Brian Terrell, Pharm.D., BCACP
Hello PRN! The world looks a little different than the last time that I had the pleasure to talk to you all through this medium. I sincerely hope that each of you and the ones you care about are safe and have the resources that you need.
Speaking of resources, while it has been on the upswing in popularity in recent years, I think it is safe to say that mindfulness is having a moment, and rightly so. I am usually quite eager to talk to the group about the newest drug or the newest outcomes trial, but this month it felt appropriate to deviate from that (but don’t worry, I will still report some statistics). With so many individuals facing challenges on a spectrum of causality and severity that are far beyond my ability to discuss here, I wanted to take this opportunity to review how mindfulness skills may be utilized in diabetes management.
First, a brief reminder that patients with diabetes may be dealing with different stressors and conditions than other individuals. We even have a term for it, diabetes distress, referred to by the American Diabetes Association (ADA) as “significant negative psychological reactions related to emotional burdens and worries specific to an individual’s experience in having to manage a severe, complicated and demanding chronic disease such as diabetes”.1 The organization recommends that providers should screen for this condition as well as depression, anxiety, disordered eating and cognitive capacities at initial visits, periodically and any time there is a significant change in life situation, disease or treatment.1 Psychological comorbidities and diabetes distress are common in this population and warrant attention from providers.2
Food insecurity, housing instability and financial barriers are already common in patients with diabetes, and these social determinants of health are moving in an unpredictable direction in the current global state of affairs.1,3-4 Understandably, these changes may be increasing challenges and stress for patients with diabetes.5 While mindfulness cannot directly correct any of these issues, it may be able to assist with dealing with the emotional/psychological stress created in their wake.
If mindfulness is a new term for you, one of the most applicable definitions that I have found is “the quality of being present and fully engaged with whatever we’re doing at the moment – free from distraction or judgment, and aware of our thoughts and feelings without getting caught up in them”.6 Typically breathing techniques and meditation exercises are used to pay attention in a nonjudgmental way to the present moment.8 There are many different types of mindfulness practices available and they can be done individually, in groups and across many settings.7-9 Training the mind in this way has many effects including metacognition, relaxation, cognitive flexibility and uncoupling of maladaptive cognitive patterns from painful physical sensations.9 The mechanism is thought to work at least in part through autonomic modulation and has evidence that physiologically it can impact the immune, nervous and endocrine systems.9 This practice has been investigated in many conditions including anxiety, depression, stress, cancer-related syndromes, fibromyalgia and other chronic pain, insomnia, psoriasis, irritable bowl syndrome, smoking cessation and many others.9
Two recent systematic reviews and meta-analyses evaluated mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) and their impact on a few different variables in patients with diabetes. MBCT is more tailored specifically to depression where MBSR is more broadly applicable.10 An example of a formal MBSR program from the Center for Mindfulness at UMass Memorial Medical Center can be found in the link in the respective reference below.10 The example is an eight week program, either in person or online, and includes many activities including guided instruction in mindfulness meditation practices, gentle stretching and mindful yoga, group dialogue and discussions aimed at enhancing awareness in everyday life and daily home assignments.10
Ni and colleagues investigated the effectiveness of diabetes-specific versions of these two types of interventions on depression, quality of life and HbA1c in this population. The review included nine studies from eleven articles of randomized controlled trials in patients with both type 1 and type 2 diabetes.7 This analysis demonstrated a significant effect favoring these interventions for reducing depression (standard mean difference -0.84, 95% CI -1.16 to -0.51; p < 0.001), improving the mental health composite score of quality of life (mean difference 7.06; 95% CI 5.09 to 9.03; p < 0.00001) and decreasing HbA1c (mean difference -0.28; 95% CI -0.47 to -0.09; p =0.004).7 Of these outcomes, significant heterogeneity was only reported for depression (I2 =72%; p = 0.0007).7 The authors caution that the limitations of their investigation include the small number of trials, a non-optimal quality of the included studies and some heterogeneity in design and interventions delivered between studies.7
The other investigation I wanted to briefly review by Guo and colleagues specifically focused on the factors that influence the effect of mindfulness-based interventions on diabetes distress. Ten articles including eight studies were included and subgroup analyses were performed to reveal the factors that impact the effect of this type of intervention.8 The specific interventions included in this analysis included MBSR, MBCT and added dialectical behavior therapy (DBT) as well as mindfulness-based self-compassion.8 The authors identified a statistically significant decrease in diabetes distress in those with elevated baseline diabetes distress (effect size -0.48, 95% CI -0.81 to -0.15, Z =2.82, p =0.005), when MBSR was the intervention (effect size -0.58, 95% CI -0.86 to -0.30, Z= 4.03, P<0.0001), when the intervention was delivered in a group format (effect size -0.36, 95% CI -0.68 to -0.04, Z =2.20, P= 0.03), when there was a home practice assignment (effect size -0.42, 95% CI -0.84 to -0.00, Z =1.95, p=0.05) and when the evaluation was completed at a six month follow up (effect size -0.56, 95% CI -0.94 to -0.18, Z =2.91, p = 0.004).8 The authors identify that their findings should only be suggestive based on limitations of population size and methodology.8
As pharmacists, we may not need to be experts in this discipline or ever even be asked to deliver this type of intervention; but being aware of it for patients, as one of the most accessible healthcare providers, is increasingly pertinent. While formal MBSR programs may potentially be time or cost prohibitive, there are many apps and resources available that offer low cost or free instruction to help individuals explore mindfulness. It should be noted that those with untreated psychosis or mania and active substance abuse may have a relative contraindication to this practice, and those with psychiatric disorders should consult with a mental health professional before they begin this type of training.9 In that same thread, as healthcare providers, we should be aware of when a patient needs a higher level of care, and mental health is no exception to that rule. The ADA provides guidance for practitioners that we should consider referral to a mental health specialist whenever self-care remains impaired after diabetes education for diabetes distress, there is a positive screen on a depression screening tool, there is presence of symptoms of disordered eating, intentional misuse of insulin or oral medications to achieve weight loss is identified, there is a positive screen for anxiety or fear of hypoglycemia, there is suspicion of a serious mental illness, there are repeated hospitalizations for DKA or a positive screen for cognitive impairment.1
In conclusion, the above investigations have demonstrated that there is likely a benefit for patients with diabetes related stress to consider mindfulness as a tool in their arsenal. In the absence of one of the contraindications, precautions or referral indicators listed above, the benefits that may be seen from recommending this practice likely outweigh the risk and may be considered a useful adjunctive therapy for our patients. Beyond that, I think all of us are dealing with challenges that could potentially be helped with this practice. I know that it has helped me tremendously. To avoid any perceived bias, I have opted not to list any particular app or product in the post itself, but I would encourage you to share any that you have found useful either for yourself or for your patients in the comments.
- American Diabetes Association. 5. Facilitating behavior change and well-being to improve health outcomes: Standards of Medical Care in Diabetes—2020. Diabetes Care. 2020; 43(Suppl. 1):S48–S65.
- Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial care for people with diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2016;39(12):2126-2140.
- Wolfson JA, Leung CW. Food insecurity and COVID-19: Disparities in early effects for US adults. Nutrients. 2020;12(6).
- Horsley S. May surprise: U.S. adds 2.5 million jobs as unemployment dips to 13.3%. NPR. June, 5, 2020. Accessed June 9, 2020. https://www.npr.org/sections/coronavirus-live-updates/2020/06/05/869821293/as-america-struggles-to-return-to-work-staggering-unemployment-numbers-loom .
- Peters A, Sherr J, Feldman H. Caring for your patients with diabetes who recently have been unemployed due to COVID-19. ADA COVID-19 Webinar Series. May 18, 2020. Accessed June 9, 2020. https://professional.diabetes.org/content-page/caring-your-patients-diabetes-who-recently-have-been-unemployed-due-covid-19.
- What is mindfulness? Accessed June 9th, 2020. https://www.headspace.com/mindfulness.
- Ni Y, Ma L, Li J. Effects of mindfulness-based stress reduction and mindfulness-based cognitive therapy in people with diabetes: A systematic review and meta-analysis. J Nurs Scholarsh. 2020; 0:0, 1-10.
- Guo J, Wang H, Luo J, et al. Factors influencing the effect of mindfulness-based interventions on diabetes distress: a meta-analysis. BMJ Open Diabetes Res Care. 2019;7(1):e000757.
- Mehta D. Meditation. In: Papadakis MA, McPhee SJ, Rabow MW. eds. Current Medical Diagnosis and Treatment 2020 New York, NY: McGraw-Hill; http://accessmedicine.mhmedical.com.ezproxy.ttuhsc.edu/content.aspx?bookid=2683§ionid=223881732. Accessed June 10, 2020.
- UMass Memorial Medical Center. MBSR 8 week in-person program. Accessed June 10, 2020. https://www.umassmemorialhealthcare.org/umass-memorial-medical-center/mbsr-8-week-person-program.