s difficult, and it’s a functional deficit. There’s an emotional concomitant to that,” said Lawrence Fisher, PhD, ABPP, of the department of family and community medicine at the University of California San Francisco School of Medicine.
Fisher and others are recommending that lower extremity practitioners who treat the feet of patients with diabetes or provide them with footwear can help by just adding a distress and depression screening and a discussion to their regular visits.
“Why is it important for practitioners to take the time to screen for depression?” asked Gonzalo Laje, MD, a psychiatrist and an associate clinical investigator for the National Institute of Mental Health in Bethesda, MD. “First of all, depression is a medical illness and it’s treatable. If we identify a medical comorbidity with diabetes, it’s important to have it treated. Secondly, patients who are depressed have a much lower ability or consistency with their self care. If they have to care for a wound, if they’re depressed, they’re less likely to do that. Even over a century ago, this was identified as something going together.”
A meta-analysis in Diabetes Care in 2001 estimated the prevalence of major depression in patients with diabetes to be 11% and the prevalence of elevated depression symptoms to be 31%, with the odds of depression in patients with diabetes calculated to be twice as high as in the general population. More recently, a June 2008 study published in the Journal of the American Medical Association found that individuals being treated for Type 2 diabetes had a 52% higher odds of developing elevated depressive symptoms, even after adjusting for lifestyle risk factors such as body mass index or socioeconomic status.
Of particular interest to lower extremity practitioners is that those depressive symptoms (whether indicative of true depressive disorder or diabetes distress) seem to contribute to poor compliance. A June 2007 study in Diabetes Care found that clinical depression is associated with about one-third of people who develop their first foot ulcer. And a September 2008 study in Diabetes Medicine concluded that depressive symptoms predict poorer self-care among patients with type 2 diabetes.
Making the connection
Hence, a connection between the diabetic brain and the diabetic foot.
“The vascular implications you can see in the lower extremity, such as a diabetic foot? That same process is happening in the brain, heart, and kidney,” Laje said. He recommends three additional steps for improving foot self care in patients with diabetes:
- practitioner awareness of the coexistence of diabetes and distress or depression,
- screening for the coexistence,
- referral to a primary care physician or neuropsychiatric professional when necessary.
The coexistence of diabetes and distress or depression is highly difficult for lower extremity practitioners to recognize, says James Wrobel, DPM, director of the Center for Lower Extremity Ambulatory Research and associate professor of medicine at Rosalind Franklin University of Medicine and Science in Chicago.
“We’re not trained in this area,” Wrobel said. “One of the advantages we do have is we tend to see patients more often than other practitioners. We may see people with foot ulcers on a weekly basis or every other week. I think that gives us an opportunity to see the subtle changes in their mental status or in the effect of their mental status on self care.”
Adding to the confusion is the fact that symptoms of depression are easily confused with those of general anxiety disorder, which in this population is also known as diabetes distress. In a December 2002 systematic review published in the Journal of Psychosomatic Research, researchers concluded that 14% of adults with diabetes exhibit symptoms of general anxiety disorder and 40% exhibit elevated symptoms of anxiety.
Fisher and colleagues, in a study published in the March 2007 issue of Diabetes Care, concluded that most diabetic patients with high levels of depressive symptoms are not clinically depressed but rather are affected by diabetes distress.
“Far, far more patients will score high on depressive symptom scales or related kinds of mood indicators, but have nothing to do with major depressive disorder (MDD) or a clinical syndrome,” Fisher said.
Diabetes and cognition
On the other end of the spectrum, changes in mental status in patients with diabetes can also include cognitive impairment. Multiple longitudinal studies, including those discussed by Scottish researchers in the April 2004 issue of the European Journal of Pharmacology, have reported associations between diabetes and accelerated cognitive decline or dementia. However, it remains unclear to what extent that association is related to comorbidities such as hypertension and hypercholesterolemia that are known to play a role in cognitive decline.
There is mounting evidence that those subtle changes can occur rapidly. A Dutch study published in the September issue of Diabetes Care found that middle-aged people with type 2 diabetes show greater decline in general cognitive function than individuals who don’t have diabetes. The researchers analyzed data from more than 2,600 people aged 43 to 70 and found that, over a five-year period, patients with diabetes experienced a 2.6 times greater decline in overall cognitive function than those without diabetes; in people over age 60, the decline in those with diabetes was 3.6 times greater than those without. The researchers also wrote that hyperglycemia appears to affect different domains of cognitive decline at different stages of time. For instance, the speed of cognitive function appears to decline early on, while memory appears to decline continuously.
P. Royce Simpson, LO, ROA, an orthotist and pedorthist with JP&O Prosthetic and Orthotic Laboratory in Jonesboro, Arkansas, estimates that up to 30% of his patients seem to have some kind of cognitive impairment that affects their ability to care for their feet.
“These patients either don’t understand the magnitude of the issues they have with their foot care, or it’s just plain lack of instruction in general. I try to explain the issues to them, but they often don’t get the magnitude,” he said.
When Simpson does explain, he does so from the personal standpoint of a person who also experienced depressive symptoms shortly after he was diagnosed with Type 1 diabetes more than eight years ago.
“Usually I can talk them through my personal issues and normal diabetic health and foot care,” he said. “Lots of times I’ll think they’re understanding on the first visit, then they’ll come in again and they haven’t been taking proper care. That’s when the red flags will come up for me—a repeat patient who hasn’t improved his or her foot self care.”
Audrey Zucker-Levin, PT, PhD, MBA, associate professor in the Physical Therapy Department at the University of Tennessee Health Science Center in Memphis, has a highly focused perspective on the issue of diabetes and cognitive impairment. She treats only patients who have already had one limb amputation.
“They’ve already had a first-hand experience with what can happen if they don’t care for their limb,” she said. “Most are not depressed, but many are frustrated with the system. We have a large indigent population and patients often get shuffled around. There’s a definite gap in care for some of these people. Although they may not be depressed, the patients still might not understand the problem, and that may be a cognitive issue or it could be a denial.”
This can be a point at which screening can be done.
“We’re beginning to make inroads by having lower extremity practitioners screen for distress and depression,” Fisher said. “It takes four items (see below) on a questionnaire scale to do both, and then raising the issue as a part of the conversation, engaging the patient and asking how they’re feeling and how upset they are about what’s going on with their feet. That opens the door to discussion and really normalizes it and defuses it.”
Common diabetes distress and depression screens include:
- The Beck Depression Inventory (BDI-II): This consists of 21 assessment items to address possible depressive symptoms over the past two weeks.
- The Patient Health Questionaire: This includes ways to assess mood, anxiety, alcohol, eating, and disorders that cannot be explained by physical medicine.
- The Diabetes Distress Scale: This offers a 17-question way to assess how distressed a person has been over the past month.
Generally, the screenings only require answering all questions only if the answers to the initial screeners are positive. In the May/June issue of the Annals of Family Medicine, Fisher and colleagues described a short version they developed of the Diabetes Distress Scale (DDS17). Their version, DDS2, asks persons to rate on a 5-point scale their degree of stress for (1) “feeling overwhelmed by the demands of living with diabetes,” and (2) “feeling that I am often failing with my diabetes regimen.” If the individuals rate their distress level at 3 or higher, the full DDS17 should be administered.
Two additional first-line screening questions relate to possible depression symptoms: (1) “not feeling motivated to keep up my diabetes routine,” and (2) “feeling angry, scared, and/or depressed when I think about living with diabetes.”
The NIMH and UCSF websites also contain searchable information on distress and depression screening.
Finding the right words
“What we’ve been learning recently is it really doesn’t make sense to call many who score high on some of these scale assessments depressed, because that pathologizes them,” Fisher said. “Most of these folks are just pretty distressed—frankly, in a highly technical term, bummed out. It makes much more sense to address these distress issues around the disease itself and saying that these levels of distress are almost part of the spectrum of having diabetes.”
Using different terminology can help focus treatment appropriately, reducing the temptation to rely on pharmacological measures that may not be effective.
“It doesn’t take much distress to really have these folks score high on these scales,” Fisher said. “This kind of distress really doesn’t respond well to medication, and many won’t follow up on a referral, so it makes much more sense to treat it as part of the disease and make it part of the clinical process where they receive care. Just simple discussion of it—bringing it up—is a powerful intervention.”
Another key to offering advice and education, however, is having a family member in on the conversation, according to Zucker-Levin.
“I think it’s important that a family member listens,” she said. “You can’t just do it with the patient.
Social supports are very important for diabetes and depression, Laje agreed.
“People without family and social support are at highest risk, because they have to care for themselves on every level, and depression can have a much more negative impact,” he said.
It takes a team to improve foot self care, and many people that this becomes even more true for patients affected by diabetes distress or other neuropsychological issues.
“Some patients just aren’t capable of caring for themselves, and that’s a cognitive issue,” Fisher said. “Some of them are just not engaged with their disease; they’re fighting it or they’re ignoring it. And when they get to see specialists, they already have a severe complication. That’s where the diabetes team really needs to take effect and coordinate care.”
He recommends raising the issue for the PCP to coordinate with an endocrinologist, podiatrist, orthotists, diabetes educators—all team members. For instance, a person in his 70s who has had Type 2 diabetes for 20 years may have mild, diabetes-related dementia, and a coordinated team approach is necessary to see what that patient is capable of and what he needs.
Zucker-Levin says wound care nurses and even dialysis centers can also be important team members, plus physical and occupational therapists.
The language a practitioner uses is important, also. Team members should use “feeling” words in discussing the issues with patients, Fisher advises.
“Use feeling words like, ‘Have you been down about it? Has it been upsetting? How frustrating has it been?’ Don’t talk about it cognitively or intellectually, or folks will say, ‘Oh fine.’ If you find somebody feeling this way, and they’ve screened [for distress or depression symptoms], talk about it,” he said. “Together make a decision about what the patient might need or want, and what resources there might be. Talk about raising the issue with a PCP to coordinate care with diabetes team and possibly refer to a psychiatrist.”
For newly diagnosed patients
If a patient is newly diagnosed with diabetes, Laje offers this advice: “Understand your treatment and follow it, keep glucose levels under control, and realize that changes in mood are going to affect your ability to take care of yourself. If that happens, bring it to the attention of a physician.”
Knowing what to expect can help patients cope, Fisher said.
“It is helpful to predict distress,” he said. “Tell them, ‘You know, over time, you may start feeling stuff like this. A lot of patients do, so you normalize it. Don’t let it surprise you because it happens to most folks.’ ”
Simpson offers his own perspective on what to tell a patient newly diagnosed with diabetes.
“From a personal standpoint, going through what I did when I was originally diagnosed, I think my depression had a greater effect on my diabetes just because I was so bummed out on all the things I was having to do and it just kept steamrolling and getting worse and worse,” he said. “With help, I was able to overcome it, and now it’s just part of living with an insulin pump. Working with a diabetes educator was the best thing for me. She helped me through all of issues.”
Larry Hand is a writer based in Massachusetts.