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

We read with great interest the American Diabetes Association’s position statement on psychosocial care for people with diabetes by Young-Hyman et al. (1). This statement complements previous international guidelines, including those of the International Society for Pediatric and Adolescent Diabetes and the International Diabetes Federation (2,3), underscoring the importance of psychosocial care in the context of diabetes management. We commend the authors for their efforts to offer a comprehensive overview of psychosocial problems that warrant our attention along with a set of evidence-based recommendations. There are two issues that in our view deserve more attention.

First, although the authors acknowledge that psychological well-being is an important outcome of diabetes care, the recommendations are all focused on mental ill health. It is important to recognize that the absence of a (serious) mental health problem does not necessarily equate to well-being or good “quality of life.” This has repercussions for language and communication with the person with diabetes. We feel it is important to adopt a positive, affirmative approach to the psychosocial needs of the person with diabetes. If we want all diabetes care providers to deliver emotionally informed care, we should avoid overpathologizing the experiences of individuals with diabetes into ill health states as opposed to well-being states. In essence, the first question (to all individuals with diabetes) should be “How well are you doing?” rather than a screening question for an eating disorder, depression, or other psychopathology. We recommend including a positively framed measure of emotional well-being in routine assessment (e.g., World Health Organization Well-Being Index [WHO-5]) either as a first step or alongside a measure of emotional distress. There is real-world evidence demonstrating the acceptability and effectiveness of such an approach (4).

Second, and related to the previous point, the practice of screening deserves more thought, particularly with respect to patient acceptance. We should be aware that from the perspective of the person with diabetes, screening for psychopathology is not always welcomed, for example, because of fear of stigmatization or low confidence in mental health services (5), and more so when screening becomes a routine procedure of simply “ticking the box.” Also, a questionnaire score indicative of a mental health problem is not to be confused with a felt need for psychological care. Too often people with diabetes report high distress but do not express a need for professional help. Asking the question “Do you want support for these problems, professionally or otherwise?” is just as important as knowing whether a person is distressed. It is therefore imperative that if screening is applied as recommended by Young-Hyman et al. (1), then diabetes health care teams are trained to do so in a constructive, patient-friendly manner and are able to make available culturally acceptable, affordable evidence-based treatment options in response to the identified psychosocial needs. We suggest putting more emphasis on these requirements when recommending screening for psychosocial problems as part of routine diabetes care.