Harness Mental 'Strength' of Those With Diabetes to Tackle COVID-19

Miriam E. Tucker

September 08, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

There are several ways clinicians can help patients with diabetes cope with COVID-19 pandemic-related mental health issues, according to two psychologists who specialize in this aspect of care.

One noted that for people with diabetes there are "common concerns about day-to-day risks of managing diabetes as well as what might happen to them in the long run. When you layer on top of that issues related to COVID-19...people have even higher levels of worries, concerns, and dread for what might come in the future."

That psychologist, Korey Hood, PhD, of Stanford University, California, added: "Elevated stress, as well as anxiety and depression and other significant psychological issues, can make it really hard to take care of diabetes."

Hood and William Polonsky, PhD, of the Behavioral Diabetes Institute, San Diego, California, offered insight and practical advice to nonmental health professionals who care for patients with diabetes during the first day of the Diabetes Technology Society's Virtual International COVID-19 and Diabetes Summit, recently held online.

Hood said that financial hardships that have come with the pandemic — in terms of layoffs and loss of health insurance leading to or worsening chaotic home environments, food insecurity, and difficulty accessing medications and supplies — have only added to the burden for many of those with diabetes.

"Many of these individuals are feeling overwhelmed," he observed.

Polonsky also noted he and his colleagues have been seeing more depressive symptoms among people with diabetes. "The core cognitive feature of depression is about powerlessness, that bad things are happening to me and there's nothing can be done about it. It's more common in diabetes, and being in the middle of a pandemic, powerlessness is realistic."

To screen patients for depression, Polonsky recommends the Personal Health Questionnaire-9 (PHQ-9), a simple, free tool used to determine which patients need further mental health evaluation.

"While the PHQ-9 can't be used to diagnose depression, it can give you a pretty good sense — especially if you use the responses as a conversation opener with patients — about how and what they're struggling with," he added.

Hood also recommends physicians advise those with diabetes that they are already well placed to tackle the mental obstacles associated with COVID-19 because, unlike the general public, they are used to thinking about their health and planning ahead.

Opening Pandora's Box: Three Strategies That May Help

Polonsky acknowledges, "For busy health care providers who aren't mental health professionals, this is tough to talk about and deal with. You already have a waiting room full of people, and your visits are fairly limited in terms of time."

"For so many of our colleagues who are busy endocrinologists, primary care physicians, and nurse practitioners, there's a fear of talking about a lot of this emotional stuff, that it will be like opening a Pandora's box."

To help with that, Polonsky suggests three simple strategies clinicians can use.

1) Label and normalize. Patients experiencing pandemic-related anxiety should be told that what they're feeling is normal. "When you're seeing folks living with diabetes who tell you they're feeling more nervous and more freaked out and more scared about the future, or more overwhelmed or more depressed, the most useful thing you can do is to just give it a name — label it — and let them know they're not alone," Polonsky advised.  

Patients should be aware that their "fears and concerns are a normal response to an abnormal situation. It seems obvious, but there's power in saying it out loud…It's very common and understandable and reasonable."

This, Polonsky said, is the most important item if time is limited. If you have more time, there are a couple more points, as follows.

2) Talk about risk. Be direct and compassionate. Explain that although people with diabetes are not at increased risk of getting COVID-19, diabetes adds substantial morbidity and mortality if they do contract the virus.

Help patients to identify needs and safety precautions and separate necessary from unnecessary activities. It is also important to dispel any misinformation the patient may have picked up about COVID-19.

But at the same time, Polonsky advised, "be humble about the fact that our information is limited and that the data are mixed and confusing...The pace that we're learning new things is hard for all of us to keep up with...People may have elevated fears and disinformation."

3) Advise simple behavioral strategies. These include advising patients to follow their daily routine as much as possible, to reach out for the social support that they need, and to use physical activity as is possible, both as an aid in diabetes management and as an antidepressant. 

Patients With Diabetes Have Extra Strength

Physicians can also advise patients to perform "life-affirming" activities such as offering to help others, taking up new hobbies, and using the "sock drawer strategy" of finding ways to regain control of their activities. The latter involves using an activity — such as rearranging their sock drawers — to focus the mind.

Finally, some patients might benefit from limiting their daily exposure to the news. "'Panic scrolling' or 'doom scrolling' can make things worse," Polonsky stressed.

He also offered a positive spin on the "layering" of stressors related to diabetes plus COVID-19 that Hood had discussed.

"For many who have been working hard to manage diabetes over the course of years, they come into this pandemic with this strength of already thinking about the future to some degree, already being faced with and coping with this invisible concern that something bad might happen to them, meaning long-term complications."

"So they bring an ability to be willing to entertain these invisible risks in the future that regular folks aren't thinking about as much...I tell patients with diabetes they have an extra strength. I think it's important."

Hood has reported receiving research support from Dexcom and consultant fees from the Lilly Innovation Center. Polonsky has reported being a consultant for Abbott, Ascensia, Dexcom, Intarcia, Johnson & Johnson, Lilly, Livongo, Novo Nordisk, Roche, Sanofi, and Servier.

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