As Lawrence Fisher recalls, something profound happened during a visit to his primary care physician.
“After I went through my list of prepared questions,” Fisher says, “he looked at me and asked, ‘OK, now what is it your wife told you to ask me?’”
Fisher is a professor of Family and Community Medicine at the University of California. He specializes in depression and diabetes care and, more specifically, how clinicians can improve outcomes for patients with chronic diseases. Yet with one small question, his doctor managed to crystalize something Fisher had learned over decades.
Sometimes simple gestures that connect with patients to show empathy and understanding can go a long way to relieving the stress of medical interactions.
Mental health has long been known as a determinant of physical health, a fact made painfully obvious during a pandemic. For those living with chronic conditions, such as diabetes, stress, isolation and uncertainty can bring on anxiety and depression, which in turn can lead to poorer self-care and worsening physical conditions. Add to that, diabetes increases the risk for cardiovascular disease—the number-one cause of death for patients with diabetes, according to the American Diabetes Association—and a challenging health picture emerges.
From Diagnosis to Daily Life
Receiving a diagnosis of a chronic disease is fraught with emotions, uncertainty and, potentially, heightened anxiety around impending lifestyle changes. In the case of diabetes, meal planning, blood glucose monitoring, insulin dosing and regular exercise become the new normal, and the enormity of confronting the condition can leave patients feeling emotionally drained.
If left unchecked, these emotional and mental burdens—often called diabetes burnout—can start a downward spiral of complications, made all the more serious from the inherent risk of associated heart disease.
Difficult though this may be, methods exist to help manage stress and open more effective channels of communication between health-care providers and patients, as well as between patients and their support networks, including partners, friends and community groups. The challenge is translating that knowledge from physicians’ journals to patients.
A Fresh Look from the Forum
This past May, Scientific American’s Custom Media division hosted a virtual salon event supported by Know Diabetes by Heart, a joint initiative of the American Heart Association and the American Diabetes Association, to explore the mental health components of diabetes and heart disease and how best to manage them.
Serving as moderator, I engaged Dr. Fisher at this roundtable event, along with Drs. Paula Trief, Distinguished Service Professor of Psychiatry and Behavioral Sciences and Medicine at the State University of New York Upstate Medical University, and Kenneth Freedland, Professor of Psychiatry and Psychology at the Washington University School of Medicine.
These three leading experts challenged some of the conventional wisdom and myths around mental health and disease. They explored diabetes and heart disease care management for clinicians and patients through awareness, support, transparency and an appreciation for the power of integrated care.
Breaking the Hopeless and Helpless Cycle
One of the most basic obstacles for a patient suffering from chronic disease and depression is to overcome two powerful forces: feelings of hopelessness and helplessness.
“Hopelessness is the feeling that nothing is ever going to get any better,” Trief said at the event. “Helplessness is the feeling that there is nothing a person can do to make things better.”
When a patient with diabetes is caught in this “hopeless-helpless” mindset, it can be difficult to change deleterious lifestyle habits. Eating well and exercising regularly can seem impossible tasks, while self-administering insulin injections and following health guidelines can slip. “Self-care is impacted by those feelings,” Trief said.
Freedland added that for some individuals with chronic disease, particularly those with heart conditions, fear can fuel the inability to adopt better lifestyle habits.
“Part of the challenge is that people often are afraid of doing things they used to do because of their illness,” he said. “When someone develops heart disease, they may feel like if they go out for a walk, they might drop dead in this street, so I better stop exercising all together.”
Freedland stressed that in such scenarios, clinicians have to remind patients that under the right conditions more exercise is good and will do much to improve their condition. That simple act of communication can start to break the hopeless-helpless cycle. “To help people deal with self-care,” he said, “we need to address fears and uncertainties.”
Emotions Are as Important as Clinical Conditions
Early in the discussion, Fisher noted that patients do not need a clinically diagnosed condition (depression, clinical anxiety, eating disorders, etc.) for mental health to impact a chronic disease, such as diabetes. The pressure to keep up with diet, keep track of an at times overwhelming number of caregivers or be labeled as a person with diabetes can all increase stress and the risk of diabetes and associated cardiovascular disease.
“Frankly, I don’t know of anybody with a chronic disease who doesn’t worry about it at some level,” Fisher said. “How they worry, how it’s dealt with, and how people interact with you around it is all very impactful.”
In this regard, caregivers can help patients by simply encouraging transparent dialogue and setting realistic goals for improvement and progress. Fisher, later in the conversation, pointed out that in a typical provider-patient interaction, usually 80 percent of the dialogue is initiated by the health provider. The goal, according to him, should be more like 50 percent or an equal give and take. That can help patients feel more in control of their care and like they have more agency in realizing their potential for improvement.
Towards Better Outcomes
In exploring mental health and its impact on diabetes and heart disease, all of the participants advocated for a more integrated structure for health care. Freedland pointed to some models, like the Veterans Administration, in which mental health care is embedded in the total patient experience. The health-care ecosystem needs to include primary care providers, specialists, mental health professionals, community groups and other public resources. Additionally, mental health challenges can stem from economic and social conditions, so greater attention to societal equity can help guide the direction of care.
As all noted in the discussion, we live in an era where health-care professionals are placing a greater focus on the stresses and anxieties of chronic disease than in the past. Entities such as KnowDiabetesByHeart.org provide clinicians, patients and their allies with many helpful resources to assist in diabetes care, cardiovascular risk mitigation and mental health considerations.
For information and tools to manage type 2 diabetes and heart disease, visit KnowDiabetesByHeart.org.
