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Psychosocial

Evidence Summary

Diabetes Service, Country Health SA

April 2017

Psychosocial – April 2017 of 33

Authors/Reviewers

Collette Hooper, Nurse Practitioner - Diabetes, RN CDE,


Jane Giles, Advanced Clinical Practice Consultant RN CDE,


Reviewers

Dr David Jesudason Director of Endocrinology Services,

Country Health SA

Abigail English Mental Health Clinician - Psychologist

Inner North Community Mental Health Team

Barossa Hills Fleurieu Region

Country Health SA

Cathy Brook Advanced Clinical Lead - Social Work

Port Augusta Community Health

Flinders and Upper North Region

Country Health SA

Liz Cooke Associate Clinical Service Coordinator – Diabetes Educator

Port Lincoln Health Service

Eyre and Far North Region

Country Health SA


Psychosocial

Emotional well-being is an important part of diabetes care and self-

management. Psychological and social problems can impair the person’s

and/or their carer’s ability to carry out diabetes related tasks and therefore

can compromise their overall health status.1

Depression and anxiety are common in older children, and adolescents with

diabetes.2 Adolescents with type 1 diabetes are at an increased risk for an

eating disorder. Adults aged greater than 65 years with diabetes should be

considered a high-priority population for depression screening and

treatment.

Routine screening for psychosocial problems such as anxiety, diabetes-

related distress, eating disorders, cognitive impairment and depression may

help identify the persons (and/or carers) at risk for poor adherence and poor

diabetes control.3

The person with diabetes must be assessed at diagnosis and their

psychological and social situation should be included as an ongoing part of

the medical management of diabetes.

Incorporating psychological assessment and treatment into routine care

rather than waiting for a specific problem or deterioration in metabolic or

psychological status is preferred. Psychosocial interventions can improve

glycaemic control and reduce hospitalization even in the high-risk person.4


Contents

Evidence

Glycaemia control

Screening

Psychological problems

Caution

Indications for referral

Treatments

Antidepressant medication

Patient information

Better Access initiative

Helpful websites

Appendices 1-8

References


Evidence

Studies investigating the relationships among psychological and social variables and

diabetes outcomes are limited. In addition, researchers use different terms to describe

psychological studies and use a wide variety of psychological terms to describe human

behaviour and the nature of psychological interventions. However, research on the efficacy

of psychological interventions in diabetes is evolving.

Depression affects about 20–25% of people with diabetes5 and increases the risk for

myocardial infarction and post-myocardial infarction6 and all-cause mortality.

7

Diabetes related distress is distinct from clinical depression and is very common among

people with diabetes and their family members. The prevalence is reported as 18–45%,

with an incidence of 38–48% over 18months.8 High levels of distress are significantly linked

to HbA1c, self-efficacy, dietary and exercise behaviours, and medication adherence.9

The prevalence of disordered prevalence of disordered eating behaviours and diagnosable

eating disorders in people with diabetes varies. For people with type 1 diabetes, insulin

omission causing glycosuria in order to lose weight is the most commonly reported

disordered eating behaviour. In people with type 2 diabetes, bingeing (excessive food

intake with an accompanying sense of loss of control) is most commonly reported.10

Adults with type 1 diabetes and eating disorders have poorer metabolic control, require

more frequent hospitalisation, and are more likely to develop microvascular complications

as compared with those without eating disorders.11

They also have an increased mortality

rate compared with patients with only diabetes or only an eating disorder.12

In older children and adolescents, family conflict can arise over the level of adult

involvement in the care of the person with diabetes during a normal developmental period

of increasing independence and self-assertiveness.

Socioeconomic factors such as single parent families, poor socioeconomic status, and

chronic physical or mental health problems in a parent and/or carer is associated with

poorer diabetes control and increased hospitalizations for the person with diabetes.13

A systematic review and meta-analysis showed that psychosocial interventions significantly

improved HbA1c and mental health outcomes.14

Glycaemia control

There is evidence that a range of psychological and social factors can impact on the ability

of people with diabetes to manage their condition. Whether the burden of managing

diabetes causes psychological and social problems or vice versa, however, is unclear.

The following factors are associated with poorer control in children and young people with

type 1 diabetes:

aspects of family functioning including conflict; lack of cohesiveness and lack of

openness

depression

anxiety

maternal distress

eating disorders

behavioural problems.15


The following factors are associated with poorer control in adults with type 1 diabetes:

clinical depression and subclinical levels of mood disruption

anxiety

eating disorders.16

The presence of microvascular and macrovascular complications is associated with a

higher prevalence of depression and lower quality of life. 3 However, remission of

depression is often associated with an improvement in glycaemic control.10

Age Related

Considerations

Young children with diabetes are dependent on social support systems (family and care

providers) and must eventually transition to independent diabetes self-management, their

families and related social networks need to be included in psychosocial assessment and

treatment.

Adolescence can be challenging and communication between the young person with

diabetes, their family, their carers (eg school teachers and support staff) and health care

team can be difficult. Cognitive development and medical decision-making skills will impact

a wide variety of risk-taking behaviours and acceptance of self-management behaviours

into their daily diabetes management tasks. Discussions should include questions about

well-being in general, sexual health and behavioural risk (eg substance use and unsafe

sexual activity).10

The South Australian Children’s Protection Act (1993) identifies that health care

professionals are required by law to report suspected child abuse and neglect. Country

Health SA supports the reporting of child abuse and neglect to ensure children are kept

safe from harm. Child abuse and neglect has immediate and lifelong impacts on health and

wellbeing.

As people with diabetes enter adulthood, establishment of a work role, intimate partnering,

raising children impact all short and long term decisions.

Older adults may have issues particular to their age, such as advanced disease, cognitive

dysfunction, complex treatment regimens, comorbid health conditions, functional

impairment, limited social and financial resources. Assistance and support may be

provided by family members and staff in their homes or in residential aged care facilities.

The psychosocial treatment must take into consideration the context and caregiver

capacities.10

Screening

People are more likely to exhibit psychological vulnerability when their medical status

changes. Key opportunities for routine screening of psychosocial status occurs:

at diagnosis

at the end of the honeymoon period (in type 1 diabetes)

when the need for intensified treatment is evident

during hospitalisations

with new-onset complications

when problems with glucose control, quality of life, or self-management are identified.

during regular scheduled reviews with the medical practitioner/specialist physician,

endocrinologist and/or health care professional.


Psychosocial screening and follow up may include, but may not be limited to:

attitudes about the illness,

expectations for medical management and outcomes,

affect/mood,

resilience and positive coping skills

general and diabetes related quality of life,

resources (financial, social, and emotional), and

psychiatric history.

Health care professionals should have sufficient levels of consulting skills to be able to

identify psychological problems and be able to decide whether or not referral to specialist

mental health services is required.16

Further information and to access the Headspace Clinical Toolkit which includes clinical

tips for assessing risk of suicide and self-harm, please visit the Headspace website.

Psychological problems

Anxiety

Anxiety is more than just feeling stressed or worried. Anxious feelings are a normal

reaction to a situation where a person feels under pressure (eg meeting work deadlines,

sitting exams or speaking in front of a group of people). However, for some people these

anxious feelings happen for no apparent reason or continue after the stressful event has

passed.

The symptoms for the different types of anxiety vary, some general signs and symptoms

include:

feeling very worried or anxious most of the time

finding it difficult to calm down

feeling overwhelmed or frightened by sudden feelings of intense panic/anxiety

experiencing recurring thoughts that cause anxiety, but may seem silly to others

avoiding situations or things which cause anxiety (eg social events or crowded places)

experiencing ongoing difficulties (eg nightmares/flashbacks) after a traumatic event.

For further information on anxiety, please visit the Beyond Blue website.

Diabetes related distress

Diabetes related distress is defined as the emotional struggles associated with the many

expected worries, fears and concerns that come with managing a progressive, chronic and

demanding condition.

For a person with diabetes, it is those unique, often hidden emotional burdens, like getting

overwhelmed about checking blood glucose, avoiding hypoglycaemia at work/school, the

possibility of developing a diabetes related chronic complication/s, or how their diabetes

negatively impacts their work or family life on a regular basis. If the person has a negative

view of their future in terms of diabetes management and wellbeing, this will impact on their

levels of emotional distress, illness management and openness to services and resources

that can support good health and self-care.

https://headspace.org.au/assets/Uploads/Resource-library/Health-professionals/Clinical-Toolkit/CT-Assessing-suicide-and-self-harm.pdf

http://www.beyondblue.org.au/the-facts/anxiety


Diabetes related distress describes a transient aversive state, interfering with a person's

ability to adequately adapt to stressors.

The Problem Areas in Diabetes (PAID) questionnaire (Appendix 1) is a psychometrically

sound tool for detecting diabetes related distress.

Focusing on commonly experienced problems, the person with diabetes indicates how

much each problem area affects them personally using a scale of 0 (not a problem) to 4

(serious problem). Individual items scored greater than (or equal to) 3 (indicating a

somewhat serious or serious problem area) should be discussed with the patient.

Eating disorders

There are four eating disorders that are recognised by the Diagnostic and Statistical

Manual of Mental Disorders (DSM), which are:

Anorexia Nervosa - restricted energy intake, a fear of gaining weight and a disturbed

body image

Bulimia Nervosa - repeated episodes of binge eating followed by compensatory

behaviours (eg vomiting, misusing laxatives/diuretics, fasting. excessive exercise and/or

use of any drugs (illicit, prescription and/or ‘over the counter’ inappropriately)) for weight

control.

Binge Eating Disorder - frequent episodes of binge eating with a range of identifiable

eating habits (eg eating quickly or even when full), feelings of guilt and shame, secretive

about eating habits and choosing to eat alone.

Other Specified Feeding and Eating Disorders (OSFED) - extremely disturbed eating

habits, distorted body image, overvaluation of shape and weight and/or an intense fear of

gaining weight (if underweight).

A person with an eating disorder may have disturbed eating behaviours coupled with

extreme concerns about weight, shape, eating and body image.17

For a person with diabetes, an eating disorder with the purposeful omission of insulin for

weight loss (sometimes known as “diabulimia”) has been noted.18

The Eating Disorders Screen for Primary Care (EPC) and SCHOFF Screening Tool

(Appendix 2) offer questions which may assist to identify the possible presence of an

eating disorder and when referral to specialist mental health services is warranted.

For further information, please visit the National Eating Disorders Collaboration website.

Cognitive impairment

Cognition refers to the intellectual skills that allow a person to perceive, acquire,

understand and respond to information to allow them to function in their environment.

Cognitive impairment may be experienced in different ways:

Attention - difficulty paying attention to conversations/directions, to concentrate to read or

focus on one thing when other things are happening. The person may get distracted or

conversely, become so involved in one thing that they fail to attend to something else that

is happening.

Memory - difficulty remembering and recalling information, particularly verbal material.

The person may not have trouble remembering routines they have learned, but they may

find that they do not hold onto new information as well as they used to.

The ability to process and respond to information - the family/carer may notice that the

person’s response time is slower or that it takes longer to register and understand

information.

http://nedc.com.au/eating-disorders-explained


Thinking skills - Critical thinking, planning, organisation and problem solving are difficult.

The person may seem less able to think of alternate strategies for dealing with problems

that arise, or they may have difficulty coming up with a plan, or find it hard to listen

critically to new information and know what is important and what is not.

For a person with diabetes, cognitive impairment may impact their ability to function in the

community, at school, at work and in their various relationships.

The Mini-Mental State Examination (MMSE) (Appendix 3) is an 11 item screening tool

used to grade cognitive impairment in adults (aged 18–100 years).

Depression

Depression is a state of low mood and aversion to activity that can affect a person's

thoughts, behaviour, feelings and sense of well-being. People with depressed mood can

feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, ashamed or

restless. Depression may cause a person to withdraw socially and lose motivation to attend

social outings or events that were once pleasurable or feel less able to engage in

relationships that are meaningful and contribute to well-being.

Depression is more common in people with diabetes than in the general population. The

presence of microvascular and macrovascular complications is associated with a higher

prevalence of depression and lower quality of life.

The combination of diabetes and depression present a major clinical challenge as the

outcomes of both conditions are worsened by the presence of the other. For a person with

diabetes, depression may cause them to lose interest in activities that were once

pleasurable, experience loss of appetite or lead to overeating, have difficulty concentrating,

feel excessively tired/fatigued, have difficulty remembering details or making decisions, and

may have insomnia or want to sleep excessively. If untreated, depression may lead to

contemplation of, attempt to or commit suicide.

Antenatal depression is when a woman experiences depression during pregnancy.

Postnatal depression is when a woman experiences depression between one month and

up to one year after the birth of a baby.

Depression can be assessed using simple questions regarding mood and enjoyment of day

to day activities, using self-completed measures or via a more intensive clinical interview

(normally carried out by psychologists/psychiatrists). The following screening tools have

been validated and are widely used.

The Patient Health Questionnaire (Appendix 4) is a psychometrically sound tool for

detecting depression and anhedonia (inability to experience pleasure from activities usually

found enjoyable). The PHQ-2 is composed of the first two questions from the PHQ-9 (each

describing a different problem/symptom of depression).

The Antenatal Risk Questionnaire (Appendix 5) is designed to consider specific key risk

factors thought to increase the risk of women developing perinatal mental health morbidity

(eg postnatal depression or anxiety disorder) and sub-optimal mother infant attachment.

The ANRQ Questionnaire components include:

past mental health history

past history of physical (including domestic violence), sexual or emotional abuse

current level of supports

relationship with mother and partner

anxiety and obsessionality levels


stressors in the last year (including bereavement, separation etc).

There is no absolute cut-off score for the ANRQ, but a score of 23 or more suggests

presence of significant psychosocial risk factors, and consideration of the woman as at

significant risk of perinatal mental health problems.

The Edinburgh Postnatal Depression Scale (Appendix 6) is a questionnaire originally

developed to assist in identifying possible symptoms of depression in the postnatal period.

However, it has adequate sensitivity and specificity to identify depressive symptoms in the

antenatal period and is useful in identifying symptoms of anxiety.

The need for follow up of possible depressive symptoms is recommended in a total score

of 13 or more. In the antenatal period, a repeat EPDS in 2–4 weeks is recommended if a

women’s score is 13 or more. If the second EPDS score is 13 or more, the patient is to be

referred. In the postnatal period, referral or ongoing care is recommended if a women’s

score is 13 or more.

The Hospital Anxiety and Depression Scale (Appendix 7) is the most widely used self-

reporting screening tool for adults with medical conditions, including diabetes, to determine

the levels of anxiety and depression that a person in hospital is experiencing.

The HADS questionnaire relates to anxiety and depression, specifically designed to avoid

reliance on aspects of these conditions that are also common somatic symptoms of illness

(eg fatigue, insomnia or hypersomnia).

Each item on the questionnaire is scored from 0–3 and this means that a person can score

between 0 and 21 for either anxiety or depression. The HADS uses a scale and therefore

the data returned from the HADS is ordinal.

Patients who are subsequently diagnosed with depression should be provided with ongoing

health care professional support for the management and treatment for their depression

and their ongoing diabetes care.

Diabetes Complications

Diabetes complications, including peripheral neuropathy, foot ulcers, limb amputation,

diabetic kidney disease, vision impairment, stroke, and heart attack, are associated with

depression, anxiety, reduced autonomy, role impairment, and reduced overall physical

function and quality of life.3

The onset of diabetes complications threatens independence, self-image, and quality of

life. Chronic pain from neuropathy is associated with distress, depression, and sleep

disturbances.

Three ways of measuring pain include:

self report - what the person says

behavioural –how the person behaves

physiological –clinical observations.

The FLACC (acronym FLACC stands for Face, Legs, Activity, Cry and Consolability),

the Wong-Baker Faces Pain Scale and the Visual Analogue Scale (Appendix 8) are

recognized by pain specialists to be clinically effective in assessing acute pain. All share a

common numeric and recorded as values 0-10.

Bariatric Surgery

People presenting for bariatric surgery have increased rates of depression and other major

psychiatric disorders compared with healthy people and are prone to clinically significant

body image disorders, sexual dysfunction, and suicidal behaviour.


Psychosocial assessment is an essential component of the pre and post-surgical

evaluation.10

Caution

The performance of some self-report screening tools has been assessed in people with

type 1 and type 2 diabetes.

Caution must be used as some symptoms of diabetes overlap with symptoms of common

psychological problems (eg identification of psychological problems may be more difficult,

false positives may be obtained).

It must also be noted that scores may be influenced by several factors, including the

patients understanding of the language used, their fear of the consequences if depression

is identified, and differences in emotional reserve and perceived degree of stigma that is

associated with depression.

Indications for referral

It is preferable to incorporate psychological assessment and treatment into routine care

within the general practice setting rather than waiting for a specific problem or deterioration

in metabolic or psychological status.

Although the health care professional may not feel qualified to treat psychological

problems, optimizing the patient health care provider relationship as a foundation can

increase the likelihood that the patient will accept referral for other services.

The American Diabetes Association Psychosocial Care for People with Diabetes Position

Statement (2016) recommends referral of a person with diabetes to a mental health

provider (eg. psychiatrists, clinical psychologists, registered psychologists, mental health

accredited social workers and occupational therapists) in the following situations:

if self-care remains impaired after tailored diabetes education

following a positive screen on a validated screening tool for depressive symptoms

in the presence of symptoms or suspicions of disordered eating behaviour, an eating

disorder or disrupted patterns of eating

if intentional omission of insulin or oral diabetes medication to cause weight loss is

identified

if a serious mental illness is suspected

in youth and families with behavioural self-care difficulties, repeated hospitalisations for

diabetic ketoacidosis or significant distress

following a positive cognitive impairment screening

in declining or impaired ability to perform diabetes self-care behaviours

before undergoing bariatric surgery and after if assessment reveals a need for

adjustment support.

Health care professionals should be aware of cultural differences in type/presentation

of psychological problems within indigenous and minority ethnic communities living

with diabetes and facilitate appropriate psychological/emotional support.


Social Workers in Country Health SA aim to improve health and wellbeing outcomes for the

people with diabetes by focussing on enhancing their emotional, social, spiritual and well-

being needs. For further information (SA Health staff only), visit the CHSA Social Work

Network WIKI page.

Mental Health Services in Country Health SA offer local services, distance consultation and

bed based services at the Whyalla and Riverland (Berri) and Mount Gambier campuses.

For further information (SA Health staff only), visit the CHSA Mental Health Services WIKI

page.

Collaborative care interventions and use of a team care approach have demonstrated

efficacy in diabetes and depression.10, 19

Interventions to enhance self-management and

address severe distress have demonstrated efficacy in diabetes related distress.20

Treatments

Psychological treatments (also known as talking therapies) help people to change negative

patterns of thinking and improve their coping skills so they are better equipped to deal with

life's stresses and conflicts.

There are several types of psychological treatments shown to be effective:

Cognitive Behaviour Therapy (CBT)

CBT is a structured psychological treatment which recognises that a person's way of

thinking (cognition) and acting (behaviour) affects the way they feel. CBT is one of the most

effective treatments for depression, and has been found to be useful for a wide range of

people, including children, adolescents, adults and older people.

In CBT, a person works with a health care professional to identify the patterns of thought

and behaviour that are either making them more likely to become depressed, or stopping

them from improving once they become depressed.

CBT has an emphasis on changing thoughts and behaviour by teaching people to think

rationally about common difficulties, helping them to shift their negative or unhelpful

thought patterns and reactions to a more realistic, positive and problem solving approach.

CBT, psychotherapy programmes and coping skills training are useful in treating

depression in patients with diabetes. However, cognitive behavioural therapy may be less

effective in patients with complications.19

CBT is also well suited to being delivered

electronically (often called e-therapies).

Interpersonal Therapy (IPT)

IPT is a structured psychological therapy that focuses on problems in personal

relationships and the skills required to deal with these problems. IPT is based on the idea

that relationship problems can have a significant impact on a person, and can even

contribute to depression.

IPT is thought to work by helping people to recognise patterns in their relationships that

make them more vulnerable to depression. Identifying these patterns means they can

focus on improving relationships, cope with grief and find new ways to get along with

others.

Behaviour therapy

Behaviour therapy is a major component of cognitive behaviour therapy (CBT), but

behaviour therapy focuses exclusively on increasing a person's level of activity and

pleasure in their life.

http://wiki.health.sa.gov.au/Country/1-Clinicians/Allied_Health/Professions/Social_Work/CHSA_Social_Work_Network?highlight=social+work+clinical+priorities

http://wiki.health.sa.gov.au/Country/1-Clinicians/Allied_Health/Professions/Social_Work/CHSA_Social_Work_Network?highlight=social+work+clinical+priorities

http://wiki.health.sa.gov.au/Country/3-Whole_of_Country_Services/Mental_Health


Unlike CBT, it does not focus on changing the person's beliefs and attitudes. Instead, it

focuses on encouraging people to undertake activities that are rewarding, pleasant or give

a sense of satisfaction, in an effort to reverse the patterns of avoidance, withdrawal and

inactivity that make depression worse.

Mindfulness Based Cognitive Therapy (MBCT)

MBCT is most often delivered in a group setting and involves learning a type of meditation

called 'mindfulness meditation'. This meditation teaches people to focus on the very

present moment, just noticing whatever they are experiencing, be it pleasant or unpleasant,

without trying to change it. At first, this approach is used to focus on physical sensations

(like breathing), but later it is used to focus on feelings and thoughts.

MBCT helps people to stop their mind wandering off into thoughts about the future or the

past, or trying to avoid unpleasant thoughts and feelings. This is thought to be helpful in

preventing depression from returning because it allows people to notice feelings of

sadness and negative thinking patterns early on, before they have become fixed and move

on.

Interventions reviewed include behaviour modification, motivational interviewing, cognitive

behavioural therapy, acceptance and commitment therapy, goal setting, guided self-

determination and coping skills.

A further model that has assisted people with diabetes from other cultures might be

Narrative Therapy. Narrative Therapy uses a storytelling type model and encourages the

person to separate themselves from the stressor (eg risk of hypoglycaemia). The stressor

is discussed as a separate entity but then linked to how ‘it’ impacts the person, resulting in

a new story (re-authoring).

Antidepressant medication

Health care professionals working with children, adolescents and adults with diabetes

should refer those with significant psychological problems to services or colleagues with

expertise in this area.

There is a wide range of antidepressant medication available. According to the Australian

Medicines Handbook, the different classes of antidepressants used are:

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs selectively inhibit the presynaptic reuptake of serotonin (5‑hydroxytryptamine, 5HT)

and are indicated in major depression, anxiety disorders (eg panic disorder, obsessive

compulsive disorder), bulimia nervosa and premenstrual dysphoric disorder.

Practice Points

SSRIs are less likely to alter ability to drive or operate machinery than tricyclic

antidepressants, increasing the SSRI dose may not provide further improvement, except

where some psychiatric comorbidities exist

Psychological interventions are generally acceptable to people with diabetes, increase their

satisfaction with treatment, and apply in children, adolescents, and adults with diabetes,

including those whose diabetes is poorly controlled.

Children, adolescents and adults with diabetes should be offered psychological interventions

to improve glycaemic control in the short and medium term.


in the management of OCD or eating disorders, the dose is often higher than that needed

for depression or anxiety disorders

in the management of anxiety disorders (eg panic disorder), half the normal starting dose

is recommended to begin with and using high maintenance doses should be avoided as

the activating effects may exacerbate anxiety

sodium concentration should be checked at baseline, and then soon after starting

treatment, especially if at risk for hyponatraemia (eg elderly)

increased suicidal thoughts and behaviour can occur soon after starting antidepressants,

particularly with some SSRIs in young people; monitor patients frequently and carefully

early in treatment

sexual dysfunction is an adverse effect that may affect compliance

generally well tolerated by most people

generally non-sedating

when ceasing SSRIs treatment, doses should be tapered off over several weeks to avoid

withdrawal symptoms (eg reduce the daily dose by half no faster than weekly).

SSRIs are a useful treatment in depressed patients with diabetes and may improve

glycaemic control.

Serotonin and Noradrenalin Reuptake Inhibitors (SNRIs)

Inhibit serotonin and noradrenaline reuptake and indicated in major depression.

Practice Points:

treatment with a Monoamine Oxidase Inhibitors (MAOI) or within 14 days of stopping a

MAOI is contraindicated due to the risk of serotonin toxicity

check blood pressure before starting treatment, and then check regularly

consider checking sodium concentration at baseline, and then soon after starting



particularly in young people; monitor patients frequently and carefully early in treatment.

Reversible Inhibitors of MonoAmine oxidase (RIMAs)

RIMAs competitively and reversibly inhibits monoamine oxidase (MAO), are relatively

selective for type A (MAO-A) and increase synaptic concentrations of serotonin,

noradrenaline and dopamine.

Practice Points:

may be less effective in treating more severe forms of depression than other

antidepressants

are helpful for people who are experiencing anxiety or sleeping difficulties

avoid use in acute confusional states


particularly in young people; monitor patients frequently and carefully early in treatment

low tyramine diet is not usually required below the maximum dose

relatively nontoxic in overdose, and less likely to cause sexual dysfunction than

nonselective MAOIs and SSRIs.


TriCyclic Antidepressants (TCAs)

TCAs inhibit reuptake of noradrenaline and serotonin into presynaptic terminals. Although

unrelated to the therapeutic effects of the TCAs, they also block cholinergic, histaminergic,

alpha1-adrenergic and serotonergic receptors.

Practice Points:

treatment with either moclobemide or a MAOI (or within 14 days of stopping a MAOI or

within 2 days of stopping moclobemide) is contraindicated due to the risk of serotonin

toxicity

check blood pressure (supine and standing) before and after starting treatment and after

each dose change

although adverse effects may appear early, therapeutic response is usually delayed by 2

weeks



use high-strength TCA tablets and capsules in maintenance treatment only, as overdose

with high-strength products is associated with increased mortality compared with low

strengths

TCAs are not a first-line therapy for children or adolescents; consider specialist referral

and obtain a baseline ECG in this population

TCAs are sometimes used as prophylaxis for migraine, but they are not first-line agents

give as a single dose at night to aid compliance; if insomnia develops or reduction in

daytime anxiety levels are desirable, give in 2 or 3 divided doses

alter dose in increments every 2-3 days as needed

withdraw TCAs slowly to avoid withdrawal symptoms effective, but have more harmful

side effects than newer drugs (ie SSRIs).

In a person with diabetes, TCAs may adversely affect metabolic control.

Noradrenaline-Serotonin Specific Antidepressants (NaSSAs)

Inhibit serotonin and noradrenaline reuptake and are indicated in major depression.

Practice Points:

check blood pressure before starting treatment, and then check regularly.

consider checking sodium concentration at baseline, and then soon after starting




helpful when there are problems with anxiety or sleeping

generally low in sexual side effects, but may cause weight gain.

Noradrenalin Reuptake Inhibitors (NARIs)

Inhibits noradrenaline reuptake; weakly inhibits serotonin reuptake and is indicated in major

depression.


Practice Points:


particularly in young people; monitor patients frequently and carefully early in treatment.

Monoamine Oxidase Inhibitors (MAOIs)

Nonselective MAOIs irreversibly inhibit monoamine oxidases A and B (MAO-A and

MAO‑B), increasing the synaptic concentrations of adrenaline, noradrenaline, dopamine

and serotonin. MAOIs are indicated in major depression (second-line) and in some anxiety

disorders, including phobic disorders and panic disorder (second-line).

Practice Points:

MAOIs are second-line antidepressants, and are usually reserved for use by

psychiatrists; they may be useful in atypical depression and psychotic depression; some

specialists use MAOIs for post-traumatic stress disorder



the potential for drug interactions persists for 2–3 weeks after stopping treatment

do not increase dose if patient becomes hypotensive; this is usually temporary, but the

drug may have to be stopped if hypotension persists.

For further information on antidepressant medications, please visit the Australian

Medicines Handbook website and the NPS Medicine Wise website.

When symptoms are directly due to depression, the person is likely to begin to improve

after 4–6 weeks of effective therapy. For example, although SSRIs commonly make sleep

difficulties or insomnia worse initially, they are associated with improved sleep 4–6 weeks

later.

Like any medication, the length of time a person needs to take antidepressants for

depends on how severe the illness is and how they respond to treatment. Some people

only need to take them for a short time (usually 6–12 months), while others may need to

take them over the long term.

Continued antidepressant treatment for one year after recovery may prevent recurrence of

depression in some patients with diabetes. Stopping antidepressant medication should only

be done gradually, on a medical practitioner / specialist physician recommendation and

under supervision.

Patient information

The following checklist is neither exhaustive nor exclusive. Health care professionals

should:

on those occasions where significant psychosocial problems are identified, explain the

link between these and poorer diabetes control. If possible, it is good practice to also give

suitable consumer information fact sheets.

advise patients where best to obtain further help, and facilitate this if appropriate.

be mindful of the burden caused by psychosocial problems when setting goals and

adjusting complex treatment regimens (typically children, adolescents and adults will be

less able to make substantial changes to their lives during difficult times).

https://amhonline.amh.net.au/

https://amhonline.amh.net.au/

http://www.nps.org.au/medicines/brain-and-nervous-system/antidepressant-medicines


People with diabetes (and/or their carers) should be encouraged to:

try to speak to their medical practitioner, specialist physician, endocrinologist or

credentialled diabetes educator if they feel they (or their child/ren) have significant

psychosocial issues.

be mindful that many psychosocial problems make diabetes self-care harder, and also

that many difficulties can be successfully treated with the right help.

Better Access initiative

The purpose of the Better Access initiative is to improve treatment and management of

mental illness within the community.

The Better Access initiative is increasing community access to mental health care

professionals and team-based mental health care, with medical practitioners or specialist

physicians encouraged to work more closely and collaboratively with psychiatrists, clinical

psychologists, registered psychologists, mental health accredited social workers and

occupational therapists.

Medicare rebates are available for up to ten individual and ten group allied mental health

services per calendar year to patients with an assessed mental disorder who are referred

by:

a medical practitioner or specialist physician managing the patient under a GP Mental

Health Treatment Plan; or

under a referred psychiatrist assessment and management plan; or

a psychiatrist or paediatrician.

Allied mental health services under this initiative include psychological assessment and

therapy services provided by clinical psychologists, and focussed psychological strategies

services provided by appropriately qualified medical practitioners or specialist physicians

and eligible psychologists, social workers and occupational therapists.

The Focussed Psychological Strategies (FPS) Services offered are:

Psycho-education (including motivational interviewing);

Cognitive Behavioural Therapy (including behavioural interventions and cognitive

interventions);

Relaxation strategies (including progressive muscle relaxation and controlled breathing);

Skills training (including problem-solving skills and training, anger management, social

skills training, communications training, stress management, and parent management);

Interpersonal Therapy (especially for depression); and

Narrative therapy for Aboriginal and Torres Strait Islander people

For further information on the Better Access initiative, visit the Australian Government -

Department of Health website.

http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba



Helpful Websites

Australian Psychological Society www.psychology.org.au

Australian Association of Social Workers www.aasw.asn.au

Eating Disorder Association of South Australia www.edasa.org.au

Beyond Blue www.beyondblue.org.au

Black Dog Institute www.blackdoginstitute.org.au

Headspace www.headspace.org.au

National Eating Disorder Collaboration www.nedc.com.au

Australian Government Better Access Initiative


Royal Australian and New Zealand College of Psychiatrists

https://www.ranzcp.org/Publications/Statements-Guidelines.aspx

http://www.psychology.org.au/

http://www.aasw.asn.au/

http://www.edasa.org.au/

http://www.beyondblue.org.au/

http://www.blackdoginstitute.org.au/

http://www.headspace.org.au/

http://www.nedc.com.au/


https://www.ranzcp.org/Publications/Statements-Guidelines.aspx


Appendix 1

Not a

problem Minor

problem Moderate problem

Somewhat serious problem

Serious problem

1. Not having clear and concrete goals for your diabetes care? 0 1 2 3 4

2. Feeling discouraged with your diabetes treatment plan? 0 1 2 3 4

3. Feeling scared when you think about living with diabetes? 0 1 2 3 4

4. Uncomfortable social situations related to your diabetes care (eg people telling you what to eat)?

0 1 2 3 4

5. Feelings of deprivation regarding food and meals? 0 1 2 3 4

6. Feeling depressed when you think about living with diabetes? 0 1 2 3 4

7. Not knowing if your mood or feelings are related to your diabetes?

0 1 2 3 4

8. Feeling overwhelmed by your diabetes? 0 1 2 3 4

9. Worrying about low blood sugar reactions? 0 1 2 3 4

10. Feeling angry when you think about living with diabetes? 0 1 2 3 4

11. Feeling constantly concerned about food and eating? 0 1 2 3 4

12. Worrying about the future and the possibility of serious complications?

0 1 2 3 4

13. Feelings of guilt or anxiety when you get off track with your diabetes management?

0 1 2 3 4

14. Not "accepting" your diabetes? 0 1 2 3 4

15. Feeling unsatisfied with your diabetes physician? 0 1 2 3 4

16. Feeling that diabetes is taking up too much of your mental and physical energy every day?

0 1 2 3 4

17. Feeling alone with your diabetes? 0 1 2 3 4

18. Feeling that your friends and family are not supportive of your diabetes management efforts?

0 1 2 3 4

19. Coping with complications of diabetes? 0 1 2 3 4

20. Feeling "burned out" by the constant effort needed to manage diabetes?

0 1 2 3 4

© 1999 Joslin Diabetes Center

Problem Areas In Diabetes (PAID) Questionnaire

INSTRUCTIONS: Which of the following diabetes issues are currently a problem for you?

Circle the number that gives the best answer for you. Please provide an answer for each question.


Appendix 2


Appendix 3


Appendix 4


Appendix 5


Appendix 6


Appendix 7


Appendix 8

FLACC SCALE

Categories Scoring

0 1 2

FACE No particular expression or smile.

Occasional grimace or frown, withdrawn,

disinterested.

Frequent to constant quivering.

LEGS Normal position or relaxed.

Uneasy, restless, tense.

Kicking or legs drawn up.

ACTIVITY Lying quietly, normal position moves easily.

Squirming, shifting back and forth,

tense.

Arched, rigid or jerking.

CRY No cry (awake or asleep).

Moans or whimpers; occasional complain.

Crying steadily, screams or sobs,

frequent complaints.

CONSOLABILITY Content, relaxed. Reassured by occasional touching,

hugging or being talked to,

distractible.

Difficulty to console or comfort.


References

1. Kovacs, B, Nicolucci, A, Holt, R, Willaing, I, Hermanns, N, Kalra, S, Wens, J, Pouwer, F, Skovlund, S, and Peyrot, M, 2013, Diabetes Attitudes, Wishes and Needs second study (DAWN2): Cross-national benchmarking indicators for family members living with people with diabetes, Diabetes Medicine, United Kingdom.

2. Craig, M, Twigg, S, Donaghue, K, Cheung, N, Cameron, F, Conn, J, Jenkins, A, and Silink, M, 2011, National evidence-based clinical care guidelines for type 1 diabetes in children, adolescents and adults Australian Government Department of Health and Ageing, Canberra.

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