SARAH: Welcome back to the Qi Hub videos. I am joined today by Dr. Liz Beverly, and we are continuing our behavioral health series. So we have covered so far, diabetes distress, depression. Now we're going to talk about anxiety today. So Dr. Beverly, LIZ: Dr. Atkins... SARAH: Talk to me about anxiety. What is it? What is it? LIZ: Most of us are familiar with anxiety. Right? SARAH: Not me. LIZ: No? Let me explain it to you. SARAH: Thank you. LIZ: So, anxiety, like depression, it follows what the DSM five says, and it's a psychological condition that you can diagnose. It's persistent, intense worry, you know, and nervousness that lasts about six months. So experiencing persistent, intense worries for a period of, you know, a long time, you know, people estimate, you know, three to six months. That's anxiety. SARAH: Okay. I was gonna say fantastic. Not fantastic. LIZ: Yeah. It's like what we experience day-to-day. SARAH: Yeah. It's a lot. LIZ: It can be lot. SARAH: Yeah. Can be a lot. So how common is it in people with diabetes? LIZ: Great question. So there was another recent systematic review in meta-analysis that looked at prevalence rates of anxiety in people with diabetes from all of the research studies. And what they found is that the prevalence rate for anxiety disorders, 28% SARAH: That's even higher than depression. LIZ: That's even higher than depression. It's not as high as diabetes to stress, but 28%, that's almost 1 out of 3 people. SARAH: That's a lot. LIZ: It's very high. SARAH: So is it just one kind of anxiety or what, what types of anxiety might you see? LIZ: Great Question. It's not just one type of anxiety. So the most common is generalized anxiety disorder. You know, that's where it's general anxiety, so the persistent intense worry, right. But there are other things that affect people with diabetes. So someone can experience, you know, post-traumatic stress. And think about it this way. So if you have a person with diabetes who's experienced an extreme, you know, hypoglycemic event, right. SARAH: Terrifying. LIZ: It's terrifying. You know, so you can experience post-traumatic stress from that experience, right. And you can have continuous intense persistent worry over it. Similarly, if you had DKA or HHS, um, and were hospitalized for it. Those are other reasons. And HHS stands for hyperosmolar hyperglycemic state. Yeah. SARAH: Well done. LIZ: Thank you. Um, so you can experience post-traumatic stress if you experience, you know, a very severe acute complications from diabetes SARAH: ...and not uncommon LIZ: Right. SARAH: To have in diabetes. LIZ: Of course. You can also have, um, obsessive compulsive tendencies. So think about patients you've had, have you ever had somebody who only checked glucose on one finger or only injected insulin or even an injectable in one area of their stomach? Um, so, or only would put their CGM device on one arm and they wouldn't change and rotate sites. So there are things that you, you know, some individuals get so hyper-focused on something, um, and it can actually become something that affects their daily day-to-day activities and their ability to manage their diabetes. SARAH: Is there Screening tools we can use for anxiety or no? I don't know. LIZ: Yes. SARAH: Oh, okay. LIZ: And I also wanted to point out that another thing that's just unique to diabetes is people can have fear of hypoglycemia. And that relates to what you just said, because there is a screening tool just for fear of hypoglycemia. And you can find it online, and I'm also happy to send it to you. And if you, if someone is expressing fear of going low where they intentionally keep themselves high, you know, and they, you know, express to you that they're afraid of going low, they're afraid of physical activity for fear of going low, and they're also afraid of driving, that's another key indicator. Because they're afraid to drive because they don't want to go low for fear of an accident. So those are some key indicators for fear of hypoglycemia. But in terms of general screening, you know, you can ask the question, have you been, you know, have you been extremely nervous or worried you know, for a long time and does, does it affect your ability to manage your diabetes? That might be a simple one. Question screener. But many of you are probably familiar with the GAD-seven. The generalized anxiety disorder-seven. Seven questions screened for generalized anxiety disorder. Excellent. And what I would say, you know, the American Diabetes Association, the USPSTF, the United States Preventive Services Task Force. It's a mouthful. SARAH: It is. LIZ: It's, they all, we all recommend screening for anxiety annually. But at the same time, we're also recognizing you can't screen for everything and we ask you to screen for everything. So, you know, what I would say is look for some of the, the, um, symptoms and signs of anxiety. So if you're with somebody, they seem really tense, right. You know, they're, you know, they're kind of, you know, shoulders up. They seem really tense in their behaviors, you know, if, if there are, you know, like on the edge of their seat or if they just seem like any moment with whatever you say, they could lose it. Right? If, if they just seem extra fatigued, you know, because when you're, when you're really anxious and struggling and stressed out, it's exhausting. It's exhausting dealing with anxiety if you're very irritable, if you're talking about muscle tension. You know, some of those things are, you know, giveaways. And then the other thing, if you're having problems sleeping. SARAH: Yeah. It's Huge, right. LIZ: Is it possible that it's a sleep disorder? Sure. But anxiety interferes with someone's ability to sleep. Yeah. SARAH: So many things to think about. LIZ: Yeah. So you could just ask someone, are they feeling more anxious or more nervous or worried than they have been in the past? And that might be just like a one question you can ask rather than doing the GAD seven. SARAH: Okay. That's helpful. Yeah, that's helpful. Is there anything else we need to know about anxiety? LIZ: So, just like I've said in some of the other videos, why do we need to care about anxiety? Just like with depression, just like with diabetes distress, we have to care about anxiety. First of all, 28% of people with diabetes have it. SARAH: That's Huge. Right. LIZ: We know that it affects someone's ability to perform self-care, right. And largely diabetes is about self-care. It increases the A1C. Right? It affects quality of life. It's associated with both microvascular and macrovascular complications, SARAH: Diabetes, depression, right. Depression and diabetes. Right? LIZ: If you have anxiety, you're also more likely to have depression and diabetes distress, right? Because diabetes affects the emotions. It affects quality of life, like I mentioned. And then again, similar diabetes distress and depression anxiety for people with type two diabetes only is associated with mortality. SARAH: Uhhuh. Yeah. That's Interesting. LIZ: It's interesting. SARAH: So we know that it's a high percentage of patients who have diabetes that also have anxiety. Right. So what can we do about that? What strategies do we have to help to help with this? LIZ: So if you screen and the screen is positive, right? So of course you can do pharmacologic therapy, right. We know that that works. Yep. I'm not gonna discuss it because I don't do the drug part. That's Sarah. Um, but in terms of evidence-based treatments for anxiety, I'm gonna say cognitive behavioral therapy again. So by and large, cognitive behavioral therapy is just the most effective therapy for anything behavioral. With diabetes, but in general, um, for anybody. We also know with research, with anxiety, and this is specific with diabetes. Um, collaborative care. So in an ideal world... SARAH: That's interesting. LIZ: This isn't an ideal world. Every diabetes, everybody who's providing care for people with diabetes would have a team. And that team would consist of, you know, the, the primary care provider, maybe a specialist if needed, you know, but you would have your diabetes educator, you'd have a dietician at hand if needed, but then you'd have your behavioral health professional. In an ideal world. SARAH: That's fantastic. LIZ: And that has been shown if you have that team, that it can make a huge difference on people who have anxiety and diabetes, but it's also not realistic all across the country. SARAH: Sure, Sure. Yeah. So short, you had mentioned before exactly short on behavioral healthcare. LIZ: So in southeastern Ohio, that's tough. SARAH: Right, right. LIZ: You know, we're not gonna be able to do collaborative care. So if you're able to refer to behavioral health, right. And have someone do cognitive behavioral therapy or even mindfulness based therapy, that would be ideal. But let's say you can't refer Or someone's not willing to. What can you do? What we know is that physical activity is very helpful, for anxiety as well. You know, it's, think of it this way. Like when you're really stressed, right. You need to get that stress outta your system. And I always think of it as you're completing the stress cycle and anxiety can complete that stress cycle for you, right. SARAH: So exercise... LIZ: So exercise. SARAH: ...to get that anxiety out. LIZ: I would also say deep breathing. Deep Breathing. People talk about it all the time. Guess what? It works. It really works. So just if you take a moment and talk to your patients and show them different techniques for deep breathing, it really works. Even just mindfulness, you know, take a few moments outta your day, spend time in nature if you can. And I know, but for some people, finding a few minutes is hard. SARAH: Right, LIZ: Right. SARAH: Right. LIZ: We are working in a community where we have grandparents taking care of, you know, their grandchildren. Absolutely. And maybe working multiple jobs and doing everything they can just to put food on the table. And that's really, really hard. If there is just something that they can do where even practicing gratitude. At the end of the day, what were three things that made my day great. You know, and sometimes it's hard to find those three things. But you can train your brain, you know, to be more appreciative and focus on more positive things. It doesn't take away the negative things that you're happening in your life, but it can slowly retrain your brain, to focus on more positive things. And slowly over time, it can work on anxiety. Yeah. SARAH: All right. Thank you. I appreciate that. LIZ: Was That a deep breath, Sarah? SARAH: That was a deep breath. It was. Thank you for joining us for this QI Hub video series on, uh, behavioral health issues in our patients who have diabetes. And, um, this was our third topic in the series. We cover diabetes, distress, depression, anxiety, and our next episode will be on disordered eating behaviors. We hope you'll join us.