What Is Cancer? What Causes Cancer?

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What Is Cancer? What Causes Cancer?

Cancer is a class of diseases characterized by out-of-control cell growth. There are over 100 different types of cancer, and each is classified by the type of cell that is initially affected.

Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue called tumors (except in the case of leukemia where cancer prohibits normal blood function by abnormal cell division in the blood stream). Tumors can grow and interfere with the digestive, nervous, and circulatory systems, and they can release hormones that alter body function. Tumors that stay in one spot and demonstrate limited growth are generally considered to be benign.

More dangerous, or malignant, tumors form when two things occur:

1. a cancerous cell manages to move throughout the body using the blood or lymph systems, destroying healthy tissue in a process called invasion
2. that cell manages to divide and grow, making new blood vessels to feed itself in a process called angiogenesis.

When a tumor successfully spreads to other parts of the body and grows, invading and destroying other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the result is a serious condition that is very difficult to treat.

How cancer spreads - scientists reported in Nature Communications (October 2012 issue) that they have discovered an important clue as to why cancer cells spread. It has something to do with their adhesion (stickiness) properties.

Certain molecular interactions between cells and the scaffolding that holds them in place (extracellular matrix) cause them to become unstuck at the original tumor site, they become dislodged, move on and then reattach themselves at a new site.

The researchers say this discovery is important because cancer mortality is mainly due to metastatic tumors, those that grow from cells that have traveled from their original site to another part of the body. Only 10% of cancer deaths are caused by the primary tumors.

The scientists, from the Massachusetts Institute of Technology, say that finding a way to stop cancer cells from sticking to new sites could interfere with metastatic disease, and halt the growth of secondary tumors.

In 2007, cancer claimed the lives of about 7.6 million people in the world. Physicians and researchers who specialize in the study, diagnosis, treatment, and prevention of cancer are called oncologists.

Malignant cells are more agile than non-malignant ones - scientists from the Physical Sciences-Oncology Centers, USA, reported in the journal Scientific Reports (April 2013 issue) that malignant cells are much “nimbler” than non-malignant ones. Malignant cells can pass more easily through smaller gaps, as well as applying a much greater force on their environment compared to other cells.

Professor Robert Austin and team created a new catalogue of the physical and chemical features of cancerous cells with over 100 scientists from 20 different centers across the United States.
The authors believe their catalogue will help oncologists detect cancerous cells in patients early on, thus preventing the spread of the disease to other parts of the body.

Prof. Austin said "By bringing together different types of experimental expertise to systematically compare metastatic and non-metastatic cells, we have advanced our knowledge of how metastasis occurs."

What causes cancer?

Cancer is ultimately the result of cells that uncontrollably grow and do not die. Normal cells in the body follow an orderly path of growth, division, and death. Programmed cell death is called apoptosis, and when this process breaks down, cancer begins to form. Unlike regular cells, cancer cells do not experience programmatic death and instead continue to grow and divide. This leads to a mass of abnormal cells that grows out of control.

What is cancer? - Video

A short, 3D, animated introduction to cancer. This was originally created by BioDigital Systems and used in the Stand Up 2 Cancer telethon.

Genes - the DNA type

Cells can experience uncontrolled growth if there are damages or mutations to DNA, and therefore, damage to the genes involved in cell division. Four key types of gene are responsible for the cell division process: oncogenes tell cells when to divide, tumor suppressor genes tell cells when not to divide, suicide genes control apoptosis and tell the cell to kill itself if something goes wrong, and DNA-repair genes instruct a cell to repair damaged DNA.

Cancer occurs when a cell's gene mutations make the cell unable to correct DNA damage and unable to commit suicide. Similarly, cancer is a result of mutations that inhibit oncogene and tumor suppressor gene function, leading to uncontrollable cell growth.

Carcinogens

Carcinogens are a class of substances that are directly responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos, arsenic, radiation such as gamma and x-rays, the sun, and compounds in car exhaust fumes are all examples of carcinogens. When our bodies are exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in the body. Theses free radicals damage cells and affect their ability to function normally.

Genes - the family type

Cancer can be the result of a genetic predisposition that is inherited from family members. It is possible to be born with certain genetic mutations or a fault in a gene that makes one statistically more likely to develop cancer later in life.

Other medical factors

As we age, there is an increase in the number of possible cancer-causing mutations in our DNA. This makes age an important risk factor for cancer. Several viruses have also been linked to cancer such as: human papillomavirus (a cause of cervical cancer), hepatitis B and C (causes of liver cancer), and Epstein-Barr virus (a cause of some childhood cancers). Human immunodeficiency virus (HIV) - and anything else that suppresses or weakens the immune system - inhibits the body's ability to fight infections and increases the chance of developing cancer.

What are the symptoms of cancer?

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. Some cancers can be felt or seen through the skin - a lump on the breast or testicle can be an indicator of cancer in those locations. Skin cancer (melanoma) is often noted by a change in a wart or mole on the skin. Some oral cancers present white patches inside the mouth or white spots on the tongue.

Other cancers have symptoms that are less physically apparent. Some brain tumors tend to present symptoms early in the disease as they affect important cognitive functions. Pancreas cancers are usually too small to cause symptoms until they cause pain by pushing against nearby nerves or interfere with liver function to cause a yellowing of the skin and eyes called jaundice. Symptoms also can be created as a tumor grows and pushes against organs and blood vessels. For example, colon cancers lead to symptoms such as constipation, diarrhea, and changes in stool size. Bladder or prostate cancers cause changes in bladder function such as more frequent or infrequent urination.

As cancer cells use the body's energy and interfere with normal hormone function, it is possible to present symptoms such as fever, fatigue, excessive sweating, anemia, and unexplained weight loss. However, these symptoms are common in several other maladies as well. For example, coughing and hoarseness can point to lung or throat cancer as well as several other conditions.

When cancer spreads, or metastasizes, additional symptoms can present themselves in the newly affected area. Swollen or enlarged lymph nodes are common and likely to be present early. If cancer spreads to the brain, patients may experience vertigo, headaches, or seizures. Spreading to the lungs may cause coughing and shortness of breath. In addition, the liver may become enlarged and cause jaundice and bones can become painful, brittle, and break easily. Symptoms of metastasis ultimately depend on the location to which the cancer has spread.

How is cancer classified?

There are five broad groups that are used to classify cancer.

1. Carcinomas are characterized by cells that cover internal and external parts of the body such as lung, breast, and colon cancer.
2. Sarcomas are characterized by cells that are located in bone, cartilage, fat, connective tissue, muscle, and other supportive tissues.
3. Lymphomas are cancers that begin in the lymph nodes and immune system tissues.
4. Leukemias are cancers that begin in the bone marrow and often accumulate in the bloodstream.
5. Adenomas are cancers that arise in the thyroid, the pituitary gland, the adrenal gland, and other glandular tissues.

Cancers are often referred to by terms that contain a prefix related to the cell type in which the cancer originated and a suffix such as -sarcoma, -carcinoma, or just -oma. Common prefixes include:

• Adeno- = gland
• Chondro- = cartilage
• Erythro- = red blood cell
• Hemangio- = blood vessels
• Hepato- = liver
• Lipo- = fat
• Lympho- = white blood cell
• Melano- = pigment cell
• Myelo- = bone marrow
• Myo- = muscle
• Osteo- = bone
• Uro- = bladder
• Retino- = eye
• Neuro- = brain

How is cancer diagnosed and staged?

Early detection of cancer can greatly improve the odds of successful treatment and survival. Physicians use information from symptoms and several other procedures to diagnose cancer. Imaging techniques such as X-rays, CT scans, MRI scans, PET scans, and ultrasound scans are used regularly in order to detect where a tumor is located and what organs may be affected by it. Doctors may also conduct an endoscopy, which is a procedure that uses a thin tube with a camera and light at one end, to look for abnormalities inside the body.

Extracting cancer cells and looking at them under a microscope is the only absolute way to diagnose cancer. This procedure is called a biopsy. Other types of molecular diagnostic tests are frequently employed as well. Physicians will analyze your body's sugars, fats, proteins, and DNA at the molecular level. For example, cancerous prostate cells release a higher level of a chemical called PSA (prostate-specific antigen) into the bloodstream that can be detected by a blood test. Molecular diagnostics, biopsies, and imaging techniques are all used together to diagnose cancer.

After a diagnosis is made, doctors find out how far the cancer has spread and determine the stage of the cancer. The stage determines which choices will be available for treatment and informs prognoses. The most common cancer staging method is called the TNM system. T (1-4) indicates the size and direct extent of the primary tumor, N (0-3) indicates the degree to which the cancer has spread to nearby lymph nodes, and M (0-1) indicates whether the cancer has metastasized to other organs in the body. A small tumor that has not spread to lymph nodes or distant organs may be staged as (T1, N0, M0), for example.
TNM descriptions then lead to a simpler categorization of stages, from 0 to 4, where lower numbers indicate that the cancer has spread less. While most Stage 1 tumors are curable, most Stage 4 tumors are inoperable or untreatable.

How is cancer treated?

Cancer treatment depends on the type of cancer, the stage of the cancer (how much it has spread), age, health status, and additional personal characteristics. There is no single treatment for cancer, and patients often receive a combination of therapies and palliative care. Treatments usually fall into one of the following categories: surgery, radiation, chemotherapy, immunotherapy, hormone therapy, or gene therapy.

Surgery

Surgery is the oldest known treatment for cancer. If a cancer has not metastasized, it is possible to completely cure a patient by surgically removing the cancer from the body. This is often seen in the removal of the prostate or a breast or testicle. After the disease has spread, however, it is nearly impossible to remove all of the cancer cells. Surgery may also be instrumental in helping to control symptoms such as bowel obstruction or spinal cord compression.

Innovations continue to be developed to aid the surgical process, such as the iKnife that "sniffs" out cancer. Currently, when a tumor is removed surgeons also take out a “margin” of healthy tissue to make sure no malignant cells are left behind. This usually means keeping the patients under general anesthetic for an extra 30 minutes while tissue samples are tested in the lab for “clear margins”. If there are no clear margins, the surgeon has to go back in and remove more tissue (if possible). Scientists from Imperial College London say the iKnife may remove the need for sending samples to the lab.

Radiation

Radiation treatment, also known as radiotherapy, destroys cancer by focusing high-energy rays on the cancer cells. This causes damage to the molecules that make up the cancer cells and leads them to commit suicide. Radiotherapy utilizes high-energy gamma-rays that are emitted from metals such as radium or high-energy x-rays that are created in a special machine. Early radiation treatments caused severe side-effects because the energy beams would damage normal, healthy tissue, but technologies have improved so that beams can be more accurately targeted. Radiotherapy is used as a standalone treatment to shrink a tumor or destroy cancer cells (including those associated with leukemia and lymphoma), and it is also used in combination with other cancer treatments.

Chemotherapy

Chemotherapy utilizes chemicals that interfere with the cell division process - damaging proteins or DNA - so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not necessarily just cancer cells), but normal cells usually can recover from any chemical-induced damage while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or metastasized because the medicines travel throughout the entire body. It is a necessary treatment for some forms of leukemia and lymphoma. Chemotherapy treatment occurs in cycles so the body has time to heal between doses. However, there are still common side effects such as hair loss, nausea, fatigue, and vomiting. Combination therapies often include multiple types of chemotherapy or chemotherapy combined with other treatment options.

Immunotherapy

Immunotherapy aims to get the body's immune system to fight the tumor. Local immunotherapy injects a treatment into an affected area, for example, to cause inflammation that causes a tumor to shrink. Systemic immunotherapy treats the whole body by administering an agent such as the protein interferon alpha that can shrink tumors. Immunotherapy can also be considered non-specific if it improves cancer-fighting abilities by stimulating the entire immune system, and it can be considered targeted if the treatment specifically tells the immune system to destroy cancer cells. These therapies are relatively young, but researchers have had success with treatments that introduce antibodies to the body that inhibit the growth of breast cancer cells. Bone marrow transplantation (hematopoetic stem cell transplantation) can also be considered immunotherapy because the donor's immune cells will often attack the tumor or cancer cells that are present in the host.

Hormone therapy

Several cancers have been linked to some types of hormones, most notably breast and prostate cancer. Hormone therapy is designed to alter hormone production in the body so that cancer cells stop growing or are killed completely. Breast cancer hormone therapies often focus on reducing estrogen levels (a common drug for this is tamoxifen) and prostate cancer hormone therapies often focus on reducing testosterone levels. In addition, some leukemia and lymphoma cases can be treated with the hormone cortisone.

Gene therapy

The goal of gene therapy is to replace damaged genes with ones that work to address a root cause of cancer: damage to DNA. For example, researchers are trying to replace the damaged gene that signals cells to stop dividing (the p53 gene) with a copy of a working gene. Other gene-based therapies focus on further damaging cancer cell DNA to the point where the cell commits suicide. Gene therapy is a very young field and has not yet resulted in any successful treatments.

Using cancer-specific immune system cells to treat cancer

Scientists from the RIKEN Research Centre for Allergy and Immunology in Yokohama, Japan, explained in the journal Cell Stem Cell (January 2013 issue) how they managed to make cancer-specific immune system cells from iPSCs (induced pluripotent stem cells) to destroy cancer cells.

The authors added that their study has shown that it is possible to clone versions of the patients’ own cells to enhance their immune system so that cancer cells could be destroyed naturally.

Hiroshi Kawamoto and team created cancer-specific killer T-lymphocytes from iPSCs. They started off with mature T-lymphocytes which were specific for a type of skin cancer and reprogrammed them into iPSCs with the help of “Yamanaka factors”. The iPSCs eventually turned into fully active, cancer-specific T-lymphocytes - in other words, cells that target and destroy cancer cells.

How can cancer be prevented?

Cancers that are closely linked to certain behaviors are the easiest to prevent. For example, choosing not to smoke tobacco or drink alcohol significantly lower the risk of several types of cancer - most notably lung, throat, mouth, and liver cancer. Even if you are a current tobacco user, quitting can still greatly reduce your chances of getting cancer.

Skin cancer can be prevented by staying in the shade, protecting yourself with a hat and shirt when in the sun, and using sunscreen. Diet is also an important part of cancer prevention since what we eat has been linked to the disease. Physicians recommend diets that are low in fat and rich in fresh fruits and vegetables and whole grains.

Certain vaccinations have been associated with the prevention of some cancers. For example, many women receive a vaccination for the human papillomavirus because of the virus's relationship with cervical cancer. Hepatitis B vaccines prevent the hepatitis B virus, which can cause liver cancer.

Some cancer prevention is based on systematic screening in order to detect small irregularities or tumors as early as possible even if there are no clear symptoms present. Breast self-examination, mammograms, testicular self-examination, and Pap smears are common screening methods for various cancers.

Researchers from Northwestern University Feinberg School of Medicine in Chicago reported in the journal Circulation that the 7 steps recommended for protection against heart disease can also reduce the risk of developing cancer,. They include being physically active, eating a healthy diet, controlling cholesterol, managing blood pressure, reducing blood sugar and not smoking.

Targeting cancers for new drug therapies

Researchers at The Institute of Cancer Research reported in the journal Nature Reviews Drug Discovery (January 2013 issue) that they have found a new way of rapidly prioritizing the best druggable targets online. They managed to identify 46 previously overlooked targets.

The researchers used the canSAR database together with a tool and were able to compare up to 500 drug targets in a matter of minutes. With this method, it is possible to analyze huge volumes of data to discover new drug targets, which can lead to the development of effective cancer medications.

The scientists analyzed 479 cancer genes to determine which ones were potential targets for medications. Their approach was effective - they found 46 new potentially “druggable” cancer proteins.

Not only will this approach lead to much more targeted cancer drugs, but also considerably cheaper ones, the authors added.

Cancer / Oncology news

Medical News Today is a leading resource for the latest news on cancer. You can find our cancer news section here.

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This what is cancer? information section was written by Peter Crosta for Medical News Today in September 2008 and was last updated in 19 July 2013. The contents may not be re-produced in any way without the permission of Medical News Today.

Business Day

Drug Shortages Persist in U.S., Harming Care

Chip Litherland for The New York Times

 

Jennifer Lacognata with her son Nic. Her doctor prescribed a liquid vitamin for her, but the manufacturer stopped making it.

By KATIE THOMAS

Published: November 16, 2012

Paul Davis, the chief of a rural ambulance squad in southern Ohio, was down to his last vial of morphine earlier this fall when a woman with a broken leg needed a ride to the hospital.

The trip was 30 minutes, and the patient was in pain. But because of a nationwide shortage, his morphine supply had dwindled from four doses to just one, presenting Mr. Davis with a stark quandary. Should he treat the woman, who was clearly suffering? Or should he save it for a patient who might need it more? 

In the end, he opted not to give her the morphine, a decision that haunts him still. “I just feel like I’m not doing my job,” said Mr. Davis, who is chief of the rescue squad in Vernon, Ohio. He has since refilled his supply. “I shouldn’t have to make those kinds of decisions.” 

From rural ambulance squads to prestigious hospitals, health care workers are struggling to keep vital medicines in stock because of a drug shortage crisis that is proving to be stubbornly difficult to fix. Rationing is just one example of the extraordinary lengths being taken to address the shortage, which health care workers say has ceased to be a temporary emergency and is now a fact of life. In desperation, they are resorting to treating patients with less effective alternative medicines and using expired drugs. The Cleveland Clinic has hired a pharmacist whose only job is to track down hard-to-find drugs. 

Caused largely by an array of manufacturing problems, the shortage has prompted Congressional hearings, a presidential order and pledges by generic drug makers to communicate better with federal regulators. 

The problem peaked in 2011, when a record 251 drugs were declared in short supply. This year, slightly more than 100 were placed on the list, and workers say the battle to keep pharmacy shelves stocked continues unabated. The list of hard-to-find medicines ranges from basic drugs like the heart medicine nitroglycerin to a lidocaine injection, which is used to numb tissue before surgery. 

A deadly meningitis outbreak caused by contamination at a large drug producer could worsen the situation, federal officials have warned. The Food and Drug Administration said that shortages of six drugs — medicines used during surgery and to treat conditions like congestive heart failure — could get worse after a big compounding pharmacy closed over concerns about drug safety. The pharmacy, Ameridose, shares some management with the New England Compounding Center, which is at the center of a meningitis outbreak that has claimed 33 lives. 

“When you can’t treat basic things — cardiac arrest, pain management, seizures — you’re in trouble,” said Dr. Carol Cunningham, the state medical director for the Ohio Department of Public Safety’s emergency services division. “When you only have five tools in your toolbox and three of them are gone, what do you do?” 

Dr. Margaret A. Hamburg, the F.D.A. commissioner, said in an interview this week that she was “guardedly optimistic” that the shortage crisis was abating. “I think there’s been an enormous amount of progress,” she said. “We’re seeing real change in the number of shortages that we’re able to recognize early.” More than 150 new shortages have been prevented this year, according to the agency.

But Erin Fox, who tracks supply levels for a broader range of drugs at the University of Utah, said once a drug became scarce, it tended to stay scarce. The university’s Drug Information Service was actively tracking 282 hard-to-find products by the end of the third quarter of this year, a record. 

“The shortages we have aren’t going away — they’re not resolving,” she said. “But the good news is we’re not piling more shortages on top.” 

In 2011, prompted by emotional pleas by cancer patients and others who said the drug shortage was threatening lives, President Obama issued an executive order requiring drug makers to notify the F.D.A. when a shortage appeared imminent. The agency also loosened some restrictions on importing drugs, and sped up approvals by other manufacturers to make certain medicines. 

A law passed this summer contains several provisions aimed at improving the situation, including expediting approval of new generic medicines and requiring the agency’s enforcement unit to better coordinate with its drug-shortage officials before it takes action against a manufacturer. 

Ralph G. Neas, the chief executive of the Generic Pharmaceutical Association, said fixing the drug shortage was complex and would take time, but was a top priority. “One shortage is one shortage too many,” he said. “One patient not getting a critical drug is one patient too many.” 

Federal drug officials trace much of the drug shortage crisis to delays at plants that make sterile injectable drugs, which account for about 80 percent of the scarce medicines. Nearly a third of the industry’s manufacturing capacity is not running because of plant closings or shutdowns to fix serious quality issues. Other shortages have been caused by supply disruptions of the raw ingredients used to make the drugs, or by manufacturers exiting the market. 

Some people have accused the F.D.A. of causing the shortages, saying overzealous enforcement and poor communication have led plants to close needlessly or to slow production. Others have cited economic factors, like market pressures and reimbursement policies that have set prices so low that some companies have stopped making certain drugs. Earlier this week, several Democratic members of Congress asked the Government Accountability Office to investigate whether the practices of so-called group purchasing organizations, which buy drugs on behalf of hospitals, was contributing to the shortage. 

Regardless of the cause, the drug shortage has forced the F.D.A. to make some tough choices, including allowing manufacturers to sell drugs that, if it were not for the crisis, most likely would have been recalled. Last year, for example, the agency allowed the manufacturer American Regent to sell a drug used during chemotherapy that was found to contain glass particles. Doctors and nurses were instructed to filter the drug, sodium thiosulfate, before administering it to patients. 

“If there wasn’t a shortage, we would never allow a company to continue marketing” in such cases, Dr. Sandra Kweder, deputy director of the F.D.A.’s office of new drugs, said. But “patients need it.” 

Dr. Hamburg said drug manufacturers had invested significantly in improving their facilities, upgrades that will ultimately help ease the crisis but that in the near term are making some shortages difficult to resolve. “It’s not going to happen overnight, but we’re in the midst of a period of really, very significant change that offers great promise for the future,” she said. 

Patients like Jennifer Lacognata, a mother of two in suburban Florida, say they cannot afford to wait. She has debilitating night blindness, skin lesions and other health problems because she cannot absorb vitamin A through her diet, a rare side effect of weight-loss surgery she had years ago. In 2011, her doctor prescribed Aquasol A, a liquid form of the vitamin, to be injected into her shoulder. 

But Hospira has temporarily stopped selling Aquasol A after it decided to move manufacturing of the product from an outside company to one of its plants. The company recently decided to abort the plan, citing complex technical challenges, and now has a deal with another company to begin making the vitamin.

Ms. Lacognata sued Hospira unsuccessfully to try to compel the company to make it again. 

A company spokeswoman said Hospira recognized the critical need for Aquasol A and was “working diligently” to return it to the market, but declined to provide an estimate of when. 

Given that the delays have stretched for more than a year, Ms. Lacognata said she was not holding her breath. “If they don’t get their act together and do this, they’re not going to suffer,” she said. “They’re still going to be making millions of dollars. It’s the little guy in the end who ends up with nothing.”

A version of this article appeared in print on November 17, 2012, on page A1 of the New York edition with the headline: Drug Shortages Persist in U.S., Harming Care.

A mad world: A diagnosis of mental illness is more common than ever – did psychiatrists create the problem, or just recognise it?

Aeon Magazine 

A mad world

A diagnosis of mental illness is more common than ever – did psychiatrists create the problem, or just recognise it?

by Joseph Pierre 

When a psychiatrist meets people at a party and reveals what he or she does for a living, two responses are typical. People either say, ‘I’d better be careful what I say around you,’ and then clam up, or they say, ‘I could talk to you for hours,’ and then launch into a litany of complaints and diagnostic questions, usually about one or another family member, in-law, co-worker, or other acquaintance. It seems that people are quick to acknowledge the ubiquity of those who might benefit from a psychiatrist’s attention, while expressing a deep reluctance ever to seek it out themselves.

That reluctance is understandable. Although most of us crave support, understanding, and human connection, we also worry that if we reveal our true selves, we’ll be judged, criticised, or rejected in some way. And even worse – perhaps calling upon antiquated myths – some worry that, if we were to reveal our inner selves to a psychiatrist, we might be labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket. Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.

As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications. Debates about psychiatric overdiagnosis have amplified in the wake of last year’s release of the newest edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-5), the so-called ‘bible of psychiatry’, with some particularly vocal critics coming from within the profession.

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It’s true that the scope of psychiatry has greatly expanded over the past century. A hundred years ago, the profession had a near-exclusive focus on the custodial care of severely ill asylum patients. Now, psychiatric practice includes the office-based management of the ‘worried well’. The advent of psychotherapy, starting with the arrival of Sigmund Freud’s psychoanalysis at the turn of the 20th century, drove the shift. The ability to treat less severe forms of psychopathology – such as anxiety and so-called adjustment disorders related to life stressors – with the talking cure has had profound effects on mental health care in the United States.

Early forms of psychotherapy paved the way for the Mental Hygiene Movement that lasted from about 1910 through the 1950s. This public health model rejected hard boundaries of mental illness in favour of a view that acknowledged the potential for some degree of mental disorder to exist in nearly everyone. Interventions were recommended not just within a psychiatrist’s office, but broadly within society at large; schools and other community settings were all involved in providing support and help.

A new abundance of ‘neurotic’ symptoms stemming from the trauma experienced by veterans of the First and Second World Wars reinforced a view that mental health and illness existed on a continuous spectrum. And by the time DSM was first published in 1952, psychiatrists were treating a much wider swath of the population than ever before. From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.

In the modern era, psychotherapy has steered away from traditional psychoanalysis in favour of more practical, shorter-term therapies: for instance, psychodynamic therapy explores unconscious conflicts and underlying distress on a weekly basis for as little as a few months’ duration, and goal-directed cognitive therapy uses behavioural techniques to correct disruptive distortions in thinking. These streamlined psychotherapeutic techniques have widened the potential consumer base for psychiatric intervention; they have also expanded the range of clinicians who can perform therapy to include not only psychiatrists, but primary care doctors, psychologists, social workers, and marriage and family therapists.

In a similar fashion, newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses. Such medications can be prescribed by a family physician or, in some states, a psychologist or nurse practitioner.

Viewed through the lens of the DSM, it is easy to see how extending psychiatry’s helping hand deeper into the population is often interpreted as evidence that psychiatrists think more and more people are mentally ill. Recent epidemiological studies based upon DSMcriteria have suggested that half or more of the US population will meet the threshold for mental disorder at some point in their lives. To many, the idea that it might be normal to have a mental illness sounds oxymoronic at best and conspiratorially threatening at worst. Yet the widening scope of psychiatry has been driven by a belief – on the parts of both mental health consumers and clinicians alike – that psychiatry can help with an increasingly large range of issues.

The diagnostic creep of psychiatry becomes more understandable by conceptualising mental illness, like most things in nature, on a continuum. Many forms of psychiatric disorder, such as schizophrenia or severe dementia, are so severe – that is to say, divergent from normality – that whether they represent illness is rarely debated. Other syndromes, such as generalised anxiety disorder, might more closely resemble what seems, to some, like normal worry. And patients might even complain of isolated symptoms such as insomnia or lack of energy that arise in the absence of any fully formed disorder. In this way, a continuous view of mental illness extends into areas that might actually be normal, but still detract from optimal, day-to-day function.

While a continuous view of mental illness probably reflects underlying reality, it inevitably results in grey areas where ‘caseness’ (whether someone does or does not have a mental disorder) must be decided based on judgment calls made by experienced clinicians. In psychiatry, those calls usually depend on whether a patient’s complaints are associated with significant distress or impaired functioning. Unlike medical disorders where morbidity is often determined by physical limitations or the threat of impending death, the distress and disruption of social functioning associated with mental illness can be fairly subjective. Even those on the softer, less severe end of the mental illness spectrum can experience considerable suffering and impairment. For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.

The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.

Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine. Few lament that nearly all of us, at some point in our lives, seek care from a physician and take all manner of medications, most without need of a prescription, for one physical ailment or another. If we can accept that it is completely normal to be medically sick, not only with transient conditions such as coughs and colds, but also chronic disorders such as farsightedness, lower back pain, high blood pressure or diabetes, why can’t we accept that it might also be normal to be psychiatrically ill at various points in our lives?

The answer seems to be that psychiatric disorders carry a much greater degree of stigma compared with medical conditions. People worry that psychiatrists think everyone is crazy because they make the mistake of equating any form of psychiatric illness with being crazy. But that’s like equating a cough with tuberculosis or lung cancer. To be less stigmatising, psychiatry must support a continuous model of mental health instead of maintaining an exclusive focus on the mental disorders that make up the DSM. If general medicine can work within a continuous view of physical health and illness, there is no reason why psychiatry can’t as well.

Criticism of this view comes from concern over the type of intervention offered at the healthier end of the continuum. If the scope of psychiatry widens, will psychiatric medications be vastly overprescribed, as is already claimed with stimulants such as methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)? This concern is well worth fretting over, given the uncertain effectiveness of medications for patients who don’t quite meet DSMcriteria. For example, a 2008 study by the Harvard psychologist Irving Kirsch published in PLOS Medicine found that, for milder forms of depression, antidepressants are often no better than placebos. Likewise, recent research suggests that children at risk of developing psychosis – but not diagnosable just yet – might benefit more from fish oil or psychotherapy than antipsychotic drugs.

In the end, implementing pharmacotherapy for a given condition requires solid evidence from peer-reviewed research studies. Although by definition the benefit of medications decreases at the healthier end of a mental health continuum (if one isn’t as sick, the degree of improvement will be less), we need not reject all pharmacotherapy at the healthier end of the spectrum, provided medications are safe and effective. Of course, medications aren’t candy – most have a long list of potential side effects ranging from trivial to life-threatening. There’s a reason such medications require a prescription from a physician and why many psychiatrists are sceptical of proposals to grant prescribing privileges to health practitioners with far less medical training.

People worry that psychiatrists think everyone is crazy because they make the mistake of equating any form of psychiatric illness with being crazy. But that’s like equating a cough with tuberculosis or lung cancer

Pharmacotherapy for healthier individuals is likely to increase in the future as safer medications are developed, just as happened after selective serotonin re-uptake inhibitors (SSRIs) supplanted tricyclic antidepressants (TCAs) during the 1990s. In turn, the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists. The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.

In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.

The good news for mental health consumers is that clinicians worth their mettle (and you might have to shop around to find one) don’t rely on the DSM as a bible in the way that many imagine, checking off symptoms like a computer might and trying to ‘shrink’ people into the confines of a diagnostic label. A good psychiatrist draws upon clinical experience to gain empathic understanding of each patient’s story, and then offers a tailored range of interventions to ease the suffering, whether it represents a disorder or is part of normal life.

19 March 2014

10 Subtle Signs of Bipolar Disorder and more...

10 Subtle Signs of Bipolar Disorder

Here are 10 signs that mood problems may be due to more than a quirky or difficult personality.

Bipolar symptoms

by Tammy Worth

When it comes to mental illness, there are plenty of stereotypes. But in reality, mood disorders can be hard to pinpoint—particularly in people with bipolar disorder symptoms.

"Chalking it up to moodiness or trouble at work or tiredness is pretty common," says Carrie Bearden, PhD, an associate professor in residence of psychiatry and behavioral sciences and psychology at the David Geffen School of Medical at UCLA. "The disorder varies in severity."

Here are 10 signs that mood problems may be due to more than a quirky or difficult personality. 

 

Great mood

Bipolar disorder is characterized by up-and-down episodes of mania and depression. During a manic phase, some patients can have a total break from reality.

But hypomania, which is also a symptom of the disorder, is a high-energy state in which a person feels exuberant but hasn’t lost his or her grip on reality.

"Hypomania can be a pretty enjoyable state, really," Dr. Bearden says. A person’s mood can be elevated, they may have a lot of energy and creativity, and they may experience euphoria. This is the "up" side of bipolar disorder that some people with the condition actually enjoy—while it lasts.

Inability to complete tasks

Having a house full of half-completed projects is a hallmark of bipolar disorder. People who can harness their energy when they are in a hypomanic phase can be really productive.

Those who can’t often go from task to task, planning grand, unrealistic projects that are never finished before moving on to something else.

"They can be quite distractible and may start a million things and never finish them," says Don Malone, MD, the director of the Center for Behavioral Health and chair of the Department of Psychiatry at Cleveland Clinic, in Ohio.

Depression

A person who is in a bipolar depressive state is going to look just like someone who has regular depression. "They have the same problems with energy, appetite, sleep, and focus as others who have 'plain old depression,'" Dr. Malone says.

Unfortunately, typical antidepressants alone don't work well in patients who are bipolar. They can even make people cycle more frequently, worsening their condition, or send someone into a break-with-reality episode.

"Antidepressants can be downright dangerous in people with bipolar because they can send them into mania," he says.

 

Irritability

Some people with this condition suffer from "mixed mania," where they experience symptoms of mania and depression at the same time. During this state, they are often extremely irritable.

Everyone has bad days, which is one reason this kind of bipolarity is much harder to recognize.

"We are all irritable or moody sometimes," Dr. Bearden says. "But in people with bipolar disorder it often becomes so severe that it interferes with their relationships—especially if the person is saying, 'I don’t know why I’m so irritable…I can’t control it.

 

Rapid speech

Some people are naturally talkative; we all know a motormouth or Chatty Cathy. But "pressured speech" is one of the most common symptoms of bipolar disorder.

This kind of speech occurs when someone is really not in a two-way conversation, Dr. Bearden says. The person will talk rapidly and if you try to speak, they will likely just talk over you.

They will also sometimes jump around to different topics. "What’s kind of a red flag is when it is atypical for the person to talk like this," doing it only when they are in a manic cycle but not at other times, she says.

 

 

Trouble at work

People with this disorder often have difficulty in the workplace because so many of their symptoms can interfere with their ability to show up for work, do their job, and interact productively with others.

In addition to having problems completing tasks, they may have difficulty sleeping, irritability, and an inflated ego during a manic phase, and depression at other times, which causes excessive sleeping and additional mood problems.

A lot of the workplace problems can be interpersonal ones, Dr. Malone says. 

 

 

Alcohol or drug abuse

About 50% of people with bipolar disorder also have a substance abuse problem, particularly alcohol use, Dr. Bearden says.

Many people will drink when they are in a manic phase to slow themselves down, and use alcohol to improve their mood when they are depressed.

 

Erratic behavior

When they are in a manic phase, people with bipolar disorder can have an inflated self-esteem.

"They feel grandiose and don't consider consequences; everything sounds good to them," Dr. Malone says.

Two of the most common types of behavior that can result from this are spending sprees and unusual sexual behavior. "I have had a number of patients who have had affairs who never would have done that if they weren't in a manic episode…during this episode they exhibited behavior that is not consistent with what they would do normally," he says. 

Sleep problems

People with this condition often have sleep problems. During a depression phase, they may sleep too much, and feel tired all the time.

During a manic phase, they may not sleep enough—but still never feel tired.

Even with just a few hours of sleep each night, they may feel great and have lots of energy.

Dr. Bearden says staying on a regular sleep schedule is one of the first things she recommends for bipolar patients. 

 

 

Flight of ideas

This symptom may be something that is hard to recognize, but it occurs frequently when someone is in a manic phase. People feel like their mind is racing and that they can't control or slow down their thoughts.

This flight of ideas sometimes occurs with pressured speech.

People with bipolar may not recognize or admit that their mind is racing out of control, says Dr. Bearden.

 

 Next: What Is Mania in Bipolar Disorder?

 

Bipolar disorder, sometimes called manic depression, affects nearly 6 million American adults, or about 2.5% of the adult population. Most people with this disorder swing from depression to manic states.

Understanding mania in bipolar disorder

Bipolar disorder, sometimes called manic depression, affects nearly 6 million American adults, or about 2.5% of the adult population. Most people with this disorder swing from depression to manic states.

Mania symptom: increased energy and mental activity

And who wouldn't like to experience this effect? One of the reasons some people with bipolar disorder don't like the mood-flattening medication is that they miss this perk, which almost always ends with a corresponding depression.

 

 

Mania symptom: exaggerated self-confidence

We're not saying this guy has mania, but some people with bipolar disorder do experience a heightened mood and super self-confidence during their "highs."

 

Mania symptom: aggressive behavior

Road rage can happen to anyone. However, sufferers of bipolar disorder will almost certainly experience excessive irritability or aggressive behavior during manic phases. 

 

Mania symptom: sleeplessness

We're not talking garden variety insomnia here. People with bipolar disorder sometimes experience a decreased need for sleep without fatigue during their manic phases, and feel much more productive. 

 

 

Mania symptom: grandiosity

It's fine to have high self-esteem, but during a manic phase people with bipolar disorder sometimes experience grandiose thoughts and an inflated sense of self-importance.

 

Mania symptom: racing speech and thoughts

You know how some people talk and think so fast you can hardly follow what they are saying? During a manic phase, people with bipolar disorder sometimes experience racing speech, racing thoughts, and a flight of ideas.

 

Mania symptom: dangerous behavior

Experts who deal with people with bipolar disorder tell incredible tales of risk-taking during the manic phase, from inappropriate sexual behavior to stealing cars. Impulsiveness, poor judgment, and distractibility are all hallmarks of mania.

 

Mania symptom: displaying reckless behavior

We're not implying here that this streaker is bipolar, but people with bipolar disorder can display reckless behavior during a manic phase. They lack the internal censor that tells healthy people how to curb their actions. 

 

Mania symptom: hallucinations

In the most severe cases, people with bipolar disorder can experience delusions and hallucinations.

Source: Depression and Bipolar Support Alliance

Depression in Bipolar Disorder

 

Depression symptom 1: extreme sadness

When sad spells come on for no reason and don't let up, it can be a sign of depression. People with bipolar disorder sometimes experience prolonged sadness or unexplained crying spells.

 

Depression symptom 2: changes in appetite

If you are not interested in foods you normally love or you are binge eating for emotional reasons, it can be a sign of depression. People with bipolar disorder sometimes experience significant changes in appetite and sleep patterns.

 

Depression symptom 3: anxiety

Worried for no reason? People with bipolar disorder sometimes experience irritability, anger, worry, agitation, and anxiety.

 

Depression symptom 4: indifference

People with bipolar disorder sometimes experience pessimism and indifference.

 

Depression symptom 5: low energy

Do you ever feel like you are running on empty, especially after a manic phase during which you felt as if you couldn't be stopped? People with bipolar disorder sometimes experience loss of energy. 

 

Depression symptom 6: feeling worthless

People with bipolar disorder sometimes experience feelings of guilt and worthlessness.

 

Depression symptom 7: indecisiveness

Ever feel like you can't make up your mind? People with bipolar disorder sometimes feel hobbled by indecision.  

 

Depression symptom 8: feeling disinterested

People with bipolar disorder sometimes experience inability to take pleasure in former interests.

 

Depression symptom 9: unexplained aches and pains

People with bipolar disorder sometimes experience unexplained aches and pains.

 

Depression symptom 10: feeling suicidal

People with bipolar disorder are more likely to commit suicide than the general population, and are more likely to consider killing themselves when depressed versus when they are in a manic phase. 

Definition

By Mayo Clinic staff
 
Bipolar disorder — sometimes called manic-depressive disorder — is associated with mood swings that range from the lows of depression to the highs of mania. When you become depressed, you may feel sad or hopeless and lose interest or pleasure in most activities. When your mood shifts in the other direction, you may feel euphoric and full of energy. Mood shifts may occur only a few times a year, or as often as several times a day. In some cases, bipolar disorder causes symptoms of depression and mania at the same time.

Although bipolar disorder is a disruptive, long-term condition, you can keep your moods in check by following a treatment plan. In most cases, bipolar disorder can be controlled with medications and psychological counseling (psychotherapy).

Symptoms

By Mayo Clinic staff Bipolar disorder is divided into several subtypes. Each has a different pattern of symptoms. Types of bipolar disorder include:

• Bipolar I disorder. Mood swings with bipolar I cause significant difficulty in your job, school or relationships. Manic episodes can be severe and dangerous.
• Bipolar II disorder. Bipolar II is less severe than bipolar I. You may have an elevated mood, irritability and some changes in your functioning, but generally you can carry on with your normal daily routine. Instead of full-blown mania, you have hypomania — a less severe form of mania. In bipolar II, periods of depression typically last longer than periods of hypomania.
• Cyclothymic disorder. Cyclothymic disorder, also known as cyclothymia, is a mild form of bipolar disorder. With cyclothymia, hypomania and depression can be disruptive, but the highs and lows are not as severe as they are with other types of bipolar disorder.

Bipolar disorder symptoms reflect a range of moods.

The exact symptoms of bipolar disorder vary from person to person. For some people, depression causes the most problems; for other people, manic symptoms are the main concern. Symptoms of depression and symptoms of mania or hypomania may also occur together. This is known as a mixed episode.
Manic phase of bipolar disorder
Signs and symptoms of the manic or hypomanic phase of bipolar disorder can include:

• Euphoria
• Inflated self-esteem
• Poor judgment
• Rapid speech
• Racing thoughts
• Aggressive behavior
• Agitation or irritation
• Increased physical activity
• Risky behavior
• Spending sprees or unwise financial choices
• Increased drive to perform or achieve goals
• Increased sex drive
• Decreased need for sleep
• Easily distracted
• Careless or dangerous use of drugs or alcohol
• Frequent absences from work or school
• Delusions or a break from reality (psychosis)
• Poor performance at work or school

Depressive phase of bipolar disorder
Signs and symptoms of the depressive phase of bipolar disorder can include:

• Sadness
• Hopelessness
• Suicidal thoughts or behavior
• Anxiety
• Guilt
• Sleep problems
• Low appetite or increased appetite
• Fatigue
• Loss of interest in activities once considered enjoyable
• Problems concentrating
• Irritability
• Chronic pain without a known cause
• Frequent absences from work or school
• Poor performance at work or school

Other signs and symptoms of bipolar disorder
Signs and symptoms of bipolar disorder can also include:

• Seasonal changes in mood. As with seasonal affective disorder (SAD), some people with bipolar disorder have moods that change with the seasons. Some people become manic or hypomanic in the spring or summer and then become depressed in the fall or winter. For other people, this cycle is reversed — they become depressed in the spring or summer and manic or hypomanic in the fall or winter.
• Rapid cycling bipolar disorder. Some people with bipolar disorder have rapid mood shifts. This is defined as having four or more mood swings within a single year. However, in some people mood shifts occur much more quickly, sometimes within just hours.
• Psychosis. Severe episodes of either mania or depression may result in psychosis, a detachment from reality. Symptoms of psychosis may include false but strongly held beliefs (delusions) and hearing or seeing things that aren't there (hallucinations).

Symptoms in children and adolescents

Instead of clear-cut depression and mania or hypomania, the most prominent signs of bipolar disorder in children and adolescents can include explosive temper, rapid mood shifts, reckless behavior and aggression. In some cases, these shifts occur within hours or less — for example, a child may have intense periods of giddiness and silliness,
long bouts of crying and outbursts of explosive anger all in one day.

When to see a doctor

If you have any symptoms of depression or mania, see your doctor or mental health provider. Bipolar disorder doesn't get better on its own. Getting treatment from a mental health provider with experience in bipolar disorder can help you get your symptoms under control.
Many people with bipolar disorder don't get the treatment they need. Despite the mood extremes, people with bipolar disorder often don't recognize how much their emotional instability disrupts their lives and the lives of their loved ones. And if you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. However, this euphoria is always followed by an emotional crash that can leave you depressed, worn out — and perhaps in financial, legal or relationship trouble.

If you're reluctant to seek treatment, confide in a friend or loved one, a health care professional, a faith leader or someone else you trust. They may be able to help you take the first steps to successful treatment.

If you have suicidal thoughts

Suicidal thoughts and behavior are common among people with bipolar disorder. If you or someone you know is having suicidal thoughts, get help right away. Here are some steps you can take:

• Contact a family member or friend.
• Seek help from your doctor, a mental health provider or other health care professional.
• Call a suicide hot line number — in the United States, you can reach the toll-free, 24-hour hot line of the National Suicide Prevention Lifeline at 800-273-8255 to talk to a trained counselor.
• Contact a minister, spiritual leader or someone in your faith community.

When to get emergency help
If you think you may hurt yourself or attempt suicide, call 911 or your local emergency number immediately. If you have a loved one who has harmed himself or herself, or is seriously considering doing so, make sure someone stays with that person. Take him or her to the hospital or call for emergency help.

Causes

By Mayo Clinic staff The exact cause of bipolar disorder is unknown, but several factors seem to be involved in causing and triggering bipolar episodes:

• Biological differences. People with bipolar disorder appear to have physical changes in their brains. The significance of these changes is still uncertain but may eventually help pinpoint causes.
• Neurotransmitters. An imbalance in naturally occurring brain chemicals called neurotransmitters seems to play a significant role in bipolar disorder and other mood disorders.
• Hormones. Imbalanced hormones may be involved in causing or triggering bipolar disorder.
• Inherited traits. Bipolar disorder is more common in people who have a blood relative (such as a sibling or parent) with the condition. Researchers are trying to find genes that may be involved in causing bipolar disorder.
• Environment. Stress, abuse, significant loss or other traumatic experiences may play a role in bipolar disorder.

Risk factors Symptoms

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• Slide show: How genetic disorders are inherited
• Self-esteem: 4 steps to feel better about yourself

National recommendations: Psychosocial Management of Diabetes

US National Library of Medicine
National Institutes of Health
 

National recommendations: Psychosocial management of diabetes in India

Sanjay Kalra, G. R. Sridhar,¹ Yatan Pal Singh Balhara,² Rakesh Kumar Sahay,³ Ganapathy Bantwal,⁴ Manash P. Baruah,⁵ Mathew John,⁶ Ambika Gopalkrishnan Unnikrishnan,⁷ K. Madhu,⁸ Komal Verma,⁹ Aswathy Sreedevi,¹⁰ Rishi Shukla,¹¹ and K. M. Prasanna Kumar¹

Abstract

Although several evidence-based guidelines for managing diabetes are available, few, if any, focus on the psychosocial aspects of this challenging condition. It is increasingly evident that psychosocial treatment is integral to a holistic approach of managing diabetes; it forms the key to realizing appropriate biomedical outcomes. Dearth of attention is as much due to lack of awareness as due to lack of guidelines. This lacuna results in diversity among the standards of clinical practice, which, in India, is also due to the size and complexity of psychosocial care itself. This article aims to highlight evidence- and experience-based Indian guidelines for the psychosocial management of diabetes. A systemic literature was conducted for peer-reviewed studies and publications covering psychosocial aspects in diabetes. Recommendations are classified into three domains: General, psychological and social, and graded by the weight they should have in clinical practice and by the degree of support from the literature. Ninety-four recommendations of varying strength are made to help professionals identify the psychosocial interventions needed to support patients and their families and explore their role in devising support strategies. They also aid in developing core skills needed for effective diabetes management. These recommendations provide practical guidelines to fulfill unmet needs in diabetes management, and help achieve a qualitative improvement in the way physicians manage patients. The guidelines, while maintaining an India-specific character, have global relevance, which is bound to grow as the diabetes pandemic throws up new challenges.

Keywords: Diabetes, India, management, psychosocial, recommendations

INTRODUCTION

As India moves from a high prevalence of acute to chronic disease, type 2 diabetes mellitus (T2DM) is becoming a major health concern. Diabetes has been known in India since ancient times and finds mention in the well-referenced samhita texts, Charaka Samhita and Susruta Samhita. Together with Atharva Veda, they are among the oldest texts to describe and classify diabetes.[1] The Susruta Samhita treats diabetes in great detail and lists numerous symptoms that are included in the classical symptomology of diabetes, viz. excess urination, “sweet” urine, weight loss, impotence, and ulcers. Even the differences between hereditary, early-manifesting “thin” diabetes and later-onset, food-related “fat” diabetes was identified, which evidently correspond to modern types 1 and 2. Both Charaka Samhita and Susruta Samhita recognize unbalanced nutrition and lack of sufficient physical activity as probable causes of diabetes, and recommend dietary control and regular exercise for managing diabetes (in addition to treatment options from the ayurvedic pharmacopeia).[1]

Since the introduction of insulin for management of diabetes in 1922 by Dr. Frederick Banting, several important breakthroughs have been seen in diabetes management strategies.[2] (Nonetheless, successful diabetes management has remained elusive even with a wide variety of therapeutic options now accessible to clinical practitioners.[3]) Certainly, a purely pharmacological approach to successfully contain and, perhaps, even reverse the effects of diabetes, is insufficient; factors beyond the pale of pharmacological interventions, which dwell upon the holistic approach of supporting the patient psychologically, socially, and emotionally through the treatment process must be given due consideration.

The importance of emotional issues in diabetes was first noted over 300 years ago in 1674 by Thomas Willis, who claimed that diabetes was caused by “extreme sorrow.”[4] It has been emphasized that there is more to diabetes than just glucose control, and emotions play an important role in diabetes.[5] The emotional and psychological needs of people living with diabetes are complex. Indian diabetes patients have one of the lowest levels of psychological well-being on the World Health Organization-5 (WHO-5) Well-being Index, which is similar to the global trends. Indian patients also showed a significantly higher perception of burden of social and personal distress associated with diabetes.[3] These not only impact the patients’ ability to adhere to therapy but also their psychosocial well-being.

Acknowledging that psychosocial factors play an important role in diabetes therapy, several national and international stakeholders have included guidelines seeking to incorporate psychosocial management of diabetes as a part of standard clinical practice. The American Association of Clinical Endocrinologists (AACE) not only makes specific mention of psychosocial impact in evaluating therapeutic options but also gives independent recommendations for the treatment of comorbidities like depression, inclusion of team care and counseling. The AACE recommends using cultural and faith-based aspects of therapy during counseling.[6] The Scottish Intercollegiate Guidelines Network (SIGN)[7] for the management of diabetes also introduced psychosocial management in 2010. Similar trends are seen in many national guidelines in Europe and in the American Diabetes Association (ADA).[3,8]

Similarly, the global guideline for type 2 diabetes by the International Diabetes Federation (IDF) devotes an entire chapter to recommend standards of minimal, routine and comprehensive care for psychological management. The IDF clinical guidelines task force states in its rationale that “psychosocial factors are relevant to nearly all aspects of diabetes management.” In its recommendations for psychosocial care, the IDF recommends the inclusion of a mental health specialist in the multidisciplinary team for diabetes and indicates the need for counseling the person with diabetes in the context of on-going diabetes education and care. Particularly important is the recognition that signs of cognitive, emotional, behavioral and social problems, which may be complicating self-care, be considered a part of minimal care required for diabetes patients.[9] The International Society for Paediatric and Adolescent Diabetes (ISPAD) guideline also devotes a chapter on psychological care of children and adolescents with diabetes. The ISPAD Consensus Guidelines 2000 stated that “psychosocial factors are the most important influences affecting the care and management of diabetes,” and went on to make the following three general recommendations:[10]

• Social workers and psychologists should be part of the interdisciplinary health care team.
• Overt psychological problems in young persons or family members should receive support from the diabetes care team and expert attention from mental health professionals.
• The diabetes care team should receive training in the recognition, identification and provision of information and counseling on psychosocial problems related to diabetes.

Despite the availability of international guidelines and multiple treatment options globally, the management of diabetes in clinical practice remains sub-par.[11] The available guidelines in most cases do not have cross-cultural applications and contribute little to the local understanding of diabetes. In the Indian context, less than one-third of the doctors reported using clinical guidelines in their practice. The biggest hindrances to the use of these guidelines locally are poor knowledge and the non-applicability of western guidelines in the Indian context.[12] The linguistic, social, cultural, economic, and ethnic heterogeneity of the Indian population and the enormous scale of the diabetes epidemic in India suggest the development of India-specific guidelines for psychosocial management, forged specifically for our sociocultural context. Both in terms of variety and in terms of the scale of challenges, the Indian diabetes landscape is unique and warrants the creation of country-specific guidelines, sensitive to our needs and limitations and based on our sociocultural strengths and resources.

PSYCHOSOCIAL FACTORS INFLUENCING DIABETES MANAGEMENT IN INDIA

Psychosocial factors are important modulators of the success of treatment and long-term prognosis of diabetes. At the same time, optimal diabetes management is associated with considerable physical, social, and psychological well-being. As the diabetes patient is at the core of executing the care process in diabetes, the outcomes of the care process and its effect on long-term prognosis depend on the social, cultural, familial and professional context that informs the patients’ psychosocial condition.[13] There is growing awareness of the importance of these factors both among providers and among patients. At the first Oxford International Diabetes Summit (2002), virtually all (98%) the participants representing medicine, politics, nursing and patient groups called for psychosocial aspects of diabetes to be included in national guidelines.[14]

Nonetheless, the number of patients receiving psychosocial care as a part of their therapy is not commensurate with its impact. It has been shown that as many as 41% of the patients had poor psychological well-being. These psychological problems were recognized by providers as affecting patients’ diabetes self-care. However, despite this, only about 10% of these patients received psychological care.[14] Additionally, there is a paucity of accurate, usable data to understand the exact impact of psychosocial factors on care, as studies investigating the relationships among psychological and social variables and diabetes outcomes are generally cross-sectional in nature, rather than longitudinal, and often fail to report pre-diagnosis baseline data.[13] In India, many of the psychosocial problems differ considerably from those encountered in the western society.[15] Some of the prominent factors that impact diabetes management, in the Indian context, by modifying acceptance of modern health care, include economic and cultural factors and traditional medicine, which are discussed below.[16]

Economic factors

In India, with about 25% of the population living under poverty and 41.6% of the population living under 1.25$ a day, cost of a therapeutic option/economic burden diabetes has a major impact on diabetes care. The direct medical cost to identify one subject with glucose intolerance is INR 5278.[17] The cost of insulin amounts to 350.00 USD (16,000 Indian Rupees) per year, while medication for non-insulin-requiring patients costs about 70.00 USD per year.[18] Out-of-pocket payments for hospital treatment for diabetes claim 17% of the annual household expenditure in poor households, a majority of whom finance the expense through borrowing.[19] Poor households can spend up to 25% of their annual household income on diabetes care.[9]

Cultural and religious factors

Health behaviors are guided by continuous interactions of intrapersonal factors with the cultural environment.[20] Endemic cultural practices and attitudes that hamper appropriate health-related behavior make diabetes management in India challenging. The low rate of literacy contributes to poor diabetes care. Lower levels of literacy in the country are associated with lower awareness of diabetes and its complications,[21] and are reported to be significantly associated with higher glycated hemoglobin (HbA1c) levels.[22] It has also been suggested that specific myths about diabetes management can modulate the success of diabetes management.[9] Another example where cultural practices impact diabetes management is the relative difference in diabetes control of both genders. It has been reported that there is significantly lesser awareness of diabetes and poorer rates of compliance to therapy among housewives. Unfortunately, in one study it was reported that all the patients who were non-complaint due to financial constraints were women. This is despite the fact that women are known to have a higher rate of prevalence compared with men.[23]

Traditional and alternative medicine

India has a wide range of alternative healthcare systems, which are patronized by the general population. A considerable number of patients (14%) still utilize the indigenous forms of medicine and one-third prefers non-allopathic medical systems for treatment. The reasons given for preferring traditional medicines were safety (31%), cost (30%), effectiveness (25%) and availability (11%).[24] Furthermore, contribution of ancient Indian medicine to patient-centered care (PCC), as evidence by the Quadruple of Atreya, has been highlighted earlier.[25] However, critics often point to the lack of acceptance of PCC in traditional, oriented culture, which follows a system of eminence and age-based hierarchy. On the other hand, there have been calls for testing the safety of traditional therapies,[26] in light of questions on their safety, due to incidents of death as a result of administration of folk remedies for diabetes.[27]

Given the scale of challenges that are bound to present themselves as the Indian diabetes management scenario evolves, it behooves a country taking India's growth trajectory to gear up to face these challenges head-on. As noted earlier, the western guidelines have limited applicability in everyday clinical practice in India, but might serve as valuable guides to help frame our own national guidelines. India has a linguistically, culturally, religion-wise and socioeconomically heterogeneous population. Furthermore, it is a developing country and the limited resources severely restrict the availability of resources for diabetes care.[9] At the same time, its strong sociocultural ethos can be utilized to manage diabetes more efficiently at the individual, family, and community level. Given these challenges and strengths, our objective is to frame a clinical practice guideline (CPG) for the psychosocial management of diabetes, sensitive to and appropriate for, the Indian context. We hope that these guidelines will find acceptance across the world.

METHODOLOGY

The recommendations have been developed in response to the need for national guidelines for psychosocial management of diabetes in India. The target is all diabetes care professionals in India. The current recommendation has been developed in accordance to the AACE protocol for CPG production [Table 1].[6] Recommendations are assigned evidence level (EL) ratings on the basis of the quality of supporting evidence, all of which have also been rated for strength [Table 2]. A thorough search of the literature pertaining to each of the classes of recommendations is presented, which are pertinent to the Indian clinical context of diabetes. A total of 94 recommendations are made. The guidelines have been written by a core group of 11 authors and reviewed by a committee of six multidisciplinary experts from India. It has been refereed by a South Asian panel of 10 reviewers.

Table 1

Evidence rating according to American association of clinical endocrinologists protocol 2010[6]

Table 2

Recommendation grading according to the American association of clinical endocrinologists protocol 2010[6]

The recommendations incorporate the subjectivity of a complex clinical scenario with the objectivity of evidence-based medicine. As individual patient circumstances and psychosocial environments differ, the ultimate clinical management should be based on what is in the best interest of the individual patient and what is appropriate for the local scenario, involving shared decision making by patient and clinician.

RECOMMENDATIONS ON PSYCHOSOCIAL ASSESSMENT AND MANAGEMENT

While the current guidelines are intended as a comprehensive picture of psychosocial management in clinical practice, to make their application and utility more topical, they have been grouped based on their utility in different clinical contexts. This arrangement lends itself to contextualizing the recommendations in a given clinical scenario more accurately, while still remaining a part of the larger picture, to present a flavor of the guiding principles of psychosocial management. Current recommendations have been broadly presented in three clinical domains [Table 3]:

Table 3

Recommendations for psychosocial management of diabetes in India

• General issues
• Psychological assessment and management
• Social assessment and management.

GENERAL ISSUES

Improving awareness/skills of healthcare professionals

• Recommendation 1: Healthcare professionals should receive at least informal and, preferably, formal training in psychological interventions involving coping and counseling for improved patient satisfaction and therapeutic outcomes[28] (Grade A; EL 1).
• Recommendation 2: Healthcare professionals must be made aware of the bio-psychosocial model of managing diabetes and obtain basic grounding in psychosocial aspects of diabetes[15] (Grade A; EL 3).
• Recommendation 3: Ability of health professionals to counsel patients with diabetes must be enhanced by receiving training in specific courses associated with teaching and counseling techniques, such as “Effective Patient Teaching and Problem Solving”[29] SWOT analysis[30] and CARES[31] (Grade A; EL 3).
  • SWOT analysis[32,33,34]: SWOT (strength, weaknesses, opportunities, threats) analysis is an effective tool for personal growth and development. This tool aids doctors in evaluating patient's current strengths and weaknesses and decide the best strategy which can be utilized for patient's development as it will provide information about future threats which can be taken care off with insight into available opportunities for a win–win situation for both doctor and patient.
• Recommendation 4: Healthcare professionals should adopt approaches like WATER that involve patients actively, ensure provider-patient bonding and improve therapeutic outcomes[31] (Grade A; EL 4).

Improving awareness among patients

• Recommendation 5: In patients with low health literacy and numeracy, diabetes education may be facilitated using interactive modules such as diabetes literacy and numeracy education toolkit[35] (Grade A; EL 1).
• Recommendation 6: Self-awareness tools such as “Johari Window” is recommended in patients with diabetes to enhance his/her knowledge about oneself that aid in better handling of one's emotional and personal issues, which will further boost one's self-esteem[36] (Grade A; EL 4).
  • Johari window[36,37]: Johari window model developed by Joseph Luft and Harry Ingham is an effective tool for self-awareness to handle one's emotions and personal issues. This tool helps in enhancing patient's knowledge about oneself and thus exploring facts about who he/she is as an individual by following 360° feedback approach and sharing information with others. The expansion of open arena by the patient will make him/her confident and comfortable which will further boost one's self esteem.
• Recommendation 7: There is a need to create interactive modules for India, where most patients present with low health literacy/numeracy (Grade A; EL 4).

Improving community awareness

• Recommendation 8: Improving community awareness about diabetes is necessary[16] (Grade A; EL 1).
• Recommendation 9: Creating public awareness about psychiatric comorbidities with diabetes, and diabetes occurring with psychoactive drugs, is recommended[38,39] (Grade B; EL 4).

Patient-centered approach

PCC is now an accepted part of medical practice today. Initially proposed in psychology as client-centered care, this term was popularized by bodies such as the Picker Institute and Institute of Medicine, through popular publications.[40,41] Recent guidelines on the management of diabetes have further reinforced the need for patient-centeredness, using the term “patient-centered approach” in their nomenclature,[42] which is defined as an approach to “providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions.”[43] This approach customizes seeking and accepting the patient's ideas, seeking and giving recognition and encouragement, treatment recognition and decision making in response to the individual patient's perspective. Patient-centered approach has a beneficial impact on improving the health status of type 2 diabetes in terms of biological (glycemic control) and behavioral indicators (eating and exercise, compliance, symptoms of diabetes).[44] Experts also accept the need for, and importance of, therapeutic patient education through patient-centered approach in diabetes management.[45]

• Recommendation 10: Patients should be encouraged to participate in patient empowerment programs that result in improved psychosocial self-efficacy and attitudes[46] (Grade A; EL 1).
• Recommendation 11: Physicians are recommended to practice patient-centered professionalism, which encompasses competence, accessibility, respect, empathy, and honesty, best described by CARES[47] (Grade A; EL 4).
• Recommendation 12: Physicians should explore the social situation, attitudes, beliefs and worries related to diabetes and self-care. Physicians are responsible for assessing the well-being and psychological status of the patient using questionnaires or validated measures[15] (Grade B; EL 2).
• Recommendation 13: In communicating with a patient, physician should adopt a whole-person approach, and discuss outcomes and clinical implications if necessary[48] (Grade B; EL 3).
  • Five attributes of diabetes care professionals: CARES[47]
    • C = Confident competence
    • A = Authentic accessibility
    • R = Reciprocal respect
    • E = Expressive empathy
    • S = Straightforward simplicity

Relationship-centered approach

Relationship-centered approach is a framework that recognizes the nature and quality of relationship between patient and provider, which needs to be given due importance.[49] It involves extending the principles of a patient-centered approach to encompass other participants in the medical system. Successful management of disease requires a development goal and is facilitated by stronger physician–patient relationships, where communication is a core tool.

• Recommendation 14: Open communication between patient and physician must be encouraged for treatment that is logical, acceptable and feasible to both[50] (Grade A; EL 4).
• Recommendation 15: Health professionals should aim for greater integration with patients based on cultural, social, cognitive and linguistic comprehension, and must be responsive to cognitive, motivational and emotional barriers in the provider–patient relationship[51] (Grade B; EL 4).

PSYCHOLOGICAL ASSESSMENT AND MANAGEMENT

Although many people with diabetes cope well and live normal, healthy lives with diabetes, several studies, including diabetes attitudes and the wishes and needs (DAWN) study, emphasized that psychological support is under-resourced and inadequate in both adults and children with diabetes, resulting in poor quality of life and reduced general well-being.[3] It is important to establish ways to achieve emotional well-being as part of diabetes management and to include psychological assessment and treatment into routine care rather than wait for the identification of a specific problem or deterioration in psychological status.[52] Furthermore, improved access to health care professionals trained in identifying patients’ needs for providing counseling and psychosocial support is needed for effective management of diabetes.[53] Psychological interventions that use the therapeutic alliance between patient and therapist are understood in emotional, cognitive, and behavioral context.[54] It is known that addressing psychological needs has a positive effect on diabetes outcomes in terms of reduced glycosylated hemoglobin[55] as well as co-morbid depression and systolic blood pressure.[56]

Evidence-based guidelines for psychosocial care in adults with diabetes have been included in the Canadian Diabetes Association,[57] SIGN,[7] National Institute of Health and Clinical Excellence (NICE),[58] Institute for Clinical Systems Improvement,[59] German Diabetes Association[60] and, for the first time in 2005, in the ADA standards of care,[8] indicating the importance of psychological interventions in different problem areas.

Psychological assessment

The considerable impact that diabetes and its treatment can have on quality of life is, perhaps, that this disease has spurred a large number of attempts to develop patient-assessed health outcome measures specific to diabetes. Several reliable instruments useful in assessing psychosocial adjustment to diabetes have been included in various evidence-based guidelines for psychosocial care, such as Well-being Questionnaire (WHO-5)[61] (in SIGN, ADA, IDF-2005; Patient Health Questionnaire-9 (PHQ-9)[62] by SIGN, German Diabetic Association; Problem Areas in Diabetes (PAID) Scale[63] by NICE and ADA guidelines. Studies reported several other diabetes-specific psychological screening instruments with good evidence of reliability and validity, which are currently being implemented [Table 4].[64]

Table 4

Populations in which the instruments were evaluated[64]

• Recommendation 16: When psychosocial problems are identified, healthcare professionals should explain the link between these and poorer diabetes control. They should advise patients where best to obtain further help, and facilitate this if appropriate[65,66] (Grade A; EL 1).
• Recommendation 17: Assessment of the patient's psychological and social situation must be part of the diabetes management using reliable, validated tools that include instruments and questionnaires[53] (Grade A; EL 1).
• Recommendation 18: From the Indian perspective, consider Self-perception of Health Questionnaire,[54] WHO-5, PAID and other diabetes-specific questionnaires available in local languages as suitable tools[15,46] (Grade B; EL 2).

Psychological management

In medical and mental health settings, psychological treatments are routinely used to improve outcomes, e.g., to reduce psychological distress and improve adherence. The need for effective, well-evaluated psychosocial interventions to help people to deal with the routine stress of diabetes (diabetes distress) has been widely noted in the literature.[67] Especially now that treatment regimens are becoming more and more intensive, comprehensive behavioral changes are required. Additional psychosocial support is called for to help people to make these changes and to preserve and sustain their efforts with the goal of optimizing both glycemic control and quality of life.[54]

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT), also called “Socratic Dialogue,” is an approach that helps patients recognize the power of “self-talk” (what they say to themselves) and enhances emotion-focused coping skills in dealing with emotional distress. CBT has gained much prominence as psychotherapy for depression and other problems.[68,69] In CBT, individuals are educated and trained on changing habitual patterns of responding to challenges or problems. It uses measurement tools designed to determine the individual's perception (cognition) and understanding of diabetes and its self-management (behavioral changes). Thus, the cognitions and behaviors are intertwined and the cognitions are changed the same way one would change other behaviors, through identifying alternatives.

CBT is recommended as a primary psychological intervention for looking at “negative behaviors” and “dysfunctional thoughts” among people with diabetes by the NICE, SIGN, ADA and IDF guidelines.[70] Studies have shown that CBT is either similar or more effective than medication in the treatment of psychological problems, including depression, anxiety, and stress.[71,72] Several reviews concluded that cognitive behavioral interventions have beneficial effects on mood and metabolic control with improvements in course and outcome.[73,74] It has been suggested that integrating CBT with the current practice of diabetes management would be ideal for the future.[75] As evident from a randomized controlled trial, CBT was shown to improve glycemic control in patients with diabetes when combined with patient education.[76]

The questions used in CBT are termed the five W's: What, where, when, why, and whom, and the model used is termed FIND: Frequency, intensity, number of times and duration of the individual's problem. However, implementing CBT requires a fair amount of experience and skill, which demand substantial clinical training with backgrounds in counseling, nursing, psychiatry, psychology, or social work. Discussing patient's behavior, resistance, rituals and consequences aligned with interpersonal problems can further increase the healthcare professional's understanding of the patient's perspective.[77]

• Recommendation 19: CBT should be recommended either alone or in combination with other strategies to diabetes patients with co-morbid psychiatric disorders or to improve glycemic control and emotional well-being[78,79] (Grade A; EL 1).
• Recommendation 20: Healthcare professionals should receive formal training in CBT[28] (Grade A; EL 1).
• Recommendation 21: A simple method that can be followed in the Indian context is the Karnal Model for counseling[80] (Grade A; EL 1).
• Recommendation 22: Healthcare professionals should have at least eight sessions with the patient during the therapy[76] (Grade C; EL 3).
  • Karnal model[31,80]: The Karnal model relies on the cognitive behavioral therapy approach, which follows the “antecedents’ lead to behavior’ leads to consequences” (ABC) framework which will be effective only if a complete history of the patient is considered. The model represents an easy, simple and acceptable method of counseling applicable to various psychological disorders and can be used in all health care situations, including similar resource-challenged settings with social constraints.

Motivational therapy

Motivational enhancement therapy is a brief counseling method for enhancing motivation to change problematic health behaviors by exploring and resolving ambivalence. Although it has successfully been used in the field of addictions, it lacks sufficient evidence for effectiveness in improving diabetes control.[78] It is more patient-centered and empowering than traditional care.[81] The therapy has been recommended by IDF, ADA and SIGN for improving the psychological well-being in patients with diabetes.

This therapy involves a patient-centered counseling through motivational interviewing (MI), and has been shown to enhance glucose control in specific patient groups (older obese women with non-insulin-dependent DM).[82] MI appears to be a promising approach for adolescents as well, with initial studies showing improved glycemic control.[83,84] A recent multi-center randomized trial demonstrated that MI with adolescents improved long-term glycemic control and quality of life.[85] A modified version of MI, known as “WATER,” involves a checklist designed for healthcare professionals to change the patient's attitude toward problematic behaviors and improve diabetes care-related behaviors.[86]

• Recommendation 23: Physicians should receive formal training in interventions involving MI, like WATER[86] (Grade A; EL 3).
• Recommendation 24: Patients should be motivated to initiate or intensify insulin using motivational approaches, such as analogy building, which reduce clinical inertia as well as patient resistance related to insulin usage[31,86] (Grade A; EL 4).
• Recommendation 25: Long-term motivational therapy with suitable follow-up is recommended in combination with CBT for improvement in HbA1c levels in poorly controlled type 1 diabetes mellitus (T1DM) adults[87] (Grade B; EL 1).

Problem-solving therapy

Problem-solving is a learned behavior involving strategies for problem resolution. In this, the individual is required to select, apply and evaluate the effectiveness of a chosen strategy.[88] It is a prerequisite for decision making to help reinforce healthy behaviors on a daily basis and involves problem specification, goal and barrier identification and application of skills, and knowledge and experiential learning.[89]

Several tools are available to assess the problem-solving approach, such as the Diabetes Self-Management Assessment Report Tool (D-SMART^®),[90] Diabetes problem-solving inventory,[91] Assessment of primary care resources and supports for chronic disease self-management tool, to facilitate assessment and improvement of support for patient self-management.[92]

• Recommendation 26: Therapy should be individualized, and is recommended in children/adolescents for improvement in behaviors and adherence and in adults for dietary behavior[93] (Grade A; EL 1).
• Recommendation 27: Problem-based approach should be used in conjunction with diabetes self-management education, patient empowerment and life-long management programs to improve diabetes-related outcomes and quality of life[94] (Grade A; EL 1).
  • Modified version of MI: WATER approach[86]
    • W = Welcome warmly
      Body Language
      The OPD encounter
    • A = Ask and assess
      Identifying and using cues
      Internal, external, laboratory
      Hierarchy of questioning
      The insulin encounter
    • T = Tell truthfully
      Mid-sentence analysis
      Verbal/non-verbal cues
      Analogy building
    • E = Explain with empathy
      Examples/Experience-sharing
      Demonstration
      Coping skills training
    • R = Reassure and return
      Prochaska's theory of motivation
      Minimizing discomfort of change
      Working the environment (Eco-sensitivity)

Coping and counseling therapy

The basic idea of a coping strategy is that it should ease stress, provide comfort or enhance one's mood in a difficult situation and have a constructive, lasting impact on the mind and body. Coping is a complex process that can be defined as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person.”[95] Tools like Ways of Coping Questionnaire are available to assess parents in coping with their child's insulin-dependent diabetes.[96]

• Recommendation 28: Group-based counseling programs in conjunction with psychological counseling, CBT and behavioral family systems therapy-diabetes (BFST-D) are recommended to reduce diabetes-related stress as well as achieve glycemic control in problematic diabetics[5] (Grade A; EL 1).
• Recommendation 29: It is recommended that healthcare professionals should receive formal training in psychological interventions involving coping and counseling for improved patient satisfaction and therapeutic outcomes[28] (Grade A; EL 1).
• Recommendation 30: Greater social support, patient empowerment and supporting coping skills must be considered among women with diabetes for better psychosocial adjustment to illness[46,97] (Grade A; EL 2).
• Recommendation 31: Family physicians should encourage patients with diabetes to integrate positive coping skills and de-learn negative coping mechanisms such as rumination (excessive thinking about the disease), catastrophizing (assuming undue negative impact to the disease), self-blame (blaming oneself for the illness) and other-blame (blaming others for one's condition) in their daily life[98] (Grade A; EL 2).
• Recommendation 32: Therapy to improve resilience resources and coping strategies of patients is recommended in patients finding difficulty in adjustment with treatment and lifestyle modification[99] (Grade B; EL 3).

Family therapy

Several studies have shown the link between high levels of non-diabetes-specific family factors, such as conflict, stress and family cohesion, with poorer glycemic control and adherence.[100] Family therapy helps to reduce diabetic-related conflict between family members and reduces the impact of stress and mental health disorders associated with diabetes, particularly in children and adolescents.[101] An intervention based on family-focused teamwork increased family involvement without causing family conflict or adversely affecting youth quality of life, and helped prevent worsening of glycemic control.[102]

• Recommendation 33: BFST-D in combination with educational support is recommended in reducing family conflict and improving treatment adherence in patients with diabetes with poor glycemic control and improving overall family communication and problem-solving skills[15,103] (Grade A; EL 1).
• Recommendation 34: Family therapy should be recommended in children to allow for a better balance between parental and self-care of the child[104,105] (Grade A; EL 4).
• Recommendation 35: Physicians should explore the role of family support and family functioning in implementing family-oriented programs for individuals with diabetes[15] (Grade B; EL 3).

Yoga and meditation

Lifestyle modification through yoga produces consistent physiological changes and can make an appreciable contribution to primary prevention as well as management of diabetes. Yoga has been studied for controlling the symptoms and complications of diabetes. A comprehensive yogic breathing program has been shown to improve the physical, psychological, and social domains and total quality of life in people with diabetes taking oral hypoglycemic drugs (OADs),[106] and is recommended as an effective complementary or integrative therapy program for diabetes management.[107,108] Table 5 summarizes the important yoga practices and their advantages.

Table 5

Benefits of yoga practices on management of diabetes[108]

• Recommendation 36: Yoga is recommended as it can improve well-being, reduce weight and improve sleep in individuals with diabetes[109,110] (Grade A; EL 4).
• Recommendation 37: Comprehensive yogic breathing can be prescribed to improve the quality of life in patients with diabetes[106] (Grade B; EL 1).
• Recommendation 38: Patients with pre-existing complications such as cardiovascular and other comorbidities are recommended to practice yoga regularly for the better management of diabetes[111] (Grade B; EL 1).
• Recommendation 39: Physicians should use stress management educational programs like yoga to improve the subjective well-being scores of people with diabetes and to contribute to the primary prevention as well as management of diabetes[112] (Grade C; EL 3).

Folk dance therapy

Dance/movement therapy is a popular form of physical activity that deals with individual's physical, emotional, cognitive and social integration. A total body movement such as dance enhances the functions of other body systems, such as circulatory, respiratory, skeletal and muscular systems, and is known to increase neurotransmitter and endorphins in the brain, which create a state of well-being. Today, dance/movement therapy is a well-recognized form of complementary therapy used in hospitals for special settings associated with physical and psychological problems.[107]

• Recommendation 40: Dancing twice a week for 8-12 weeks is recommended for diabetes patients for improved outcomes of HbA1c, weight, body fat and blood pressure[113] (Grade B; EL 2).
• Recommendation 41: Group activities such as round dances, where singing, dancing, and socializing are to be embedded in the Diabetes Prevention Program under a community-based participatory research approach, can improve outcomes in patients with diabetes[114] (Grade C; EL 3).

Sexual dysfunction counseling

Chronic medical conditions, particularly diabetes, are frequently associated with sexual difficulties and problems, which are often underreported and underdiagnosed. Furthermore, patients and physicians may feel uncomfortable while discussing such issues. They may feel that sexual problems are not important enough to be mentioned in the context of disease, resulting in poor glycemic control. The situation gets worse with the presence of a comorbidity such as depression. Patients should be encouraged to talk about their sexual problems with the therapist or physician, as both biomedical and psychosocial factors have to be explored. Therapeutic interventions should include basic counseling, biomedical treatment of atrophy and lubrication difficulties, as well as treatment of comorbidities and/or sex therapy.

• Recommendation 42: Physicians should be trained to evaluate sexual problems in both genders in order to facilitate recognition and possible treatment[80,115] (Grade A; EL 3).
• Recommendation 43: Diabetic hypertensive/neuropathic patients should be evaluated for sexual dysfunction and appropriate therapy should be considered[116] (Grade A; EL 3).
• Recommendation 44: Therapeutic interventions should include basic psychological counseling, biomedical treatment as well as treatment of comorbidities and/or sex therapy[117] (Grade A; EL 3).

Eating habits

Diet adherence and managing wrong eating habits are crucial in the management of diabetes. Eating disorders are frequently seen in patients with T1DM, especially children and adolescents who also skip insulin as a form of weight control. This leads to an earlier than expected onset of diabetes-related microvascular complications, particularly retinopathy.[118] There is also evidence that adolescents with diabetes, especially girls, have a higher incidence of eating disorders, and that eating disorders are associated with poor glycemic control.[119,120,121] A dietary regimen adherence in diabetes mellitus (DRADMS) questionnaire was developed to obtain a measure of the T2DM patients’ problems in preventing adherence to the regimen.[122]

• Recommendation 45: Management of eating disorders requires a multidisciplinary team: Endocrinologist/diabetologist, nurse educator, nutritionist, psychologist and, frequently, psychiatrist[118] (Grade B; EL 4).
• Recommendation 46: While treating T1DM patients with eating disorders, physicians should consider including diabetes treatment, nutritional management, and psychological therapy[118] (Grade B; EL 4).
• Recommendation 47: For T2DM patients with non-adherence to diet, closer scrutiny, use of DRADMS questionnaire and psychosocial counseling are recommended[122] (Grade B; EL 2).
• Recommendation 48: Policy decision about built environment and accessibility of fast foods must be incorporated in residential areas and near educational institutions[123,124] (Grade B; EL 4).

Management of type 1 diabetes in adolescents

Management of T1DM in adolescents and children is an important psychological aspect that requires utmost care, particularly in the adolescent age group. It is at this period of life when the child desires freedom and independence, and this produces barriers in achieving a good glycemic control. The ISPAD Consensus Guidelines 2000, which stated that “Psychosocial factors are the most important influences affecting the care and management of diabetes,” also emphasized the importance of psychological care of children and adolescents with diabetes.[10] In a 10-year prospective study from diagnosis of type 1 diabetes, it was found that adolescents were at high risk for various psychiatric disorders.[125,126] Furthermore, there is also evidence that adolescents with diabetes have a higher incidence of eating disorders and are associated with poor glycemic control and early onset of diabetes-related complications.[118,119,120,121]

For adolescents with T1DM family communication, conflict resolution and problem-solving skills are critical elements for the effective management of diabetes. Family communication helps to reduce diabetic-related conflict between family members and reduces the impact of stress and mental health disorders associated with diabetes in children and adolescents.[101] Other therapies like MI and behavioral family systems therapy appear to be promising approaches for adolescents for improved glycemic control.[83,84] A recent multi-center randomized trial demonstrated that MI with adolescents improved long-term glycemic control and quality of life.[85]

• Recommendation 49: Therapies such as problem solving and MI should be individualized in children/adolescents with diabetes for enhancement in behaviors, adherence to medication and change in dietary patterns for improved glycemic control[85,88] (Grade A; EL 1).
• Recommendation 50: BFST-D in combination with educational support is recommended for adolescents with diabetes, which helps in refining problem-solving skills for reducing family conflict and improving treatment adherence in order to achieve better glycemic control[103] (Grade A; EL 1).
• Recommendation 51: Problem-focused coping strategies and behavioral coping skills are recommended in adolescents with T1DM for better metabolic control, psychosocial adjustment and treatment adherence[127] (Grade A; EL 3).
• Recommendation 52: Adolescents with difficulty in achieving treatment goals or with recurrent diabetes ketoacidosis should be screened for psychiatric disorders[128] (Grade B; EL 1).

PSYCHIATRIC ASSESSMENT

The impact of mental illness on diabetes patients has become a major concern for overall health, as they are at least twice as common in them compared with the general population. A study reported that at least 30% of the diabetes patients had anxiety disorders, while 8.5-32.5% had depression.[129] There is growing evidence, particularly from North America, that young people with diabetes appear to have a greater incidence of psychiatric disorders.[125,126,130] In a 10-year prospective study from diagnosis of type 1 diabetes, adolescents were at high risk for various psychiatric diagnoses; females were more likely than males to receive a diagnosis, and half of those with a history of poor glycemic control had a psychiatric diagnosis.[126] Diabetes and psychiatric disorders share a bidirectional association, both influencing each other in multiple ways. The severity of one disorder often contributes to the pathogenesis of the other resulting in comorbidity. For instance, diabetes in individuals results in emergence of psychiatric disorder or psychiatric disorders like depression can not only act as a significant risk factor in the development of diabetes but also interferes with the management of diabetes by influencing treatment adherence. Furthermore, impaired glucose tolerance and diabetes could merge as a side-effect of the medications used in the treatment of psychiatric disorders.[131] Psychiatric comorbidity with diabetes is associated with impaired quality of life, increased cost of care, poor treatment adherence and poor glycemic control.

Strategies to address psychiatric comorbidities

• Recommendation 53: Training of general practitioners and physicians in the identification and management of psychiatric comorbidities in rural and urban areas is recommended[38] (Grade C; EL 4).

Depression

Diabetes and depression appear to have a consistent bidirectional relationship, with depression often preceding the development of T2DM in adults.[132] Depression and diabetes may be related through either biological or behavioral pathways. Biological pathways include hormonal abnormalities, alterations in glucose transport function and increased immuno-inflammatory activation.[133] While negative health behaviors associated with depression, such as inactivity, poor diet, smoking and non-adherence to treatment, recommendations and self-care may be important explanatory behavior factors that may impact diabetes and its complications.

Assessment of depression

• Recommendation 54: A careful assessment of depression in diabetes should include the use of a structured clinical interview (Grade A; EL 4).
• Recommendation 55: Self-reported measures such as the Beck Depression Inventory,[134] Centers for Epidemiologic Studies Depression Scale,[135] PHQ-9,[136] Hamilton Rating Scale for Depression and Hospital Anxiety and Depression Scale (HADS) are to be considered to assess depression in patients with diabetes.[137] The Geriatric Depression Scale is used to screen for depressive symptoms in older individuals. Validated diabetes-specific psychological instruments are also available that can be used in diabetes management[15,46] (Grade A; EL 1).
• Recommendation 56: Recognizing and providing treatment for subclinical presentations of depression are recommended[52,138] (Grade B; EL 3).
• Recommendation 57: Differentiating symptoms of depression that are directly associated with diabetes from those that may be more independent of diabetes is recommended based on the International Statistical Classification of Diseases and Related Health Conditions-10 of the WHO and Diagnostic and Statistical Manual of Mental Disorders-IV of the American Psychiatric Association[131] (Grade C; EL 2).

Anxiety

Diabetes-related stress, including feeling overwhelmed by diabetes and its care, feeling discouraged with the treatment plan and feeling fearful of the future, may contribute to the symptoms of anxiety. The stress of dealing with diabetes may impact patients’ psychosocial functioning and quality of life, which may also increase the risk for developing anxiety symptoms.[139] Diabetes patients may experience short-term, episodic stress related to self-care activities or more long-term, chronic stress related to living with a chronic illness, which may eventually develop into anxiety symptoms or a chronic anxiety disorder.[13]

Assessment of anxiety

• Recommendation 58: Proper identification and diagnosis of anxiety is recommended to distinguish diabetes-related physical symptoms from an anxiety disorder[140] (Grade B; EL 4).
• Recommendation 59: Screening tools such as the HADS[141] and the Generalized Anxiety Disorder-7 Scale,[142] PHQ and Symptom Checklist-90 are to be considered (Grade B; EL 1).
• Recommendation 60: Physicians should consider standardized scales facilitating diabetes-focused assessment that include the Diabetes Distress Scale,[143] Diabetes Quality of Life Questionnaire,[144] hypoglycemia fear survey[145] and Diabetes Fear of Injection and Self-Testing Questionnaire[146] (Grade A; EL 1).

PSYCHIATRIC MANAGEMENT

Psychopharmacologic medication

Psychotropic medications, helpful in reducing the psychological symptoms in individuals with emotional health problems, are most effective when used in conjunction with other approaches such as CBT, Problem-Solving Therapy, etc., A number of medications have been shown to effectively treat a variety of emotional health problems[147] of varying intensity.[148] Nonetheless, psychotherapy and pharmacotherapy do not show strong differences in effect sizes and, hence, the option of using psychopharmacologic agents in therapy must be made after due consideration of all the factors of patient well-being and empowerment.[148]

• Recommendation 61: Choice of pharmacotherapy should give due consideration to criteria such as contraindications, treatment access or patient preferences, and must be used as a complement to psychotherapy[39,149] (Grade A; EL 1).
• Recommendation 62: Physicians should be aware of the possible metabolic adverse effects of psychotropic medications[39] (Grade A; EL 4).

Management of depression

• Recommendation 63: Psychotropics such as antidepressants (Phenylzine), antipsychotics (Haloperidol, Ziprasidone, and Aripiprazole) and mood stabilizers (Topiramate) associated with a low risk of impaired glycemic control are recommended to manage depression with diabetes[131] (Grade A; EL 4).
• Recommendation 64: Tricyclic antidepressants, selective serotonin reuptake inhibitors, norepinephrine reuptake inhibitors and serotonin modulators are to be avoided as they have been shown to be associated with increased risk of diabetes following intermittent and continued long-term use[150] (Grade A; EL 1).
• Recommendation 65: Non-pharmacological interventions such as CBT and interpersonal therapy can be used either alone or in combination with pharmacotherapy[72,131] (Grade A; EL 4).
• Recommendation 66: Psychiatrists should be sensitized to understand the multifaceted interactions between diabetes and psychiatric disorders for improved therapeutic outcomes[131] (Grade A; EL 4).

Management of anxiety

• Recommendation 67: Psychological interventions focused on self-care, such as group education programs including coping skills, behavioral-cognitive skills, relaxation techniques, problem-solving skills, mindfulness-based stress management and family therapy, are to be considered[139,151] (Grade B; EL 3).
• Recommendation 68: Behavioral intervention can be included as an adjunct to routine medical care in the management of young people with T1DM[152] (Grade B; EL 1).

Electroconvulsive therapy in diabetes

The literature on the effect of electroconvulsive therapy (ECT) on DM remains controversial, with evidence of both amelioration and worsening of hyperglycemia.[153] Reports of ECT leading to dangerous hyperglycemia in a previously non-diabetic patient suggested the possibility of an unmasking or exacerbation of diabetic pathology during a course of ECT.[154] But, another more recent study included 19 patients with insulin-requiring T2DM undergoing ECT, none of whom were on oral hypoglycemic drugs. There was no statistically significant difference in the average daily insulin requirements or acute glycemic control associated with ECT, suggesting that ECT in insulin-requiring type 2 diabetes patients is safe and efficacious.[155]

• Recommendation 69: ECT is suggested to be safe and efficacious for T2DM patients requiring insulin in some literature, although caution must be practiced before prescribing it[155] (Grade C; EL 3).

SOCIAL ASSESSMENT AND MANAGEMENT

Social factors currently play a small role in the treatment plan for diabetes. Nonetheless, social factors have an important role in the acceptance, adherence to treatment and overall outcome of diabetes management. Studies have found the importance of social (economic class, financial expenditure, regional disparities, family structure, affordability to medical care, educational profile) and cultural factors (ethnicity, customs, food habits, fasting conditions, community beliefs) in the prevalence and management of diabetes care.

In resource-limited countries like India, diverse social, cultural as well as religious economic, psychological, regional, educational, and familial factors have consequences on the clinical progression, treatment and outcome of any disease management.[46] Thus, we need to lay emphasis on working on the environment (eco-sensitivity) and medical anthropology for the better management of diabetes. Further, taking into consideration the perceptions of patients’ for different therapeutic agents from different social structures, ethnopharmacy also plays an important role. The socioeconomic status of households/individuals in urban as well as in rural areas in India can be assessed from the scale developed by Tiwari et al. 2005[156] and updated in 2012.[157] The scale can play a key role in the development of evidence-based guidelines based on the indication and efficacy of care practices directed at social issues, which is much needed for health care professionals engaged in diabetes care.

Social structure

The influence of social class or socioeconomic status on the incidence and management of diabetes is observed globally as well as in India. In India, cultural diversity and deep-rooted social structures have great implications on the clinical course, treatment and ultimate outcome of any disease. Prevalence of diabetes is reportedly higher in the highest socioeconomic groups, and decreases with decreasing socioeconomic status in India.[158] However, populations with diabetes from the lower social class and no health insurance were found to be at the greatest risk of not receiving preventive care[159] in the USA or admission to hospital for diabetes care[160] in the UK. While diabetes was once considered a disease of affluence, in the last decade, its prevalence rates in the middle and lower income groups have shown a trend toward convergence.[161] Families with higher average family income and education profile are known to spend more on diabetes care.[162]

• Recommendation 70: Because socioeconomic status and health insurance play an important role in access to diabetes care, physicians are recommended to assess the socioeconomic class of the patient for better disease management[159] (Grade B; EL 2).
• Recommendation 71: Physicians must be sensitive to the income and education profile of patients while choosing therapeutic options, to promote greater adherence to therapy and to improve outcome[162] (Grade B; EL 4).

Family structure

Several studies from India have demonstrated the importance of family structure in the management of diabetes. In India, it is reported that cost-effective focus for overall diabetes care can be placed on the nuclear family as a unit,[39] which occupies 60% of the total household units[163] with mean size of 4.8 persons per house, (rural areas – 4.9 persons, urban areas – 4.6 persons). Other aspects in diabetes management and involving family risk factors associated with the same are[5] low marital satisfaction; high criticalness, hostility, conflict; poor problem-solving skills; low family coherence; low closeness/cohesion; low family organization; lack of congruence in diabetes beliefs and expectations. For adolescents with T1DM, family communication, conflict resolution and problem-solving skills are critical elements for the effective family management of diabetes. Moreover, social bonds, especially family bonds, are known to influence outcomes of diabetes management, which holds the key to avoiding negative progression of the disease.[164] The practical and emotional strains arising out of this affect diabetes management and family beliefs and emotion management and help manage this impact by improving patient morale. However, unresolved family conflicts about diabetes are associated with more depressive symptoms and lower quality of life.

• Recommendation 72: Physicians should encourage patients to seek support from family members, based on individual family structures, overcome barriers in adherence to treatment and promote patterns of behavior, which may make diabetes management easier[165] (Grade A; EL 2).
• Recommendation 73: In weight loss programs, healthcare providers should recommend the collaboration of a spouse to actively work together to reach a common goal[166] (Grade A; EL 2).
• Recommendation 74: Diabetes management should be made more flexible and convenient in a familial context to reinforce the patient's personal sense of health, emotional well-being and ability to maintain diabetes care[164] (Grade C; EL 4).

Gender discrimination

Gender discrimination toward healthcare, including diabetes, is observed all over the world. In India, higher outpatient attendance for T1DM is recorded for men than for women (<30 years age). Interestingly, half of these young women who are at a marriageable age often lose their follow-up to clinic due to perceived social stigma, often leading them to medical consequences, including diabetic ketoacidosis.[167] The reasons for the same are mainly disbeliefs as “will she be able to cope with the house work, can she have a normal baby, she will require more care and so on.” Women show poorer compliance to therapy due to greater economic dependence on family members.[23] Differences in functional limitations between adults with and without diabetes are more evident in women than they are in men, due to their strong association with biological and behavioral factors.[97]

Diabetes is often perceived as a costly disorder in India; parents usually get their daughters married without disclosing that she has diabetes, which has eventually lead to very grave consequences. Another aspect of gender discrimination in diabetes care comes from the role of parents in the management of children with T1DM, where mothers often share a disproportionate burden of diabetes care in the child. If fathers do not share in the responsibility, they feel out of touch with the complexities of management. Therefore, care should be taken to ensure distribution of responsibility between the parents.[168] Affirmative action is required on the part of diabetes care professionals to ensure that women are not discriminated against as far as diabetes care is concerned.

• Recommendation 75: Inclusion of interventions that increase women's perceived self-confidence and social support for positive health outcomes is recommended[169] (Grade B; EL 3).
• Recommendation 76: Social support and self-confidence of women with type 2 diabetes in determining their individualized goals and strategies must be assessed[170] (Grade C; EL 4).
• Recommendation 77: Diabetes health care professionals treating young women who are at a marriageable age with diabetes should engage in educating parents, the girl to be married and the prospective groom and his parents about the management of the disorder and provide confidence and reassurance that she can lead a normal life if taken care of properly with respect to medication and regular checkup (Grade A; EL 4).

Custom/religion

Cultural differences in the form of language, educational backgrounds, religion, health attributions, beliefs and practices toward illness must be acknowledged and considered by healthcare providers for treatment decisions and to determine how to obtain this information from patients,[171] especially in people with a South Asian origin.[172] Because of the vast diversity of cultural and religious health attributions, beliefs and practices, it is important to prioritize such factors in diabetes care and education.[171] In chronic conditions like diabetes, religious or spiritual beliefs become increasingly important; firstly, because they provide the social and emotional support and, secondly, because they aid in coping with the stress of the disease. Hindus observe fasting and go to strenuous pilgrimage like Amarnathji as part of their religious traditions during various times of the year. Jains may not eat from dusk to dawn, irrespective of the duration of this period. Buddhists observe the 3-month-long Buddhist lent during the rainy season.

People with diabetes are recommended to follow the physician's advice in observing fasts or going to pilgrimages to avoid any glycemic emergencies.[173] Similarly, worldwide, Muslims fast during the month of Ramadan. People with diabetes, who wish to fast, have been stratified based on the severity of disease, and specific rules and recommendations have been issued.[174] People with diabetes who are categorized in the “observe fasting” group are further advised to follow the recommended strategies to ensure safety before, during and after the month of Ramadan.

• Recommendation 78: “Culturally competent assessment tool” can be used to test the cultural competency of healthcare delivery interventions[175] (Grade B; EL 1).
• Recommendation 79: Indian physicians, who often have to manage a multilingual, multi-ethnic population, should be sensitized to the importance of cultural and religious health attributes, beliefs and practices (Grade A; EL 4).
• Recommendation 80: Physicians should recommend pilgrims to undergo pre-pilgrimage health clearance and educate them about hypoglycemia, need of caloric intake, compliance with medications or insulin, glucose monitoring, carrying their medical records and importance of protective wear[173] (Grade A; EL 3).
• Recommendation 81: Those who are medically fit to fast need education about the importance of balanced diet, moderate physical exercise, adherence to advised medications, self-monitoring of glycemia, early recognition of dangerous situations and necessary remedial measures[165] (Grade B; EL 4).
• Recommendation 82: Ramadan-focused patient education should focus on pre-Ramadan evaluation, risk stratification and generous religious exemptions available for deserving individuals[176] (Grade B; EL 4).
• Recommendation 83: Physicians should educate patients on the availability of modern insulin analogues for diabetes care during Ramadan for better control and therapeutic outcome[176] (Grade A; EL 4).
• Recommendation 84: Religious and cultural leaders should be requested and encouraged to speak positively about modern diabetes care[177] (Grade A; EL 4).
• Recommendation 85: Physicians should be trained to enquire about the role of religion and spirituality in patient's life using standardized screening questions[178] (Grade C; EL 4).
• Recommendation 86: Physicians should pose questions about religion and spirituality that are framed specifically in the context of patients’ coping and self-managing with diabetes that are comfortable for both the patient and the clinician[178] (Grade C; EL 4).
• Recommendation 87: Physicians should provide information, training and skill-building activities to sensitive patient's cultural context and disseminate diabetes education[179] (Grade D; EL 3).
• Recommendation 88: A culturally competent perspective should be the key for treatment of diabetes in people with diverse cultural and religious backgrounds[171] (Grade D; EL 4).
• Recommendation 89: Important diagnostic and racial differences in religious participation and the supports required for enhanced quality of life for persons with serious mental illness and diabetes at religious participations may be considered[180] (Grade D; EL 4).

Urban/rural settings

The prevalence of diabetes has increased in the urban and rural areas of India, with an urban-rural split of 2:1 or 3:1 sustained through the last two to three decades.[181] Lifestyle factors and family history play synergistic roles in increasing the risk of diabetes in the urban population,[182] which is consistent with the rise in burden of overweight and obesity.[183] Awareness about diabetes and management are also lower in the rural population.[184]

Because the demography of India is predominantly rural, even with a lower rate of prevalence, the rural population in India can be expected to constitute a larger proportion of the diabetes population. Unfortunately, lack of access to early diagnosis of disease, quality healthcare, and healthcare infrastructure is impeding healthcare standards in rural India. Affirmative action is required on the part of diabetes care professionals to ensure that no section of society is discriminated against as far as diabetes care is concerned.

• Recommendation 90: While treating the rural population with diabetes, physicians should assess people at risk of psychosocial problems and provide counseling on self-care and psychosocial management[65] (Grade A; EL 4).

Community reaction

Job discrimination and social isolation are common fears about the expected community reaction to a person living with diabetes. In India, families with young female diabetes patients fear ill-treatment at school or college, reduced future marriage prospects, isolation in social relations, etc., as a result of disclosure of their diabetic status.[167]

• Recommendation 91: An understanding of factors that influence patients’ decisions to maintain confidentiality about diabetes within their social networks is needed for using community-based interventions to improve diabetes self-management in ethnic minority patients[185] (Grade A; EL 3).

Affordability

Economic affordability in the context of diabetes depends on the share of annual house hold expenditure spent on diabetes care. In India, out-of-pocket payments form a large share of house hold expenditure and result in a financial strain on the household. According to the World Health Statistics, 2012, currently, India has less than half the global average of physician per 10,000 patients and healthcare expenditure (as a % Gross Domestic Product). A larger share of this expenditure comes from the private sector through the out-of-pocket expenses recovered from patients.

• Recommendation 92: Physicians should discuss the cost of medication with the patients, considering the economic status of the patient[19] (Grade B; EL 4).
• Recommendation 93: Physicians should encourage households with individuals involved in diabetes care to seek health insurance[19] (Grade C; EL 4).
• Recommendation 94: For diabetes care in a resource-poor population, physicians should recommend primary prevention through promotion of healthy lifestyles and risk reduction as the most cost-effective intervention (Grade D; EL 4).

CONCLUSIONS

The current guideline on psychosocial aspects of diabetes encapsulates global evidence and experience, while maintaining a uniquely Indian flavor. Publications from a wide range of sources have been considered while designing the recommendations, and represent a vast cross-section of opinions. This guideline bridges a crucial gap in diabetes management and hopes to address the scale and variety of challenges in the psychosocial management of diabetes in India. It should encourage all stakeholders in diabetes care to create and devote adequate time and resources to ensure optimal psychosocial management of people with diabetes.

ACKNOWLEDGMENTS

The authors thank Jeevan Scientific Technology Limited, Hyderabad, for providing writing assistance in the development of this manuscript.

The authors thank members of the South Asian Referee Panel: Dr. Fatema Jawad, Pakistan; Dr. Syed Abbas Raza, Pakistan; Dr. Aisha Sheikh, Pakistan; Dr. Kishwar Azad, Bangladesh; Dr. Fauzia Mohsin, Bangladesh; Dr. Bedowra Zabeen, Bangladesh; Dr. Noel Somasundaram, Sri Lanka; Dr. Prasad Katulanda, Sri Lanka; Dr. Jyoti Bhattarai, Nepal; and Dr. Dina Shrestha, Nepal, for their valuable comments.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared

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