Development of a Brief Diabetes Distress Screening Instrument

Most guidelines about diabetes care agree that the prevention of complications and the maintenance of an optimal quality of life are the primary goals of diabetes therapy. Diabetes as a chronic, life-long disease confronts patients with the possible development of acute and late complications. Furthermore, patients with diabetes have to deal with a complex diabetes management including lifestyle changes, blood glucose self-monitoring, control of hyperglycemia as well as the treatment of additional metabolic risk factors. Therefore patients are constantly challenged by living with diabetes and integrating the complex diabetes regimen into one’s daily routine and social life.

As a probable consequence many patients report diabetes related problems and emotional distress, like feeling depressed or anxious. More than 30% of diabetic patients have elevated symptom levels of depression, anxiety or diabetes related distress. Although in most cases emotional problems in diabetic patients are not severe enough to fulfill criteria for mental disorders (e.g. depression), they have the potential to impair quality of life and self-management of diabetes (1). There is a consistent association between emotional problems in diabetic patients and poor diabetes self-care behavior, elevated metabolic risk factors, occur-rence of late complications as well as even increased mortality. Therefore emotional problems in diabetic patients should be taken seriously. Many diabetic patients hesitate to talk to their physician about emotional distress and prefer to report medical symptoms and complaints. On the other hand, health-care professionals usually are primarily trained and qualified to respond to somatic complaints and medical problems. Therefore, unfortunately emotional problems in diabetic patients often remain unrecognized. In our own diabetes center only 25% of diabetic patients with mild depressive symptoms have been recognized (2). Even more severe clinical disorders like clinical depression are only identified in 25-30% of all cases.

For this reason it seems appropriate to screen for emotional problems in diabetic patients. This article of Fisher et al. introduces a very valuable tool for diabetes related distress screening in diabetic patients. A short screener of only two questions seems to have sufficient sensitivity to detect more than 95% of all diabetic patients with elevated diabetes related distress. If patients are screened positive, a more comprehensive measure, like the diabetes distress scale, can be used to identify the specific subjects of diabetes related problems (e.g. emotional burden, phy-sician related distress, regimen related distress or interpersonal distress). This questionnaire cannot only be used as a diagnostic tool but could also facilitate to get into a discussion about emotional problems related to diabetes. In a Dutch outpatient setting the use of a questionnaire to detect diabetes related problems and the offer to patients to talk about elevated scores, resulted in a remarkable shift in conversation topics during the visit. Coping with emotional problems was discussed more frequently than technical details of medical therapy. The outcome of implementing screening for emotional problems in diabetic patients resulted in a significant improvement in quality of life and a satisfactory glycaemic control (3).

Therefore the use of the two screening items introduced to detect diabetes related distress implies only a small change of clinical routine, but could result in a big step towards a better quality of life and a better prognosis of diabetes.

Reference List

(1) Fisher L, Skaff MM, Mullan JT, Arean P, Mohr D, Masharani U et al. Clinical Depression Versus Distress Among Patients With Type 2 Diabetes: Not just a question of semantics. Diabetes Care 2007; 30(3):542- 548.

(2) Hermanns N, Kulzer B, Krichbaum M, Kubiak T, Haak T. How to screen for depression and emotional problems in patients with diabetes: comparison of screening characteristics of depression questionnaires, measurement of diabetes-specific emotional problems and standard clinical assessment. Diabetologia 2006; 49(3):469-477.

(3) Pouwer F, Snoek FJ, Van Der Ploeg HM, Ader HJ, Heine RJ. Monitoring of psychological well-being in outpatients with diabetes: effects on mood, HbA(1c), and the patient's evaluation of the quality of diabetes care: a randomized controlled trial. Diabetes Care 2001; 24(11):1929-1935.

Competing interests:   None declared

We thank Dr. Vale for his thoughtful comments about our paper and about diabetes distress in general. We wish to make two points in response.

First, Dr. Vale suggests the clinical utility of reviewing the “repetitive thoughts” often associated with diabetes distress. We agree and urge clinicians to use the scale, and other approaches, to identify specific areas of patient concern and distress. In fact, the more specific the better. In our experience, most distressed patients with diabetes have well-defined concerns, and using the general term “distress” often is not helpful when designing an appropriate intervention. Identifying barriers, lack of support, etc. around specific behavioral management issues enables the clinician to target areas for assistance and to tailor suggestions to meet a patient’s specific needs.

Second, Dr. Vale comments on current findings that suggest that interventions for MDD and other Axis I disorders often (but not always) have little effect on diabetes-specific distress or on diabetes management behaviors or outcomes. He refers to reviews that indicate that the linkages between changes in MDD and HbA1C are modest, to say the least. Dr. Vale speculates that the lack of effect of pharmacological or behavioral treatment for MDD on distress may have to do with the diabetes process itself and on certain neuro endocrine feedback systems. We have two thoughts on this matter. First, MDD and other criteria-based Axis I disorders may be distinct from the kind of distress we see among patients with chronic conditions. Although high arousal and negative affect are common characteristics of disease-specific distress, we are not sure if the physiological parameters are the same as in MDD. Future research should focus on this issue. Second, it is not clear from our current work what the causative relationships are among distress, disease management behavior and biological markers like HbA1C. We have seen the impact progress in at least two directions, and sometimes at the same time: distress limits management and affects outcomes, and negative outcomes increases distress. Current analyses directed at teasing out these interrelationships over time should help define the direction of influence. In the meantime, however, we continue to recommend regular and repeated screening of both depression and distress among patients with diabetes.

Again, we thank Dr. Vale for his comments.

Competing interests:   None declared

Diabetes-specific distress, as stated by Fisher et al (1) “… is a common condition frequently confused with depressive disorders. However, interventions that effectively treat depression do not also improve diabetes behavioral and biological outcomes, and interventions that treat diabetes management do not necessarily reduce the depressive disorder …”. As a result, a specific concept was required and the “Diabetes-specific distress” conception has been coined.

Although with the word “distress” we thought about a neuroendocrine response to the hypothalamic-pituitary-adrenal activation (that is, a norepinephrine/serotonin surge), the use of the “Diabetes-specific distress” terms correspond to an alternative meaning, that is, a complex set of repetitive thoughts regarding 1) feeling overwhelmed by diabetes, 2) worries about access, trust, and care, 3) concerns about diet, physical activity, medications, and 4) not receiving understanding and appropriate support from others.

With the development of the Brief Diabetes Distress Screening Instrument (DDS2) and the associated DDS17, it is possible now to define the content of “diabetes-specific distress” and to direct intervention. We can also learn about the etiologic component of this alternative concept of distress. Examining in detail the repetitive thoughts embedded in negative affect that patients with positive DDS2 plus DDS17 provide, an uncontrolled obsessive disorder might be on their way, affecting severely an important subgroup of diabetic patients. Thus, this aspect deserves to be investigated in further research.

Regarding pharmacological treatments, the use of selective serotonin reuptake inhibitors (SSRIs) can be used in both, depressive and obsessive diseases. However, results with this regime do not seem to be effective in relieving symptomatology in the “diabetes-specific distressed” patients. I am tempted to speculate that there are two causes of this unfortunate situation: 1) The persistence and progression of the causative ailment, that is, the diabetic process itself, and 2) The unrelenting negative affect that can perpetuate the “distress” positive feedback (but which can be intended to tackle with agonists of the serotonin receptor 1a [5-HT1A] and antagonists of the 5-HT2 receptor) (2, 3) added to SSRIs.

With the timely contribution of Fisher et al., in developing a Brief Diabetes Distress Screening Instrument, we can now identify the affected patients and direct interventions to improve treatments when possible. An additional gain may be that we can be more alert before this situation develops in full, since its prevention will be always better in the clinic, as compared with the difficulty of treating the full developed “diabetic-specific distress” syndrome.

References:

1. Fisher L, Glasgow RE, Mullan JT, Skaff MM, Polonsky WH. Development of a brief diabetes distress screening instrument. Ann Fam Med.;6:246-252, 2008

2. Forbes EE, Dahl RE. Neural systems of positive affect: relevance to understanding child and adolescent depression? Dev Psychopathol;17:827- 850, 2005

3. Shelton RC, Papakostas GI. Augmentation of antidepressants with atypical antipsychotics for treatment-resistant major depressive disorder. Acta Psychiatr Scand;117:253-259, 2008

Competing interests:   None declared

Dr. Crownover raises the important issue of creating a diabetes team, rather than consolidating all care within the physician's 15 minute contact with the patient. Screening can take place in a variety of pre-visit settings, undertaken by trained personnel from different professional backgrounds. The different staffing, culture and flow of each practice determines what might work best. We applaud consideration of re-defining the care team and allocating tasks in ways that are cost- and time-efficient, and yield good clinical information that has a direct effect on patient care. One less pebble can make a big difference.

Competing interests:   None declared