Depression as a Barrier to Diabetes Self-Care

By Christina Psaros, Ph.D
Department of Psychiatry

Depression is a medical illness characterized by pervasive feelings of sadness and/or the inability to experience pleasure or joy. Other symptoms of depression include feeling tired or without energy, reduced appetite, difficulty concentrating or making decisions, feelings of worthlessness or guilt, and hopelessness. People with diabetes have relatively high rates of depression, which can interfere with their ability to manage their diabetes.

Effectively managing diabetes requires a number of complex steps that may include regular meetings with a health care provider, monitoring of blood sugar, taking medications, and adhering to diet and physical activity guidelines. Depression may interfere with some or all of these behaviors. For example, difficulty concentrating may make it difficult to remember to take medications. Feeling tired or without energy can make it difficult to engage in physical activity or prepare healthful meals, while changes in appetite may it difficult to eat healthful foods. Feelings of hopelessness can make people feel like giving up rather than continue with self-care efforts.

Help is available! Research shows that psychotherapy can help alleviate symptoms of depression and help individuals with diabetes better adhere to their self-care regimen. Antidepressant medications can help. Talk to your Certified Diabetes Educator or primary healthcare provider if you are struggling with your diabetes self-care or if you think you may be depressed. They may refer you to the Massachusetts General Hospital Behavioral Medicine Program, which consists of a team of psychologists specializing in helping individuals with chronic illnesses like diabetes. If you are interested in making an appointment yourself, call the Psychiatry Access Line at 617-724-5600 or visit our website.


Diabetes and the Brain

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

I’m confident that I’m not the only one who frequently goes wild because I can’t remember where I put my T-Pass, or my wallet or gloves. I know I had them, but  can’t remember where I put them. Little memory lapses like these happen to everyone no matter  how old you are, and it’s  a pretty normal occurrence.  However, there is potentially another side that worries all of us:  When are these common lapses more than just that? When is it a signal that something is seriously wrong, like the beginning of dementia or Alzheimer’s disease?

Let me start by defining these two illnesses. Dementia is a syndrome caused by a group of brain disorders, Alzheimer’s disease being the most common cause. There is a loss of memory, language, and judgment which interferes with activities of daily living. Alzheimer’s is a fatal disease characterized by progressive worsening of these symptoms thought to be due to abnormal clumps of protein in the brain.

There have been studies conducted showing people with  Type 2 Diabetes have a higher risk of developing Alzheimer’s disease and  other types of dementia later in life, though the exact connection between these conditions isn’t well understood and is still being studied. (It still isn’t clear if people with Type 1 Diabetes have the same increased risk.) There are a few possibilities to consider, however. Type 2 Diabetes is a condition that means there is insulin resistance and insulin deficiency. Inadequate insulin means glucose can’t get from the bloodstream to the cells of the body that keep it healthy and working well. This can lead to damage of the blood vessels anywhere in the body, including the brain.  This damage may go on to cause a decrease in blood flow and even blockages of the vessels. This series of events can lead to vascular dementia.

Hypoglycemia (low blood sugar) has also been indicated as a possible cause of decreased mental functioning. Glucose is the main source of energy for the brain. When you have a low blood sugar, there isn’t enough available to fuel the brain which causes decreased brain function. There is also the possibility that frequent and prolonged hypoglycemia may cause some brain damage to the cerebral cortex (the outermost covering of the brain) and the hippocampus (area responsible for memory).

There is continuous medical investigation underway to better understand the disease process of both diabetes and dementia, and achieve cures for these diseases.  What I hope you will take away with this information is an understanding that there are steps that you can take to help stay as healthy with diabetes as is possible.  Good blood sugar control is the key.  Discuss your self-monitoring goals and HbA1C range with your health care provider at your next visit as these are different for every person.  Taking care of your health is the best holiday gift you can give to yourself and your loved ones.

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Diabetes Care Redesign: Spotlight on Collaboration in Patient Care

Mass General Hospital Shield

Partners HealthCare is currently undergoing a process of care redesign in several hospital areas and conditions to improve the value of care provided to our patients by increasing the quality of care while decreasing cost. Partners established several goals for Diabetes Care Redesign, including increasing the appropriate use of insulin. Here at Mass General, we used this as an opportunity to develop a population management strategy to start eligible patients on insulin earlier, incorporate behavioral and lifestyle approaches into the diabetes care plan at this important touch point in diabetes care, and minimize the side effects of insulin therapy (hypoglycemia and weight gain). To do this, we convened a multi-disciplinary group of stakeholders, including primary care doctors, endocrinologists, nurse practitioners, nurses, dietitians, psychologists, pharmacists, and others to develop best practices for insulin initiation and titration. Over the past year, the MGH Diabetes Care Redesign Team has been working to implement its innovative new insulin initiation process within several primary care practices. 

Three sites are currently piloting this program: Internal Medicine Associates (IMA), Women’s Health Associates, and MGH Back Bay. In the pilot, a nurse from each practice’s diabetes management team is designated as the Diabetes Champion. Using TopCare Diabetes, an online population management tool, the Champion identifies which patients in the practice are eligible for insulin initiation and titration and reviews the care plan with the primary care provider. The primary care provider, in turn, begins a discussion with the patient about starting insulin. Eligible patients are screened for potential medical or behavioral barriers to success (e.g. depression, lack of motivation, fear of needles). They are then enrolled in a coordinated care process that promotes rapid cycle change, in which the Diabetes Champion uses frequent phone- or visit-based contact to help the patient start and adjust the insulin dose instead of following the usual every 3 month visit pattern.

The entire process lasts several months but reduces the overall time to develop a successful treatment plan. It includes follow up visits with both providers and dietitians, and phone calls by the Diabetes Champion to provide between-visit support. The Diabetes Champion serves as the care manager overseeing every step of the process from the preparation phase, to the insulin start phase, to follow-up after successful insulin initiation. Many of the elements incorporated into this plan were adopted from those already being done informally at many practices. The new process creates a formal standard for providers to learn from best practices and incorporates new elements from other disciplines, specifically nutrition/lifestyle and behavior change, into routine diabetes care. It also meets many chronic disease management criteria required for Patient-Centered Medical Home certification.

At its heart, the Diabetes Care Redesign is all about collaboration; participants from various areas came together to share their knowledge and learn from others’ experience with caring for patients with diabetes.  The project has been led collaboratively by Deborah Wexler, MD of the MGH Diabetes Center and Stephanie Eisenstat, MD (Women’s Health Associates) blending specialist and primary care expertise; Elizabeth Geagan, MHA (Endocrine Division); and Gianna Wilkins, BS (Process Improvement). In particular, the nutrition curriculum was developed by an international expert in diabetes nutrition, Linda Delahanty, MS, RD, LDN working with Lillian Sonnenberg (DSc, RD) Assistant Director, Community Nutrition, and Melanie Pearsall (RD, CDE) of MGH Revere.  Other key contributors to the project include Barbara Chase (APRN, BC, ANP) of MGH Chelsea and Marcy Bergeron (RN, MS, ANP) of the Bulfinch Medical Group, who have spearheaded diabetes population management at their practices for many years; Anne Thorndike, MD of the MGH Division of General Internal Medicine, an expert in behavior change in obesity; and Mira Kautzky MD, a primary care physician in the IMA. We welcome patient participation and feedback in the process; please contact Deborah Wexler, MD if you are interested in learning more.

The Care Redesign process represents a paradigm shift – a fundamental change in how we approach diabetes care. Team-based care requires changes in practice organization, and developing workflow to fit within the Patient-Centered Medical Home model presents its own challenges. But it has been a gratifying experience working with so many people from a range of disciplines, learning from and incorporating their experience and expertise in this effort. It’s our hope that the work we have done with Diabetes Care Redesign will serve as a model for other departments undergoing their own care redesign efforts.


Test Prep

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

It’s always a little nerve-wracking when you have to undergo medical tests.  Instructions  can range from very simple, to vague, to extremely detailed.  Eat, don’t eat; take some medications but not others. It makes you feel like you’re on your way to an 8th grade spelling test, convinced of a low score before even getting out of bed.  Everybody feels like that, trust me, but sometimes there are certain extra steps ot test prep if you have Diabetes.  I want to review some of the more common examples, but please note this list isn’t exhaustive.  ALWAYS check with your health care provider for specialized directions.

The timing of tests, regardless of what it is, is crucial to your Diabetes self-care.  I always suggest to patients that they get the earliest appointment of the day whenever possible. You may have to check your blood sugar more frequently if you need to fast before the test, and may need to adjust both your long and rapid acting insulin as well as oral agents such as Glyburide, Glipizide, or Glimepiride (Sulfonylureas).  In fact, you may need to hold these medications all together.

Tests requiring the use of dye also may also mean medication schedule changes.  Patients taking Metformin or Glucophage are often asked to hold these medications for up to 48 hours before and after the test (dye used in tests is cleared by the kidneys, so use of Metformin/Glucophage may cause some changes in kidney function).  Again, careful blood sugar monitoring and dietary care will be extra important during this time.

The test that causes the greatest amount of confusion for my patients, however, is the colonoscopy.  The prep for this test can start several days prior and greatly impacts diet and medication schedules.  Also, insulin doses will need to be adjusted.  Therefore, it is imperative that you review your medication dosing schedule with your care team at least one month before your test. 

I also want to stress that it may take a couple of days to get your blood sugars back on track after the test.  Any disruption in your schedule may alter your blood sugar, so careful self-monitoring is key.  Taking a little bit of time to plan ahead can make these tests a little less stressful.  And, of course, I wish you luck with all of this!