SARAH: Thank you for joining us for the QI Hub video series. I am joined by Dr. Liz Beverly who has joined us today to discuss psychosocial issues. Which Liz has done research her whole life, sort of, around psychosocial especially around diabetes. Welcome Dr. Beverly.

LIZ: Thanks so much for having me, Dr. Atkins.

SARAH: Alright. Okay. So psychosocial, um, issues...

LIZ: Yes. 

SARAH: ...is what we're gonna talk about today. So, and that's what Liz has done her research in. 

LIZ: That's right. 

SARAH: Dr. Beverly. Um, psychosocial issues are on diabetes. So this is my first question for you. 

LIZ: I'm ready. 

SARAH: Why do We call it psychosocial? 

LIZ: That's a great question. So it would be a lot easier if we just said mental health, but when you're talking about diabetes, we don't just, you know, take care of diabetes and isolation, you know? Psychosocial encompasses all factors. So it focuses on the mental health aspects, emotional wellbeing. It focuses on the environment. It focuses on the family and the friends. So it focuses on all of those aspects, which is why we say psychosocial. Also, I'm gonna tell you about some of these psychosocial things. Okay. And not all of the ones that affect people with diabetes are diagnostic, meaning that it's not a diagnosis. So that's why, another reason we say psychosocial. So we wanna factor in all the things that affect someone's emotional wellbeing and quality of life. But if you don't diagnose someone with a condition that's from the, the DSM five, we wanna say psychosocial. So it's all encompassing. 

SARAH:  Oh, I like that. 

LIZ: That was like a pretty long-winded version, but I hope that made sense. 

SARAH: I liked It, it was good. It was helpful for me. 

LIZ: I tried. 

SARAH: So that was very, I appreciate that. 

LIZ: Thank you. 

SARAH: So tell me what are the psychosocial issues? 

LIZ: There are several, okay. And so it's really important because we know psychosocial issues affect all people with diabetes. So I'm gonna go over the most common ones. Okay. So we have diabetes distress. We have depression. We have anxiety. And there are different types of anxiety disorders, but I'm just gonna say anxiety. And then we have disordered eating behaviors. Now of course we could also talk about, you know, life transitions and we can talk about social relationships and how they change and we can talk about cognitive issues, but I'm gonna really just focus on those main four. 

SARAH: I like that, that's, that's really helpful actually. Those are all really important too when I think about that, especially thinking about diabetes. So which one of those is the most common? 

LIZ: Another Great question. So the most common one isn't the one you would think it's diabetes distress and diabetes distress, which I'm gonna go into detail a little bit about. Is actually the reason why we say psychosocial. Because diabetes distress is the one condition that is not a diagnosis of a mental health condition. So you're not gonna find it in the DSM five.

SARAH: Oh, That's so interesting. Okay. 

LIZ: So what is diabetes distress? 

SARAH: Yeah. Like if it's not in the DSM five, what goes under that? Sure. 

LIZ: So diabetes distress was first, first came up about 20, 25 years ago. A bunch of behavioral psychologists came up with this. And they noticed that people with diabetes have a unique set of frustrations and worries. And it was different than depression. It was different from anxiety. And then they came up with diabetes distress. So what is it? Frustrations with self-care worries about, you know, developing future complications, right.

SARAH: That's a lot. Yeah. 

LIZ: It's a lot. And there are a lot of complications to worry about. It's concerns about the cost of your care and the quality of the care that you're gonna get. I mean, think about it, rising costs of medications. You know, rising costs, diabetes is the most expensive chronic health condition. Of course I'd worry About that. 

SARAH: Test strips, glucose monitors, CGMs. It all can be expensive. 

LIZ: Exactly. And then the last thing that involves distress is worrying about do you have enough support? Do you have enough support from family, from friends? And just kind of your greater community. So if you put all those things together, that's what people really worry about. So a person with diabetes, everyone who has diabetes has diabetes distress. The question is, how much stress do you have? 

SARAH: Oh, that's interesting. 

LIZ: And what you find is people will kind of vacillate and they'll go up and down throughout the course of their illness. And when it's really high, that's when you need to be concerned because that's when it affects certain things. 

SARAH: Like what? 

LIZ: Thank you for asking. 

SARAH: You're welcome.

LIZ: So what does diabetes distress affect? Well, we know that it decreases self-care behavior. 

SARAH: Yeah. That'd be huge. I think in diabetes. Yeah. 

LIZ: It increases your A1C, it increases your risk for microvascular and macrovascular complications. It decreases quality of life. It increases going, you know, ED visits, it increases hospitalization. And readmissions to the hospital. And it's also associated with increased risk for mortality. So we really need to be aware and care about diabetes distress. 

SARAH: That is so interesting. 

LIZ: Yes. 

SARAH: That's fantastic. So how might we identify someone who's experiencing maybe a higher level or a concerning level of diabetes distress? 

LIZ: Excellent question. So there are four times when people are more likely to experience high levels of distress. Diagnosis. 

SARAH: Okay. Oh yeah. 

LIZ: When there's a major change to someone's management plan. Right, so if you're originally on an oral medication and then you add insulin, that might be very distressing to some people. 

SARAH: Oh yeah. That's Huge. 

LIZ: Okay. If there is development of a complication, right? And then as with when we get stressed out, when there's a life transition. Imagine having diabetes with a major life transition. That's another time when there'll be higher levels of distress. So kind of paying attention to those four times would be When you should really kind of be looking out for signs and symptoms of, of distress. Now of course you can measure it. 

SARAH: Interesting. Okay. 

LIZ: As a researcher, I love measuring stuff, right. So there are surveys out there, there are validated tools. They have short screeners. There's one that's out there that's only two questions. And it just asks about, are you worried about developing complications? You know, it asks questions about do you just feel like you're not able to manage your diabetes or do all that you need to. And if you kind of score positive, meaning you have higher levels of distress on those. That indicates that you're experiencing higher distress. Right? So you can do something very simple where you could just in a medical visit say, how are you doing with your diabetes? Is there something you're really struggling with? And if somebody says, I'm really struggling with my medication, I'm really struggling. I can't figure out with my healthy eating. You know, that's an indicator and maybe you wanna screen or maybe you just wanna talk a little bit more about it. 

SARAH: That's awesome. That's so helpful. Alright, so what if we have someone who does identify as something is happening, they're in more distress than they were before their care, their self-care is decreasing. What do we do for that? Like what are treatment options? 

LIZ: So there are a handful of things that you can do. Now, the first thing that I'd recommend is any provider can just talk to the individual. Sometimes the solution is just talking to somebody. And if you talk to them, if they're having a frustration with self-care. 

SARAH: Yeah, I think that would be a lot. 

LIZ: Right? Think if you find out what that big issue with selfcare is, right? Maybe you can figure it out. Maybe it's a simple change with a medication. Maybe it's a simple change that you just need to figure something out. 

SARAH: Oh, that's good. 

LIZ: Maybe they're having problems with their CGM and they don't under, they don't understand. 

SARAH: Right. 

LIZ: Maybe they just have to move the site. You know, it could be that simple. Now maybe it's not that simple. So what do you do? So the first recommended treatment, the first line of therapy is actually diabetes, self-management, education and support. 

SARAH: Well...

LIZ: Right? 

SARAH: Perfect timing. 

LIZ: It's Perfect timing. So what they recommend is referring somebody to diabetes, self-management and support. And then wait, see how well they do with that? And they recommend like give somebody three months? If the distress doesn't seem to go down and if they don't seem to be making improvements, that's when maybe something more is there. And that's when recommend a referral to behavioral health professionals.
 
SARAH: Oh, it's fantastic. Alright. I actually really enjoyed this discussion today. 

LIZ: I did too. 

SARAH: I think it was fantastic. I learned a lot and I think I've heard the term diabetes distress used, but never really talked about the details of it. So thank you Dr. Beverly. 

LIZ: Thank you. 

SARAH: It's always a pleasure spending time with you.
 
LIZ: I feel honored to be here. Thank you. 

SARAH: Have a good rest of your day.