Integrating mental health into diabetes care

Nearly 30 years ago, clinical psychologist Amy Walters, PhD, started volunteering at a local camp for kids with diabetes. While her psychological training gave her a foundational understanding of the psychosocial factors affecting chronic illness, working with diabetic youth sparked a new passion for supporting the bidirectional relationship between physical and mental health.

Today, Walters serves as director of behavioral health for Humphreys Diabetes Center and a clinical consultant for Children’s Integrative Medicine and Pediatric Endocrinology at St. Luke’s Health System in Idaho, addressing emotional and behavioral factors that impact health and chronic disease, including diabetes, prediabetes, overweight and obesity, and metabolic syndrome.

Managing diabetes requires a multipronged approach best supported by a comprehensive team. Walters works alongside endocrinologists, nurse educators, dietitians, and social workers to provide holistic care to patients, from preventing and controlling diabetes through evidence-based behavioral strategies to support healthy lifestyle and address mental health factors that can affect quality of life and disease outcomes.

We asked Walters to explain the relationship between mental health and diabetes, how she works with patients and medical providers, and what all psychologists need to know about treating patients with chronic illness.

After I started volunteering, I began getting referrals from camp to my private practice, but people wouldn’t follow through with them. I talked to the camp director, and campers were saying they didn’t need a “shrink.” There was a total disconnect between the behavioral and medical side of the disease. I met with the camp medical director, who also directed the Humphreys Diabetes Center, and we realized psychological care should be embedded in routine diabetes care. I started working there one day a week in 2008, and as interest and demand for services grew, the role eventually became full-time.

Diabetes is greatly self-managed, but it comes with an intense medical regimen. Patients typically check their sugar multiple times a day, count carbohydrates, and dose potent medicine independently. If you dose too much, your blood sugar could go low, which is a big medical risk. If you dose too little, your blood sugar could go high, which can be harmful long-term.

These patients always need to make the right decision in the moment, which is a heavy emotional and cognitive burden. Then they’re trying to make lifestyle changes on top of that. We know diabetes patients do best when they eat healthy, exercise, sleep well, and manage their stress. I help them with all those things in my practice.

Mental and physical health have a bidirectional relationship. Anxiety is a great example. During anxiety or panic, fight-or-flight hormones are triggered, and we see an increase in cortisol and adrenaline. Both those hormones crank up blood sugar levels. Patients in a chronic state of anxiety or stress tend to have a hard time managing blood sugar, so we teach them stress management strategies and anxiety management. Folks with depression may struggle to participate in healthy activities, which can lead to weight gain and difficulty managing blood sugar.

On the other hand, when people’s disease is well managed, their mental health improves. Living with a chronic condition is inherently stressful. When it’s under control, people feel like they can live their lives—diabetes is in the backseat, not driving the bus. That’s why it’s so important for psychologists to be integrated in diabetes care. These are high-risk patients who are costly to insure. From a population health perspective, we provide value by keeping people out of the hospital and helping them live healthier lives overall.

I share office space with endocrinologists, nurse educators, dietitians, and social workers. We read each other’s patient notes. I reach out to them after I meet with one of their patients to talk about ways they can help improve care. I also attend the case staffings every week with our endocrinology team, talking about difficult cases and how emotional and behavioral factors might be at play.

I train staff in best practices based on psychological evidence, from how to deal with difficult patients to how to support behavior change. For example, I created handouts on stress management that doctors or nurses can walk through with their patients.

Patients with diabetes have higher rates of anxiety, depression, and substance use. When they start out in our Diabetes Center, they see a nurse educator or dietitian who conducts a mental health screening. If their score indicates one of these, they may refer the patient to me or another mental health provider for treatment. I do individual therapy with patients and also lead groups about behavioral strategies for weight management and binge-eating disorder and then offer a graduate group for patients who want ongoing support after finishing another group.

Our department has an open-door policy, so providers can always grab a behavioral health provider in an emergency. Recently, I was in clinic working on charting. Someone from endocrinology came to my office and told me a patient was having a panic attack. This person had been newly diagnosed with diabetes and was overwhelmed. I talked with her, helped her practice deep breathing until she felt calm, and scheduled a follow up for the next week to talk about panic.

All patients live in the context of a family and broader community. The more support we can get from them, the better patients do. Social relationships make a big difference in promoting a healthy lifestyle, so we encourage family members to help support healthy eating and physical activity. We also know all kinds of stress, including relational stress, can affect blood sugar and diabetes outcomes, so we want to help promote healthy relationships.

Many of my patients enjoy activities like hunting or fishing. If they develop painful diabetes complications like neuropathy, they may stop participating in these hobbies, which can affect their mental and physical health. We may bring their spouse in to discuss how to support the patient, adapt the activity, and encourage healthy habits without becoming the diabetes police, which can strain the relationship.

Ask about chronic illness in your assessment and understand how complex and impactful conditions like diabetes are. Diabetes affects physical health, but also identity and relationships. There’s a lot of guilt and shame when people struggle with management, along with financial demands. It’s important to validate these challenges, monitor their stress, screen them for anxiety and depression, and provide positive management strategies.

All psychologists are qualified to do these things, along with supporting patients in behavior change. Patients often comment, “I know what I am supposed to do, I just don’t know how to do it.” Psychologists can play an important role in supporting lifestyle changes and improving treatment adherence, even if they don’t have expertise in diabetes.

As integrated care continues to expand, I hope more psychologists will bring their skills into medical settings. There’s so much opportunity to improve lives by addressing both the social, emotional, and behavioral sides of chronic disease.