Mental health support lacking in U.S. diabetes care

(Reuters Health) - Most of the top diabetes treatment centers in the U.S. provide experts in hormonal disease, diet and nutrition and diabetes education as part of normal care, but mental health support is still not standard, researchers say.

In a survey of 37 top institutions, most of them treating thousands of diabetes patients per year, barely 4 in 10 said they had a behavioral health professional integrated into the practice, and even these were typically just part-time.

In contrast, 100 percent had full-time hormone specialists known as endocrinologists, 98 percent had diabetes educators and 92 percent had registered dieticians and nurse practitioners, the study team reports in a research letter to the journal Diabetes Care.

Past research “suggests that psychosocial interventions . . . improve diabetes outcomes and that behavioral interventions aimed at changing self-management behaviors have been associated with improvements in quality of life,” lead author Samantha Barry, Diabetes Center of Excellence at the University of Massachusetts Medical Center in Worcester said in an email.

In late 2016, the American Diabetes Association (ADA) put out guidelines urging that psychosocial care should be a standard part of diabetes care, and encouraging medical providers to identify and coordinate with qualified behavioral and mental health care professionals, Barry and her colleagues note. The recommendation was reiterated in the latest ADA standard of care guidelines.

To see whether mental health support is becoming more common, Barry’s team identified diabetes practices that were members of the ADA or American Diabetes Educators Association and sent a survey to each clinic’s leadership. Seventy percent of the centers attended to more than 2,000 patients annually and 87 percent were located in teaching hospitals.

Of the 15 clinics that reported having a behavioral health professional integrated into the practice, about one third had a psychologist and the rest had a social worker. Of the 22 practices with no behavioral health professional, five said they had identified an outside practitioner with diabetes expertise to whom they could refer patients.

On average, practices employed the equivalent of nearly six full-time endocrinologists and nearly three each of full-time certified diabetes educators and full-time nurse practitioners, with about two full-time registered dietitians. Among the practices with an in-house behavioral health presence, the average was 0.6 full-time-equivalents, researchers found.

One reason for the lack of progress on this front may be that there has been minimal investment in developing this aspect of diabetes care, and the reimbursement rates for mental health providers often make it so that institutions will lose money when providing these services, said Jeffrey Gonzalez of the Albert Einstein College of Medicine in New York City, who wasn’t involved in the study.

“It’s also true that few mental health providers have a full understanding of diabetes and its treatment,” Gonzalez said in an email.

The ADA and American Psychological Association recently launched a directory of mental health professionals with training or experience in diabetes care (

While certified diabetes educators play an integral role in providing information to diabetes patients, “they do not delve into how to apply this overwhelming material into a person’s new life as a diabetic,” said study co-author Dr. David Harlan, also with the U.Mass Medical Center Diabetes Center of Excellence, in a telephone interview.

“Several mental health problems, such as depression and anxiety, are common among those living with diabetes,” Gonzalez said. “Care team members with specialized mental health expertise are more likely to play a significant role in addressing these issues in ways that maximize the effectiveness of diabetes treatments.”

“Behavioral health integration is crucial,” Barry said. “As a country, we need to move towards behavioral health integration in line with recommendations supported by the literature. We’re not there yet.”

SOURCE: Diabetes Care, online April 30, 2018.