Comment on Young-Hyman et al. Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016;39:2126–2140

Our goal is to provide constructive commentary on the 2016 American Diabetes Association Position Statement on psychosocial care (1). We fully support an evidence-based approach to update these guidelines; however, we also hold the opinion that some of these recommendations go beyond the current state of knowledge and also fail to address issues central to psychosocial aspects of diabetes. We describe two examples.

First, this Position Statement recommends “routine screening” for depressive symptoms among those who have prediabetes or are at high risk of developing diabetes (1). From our perspective, there is little evidence that supports routine screening in people with prediabetes, as the prevalence of depression is not elevated among adults with prediabetes compared with those without (2). Thus, the positive predictive value of such screening in terms of accurately identifying individuals in need of appropriate mental health care is substantially attenuated.

Second, the Position Statement does not substantively address the intersection between psychosocial care and persistent disparities in diabetes burden and quality of care that impact racial/ethnic minorities and individuals of low socioeconomic status (SES). Racial/ethnic minorities and individuals with low SES are substantially more likely to develop diabetes, experience diabetes-related complications, and die of diabetes than non-Hispanic whites and those with higher SES (3). This new Position Statement does not include the terms “disparity” and “inequality” even once in its text (excluding citations) (1). The Position Statement notes that “identification of psychosocial factors influencing self-management are recommended (e.g., culture, environment, social determinants, life roles and responsibilities, and interpersonal dynamics, as well as person-based characteristics such as sex, race/ethnicity, age, language, and socioeconomic status)” (1). However, this diffuse language discounts decades of research showing substantial, and potentially growing, disparities in diabetes incidence, prevalence, outcomes, quality of care, and mortality by race/ethnicity and SES (3). Moreover, these types of recommendations do not provide specific guidance as to how such factors should be incorporated into diabetes care.

While Standards of Medical Care in Diabetes—2016 (4) notes the need to assess factors like SES, health literacy, competing demands, etc., it provides relatively little guidance as to what providers should do after evaluating these barriers. Recommendations such as “Treatment goals and plans should be individualized. . . . Health care providers should consider the patient’s age, school/work schedule and conditions, physical activity, eating patterns, social situation, cultural factors, diabetes complications, health priorities, other medical conditions, preferences for care and self-management, and life expectancy” (4) leave us struggling with questions as to what “consideration” means in the case of diabetes management and whether the evidence cited for these suggestions illustrates clinically significant benefits for doing so. Without specific, pragmatic guidance as to what to do (and not do), we worry that providers may potentially make broad assumptions about what particular disparity groups need, which may have the unintended consequence of reducing quality of care (5).

We call for continued dialogue on what we know, and do not know, about how psychosocial factors influence disparities in diabetes burden and for a research agenda that specifically aims to fill the knowledge gaps identified by this discussion.