Putting Mental Health on the Diabetes Agenda

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Most of the roughly 150,000 diabetes-related amputations that occur in the United States every year are preventable.

That’s one of the premises of National Diabetes Awareness Month (observed each November), and it’s not wrong. Most diabetes-related amputations are preventable via routine, common-sense interventions. The formula includes broader access to basic healthcare, lower prices for drugs (including insulin), better education regarding foot and wound care, and promotion of healthy diet and exercise habits.

But while those reforms are necessary to lower the amputation rate, they may not be sufficient. A pair of recent studies suggest that emotional and psychological factors also play significant roles in driving diabetes-related limb loss. “It is important to address psychological and emotional challenges at an early stage…to help reduce the risk of foot deterioration and/or amputation,” summarized one paper, published this summer in the journal Practical Diabetes. “Putting emotional health on the diabetes agenda can only benefit [patients].”

This article focuses on diabetes distress (DD), defined as “the burden of relentless daily self-management.” Originally defined in the 1990s, this well-researched condition has been shown to correlate strongly with adverse outcomes, including limb loss. Patients experiencing DD tend to exercise less often, eat more unhealthy foods, take medications less regularly, and see doctors less frequently.

Yet despite DD’s significant impact on outcomes, patient surveys show that most primary-care physicians, podiatrists, and other clinicians don’t integrate psychological and emotional factors into their management of diabetes cases. Even the Diabetes Distress Scale (DDS2), a two-question screening survey that can quickly identify patients who are experiencing DD, is only sporadically used.

The Practical Diabetes paper showed that merely being asked about their well-being can improve patients’ response to diabetes care. Those who receive routine check-ins on emotional health participate more actively in self-care, practice healthy behaviors more consistently, and report greater satisfaction with their provider. 

The second paper, a preprint article posted online at the Journal of Foot and Ankle Research, focuses on the emotional journeys of patients who’ve already lost limbs due to diabetes. It notes that although amputations “are thought to be preventable with early detection and management of risk factors,” effective management must extend beyond medical interventions to include mental health assessment and guidance.

The study surveyed 15 amputees who had lost limbs despite receiving care that seemed to check all the right boxes. They enjoyed regular access to primary care doctors and foot specialists, received vigilant screening, were provided with proper medications, and consulted with allied health professionals such as dietitians and physical therapists. But the absence of attention to the patients’ mental health undermined the otherwise comprehensive management of their diabetes.

“Ambivalence, denial, inevitability, and helplessness reflected barriers that contributed to participants’ amputations,” the researchers found. “Some participants were in denial about their own health,” while “others felt helpless, as though complications and poor health outcomes were inevitable,” and still others vacillated between commitment to treatment, denial, and fatalistic resignation.

Patients’ sense of identity, day-to-day pressures, and relationships with doctors and specialists also contributed to their limb loss. “A primary healthcare approach that understands these factors may help healthcare professionals tailor education and self-management strategies to meet patients’ needs,” the authors found.

To read the full articles, see the July/August issue of Practical Diabetes or visit the Journal of Foot and Ankle Research at jfootankleres.biomedcentral.com.

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