Psychosocial Care for People WithDiabetes: A Position Statement ofthe American Diabetes AssociationDiabetes Care 2016;39:2126–2140 | DOI: 10.2337/dc16-2053

Complex environmental, social, behavioral, and emotional factors, known as psy-chosocial factors, influence living with diabetes, both type 1 and type 2, and achiev-ing satisfactory medical outcomes and psychological well-being. Thus, individualswith diabetes and their families are challenged with complex, multifaceted issueswhen integrating diabetes care into daily life. To promote optimal medical out-comes and psychological well-being, patient-centered care is essential, definedas “providing care that is respectful of and responsive to individual patient pref-erences, needs, and values and ensuring that patient values guide all clinical decisions”(1). Practicing personalized, patient-centered psychosocial care requires that commu-nications and interactions, problem identification, psychosocial screening, diagnosticevaluation, and intervention services take into account the context of the person withdiabetes (PWD) and the values and preferences of the PWD.This article provides diabetes care providers with evidence-based guidelines for

psychosocial assessment and care of PWD and their families. Recommendationsare based on commonly used clinical models, expert consensus, and tested inter-ventions, taking into account available resources, practice patterns, and practi-tioner burden. Consideration of life span and disease course factors (Fig. 1) iscritical in the psychosocial care of PWD. This Position Statement focuses on themost common psychological factors affecting PWD, including diabetes distress andpsychological comorbidities, while also considering the needs of special popula-tions and the context of care.

GENERAL CONSIDERATIONS IN PSYCHOSOCIAL CARE

Recommendations

c Psychosocial care should be integrated with collaborative, patient-centeredmedical care and provided to all people with diabetes, with the goals ofoptimizing health outcomes and health-related quality of life. A

c Providers should consider an assessment of symptoms of diabetes distress,depression, anxiety, and disordered eating and of cognitive capacities usingpatient-appropriate standardized/validated tools at the initial visit, at periodicintervals, and when there is a change in disease, treatment, or life circumstance.Including caregivers and family members in this assessment is recommended. B

c Consider monitoring patient performance of self-management behaviors aswell as psychosocial factors impacting the person’s self-management. E

c Consider assessment of life circumstances that can affect physical and psycho-logical health outcomes and their incorporation into intervention strategies. E

c Addressing psychosocial problems upon identification is recommended. If an in-tervention cannot be initiated during the visit when the problem is identified, afollow-up visit or referral to a qualified behavioral health care provider may bescheduled during that visit. E

Practitioners should identify behavioral/mental health providers, ideally those who areknowledgeable about diabetes treatment and the psychosocial aspects of diabetes, withwhom they can form alliances and use for referrals (Table 1) in the psychosocial care ofPWD. Ideally, psychosocial care providers should be embedded in diabetes care settings.Sharedresources suchaselectronichealth records,managementdata,andpatient-reported

1Office of Behavioral and Social Science Research,National Institutes of Health, Bethesda, MD2Indiana University School of Medicine, Indian-apolis, IN3Johns Hopkins School of Medicine, Baltimore,MD4Yeshiva University and the Albert Einstein Col-lege of Medicine, Bronx, NY5Stanford University, Stanford, CA6Loyola University Maryland, Baltimore, MD

Corresponding author: Deborah Young-Hyman,younghyd@od.nih.gov.

This position statement was reviewed and ap-proved by the American Diabetes AssociationProfessional Practice Committee in September2016 and ratified by the American Diabetes As-sociation Board of Directors in October 2016.

© 2016 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered. More infor-mation is available at http://www.diabetesjournals.org/content/license.

See accompanying articles, pp. 2122,2141, 2149, 2158, 2165, 2174, 2182,2190, and 2197.

Deborah Young-Hyman,1 Mary de Groot,2

Felicia Hill-Briggs,3 Jeffrey S. Gonzalez,4

Korey Hood,5 and Mark Peyrot6

2126 Diabetes Care Volume 39, December 2016

PSYCHOSO

CIALRESEA

RCHANDCAREIN

DIABETES

information regarding adjustment to illnessand life course issues facilitate providers’capacity to identify and remediate psy-chosocial issues that impede regimen

implementation and improve diabetesmanagement and well-being. Care modelsthat take into account cultural influences, aswell as personal, family, and community

resources, and tailor care to the core val-ues and lifestyle of the individual aremore likely to be successful (2). Regard-less of how the diabetes care team is con-stituted, the PWD is central to the careprocess. If a PWD cannot act on behalf ofhim/herself in the care process, a supportperson needs to be identified to participatein treatment decisions and facilitate diseasemanagement. It is also important that pro-viders enlistmembers of the patient’s socialsupport network to aid in the identification,prevention, and resolution of psychosocialproblems.

Medical management of diabetes re-quires patient implementation of a treat-ment regimen. Thus, psychosocial factorsimpacting self-care suchasdiabetesdistress(burdens of diabetes and its treatment,worries about adverse consequences),lack of social and economic resources, and

Table 1—Situations that warrant referral of a person with diabetes to a mentalhealth provider for evaluation and treatmentc If self-care remains impaired in a person with diabetes distress after tailoreddiabetes education

c If a person has a positive screen on a validated screening tool for depressive symptoms

c In the presence of symptoms or suspicions of disordered eating behavior, an eating disorder,or disrupted patterns of eating

c If intentional omission of insulin or oral medication to cause weight loss is identified

c If a person has a positive screen for anxiety or FoH

c If a serious mental illness is suspected

c In youth and families with behavioral self-care difficulties, repeated hospitalizations fordiabetic ketoacidosis, or significant distress

c If a person screens positive for cognitive impairment

c Declining or impaired ability to perform diabetes self-care behaviors

c Before undergoing bariatric surgery and after if assessment reveals an ongoing need foradjustment support

Figure 1—Psychosocial care for PWD: life and disease course perspectives. *With depressed mood, anxiety, or emotion and conduct disturbance.**Personality traits, coping style, maladaptive health behaviors, or stress-related physiological response. ***Examples include changing schools,moving, job/occupational changes, marriage or divorce, or experiencing loss.

care.diabetesjournals.org Young-Hyman and Associates 2127

Table

2—Se

lectedmeasu

resfortheeva

luationofpsy

choso

cialco

nstru

ctsin

theclinicalse

tting

Topicarea

Measure

title

Citations

Description

Validated

population

Diabetes-related

distress

Problem

Areas

inDiabetes

(PAID)

Polonsky

WH,A

ndersonBJ,LohrerPA

,etal.A

ssessm

entof

diabetes-related

distress.D

iabetesCare

1995;18:754–760

20-item

measure

ofdiabetes-specific

distressmeasuringem

otional

distressandburden

associated

withdiabetes

Adultswithtype1andtype2

diabetes

Welch

G,W

eingerK,

AndersonB,P

olonskyWH.

ResponsivenessoftheProblem

Areas

inDiabetes

(PAID)questionnaire.Diabet

Med

2003

;20:69–72

Diabetes

DistressScale(DDS)

PolonskyWH,Fisher

L,Earles

J,et

al.Assessing

psychosocialstress

indiabetes:developmen

tofthe

Diabetes

DistressScale.

Diabetes

Care

2005

;28:626

–63

1

17-item

questionnaire

measuring

diabetes-specificdistressin

four

domains:em

otionalburden

,diabetes

interpersonaldistress,

physician-related

distress,and

regimen

-related

distress

Adultswithtype1andtype2

diabetes

Fisher

L,Hessler

DM,PolonskyWH,M

ullanJ.Whenis

diabetes

distressclinicallymeaningful?Establishing

cut

pointsfortheDiabetesDistressScale.DiabetesCare

2012;35:259–64

(39)

PAID–PediatricVersion

(PAID-Ped

s)MarkowitzJT,V

olken

ingLK,Butler

DA,LaffelLM.Youth-

perceived

burden

oftype1diabetes:ProblemAreas

inDiabetes

Survey-Ped

iatricVersion(PAID-Ped

s).

JDiabetes

SciTechnol2

015;9:10

80–10

85

20-item

measure

ofdiabetes

burden

Youth

(ages8–17

years)with

type1diabetes

PAID–Teen

Version

Weissberg-Ben

chellJ,A

ntisdel-Lomaglio,J.Diabetes-

specificem

otionaldistressam

ongadolescen

ts:

feasibility,reliability,andvalidityoftheproblemareas

indiabetes-teenversion.PediatrDiabetes

2011

;12:341

–34

4

26-item

questionnaire

measuring

perceived

burden

ofdiabetes

Adolescen

ts(ages11

–19

years)withdiabetes

PAID–ParentRevised

version

(PAID-PR)

MarkowitzJT,Volken

ingLK,ButlerDA,Antisdel-Lomaglio

JH,AndersonBJ,LaffelLM

.Re-exam

iningameasureof

diabetes-related

burden

inparen

tsofyoungpeo

ple

withtype1diabetes:theProblem

Areas

inDiabetes

Survey–ParentRevised

version(PAID-PR).Diabet

Med

2012;29

:526

–53

0

18-item

questionnaire

assessing

perceived

paren

talb

urden

of

diabetes

Parentsofchildrenand

adolescen

ts(ages8–18

years)withtype1diabetes

Dep

ression

Patien

tHealthQuestionnaire

(PHQ-9)

SpitzerRL,WilliamsJB,K

roen

keK,

etal.Utilityof

new

procedure

fordiagnosismen

tal-disordersin

primary-care:thePR

IME-MD10

00Study.JAMA

1994

;272

:174

9–17

56

9-item

measure

ofdep

ressive

symptoms(correspondingto

criteriaformajordep

ressive

disorder)

Adults

BeckDep

ressionInventory–II

(BDI-II)

BeckAT,SteerRA,BrownGK.ManualfortheBeckDepression

Inventory-II,2nded.San

Antonio,TX,Harcourt,Brace&

Company,1996

21-item

questionnaire

evaluating

somaticandcogn

itivesymptomsof

dep

ression

Adults

Child

Dep

ressionInventory

(CDI)(curren

ted

itionis

CDI-2)

Kovacs,M

.TheChildren’sDepressionInventory(CDI):

Technical

Man

ualU

pdate.NorthTonaw

anda,NY,

Multi-HealthSystem

s,20

03

27-item

measure

assessing

dep

ressivesymptomsusingchild

andparen

treport

Youth

(ages7–17

years)

GeriatricDep

ressionScale(GDS)

Sheikh

JI,Yesavage

JA.GeriatricDep

ressionScale

(GDS):recenteviden

ceanddevelopmen

tof

ashorter

version.C

linicalGerontologist

1986

;5:165–17

2

15-item

measure

was

developed

toassess

dep

ressionin

older

adults

Adults(ages55

–85

years)

Con

tinuedon

p.21

29

2128 Position Statement Diabetes Care Volume 39, December 2016

Table

2—Continued

Topicarea

Measure

title

Citations

Description

Validated

population

Eatingdisorders

EatingDisordersInventory–3

(EDI-3)

Garner

DM.Eating

DisorderInventory-3:

Profession

alMan

ual.Odessa,FL,P

sychologicalA

ssessm

ent

Resources,2

004

2interviewandself-rep

ortsurveys

aimed

atthemeasuremen

tof

psychologicaltraitsorsymptom

clustersrelevantto

the

developmen

tandmaintenance

of

eatingdisorders

Females

(ages13

–53

years)

DiabetesEating

Prob

lemsSurvey

(DEPS-R)

MarkowitzJT,B

utler

DA,V

olken

ingLK,Antisdel

JE,

AndersonBJ,LaffelLM

.Brief

screen

ingtoolfor

disordered

eatingin

diabetes:internalconsisten

cyandexternalvalidityin

acontemporary

sampleof

ped

iatricpatientswithtype1diabetes.D

iabetes

Care

2010

;33:495

–50

0

16-item

self-rep

ortmeasure

designed

toassess

diabetes-

specificeatingissues

Youth

(ages13

–19

years)with

type1diabetes

Diabetes

Treatm

entandSatiety

Scale(DTSS-20

)Young-Hym

anD,DavisC,GrigsbyC,Looney

S,PetersonC.

Developmen

toftheDiabetes

Treatm

entandSatiety

Scale:DTSS-20

(Abstract).Diabetes

2011;60

(Suppl.1):

A21

8

20-item

self-rep

ortmeasure

that

assesses

perceptionofsatietyand

fullnessin

thecontext

offood

intake,physicalactivity,

med

icationdosing,andglycem

iclevels

Youth

(ages10

–17

years)with

type1diabetes

Healthliteracy

andnumeracy

Gen

eralHealthNumeracyTest

(GHNT)

Osborn

CY,WallstonKA

,ShpigelA,C

avanaugh

K,Kripalan

iS,Rothman

RL.Developmen

tandvalidation

oftheGen

eralHealthNumeracyTest

(GHNT).Patien

tEducCouns20

13;91

:35

0–35

6

21-item

self-rep

ortquestionnaire

designed

toassess

patientlevelo

funderstandingoftheuseofnumbers

inmedications

andhealth

Adults

Diabetes

NumeracyTest(DNT)

HuizingaMM,ElasyTA,W

allstonKA

,etal.Developmentand

validationof

theDiabetesNum

eracyTest(DNT).BMC

Health

SerRes2008;1:96

5-,15-,and

43-item

wordproblem–

basedtesttoassessunderstandingof

tables,graphs,andfiguresspecificto

themanagem

entof

diabetes

Adults(ages18

–80

years)

Brief

HealthLiteracy

Scale(BHLS)

WallstonKA

,Caw

thonC,M

cNau

ghtonCD,R

othman

RL,

Osborn

CY,Kripalan

iS.Psychometricpropertiesofthe

BriefHealth

LiteracyScreen

inclinicalpractice.JG

enIntern

Med

2014;29:119–126

3-item

measureread

aloudto

patients

inan

outpatient

andem

ergency

departmentsettingto

assess

understandingof

health

concepts

Adults

Self-careefficacy

Diabetes

self-efficacy

RitterPL,LorigK,

LaurentD.Characteristicsofthe

Span

ish-andEnglish-lan

guageself-efficacy

tomanage

diabetes

scales.Diabetes

Educ20

16;42

:167

–17

7

8-item

self-rep

ortscaledesigned

toassess

confiden

cein

perform

ing

diabetes

self-careactivities

Adults

Self-efficacy

fordiabetes

managem

ent

IannottiR

J,Schneider

S,Nan

selTR,etal.Self-efficacy,

outcomeexpectations,anddiabetes

self-

managem

entin

adolescen

tswithtype1

diabetes.JDev

Beh

avPediatr20

06;27:

98–10

5(26)

10-item

self-rep

ortself-efficacy

scale

Adolescen

ts(ages10

–16

years)withtype1diabetes

Con

tinuedon

p.21

30

care.diabetesjournals.org Young-Hyman and Associates 2129

Table

2—Continued

Topicarea

Measure

title

Citations

Description

Validated

population

Anxiety

State-TraitAnxietyInventory

for

Children(STA

IC)

SpielbergerCD,EdwardsCD,Lushen

eR,M

onturiJ,

Plotzek

D.State-TraitAnxiety

Inventory

forChildren

Profession

alM

anual.Men

loPark,C

A,MindGarden

,Inc.,1

973

40item

sontw

odim

ensionsd

trait

andstateanxiety

Youth

withandwithouttype1

diabetes

BeckAnxietyInventory

(BAI)

BeckAT,SteerRA.BeckAnxiety

InventoryMan

ual.

SanAntonio,TX,ThePsychologicalCorporation,199

321

item

sassessingself-rep

orted

anxiety

Adults

Hypoglycem

iaFear

Survey-II

(HFS-II)

CoxDJ,IrvineA,Gonder-FrederickL,Nowacek

G,

ButterfieldJ.Fear

ofhypoglycem

ia:quan

tification,

validation,andutilization.D

iabetes

Care

1987

;10:617

–62

1(63)

33item

sassessingbeh

avioraland

worrydim

ensionsofh

ypoglycem

iain

adults

Adultswithtype1diabetes

Gonder-FrederickLA,SchmidtKM

,VajdaKA

,et

al.

Psychometricproperties

oftheHypoglycem

iaFear

Survey-IIforadultswithtype1diabetes.Diabetes

Care20

11;34

:801

–80

6(71)

Children’sHypoglycem

iaIndex

(CHI)

KampsJL,RobertsMC,V

arelaRE.

Developmen

tofa

new

fear

ofhypoglycem

iascale:

prelim

inaryresults.

JPediatrPsychol2

005;30

:287

–29

1

Designed

toassess

FoH(25item

s)Youth

(ages8–16

years)with

type1diabetes

Cognitivescreen

ing

inolder

adults

Mini-Men

talState

Exam

ination

(MMSE)

Folstein

MF,Folstein

SE,M

cHugh

PR.“M

ini-men

tal”

state:

apracticalmethodforgrad

ingthecogn

itive

stateofpatients

fortheclinician.JPsychiatrRes

1975

;12:189

–19

8

11-item

(30-point)screen

for

cogn

itiveim

pairm

entin

adults

Adults(ages18

–10

0years)

Crum

RM,A

nthonyJC,BassettSS,Folstein

MF.

Population-based

norm

sfortheMini-Men

talState

Exam

inationbyageanded

ucationallevel.JAMA

1993

;269

:238

6–23

91

TelephoneInterviewforCogn

itive

Status(TICS)

BrandtJ,Spen

cerM,Folstein

M.TheTelephone

InterviewforCognitiveStatus.Neu

ropsychiatry

Neu

ropsycholB

ehav

Neu

rol1

988;1:11

1–11

7

11-item

measure

assessingcogn

itive

statusbytelephone

Adults(ages60

–98

years)

BrandtJ,FolsteinMF.Teleph

oneInterviewforCog

nitive

Status

(TICS)

Profession

alM

anua

l.Lutz,FL,

PsychologicalA

ssessm

entResources,2

003

Cognitiveassessmen

ttoolkit

CordellC

B,B

orsonS,Boustan

iM,etal.Alzheimer’s

Associationrecommen

dationsforoperationalizing

thedetectionofcogn

itiveim

pairm

entduringthe

Med

icareAnnualWellnessVisitin

aprimarycare

setting.

AlzheimersDem

ent20

13;9:141–15

0

Designed

foruse

duringamed

ical

office

visitto

screen

forcogn

itive

impairm

entin

older

adults

(includes

inform

antinterviews

also)

Adults

Chronicpain

Short-form

McG

illPain

Questionnaire

(SF-MPQ

-2)

DworkinRH,TurkDC,RevickiDA,etal.Developmen

tand

initialvalidationofanexpanded

andrevisedversionof

theShort-form

McG

illPainQuestionnaire(SF-MPQ

-2).

Pain

2009;14

4:35

–42

22-item

questionnaire

designed

toassess

pain

Adults Con

tinuedon

p.21

31

2130 Position Statement Diabetes Care Volume 39, December 2016

other psychological states (e.g., depres-sion, anxiety, eating disorders, cognitiveimpairment) (3), aswell as health literacyand numeracy, should be monitored. Todetect problems early and prevent healthdeterioration, all PWD should be evalu-ated at the initial visit and on a periodicbasis going forward even if there is nopatient specific indication (4). In addition,evaluation is indicated during major dis-ease and life transitions, including theonset of complications and significantchanges in treatment (i.e., initiation ofinsulin pump or other forms of intensi-fication) or life circumstances (i.e., livingarrangements, job, and significant so-cial relationships), with prospectivemonitoring for 6 months (a period ofincreased risk) (5).

All care providers should includequeries about well-being in routinecare. Standardized and validated tools(Table 2) for psychosocial monitoring,assessment, and diagnosis can be usedby providers in a stepped sequence withpositive findings leading to further eval-uation, starting with informal verbal in-quiries for monitoring followed byquestionnaires for assessment (e.g.,PHQ-9) and finally by structured inter-views for diagnosis (e.g., StructuredClinical Interview for the DSM-V). Forexample, the diabetes care provider canask whether there have been changes inmood during the past 2 weeks or sincetheir last visit. Further, providers shouldconsider asking whether there arenew or different barriers to treatmentand self-management, such as feelingoverwhelmed or stressed by diabetesor other life stressors. Positive re-sponses can be probed with additionalquestions and/or use of standard-ized measures to inform assessmentand guide the selection of appropriateinterventions.

When referral is warranted (Table 1),formal diagnostic assessments and in-terviews should be conducted by a qual-ified behavioral health provider familiarwith the care of PWD. Standardized,age- and literacy-appropriate assess-ment and diagnostic tools should beused (Table 2). These established mea-sures were selected from a wider litera-ture on the basis of the scientific rigorused in their development and the avail-ability of norms for clinical use. The rec-ommendation of specific measures forclinical use is beyond the scope of this

Table

2—Continued

Topicarea

Measure

title

Citations

Description

Validated

population

Adheren

ceto

self-care

SummaryofDiabetes

Self-Care

Activities(SDSC

A)

ToobertDJ,Ham

psonSE,G

lasgowRE.

TheSummaryof

Diabetes

Self-CareActivitiesmeasure:resultsfrom

7studiesandarevisedscale.

Diabetes

Care

2000

;23:943

–95

0

11-item

andexpan

ded

25-item

measure

ofdiabetes

self-care

beh

aviors

Adultswithtype1andtype2

diabetes

Adheren

ceto

Refi

llsand

Med

icationsScale(ARMS-D)

Kripalan

iS,RisserJ,G

attiME,JacobsonTA

.Developmen

tandevaluationoftheAdheren

ceto

Refi

llsand

Med

icationsScale(ARMS)

amonglow-literacy

patients

withchronicdisease.ValueHealth

2009

;12:118

–12

3

11-item

self-rep

ortquestionnaire

designed

toassess

theextentto

whichpatientstake

andrefilltheir

diabetes-related

med

ications

Adults

Mayberry

LS,GonzalezJS,WallstonKA

,Kripalan

iS,

Osborn

CY.TheARMS-Doutperform

stheSD

SCA,b

ut

both

arereliable,valid,andpredictglycem

iccontrol.

Diabetes

Res

Clin

Pract20

13;10

2:96

–10

4Barriersto

diabetes

adheren

ceMulvaney

SA,H

oodKK

,SchlundtDG,etal.Developmen

tandinitialvalidationofthebarriersto

diabetes

adheren

cemeasureforadolescen

ts.D

iabetes

Res

Clin

Pract20

11;94

:77–

83

21-item

self-rep

ortquestionnaire

designed

toassess

barriersto

diabetes

self-carebeh

aviors

Adolescen

ts(ages12

–17

years)withdiabetes

care.diabetesjournals.org Young-Hyman and Associates 2131

statement. Care providers should imple-ment interventions to address the day-to-day problems of living with diabetes,particularly diabetes-related distress re-lated to self-management behaviors, aswell as diabetes-related family conflict(6–8). Support from a behavioral healthprovider may be effective when difficul-ties are persistent. However, as soon asthere is indication of a diagnosable psy-chological condition, consultation and/orreferral should be sought with a providerhaving the appropriate mental health ex-pertise. Standardized/validated interven-tion strategies specific to PWD should beutilized whenever possible.

PSYCHOSOCIAL ISSUESIMPACTING DIABETESSELF-MANAGEMENT

Recommendations

c People with diabetes should beevaluated and receive training un-til they attain competence in dia-betes self-care skills and the use oftechnologies at the time of diag-nosis, annually, if/when complica-tions arise, and if/when transitionsin careoccur. Thediabetes care teamis encouraged to directly and regu-larly assess these self-managementbehaviors. B

c Providers should consider the bur-den of treatment and patient levelsof confidence/self-efficacy for man-agement behaviors aswell as level ofsocial and family supportwhenmak-ing treatment recommendations. E

While following treatment regimensconsistently improves A1C (9–12), theimpact is modest. Multiple factorsother than patient behavior affect di-abetes treatment outcomes, includingadequacy of medical management, du-ration of diabetes, weight gain, andother health-related (e.g., comorbid ill-ness and concomitant medication) andsocial-structural factors (e.g., poverty,access to care, health insurance cov-erage) (13–16). Therefore, it is not ap-propriate to automatically attributesuboptimal A1C and adverse eventssuch as hypoglycemia (17) solely toself-management behaviors withouttheir direct assessment.Provider communications with patients/

families should acknowledge that multiplefactors impact glycemic management

but also emphasize that following collab-oratively developed treatment regimensand recommended lifestyle changes cansignificantly improve disease outcomesand well-being (14,18–20). Thus, thegoal of provider–patient communicationshould be to empower the PWD withoutblaming them for “noncompliance”whenthe outcomesof self-managementare notoptimal.

The familiar term, noncompliance,denotes a passive, obedient role forPWD in “following doctor’s orders” thatis at odds with the active role PWD areasked to take in directing the day-to-dayplanning, monitoring, evaluation, andproblem-solving involved in diabetes self-management (21). Patient perceptionsabout their own ability, or self-efficacy,to self-manage diabetes are one importantpsychosocial factor related to improved di-abetes self-management and treatmentoutcomes in diabetes (22–26) and shouldbe a target of ongoing assessment andtreatment planning.

Suboptimal self-management maybe due to functional limitations (e.g.,blindness, problems with dexterity, lowhealth literacy and numeracy), lack ofappropriate diabetes education, for-getting and disruption in routines, orpsychosocial barriers, such as inade-quate family and/or social support,misinformation or inaccurate beliefsabout illness and treatment, emotionaldistress/depressive symptoms, or deficitsin problem-solving or coping skills(23,27–30). Therefore, individual needsshould be evaluated so that inter-ventions can be tailored to the prob-lem (31–35). Self-report measures areavailable and can be used in mostpractice settings (see Table 2). Using anonjudgmental approach that normal-izes periodic lapses in self-managementmay help minimize patients’ resis-tance to reporting problems with self-management.

Making healthy food choices on adaily basis is among the most difficultaspects of diabetes self-care (36). Cur-rent medical nutrition therapy guide-lines promote flexible and healthyeating patterns personalized to the indi-vidual rather than defining a wide rangeof behaviors as dietary “nonadherence”(37). Self-monitoring of food intake mayhelp the individual with diabetes be-come more aware of their own eatingpatterns while providing information

that helps the registereddietitiannutrition-ist assist with meal planning and developpersonalized dietary recommendations.Through monitoring, it is important toassess for disordered eating behaviors(see DISORDERED EATING BEHAVIOR: CLINICAL AND

SUBCLINICAL).

DIABETES DISTRESS

Recommendation

c Routinely monitor people with di-abetes for diabetes distress partic-ularly when treatment targets arenot met and/or at the onset of di-abetes complications. B

Diabetes distress is very common and isdistinct from a psychological disorder(38–40). The constant behavioral demands(medication dosing, frequency, and titra-tion; monitoring blood glucose, food in-take and eating patterns, and physicalactivity) of diabetes self-managementand the potential or actuality of diseaseprogression are directly associated withreports of diabetes distress (39). Its preva-lence is reported to be 18–45% with anincidence of 38–48% over 18 months(41). High levels of diabetes distress signif-icantly impact medication-taking behav-iors and are linked to higher A1C, lowerself-efficacy, and poorer dietary and ex-ercise behaviors (39,41,42). It may behelpful to provide counseling regardingexpected diabetes-related versus gener-alized psychological distress at diagnosisand when disease state or treatmentchanges (43).

About one-third of adolescents withdiabetes develop diabetes distress,which may be associated with declinesin self-management behaviors and subop-timal blood glucose levels (44). Parents ofchildren with type 1 diabetes are alsoprone to diabetes distress (45), whichcould impact their ability to provide psy-chological and diabetes management sup-port for their child.

Diabetes distress should be routinelymonitored (46) using patient-appropriatevalidated measures (Table 2). If diabe-tes distress is identified, the personshould be referred for diabetes educationto address areas of diabetes self-carethat are most relevant to the patient andhave the most impact on diabetes out-comes. People whose self-care remainsimpaired after tailored diabetes educationshould be referred by their care team to a

2132 Position Statement Diabetes Care Volume 39, December 2016

behavioral health provider for evaluationand treatment.

PSYCHOLOGICAL COMORBIDITIES

Prevalence of clinically significant psy-chopathology in PWD ranges acrossdiagnostic categories, and some diag-noses are considerably more commonin PWD than in those without the dis-ease (47–52). Symptoms, both clinicaland subclinical, that interfere with theperson’s ability to carry out diabetesself-management must be addressed.

Depression

Recommendations

c Providers should consider annuallyscreening all patients with diabetesand/or a self-reported history of de-pression for depressive symptomswith age-appropriate depressionscreening measures, recognizingthat further evaluation will be nec-essary for individuals who have apositive screen. B

c Beginning at diagnosis of complica-tions or when there are significantchanges in medical status, considerassessment for depression. B

c Referrals for treatment of depres-sion should be made to mentalhealth providers with experienceusing cognitive behavioral ther-apy, interpersonal therapy, orother evidence-based treatmentapproaches in conjunction with col-laborative care with the patient’sdiabetes treatment team. A

History of depression, current depres-sion, and antidepressant medicationuse are risk factors for the developmentof type 2 diabetes, especially if the indi-vidual has other risk factors such as obe-sity and family history of type 2 diabetes(53–55).Elevated depressive symptoms and

depressive disorders affect one in fourpatients with type 1 or type 2 diabetes(47). Thus, routine screening for depressivesymptoms is indicated in this high-risk pop-ulation including people with prediabetes(particularly those who are overweight),type 1 and/or type 2 diabetes, gesta-tional diabetes mellitus, and postpar-tum diabetes. Regardless of diabetestype, women have significantly higherrates of depression than men (56).

Routine monitoring with patient-appropriate validated measures (Table 2)can help to identify whether referral iswarranted. Remission of depressivesymptoms or disorder in adult patientssuggests the need for ongoing monitor-ing of depression recurrence within thecontext of routine care (53).

Integrating mental and physicalhealth care can improve outcomes.The mental health provider should beincorporated into the diabetes treat-ment team when a patient is in psycho-logical therapy (talk therapy) (57).Incorporation of a physical activity reg-imen into routine self-managementhas also been shown to improve thehealth and mental well-being of PWD(58,59). Please refer to the PositionStatement of the American DiabetesAssociation (ADA) on physical activity/exercise and diabetes (60) for addi-tional information.

Anxiety Disorders

Recommendations

c Consider screening for anxiety inpeople exhibiting anxiety or worriesregarding diabetes complications,insulin injections or infusion, takingmedications, and/or hypoglycemiathat interferewith self-managementbehaviors and in those who expressfear, dread, or irrational thoughtsand/or show anxiety symptomssuch as avoidance behaviors, exces-sive repetitive behaviors, or socialwithdrawal. Refer for treatment ifanxiety is present. B

c People with hypoglycemia un-awareness, which can co-occurwith fear of hypoglycemia, shouldbe treated using Blood GlucoseAwareness Training (or otherevidence-based similar interven-tion) to help re-establish aware-ness of hypoglycemia and reducefear of hypoglycemia. A

Anxiety symptoms and diagnosabledisorders (e.g., generalized anxiety disor-der [GAD], body dysmorphic disorder,obsessive compulsive disorder [OCD],specific phobias, and posttraumaticstress disorder [PTSD]) are common inPWD (61); the Behavioral Risk FactorSurveillance System estimated thelifetime prevalence of GAD to be 19.5%in people with either type 1 or type 2

diabetes (62). Common diabetes-specificconcerns include fears related to hyper-glycemia (63,64), not meeting blood glu-cose targets (61), and insulin injectionsor infusion (65). General anxiety is a pre-dictor of injection-related anxiety andassociated with fear of hypoglycemia(FoH) (64,66).

Preoccupation with an imagined de-fect in appearance associated withhaving diabetes that interferes with so-cial, occupational, or other importantareas of function may reflect body dys-morphic disorder (51). When ideas andsymptoms (e.g., perceived deficits instrength, attractiveness, and sexualfunction) do not reach the level of clin-ical diagnosis, identification of thesebeliefs provides a context for providereducation about disease processes,reframing disease processes as distinctfrom the emotional response to hav-ing diabetes and questioning the in-evitability of health decline. Onsetof complications presents anothercritical point where these thoughts/beliefs can occur and may requirere-education and disease-based coun-seling (67).

If the PWD exhibits excessive diabe-tes self-management behaviors wellbeyond what is prescribed or neededto achieve glycemic targets, reports re-petitive negative thoughts about inabil-ity to prevent poor health outcomes,and/or has related thoughts and behav-iors that interfere with other functionsof daily living, the PWD may be experi-encing symptoms of OCD (68). OCDsymptoms can represent generalizedanxiety or be diabetes specific, and re-ferral to a mental health professional(such as a psychiatrist) familiar withOCD treatment should be considered,especially if diabetes re-education doesnot prove effective in reducing obsessivethoughts, behaviors, or feelings of gen-eral anxiety. Caution should be exercisedin diagnosing OCD-like symptoms, asregimen behaviors contain similar char-acteristics, such as repetition, and areaimed at achieving control over a per-ceived threat.

FoH and hypoglycemia unawarenessoften co-occur, and interventionsaimed at treating one often benefitboth (69). FoH may explain avoidanceof behaviors associated with loweringglucose such as increasing insulin dosesor frequency of monitoring. If FoH is

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identified and a person does not havesymptoms of hypoglycemia, a struc-tured program, Blood Glucose Aware-ness Training, delivered in routineclinical practice can improve A1C, re-duce the rate of severe hypoglycemia,and restore hypoglycemia awareness(70,71). Such improvements in diseasestate have been shown to reduce diabe-tes distress and improve psychologicalwell-being (69,72,73).Occurrence of severe hypoglycemia

has been shown to be associated withPTSD and PTSD-like and panic disordersymptoms (74,75). The potential for in-creased prevalence of PTSD and panicdisorder in this population, though notwell studied, is intuitive given the po-tentially life-threatening nature of thedisease, particularly for those who useexogenous insulin. Given that poten-tial stimuli for PTSD-like symptomsare recurrent for PWD, PTSD shouldbe considered among other anxietydisorders.

Disordered Eating Behavior: Clinicaland Subclinical

Recommendations

c Providers should consider re-evaluating the treatment regimenof people with diabetes who pre-sent with symptoms of disorderedeating behavior, an eating disorder,or disrupted patterns of eating. B

c Consider screening for disorderedor disrupted eating using vali-dated screening measures whenhyperglycemia and weight loss areunexplained by self-reported be-haviors related to medication dos-ing, meal plan, and physical activity.In addition, a review of the medicalregimen is recommended to iden-tify potential treatment-related ef-fects on hunger/caloric intake. B

Estimated prevalence of disorderedeating behaviors and diagnosable eatingdisorders in PWD varies (51,76,77). PWDwith diagnosable eating disorders havehigh rates of comorbid psychiatric dis-orders (78). People with type 1 diabetesand eating disorders have high rates ofdiabetes distress and FoH (79). For peo-ple with type 1 diabetes, insulin omis-sion causing glycosuria in order to loseweight is the most commonly reporteddisordered eating behavior (80,81), and

in people with type 2 diabetes, bingeing(excessive food intake with an accompa-nying sense of loss of control) is mostcommonly reported. For people withtype 2 diabetes treated with insulin, in-tentional omission is also frequently re-ported (82). Binge eating disorder hasbeen found to be more likely in PWDthan in the nondiabetes population,though studies of prevalence in specific di-abetes samples showvarying rates (77,83).Other diagnostic categories of eatingdisorders have a very low prevalence inPWD (77).

Potential confounders to the identifi-cation of symptoms of disordered eatingare behaviors that are prescribed as partof treatment (e.g., carbohydrate count-ing and calorie restriction), behaviors oreffects that are part of the disease (e.g.,loss of control over satiety regulationsecondary to disease processes), andadverse effects of treatment such as ex-cessive hunger secondary to hypogly-cemia. When evaluating symptoms ofdisordered or disrupted eating in PWD,etiology andmotivation for the behaviorshould be considered (51,84). For exam-ple, missed insulin injections as a resultof suboptimal self-management differsignificantly from intentional medica-tion omission to produce weight loss.Assessment and screening of disor-dered and disrupted eating requiresmethods that account for treatmentprescription, regimen behaviors, anddiabetes-specific eating problems at-tributable to disease processes (see Ta-ble 2). If night eating syndrome, whichis recurrent eating at night either afterawakening from sleep or excessive eat-ing after dinner, is diagnosed, changesto the medication regimen are re-quired until maladaptive eating pat-terns can be modified (85). Adjunctivemedication such as glucagon-like peptide1 receptor agonists (86) may not onlyhelp individuals meet glycemic targetsbut also help regulate hunger andfood intake, thus having the potentialto reduce uncontrollable hunger andbulimic symptoms.

Serious Mental Illness

Recommendations

c Annually screen people who areprescribed atypical antipsychoticmedications for prediabetes/diabetes. B

c Incorporate monitoring of diabetesself-care activities into treatmentgoals in people with diabetes andserious mental illness. B

Studies of people with serious mentalillness, particularly schizophrenia andother thought disorders, show signifi-cantly increased rates of type 2 diabetes(87). People with schizophrenia shouldbe monitored for type 2 diabetes be-cause of the known comorbidity. Disor-dered thinking and judgment can beexpected to make it difficult to engagein behaviors that reduce risk factors fortype 2 diabetes, such as restrained eatingfor weight management. Individuals withmajor psychiatric disorders may needconsistent monitoring and oversightin their diabetes management, even ifthought disorders remit. Coordinatedmanagement of diabetes or prediabetesand serious mental illness is recommendedto achieve diabetes treatment targets. Inaddition, those taking olanzapine requiregreater monitoring because of an increasein riskof type2diabetesassociatedwith thismedication (88). Further study is needed toexamine the association of other antipsy-chotic medications with the onset of diabe-tes and glycemic management (48,89).

LIFE COURSE CONSIDERATIONS

PWD are diagnosed earlier (e.g., type 2diabetes in childhood) (90) and living longer(48). At each point in the life course, pro-viders should considerwhich resources andaccommodations are needed to maximizedisease outcomes andwell-being. In partic-ular, identification of psychosocial factorsinfluencing self-management are recom-mended (e.g., culture, environment, socialdeterminants, life roles and responsibilities,and interpersonal dynamics, as well asperson-based characteristics such as sex,race/ethnicity, age, language, and socioeco-nomic status) (91).

Youth and Emerging Adults

Recommendations

c At diagnosis and during routinefollow-up care, consider assessingpsychosocial issues and familystresses that could impact diabetesmanagement and provide appro-priate referrals to trained mentalhealth professionals, preferably ex-perienced in childhood diabetes. E

2134 Position Statement Diabetes Care Volume 39, December 2016

c Providers should consider monitor-ing youth and their parents aboutsocial adjustment (peer relation-ships) and school performance todetermine whether further evalua-tion is needed. B

c Consider assessing youth with di-abetes for generic and diabetes-related distress starting at about7–8 years of age. B

c Providers should encourage devel-opmentally appropriate family in-volvement in diabetes managementtasks for children and adolescents,recognizing that premature transferof diabetes care to the child can re-sult in poor self-management behav-iors and deterioration in glycemicmanagement. A

c Consider the inclusion of childrenin consent processes as early ascognitive development indicatesunderstanding of health conse-quences of behavior. E

c Adolescentsmay have timeby them-selves with their care provider(s)starting at age 12 years. E

c Providers should consider initiat-ing discussions about care transi-tion to an adolescent medicine/transition clinic/adult provider nolater than 1 year prior to startingthe transfer but preferably duringearly adolescence (;14 years ofage). E

c Consider monitoring support fromparents/caretakers of emergingadults with diabetes and encourag-ing instrumental support (e.g.,ordering supplies) and collaborativedecisionmaking among caregivers. E

c Starting at puberty, preconceptioncounseling should be incorporatedinto routine diabetes clinic visits forall femalesof childbearingpotential.A

c Consider counseling males, start-ing at puberty, regarding adoptionof a healthy lifestyle to reduce riskfor sexual dysfunction. E

Given the rapid and dynamic natureof cognitive, developmental, and emo-tional changes in youth, early detectionof depression, anxiety disorders, eatingissues, and learning disabilities enhancethe range and effectiveness of potentialtreatment options and may help to min-imize adverse effects on diabetes man-agement and disease outcomes.

Because youth are dependent on socialsupport systems (family and care providers)and must eventually transition to indepen-dent diabetes self-management, their fam-ilies and related social networks need to beincluded in psychosocial assessment andtreatment (92–94). Parents of childrenwith type 1 diabetes are prone to high ratesof depression, especially around the timeofdiagnosis (95,45). Persistence of parentaldepression is associated with poorer childadjustment and diabetes management,especially in younger children (96).Teaching family members effectiveproblem-solving and conflict-resolutionskills can improve diabetes manage-ment and facilitate better glycemicmanagement, with the potential to re-duce diabetes distress (92).

The adolescent years are known for dis-ruption in diabetes care and communica-tion between family members, youth, andproviders. Hallmarks of normal adoles-cence are increased independence in de-cision making and turning to the peergroup for validation of self-concept andself-worth. Wishing to “fit in”may contrib-ute to youth hiding or minimizing diabetescare behaviors, thereby compromisingmanagement in the school setting (97).Cognitive development and medicaldecision-making skills will impact a widevariety of risk-taking behaviors and accep-tance of self-management behaviors intodaily life (98,99). Suboptimal glycemicmanagement should not automaticallybe attributed to adolescent rebellion orlack of concern for health. A thorough age-appropriate psychosocial evaluation andreview of themedical regimenwill suggesttargets for modification to facilitate self-management andwell-being. If the adoles-cent is resistant to accepting support fromclinicians, family, and friends, the possibil-ity of a more serious psychological issuemust be considered and evaluated.

Although legal and ethical issues ofyouth accepting or refusing treatmentcomponents (e.g., an insulin pump) hasnot been extensively studied, these is-sueswill undoubtedly surface in the pro-cess of treatment decisions. Thus, theissue of treatment consent must be con-sidered when making regimen choices.Although cognitive abilities vary, theethical position often adopted is the“mature minor rule,” whereby childrenafter age 12 or 13 years who appearto be “mature” ought to have the rightto consent or to withhold consent to

general medical treatment, except incases in which refusal would signifi-cantly endanger health (99). Emergingtechnologies, such as phone and com-puter transmission of managementdata, can be useful in maintaining com-munication of information through non-confrontational channels and mayprovide a means for youth to communi-cate directly with care providers as theytransition to more independent self-management (100).

Adolescents should have time by them-selves with their care provider(s) startingat age 12 years. Care should be taken torespect a teen/young adult’s privacy, aslack of confidentiality is known to nega-tively affect adolescents’ health behavior,especially regarding what are consideredtaboo or risky behaviors (101). Discussionswith adolescents should include questionsabout well-being in general, diabetes dis-tress, and risk behaviors (e.g., substanceuse and sexual activity) (102,103).

Preconception counseling for femalesduring reproductive years increases knowl-edge about diabetes-related risk, delaysage of sexual initiation, decreases unpro-tected sex, and improves preconceptioncare and health (104,105). Less researchis available regarding sexual health formales, particularly in youth; however,males with diabetes have a threefold in-creased risk of erectile dysfunction com-pared with men who do not have diabetes(106,107). Open and factual discussions ofthese topics facilitate future comfort in dis-closing any concerns regarding sexual func-tion.As less frequentattendance todiabetescare visits is typical in the 18- to 30-year-oldage-group, screening regarding risk behav-iors may be necessary at each visit.

Adults

Recommendations

c In the care of adults with childbear-ing potential, includea discussionoflife choices that could be impactedby diabetes self-management,such as pregnancy and sexualfunctioning. B

c Providers should consider assessingfor the presence of social supportproviders (e.g., family, peer support,lay diabetes educators/caretakers)whomay facilitate self-managementbehaviors, reduce burden of illness,and improve diabetes and generalquality of life. B

care.diabetesjournals.org Young-Hyman and Associates 2135

As people enter adulthood, establish-ment of a work role, intimate partner-ing, childbearing, and parenting aretypical life tasks (7). Living with andself-managing diabetes can be expectedto impact all life-course decisions forPWD and their partners. PWDmay ques-tion whether intimate partnering andbiological parenthood are viable in thecontext of their health status (108).High-quality relationshipswith and diabe-tes management support from intimatepartners improve diabetes-specific andgeneral quality of life, self-managementbehaviors, and metabolic outcomes (7).Partner roles may change if functionalability is impacted by poor health out-comes (109). Sexual dysfunction is oftenassociated with depression and is rou-tinely reported in clinical encounters(see DEPRESSION). In one study of individ-uals with type 1 diabetes, sexual dys-function was reported in as many as50% of male patients (107). It is beyondthe scope of these guidelines to discusspsychosocial issues related to preg-nancy and gestational diabetes mellitus(see ref. 110).

Older Adults

Recommendations

c Annual screening for early detec-tion of mild cognitive impairmentor dementia is indicated for adultsaged 65 years or older. B

c Assessment of neuropsychologicalfunction and dementia using avail-able standards for conducting evalu-ations of dementia and age-relatedcognitive changes is recommended.E

c Within the primary care setting, acollaborative care model, incorporat-ing structured nurse care manage-ment intervention, is recommendedfor treatment of comorbid depres-sion in older adults with diabetes. A

Older adults with diabetes may befunctional and cognitively intact andhave significant life expectancy, andthey may not require psychosocial carebeyond that of younger adults. However,older adults may have issues particular totheir age, such as advanced disease,cognitive dysfunction, complex treatmentregimens, comorbid health conditions,functional impairment, limited socialand financial resources, and depression(111). Meeting glycemic targets may be

impacted by unique nutritional require-ments, physical limitations (such as re-duced sensation), memory loss, and lowliteracy and numeracy skills. As olderadults with diabetes may receive caresupport from family members and staffat assisted living facilities, during hospital-izations, and in long-term care facilities,the treatment regimen must considercontext and caregiver capacities. Supportpeople (e.g., adult children, caretakers)who provide instrumental, social, or emo-tional support for older adults with di-abetes should be included in diabetesmanagement discussions and shareddecision making.

Psychosocial targets for intervention in-clude self-management support, access tohealth care, and financial and emotionalsupport, as well as day-to-day facilitationof physical and mental well-being. Withinthe primary care setting, older adults withdiabetes and comorbid depression arelikely to benefit from a collaborative careintervention approach, which uses a nursecaremanager supervised by a primary carephysician and psychiatrist (58,112,113).

Compared with older adults withoutdiabetes, those with the disease are atan increased risk of mild cognitive impair-ment (114). A meta-analysis of prospec-tive and observational studies in PWDshowed a 73% increased risk of all typesof dementia, a 56% increased risk ofAlzheimer dementia, and a 127% in-creased risk of vascular dementia com-pared with individuals without diabetes(115). For detection of cognitive dysfunc-tion, people .65 years of age should re-ceive cognitive screening annually withinroutine health care, using recommendedprocedures and resources for practi-tioners (Table 2) (116–118). Medicalproviders should address reversiblecontributors to cognitive dysfunctionincluding but not limited to depression,combinations of medications, thyroiddisease, and delirium (116).

PWD in Need of SpecialConsiderations

People With Diabetes Complications and

Functional Limitations

Recommendation

c Care providers should consider rou-tinely monitoring for chronic painassociated with diabetes complica-tions and its impact on quality oflife. Appropriate pain management

interventions, including referral to abehavioral health provider for painmanagement strategies, should beprovided. B

Diabetes complications, including pe-ripheral neuropathy, foot ulcers, limbamputation, diabetic kidney disease, vi-sion impairment, stroke, and heart at-tack, are associated with depression,anxiety, reduced autonomy, role impair-ment, and reduced overall physical func-tion and quality of life (119–122). Fear ofcomplications is a major component ofdiabetes distress, and depression asso-ciated with complications increasesmortality (123,124). Care should betaken when discussing rates, causes,and probability of diabetes complica-tions. Providers should acknowledgethat discussing complications can be un-comfortable and distressing and shouldencourage dialogue over multiple visits.

Chronic pain from neuropathy is asso-ciated with prevalent psychosocial dis-tress, depression, and sleep disturbance(125,126). Care providers should routinelymonitor for chronic pain associated withdiabetes complications and its impact onquality of life. Appropriate pain manage-ment therapies, including referral to a men-talhealthprovider forpainself-managementstrategies, should be provided.

Onset of diabetes complicationsthreatens independence, self-image,and quality of life. To identify the levelof self-care independence and neces-sary adjunctive supports, providersshould evaluate whether individualshave a cognitive impairment impactingthe ability to do a task (e.g., poor mem-ory or information processing), a func-tional limitation that interferes withtask performance (e.g., poor motor con-trol or impaired vision), a disability thatimpacts doing the task without assis-tance or accommodation (e.g., paralysisor amputation); or a combination of theabove (127). Unless limitations are pro-found and/or formal evaluation clearlydetermines decreased capabilities, pro-viders should not assume a patient isunable to self-manage. Reassessmentof self-management efficacy, abilities,and need for adaptations or assistanceis indicated with the onset or worseningof functional limitations or disabilitiesincluding vision, hearing, or physical im-pairment. For example, people with

2136 Position Statement Diabetes Care Volume 39, December 2016

visual disability may benefit from mate-rials that meet low-vision guidelines(128).

Bariatric Surgery

Recommendations

c People presenting for bariatricsurgery should receive a compre-hensive mental health assess-ment by a professional familiarwith weight-loss interventionsand postbariatric surgery behav-ioral requirements. B

c If psychopathology is evident, par-ticularly suicidal ideation and/orsignificant depression, postpone-ment of surgery should be consid-ered so that patient suffering canbe addressed before adding theburden of recovery and lifestyle/psychosocial adjustment. E

c For people who undergo bariatricsurgery, consider assessment forneed of ongoing mental healthservices to help them adjust tomedical and psychosocial changespostsurgery. C

Bariatric surgery supports weight lossin people with severe obesity, often withadjunctive remission of type 2 diabetes(129,130). People presenting for bariat-ric surgery have increased rates of de-pression and other major psychiatricdisorders compared with healthy peopleand are prone to clinically significantbody image disorders, sexual dysfunc-tion, and suicidal behavior (131). Psycho-social well-being and depression,anxiety, and self-care behaviors shouldbe an essential component of the pre-and postsurgical evaluation and moni-tored during the year after surgery (132).People with preoperative psychopa-

thology should be assessed at regular in-tervals following surgery to optimizecontrol over psychiatric conditions andto ensure that psychiatric symptoms donot interfere with weight loss and/or life-style change. History of eating patterns,disorderedeatingbehaviors, and clinicallysignificant eating disorders, includingnight eating syndrome, should be evalu-ated and monitored pre- and postsurgi-cally at regularly scheduled medicalmanagement visits. Bariatric surgery inand of itself does not alleviate psychiatricsymptoms, but it may result in remissionof food addiction among those who wereextremely obese (133).

CONCLUSIONS: PSYCHOSOCIALCARE IN CONTEXT

PWD must master many complex tasksand behaviors to successfully incorpo-rate diabetes care into daily life. Diseasemanagement cannot be successful unlessthe lifestyle and emotional status of theindividual is taken into consideration. Asdetailed in this Position Statement, rou-tine monitoring and screening for diabe-tes distress, depression, anxiety, eatingissues, and appropriate levels of socialand family support, as well as contextualfactors that impede implementation ofcare, are clearly indicated. Effectivenessof regimen and care provision will be en-hanced by the inclusion of behavioralhealth services into the diabetes treat-ment team. Collaborative care showsthe most promise for supporting physicaland behavioral health outcomes.

The integration of screening into clinicalsettings, with appropriate referrals to qual-ified mental health professionals for rea-sons noted in Table 1, can improveoutcomes. Challenges to accomplishingthis standard of care are considerable,including too few qualified mental healthprofessionals who understand living withdiabetes and medical care models thatare not conducive to team care. Those inmost need, the disadvantaged lower socio-economic level families, have the poorestaccess to diabetes services (134). The psy-chosocial services recommended are reim-bursable for mental health providers inroutine medical care under Centers forMedicare & Medicaid Services (CMS). Inaddition, new CMS reimbursement isplanned for the Collaborative Care Modelin routine care. With changing laws man-dating minimum standards and paymentfor diabetes care services (135) and theavailability of low-cost insurance that alsoreimburses preventive services, this bal-ance is changing, allowing the practitionerto incorporate previously unsupported ser-vices into routine practice. Knowing howto evaluate and treat common psychoso-cial issues that impact PWD can informroutine care. The integration of psychoso-cial care and ensuring access to serviceswill benefit the PWD and the care team.

Acknowledgments. The process leading to aPosition Statement regarding guidelines forthe psychosocial care of PWD originated duringthe tenure of Dr. Richard Rubin as President,Health Care & Education, ADA, 2006–2007. His

leadership in the field of behavioral diabeteshelped establish the importance of psychoso-cial care for success in promoting the healthand well-being of those affected by diabetes.The authors also thank Dr. David Marrero,President, Health Care & Education, ADA,2013–2015, for his support of this effort.The authors acknowledge the following contrib-

utors to the book Psychosocial Care for People withDiabetes, which provided the foundation materialfor this article: Linda Gonder-Frederick, Daniel Cox,Harsimran Singh, Jaclyn Shepard, Clarissa Holmes,Christopher Ryan, Garry Welch, Sofija Zagarins,Paula Trief, Lori Laffel, Judith Wylie-Rosett, BrookBailer, ThomasWadden, Lucy Faulconbridge, DavidSarwar, Richard Rubin, Tim Wysocki, BarbaraAnderson, David Marrero, Jill Weissberg-Benchell,Suzanne Bennett Johnson, and Linda Delahanty.Funding. M.d.G. was funded in part by the Na-tional Institute of Diabetes and Digestive and Kid-ney Diseases (R18-DK-092765). J.S.G. is supportedby grants from the National Institute of Diabetesand Digestive and Kidney Diseases, National Insti-tutes of Health (R01-DK-104845, R18-DK-098742,and P30-DK-111022).The content and views represent those of the

authors and do not represent the position of theNational Institutes of Health.Duality of Interest. F.H.-B. is a member of theADA Board of Directors. K.H. has served as aconsultant to Bigfoot Biomedical and Johnson &Johnson Diabetes Institute and has received re-search support from Dexcom. M.P. has receivedresearch grants from Bristol-Meyers Squibb,Genentech, andNovoNordisk; has received consul-ting fees from AstraZeneca, Calibra, Genentech, EliLilly, and Novo Nordisk; has received speaking hon-oraria from Novo Nordisk; and has participated inadvisory panels for GlaxoSmithKline, Eli Lilly, andNovo Nordisk. No other potential conflicts of inter-est relevant to this article were reported.

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