Mental health readiness is important when making the transition from a multiple daily injection regimen to insulin pump therapy or hybrid closed loop systems. Diabetes-related distress strongly correlates with general emotional distress, disordered eating, fear of hypoglycemia, short-term and long-term diabetic complications, and increasing Hemoglobin A1C (HbA1C). Diabetes-related distress also demonstrates a negative correlation with reported self-care behaviors, and is recognized as an independent, major contributor to poor adherence (1). A recent meta-analysis reported patients with diabetes are 33% more likely to develop depression (2). Favorable and unfavorable distress-related outcomes in patients initiated on insulin pump and sensor therapy (3, 4, 5) suggests that there may be different methods of addressing and treating diabetes-related distress at the time of insulin pump therapy initiation. What are some strategies that we as endocrinology and diabetes specialists can employ to facilitate greater patient engagement and self-empowerment when starting insulin pump and sensor therapy?

What to Expect During Initial Encounter with Patient Seeking Insulin Pump Therapy

During the initial encounter, patients may express feeling overwhelmed, out-of-control and frustrated by frequent medications, self-monitoring of blood glucose and complex insulin dosing protocols. When the benchmarks of glycemic control, including HbA1C, are defined as “uncontrolled,” the patient may begin to express feelings of guilt over past mistakes and perceived failures. Finally, patients may share preconceived notions that insulin pump therapy will somehow reduce the need for self-directed patient engagement. This negative mindset or desire to disengage in self-care may undermine the patient’s intentions to improve diabetes care and may even result in maladaptive coping strategies that often revolve around stress eating or drinking. At first glance, the task to assess and facilitate mental health, well-being and readiness seems daunting, but a few simple strategies, once adopted, may better equip the patient to make a smooth and successful transition to insulin pump and sensor therapy.

Start Continuous Glucose Monitoring Systems (CGMS)

HbA1C and self-monitoring blood glucose (SMBG) do not measure glycemic extremes or variability, may fail to identify nocturnal hypoglycemia and post-prandial hyperglycemic trends, and cannot predict impending hypo- or hyperglycemia trends (6). Patients with Type 1 DM and any microvascular complications have significantly higher glycemic variability as demonstrated by Continuous Glucose Monitoring Systems (CGMS), but not from SMBG (7). Standardized CGMS ambulatory glucose profile reports include the percent of time that the interstitial glucose values are below 70mg/dL, between 70-180 mg/dL, and above 180 mg/dL. Emerging metrics include “Time In Range” (TIR) and “Glycemic Variability” (GV), recognizing CGMS as a sensitive tool to assess GV (8). A recent meta-analysis in patients with Type 2 DM demonstrated that CGMS use helped to increase the time spent in range and decrease the time spent in hypoglycemia and hyperglycemia ranges (9). Patient satisfaction revealed high satisfaction scores associated with CGMS use and can serve as a motivational tool for patients to adopt healthier lifestyles, modify high-risk eating habits, and receive real-time feedback on their choices (9). Therefore, CGMS use supports positive-reinforcement learning methods that are integral to successful management of diabetes, enhances patient engagement, builds effective self-care techniques while preventing hypoglycemia and serves as a beneficial tool prior to consideration of sensor-augmented insulin pump therapy.

Acknowledge and Celebrate Patient-Centered Victories in Glycemic Control

Establishing trust and engendering a collaborative relationship is a rewarding experience for both patients and specialist. A pleasant, low-stress environment often lends to the development of a healthy rapport and confidence between provider and patient. Utilizing positive reinforcement techniques, the provider can effectively motivate patients through consistent encouragement and support.   The adage of the “glass half full versus the glass half empty” was originally published in the early 1900s and described those who utilize the “glass half full” as the “invincibles who win by counting their blessings” (10). It may be useful to consider using a similar perspective when counseling patients in preparation for insulin pump therapy.

Congratulating the patient for small victories, such as setting reminders for insulin administration, or going to choosing water instead of sugar-concentrated drinks, is the first step to building this rapport and helps foster patient self-confidence. In a recent study, researchers observed that parental presence is important in enhancing a positive mindset for the adolescents with type 1 DM and helps achieve desired glycemic outcomes. (11). Another study reported significantly more adults with Type 2 DM who met guidelines for recommended physical activity recalled receiving praise and encouragement from their provider and that praising the behavior, rather than the outcome, was more constructive in sustaining self-care strategies (12). A study using the “grounded theory” approach to in-depth interviews described two distinct archetypes in Type 2 diabetes self-care, defined as “helpful” or “unhelpful” self-care practice techniques, suggesting an ideological but arbitrary boundary between these volitional traits. As specialists gain greater insight into their patient’s personality traits and tendencies, they may be better equipped to guide their patients towards productive and away from destructive self-management practices (13).

Refer to a Mental Health Specialist for Initial and Ongoing Support

Updated guidelines on selecting the correct candidate for insulin pump therapy recommends the specialist to perform a “structured assessment of a patient’s mental and psychological status, prior adherence with diabetes self-care measures, willingness and interest in trying the device and available for the required follow-up visits” (14). Given the abundance of medical literature that has established a strong and direct relationship between diabetes and depression and diabetes distress, a referral to a mental health specialist may be warranted in select cases. A growing body of literature now recognizes the value of integrating behavioral healthcare into the management of chronic medical conditions and has the potential to optimize health outcomes, improve quality of life, and decrease fragmentation of care for patients with diabetes (15, 16). Collaborative, multidisciplinary management enhances the comprehensive approach to developing diabetes self-care strategies and would be ideal when considering initiation of insulin pump and sensor therapy.

Conclusion

Patients with DM who are referred to endocrine specialists for insulin pump and sensor therapy require special attention to mental health well-being and readiness. Utilizing data driven CGMS technologies enhances patient insight into high-risk behaviors improves self-care strategies. The delicate balance between mind and body health has a direct impact on diabetes distress/depression, and should be addressed in a proactive fashion, while utilizing positive reinforcement techniques. Mental health specialty consultation may be indicated to assist patients with DM particularly when making the transition from multiple daily injections to insulin pump and sensor therapy.

So, when you are providing guidance to a patient interested in insulin pump and sensor therapy, the strategies listed here are opportunities to positively influence the mental framework of a that patient to increase self-awareness, to identify potential pitfalls, to adopt self-empowerment strategies, with the ultimate goal of maximizing mental and behavioral readiness when initiating insulin pump and sensor therapies.

References:

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