Melissa DeCapua, DNP, PMHNP

Since the beginnings of modern medicine, experts have recognized a connection between diabetes and mental illness. In the early 1800s, Thomas Willis, an English neurologist, speculated that diabetes was caused by “long sorrow and other depressions.”

About 70 years later, British psychiatrist Sir Henry Maudsley wrote in his book

, “Diabetes is a disease which often shows itself in families in which insanity prevails.”

More recently in the 1940s and 1950s, psychiatrists used insulin-coma therapy to treat patients with schizophrenia.

Today, scientists understand a bidirectional relationship between psychiatric disorders and diabetes: each influences the other in a variety of ways. This article attempts to elucidate the prevalence of these often comorbid conditions and discuss the interface between diabetes and alcohol abuse, major depression, anxiety disorders, and schizophrenia, respectively.

Co-occurrence of Diabetes and Psychiatric Disorders

Both can occur as independent conditions with no apparent connections;

Diabetes can be complicated by the emergence of a psychiatric condition;

Specific psychiatric disorders increase the risk of developing diabetes;

Hypoglycemic and ketoacidosis episodes present with psychiatric symptoms; and,

Diabetes can result as a side effect of psychiatric medications.

When diabetes and psychiatric conditions co-occur, treatment outcomes decline through impaired quality of life, reduced patient adherence, increased emergency room visits, higher rates of hospitalizations, and increased cost of care. A 2009 study found that the cost of care actually doubles in patients with co-occurring diabetes and mental health conditions compared with those who only have 1 of the 2 illnesses.

Primary care providers are often unaware of the possible co-occurrence of psychiatric conditions in their diabetes patients. In fact, around 45% of psychiatric disorders go undiagnosed in patients treated for diabetes.

Experts recommend that clinicians screen all patients with diabetes for psychological distress using either the patient health questionnaire (PHQ) or other standardized assessment. The PHQ is a well-validated 9- or 15-question self-report questionnaire.

Psychiatric disorders are typically diagnosed using the

Diagnostic and Statistical Manual of Mental Disorders

, 5th edition, and coded using the ICD-10.

Codes for psychiatric disorders are found in chapter F and categories 00-09.

lists the categories of psychiatric disorders commonly seen co-occurring with diabetes.

About 50% to 60% of patients diagnosed with diabetes also consume alcohol.

Even when consumed safely, alcohol use increases a diabetic individual’s risk of hypoglycemia. Alcohol can impair an individual’s ability to recognize and respond effectively to a diabetic emergency, such as ketoacidosis. Both alcohol misuse and diabetes independently cause peripheral neuropathy and retinopathy, resulting in synergistic effects for both complications. Long-term alcohol use can lead to excessive weight gain further exasperating diabetes, as well.

The CAGE questionnaire is a brief 4-question tool to help screen patients for problem drinking (

). If patients answer “Yes” to more than one question, they should be referred to a substance abuse professional for a detailed evaluation. Primary care providers can offer the patient a referral and provide a brief intervention in the form of motivational interviewing, a patient-centered yet direct method for increasing intrinsic motivation by exploring and resolving patient ambivalence.

Primary care providers can use one simple MI tool in their practice: OARS (open-ended questions, affirming, reflective listening, and summarizing).

Remembering this acronym can help providers focus their therapeutic communication and encourage the patient to seek additional treatment.

This is the most common psychiatric condition in patients with diabetes. In fact, its prevalence is 2 or 3 times higher in those with diabetes than in members of the general population.

Unfortunately, the exact relationship between these 2 conditions remains uncertain. Hyperglycemia worsens during periods of depression, and it actually exacerbates and prolongs any depressive state.

Moreover, long-term use of high-dose antidepressant medications doubles a patient’s risk of developing diabetes later in life.

At each appointment, primary care providers should conduct a brief risk assessment using the PHQ-2 (

). With this 2-question tool, clinicians can quickly determine the need for a mental health referral. A score greater than or equal to 3 indicates a need for further investigation, as well as a referral to a mental health professional, such as a psychiatric nurse practitioner or psychologist. Depending on the severity and type of depression, mental health professionals will likely use a combination of antidepressant medication and psychotherapy as treatment.

The prevalence of these is higher in patients with diabetes than in members of the general population. The prevalence of generalized anxiety disorder, for example, is 3 times higher for those with diabetes.

Research has also demonstrated that symptoms of anxiety increase an individual’s risk of developing diabetes later in life. Needle-and-injection—related phobias, as well as a phobia of a hypoglycemic episode, are also sometimes found in patients with diabetes.

To screen for generalized anxiety disorder, primary care providers can use the GAD-7 scale, a 7-item self-report questionnaire (

). A score of greater than or equal to 10 indicates a possible diagnosis of generalized anxiety disorder and should be confirmed by a thorough evaluation. Phobias are characterized by a persistent, disproportional fear of a specific object or situation such as needles or a hypoglycemic episode.

Psychological treatments for anxiety disorders are extremely effective; therefore, a referral to a mental health clinician will likely substantially improve the patient’s quality of life.

For those with schizophrenia, the risk of developing diabetes is 4 times greater than for members of the general population.

Individuals with comorbid schizophrenia and diabetes have higher mortality rates than those who only have one condition, and a family history of diabetes is more common in those with schizophrenia than those without.

Research reveals that both genetic and environmental factors contribute to the high rate of impaired glucose tolerance in patients diagnosed with schizophrenia.

Inactivity, poor nutrition, and treatment with antipsychotic medications increase the risk of developing diabetes later in life.

Clozapine and olanzapine are most likely to cause metabolic syndrome, followed by risperidone and quetiapine.

There is also some evidence suggesting that schizophrenia is an independent risk factor for diabetes.

Managing patients with both a psychotic disorder and diabetes requires expert care coordination between primary care and mental health providers.

Primary care clinicians should recommend psychological approaches that will help their patients understand and remain adherent to their diabetes treatment plans. Maintaining close contact with the patients’ case managers and reinforcing self-management strategies at each appointment can help improve this population’s outcomes.

This may make a patient feel stigmatized or “crazy.” Even patients who are interested in professional counseling face significant barriers including cost and time commitment. The most successful referrals occur within a trusting and established patient-provider relationship.

Knowing when to refer a patient with diabetes can also be difficult. Referrals can be made for a psychiatric nurse practitioner who specializes in psychotropic medication management or for a psychologist with advanced training in a particular form of psychotherapy, such as motivational interviewing or cognitive-behavioral therapy. Referrals to psychiatric specialists should almost always be provided in the following cases:

Patients taking multiple psychiatric medications who are not responding to a new medication;

Patients who express suicidal ideation or demonstrate chronic suicidal tendencies;

Patients with multiple psychosocial problems;

Patients who desire help adjusting to a new acute or chronic illness;

Patients with multiple somatic complaints without discernable evidence of a physical cause; and,

Patients who need extra help with health behavior change (eg, tobacco cessations and weight loss).

The interface between diabetes and psychiatric disorders is complex and not completely understood. This comorbidity often increases the risk of poor patient outcomes; however, when primary care providers and psychiatric specialists work together, these individuals can receive effective and comprehensive treatment.

Dr. Melissa DeCapua is a board-certified psychiatric nurse practitioner. She currently works as a consultant for small health care technology companies, and she recently won the Seattle Health Innovator award. Dr. DeCapua is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Dr. DeCapua, visit her website at

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Articles

Since the beginnings of modern medicine, experts have recognized a connection between diabetes and mental illness.

Mental Health Counseling for Diabetes Patients

Irritable bowel syndrome (IBS) is the most frequently diagnosed gastrointestinal (GI) disorder by primary care clinicians. With proper treatment, IBS can be managed and symptoms can be mitigated. Unfortunately, a recent survey found that patients often disagree with their primary care providers on both the etiology of their condition and appropriate treatment.

This article reviews best practices for managing IBS in the retail clinic setting and for counseling patients with this condition.

IBS is a GI disorder with chronic and recurring abdominal pain and altered bowel habits.

This syndrome primarily affects women aged 20 to 30 years.

Worldwide, IBS affects approximately 14% of women and 9% of men; in North America, however, the prevalence increases to 16% in women and 10% in men.

For each individual, IBS symptoms fluctuate over time. Results of a survey of 1200 adults with IBS showed that 55% continued to have symptoms after 7 years.

Severe, chronic life stress accounts for 97% of the variance in IBS symptom duration and severity.

IBS is classified as a functional GI disorder with abdominal pain and distention in the absence of specific organic pathology. Patients typically describe their abdominal pain as diffuse without radiation, located in the left lower quadrant, and triggered by food.

Additional altered bowel habits may include (1) constipation with hard, narrow stools intractable to laxatives; (2) diarrhea in small volumes of loose stool preceded by urgency of defecation; or (3) an alternation between constipation and diarrhea.

Other commonly reported symptoms include clear mucorrhea, dyspepsia, nausea, sexual dysfunction, and urinary frequency. Women may also express worsening of symptoms during the perimenstrual period.

Retail clinicians should be on the lookout for the following signs and symptoms that are inconsistent with IBS, which suggest an organic pathology and require further evaluation

A comprehensive history and physical examination should help the retail clinician make a correct diagnosis of IBS. The American College of Gastroenterology does not recommend laboratory testing or diagnostic imaging in patients with a typical IBS presentation if they are younger than 50, unless the following signs and symptoms are present: weight loss, iron deficiency anemia, or a family history of inflammatory bowel disease, celiac sprue, or colorectal cancer.

Retail clinicians may use the Rome III criteria to diagnosis IBS. These criteria state that patients must have experienced abdominal pain or discomfort for at least 3 days per month during the previous 3 months and at least 2 additional symptoms as listed above.

Retail clinicians may choose to note a bowel pattern, including diarrhea predominant, constipation predominant, mixed diarrhea and constipation, or alternating diarrhea and constipation.

IBS management consists of providing the patient with psychological support and recommending dietary measures. Pharmacologic management is not recommended, but it can be used to mitigate certain symptoms.

Retail clinicians should educate patients on the chronicity of IBS and reassure them that there is no underlying organic pathology.8 Successful treatment relies on a solid, trusting patient—provider relationship.

The National Institute for Health and Clinical Excellence encourages clinicians to offer general dietary advice and reassurance to their patients as first-line treatment for IBS.

This counseling should include the following recommendations

Eat regularly and at the same times every day.

Drink at least 8 cups of water or other noncaffeinated drinks daily.

Limit caffeinated tea and coffee to 3 cups per day.

Limit fresh fruit intake to less than 240 g per day.

Incorporate 1 tablespoon of oats or linseeds into meals per day.

Retail clinicians may recommend increased consumption of soluble fibers found in foods such as ispaghula or oats, as well as insoluble fibers found in food such as bran.

Fiber supplementation may also help some patients. Retail clinicians should be careful about which supplement they recommend, as some can exacerbate abdominal pain and distention. Specifically, polycarbophil compounds (Citrucel, FiberCon) may produce less flatulence than psyllium compounds (Metamucil).

Unfortunately, research on increased fiber intake is controversial because up to 70% of patients in fiber studies respond to placebo.

review found no benefit in fiber supplementation for treating IBS.

Researchers have yet to determine what form, dose, combination, or strain of probiotics is helpful in treating IBS.

Results from a recent meta-analysis recommend the

; however, results from a different meta-analysis were inconclusive.

Overall, probiotics seem to be helpful in reducing pain, bloating, and gas, but the specific brand and dose remain unclear.

For patients interested in specific dietary modifications, retail clinicians should recommend the low FODMAP diet. The acronym FODMAP stands for fermentable oligo-, di-, and monosaccharides and polyols, which are specific carbohydrates found in foods. As osmotic carbohydrates, FODMAPs pull water into the intestinal tract and are difficult to digest, leading to symptoms of bloating, pain, and flatulance.14 FODMAPs include fructose, lactose, fructans, galactans, and polyols (

). Retail clinicians may recommend that patients avoid foods that contain these carbohydrates.

A meta-analysis of 25 randomized, controlled trials found that cognitive behavioral therapy and interpersonal psychotherapy reduced IBS symptoms immediately following these interventions.

In its 2009 position statement on IBS, the American College of Gastroenterology stated that psychological interventions such as cognitive behavioral therapy, dynamic psychotherapy, and hypnotherapy are more effective than placebo; therefore, retail clinicians may consider a psychiatric referral for patients with IBS and either significant stressors or a comorbid mental health condition.

International Classification of Diseases, Tenth Revision

F45.3: somatoform autonomic dysfunction (used for a psychogenic form of IBS)

Dr. Melissa DeCapua is a board-certified psychiatric nurse practitioner who graduated from Vanderbilt University. She has a background in child and adolescent psychiatry, as well as psychosomatic medicine. She is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care. For more about Dr. DeCapua, check out her blog at melissadecapua.com and follow her on Twitter @melissadecapua.

Bijkerk CJ, de Wit NJ, Stalman WA, Knottnerus JA, Hoes AW, Muris JW. Irritable bowel syndrome in primary care: the patients’ and doctors’ views on symptoms, etiology and management.

National Institute for Health and Care Excellence (NICE). Irritable bowel syndrome in adults: diagnosis and management. NICE guidelines CG61. https://www.nice.org.uk/Guidance/CG61. Published February 2008. Accessed January 4, 2016.

Lovell RM, Ford AC. Effect of gender on prevalence of irritable bowel syndrome in the community: systematic review and meta-analysis.

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Agréus L, Svärdsudd K, Talley NJ, Jones MP, Tibblin G. Natural history of gastroesophageal reflux disease and functional abdominal disorders: a population-based study.

Bennett EJ, Tennant CC, Piesse C, Badcock CA, Kellow JE. Level of chronic life stress predicts clinical outcome in irritable bowel syndrome.

Spiegel BM, Farid M, Esrailian E, Talley J, Chang L. Is irritable bowel syndrome a diagnosis of exclusion?: a survey of primary care providers, gastroenterologists, and IBS experts.

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Thompson WG, Heaton KW, Smyth GT, Smyth C. Irritable bowel syndrome in general practice: prevalence, characteristics, and referral.

Brandt LJ, Chey WD, Foxx-Orenstein AE, et al; American College of Gastroenterology Task Force on Irritable Bowel Syndrome. An evidence-based position statement on the management of irritable bowel syndrome.

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Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders.

Ruepert L, Quartero AO, de Wit NJ, et al. Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome.

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Moayyedi P, Ford AC, Talley NJ, et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review.

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Brenner DM, Moeller MJ, Chey WD, Schoenfeld PS. The utility of probiotics in the treatment of irritable bowel syndrome: a systematic review.

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Ford AC, Quigley EM, Lacy BE, et al. Efficacy of prebiotics, probiotics, and synbiotics in irritable bowel syndrome and chronic idiopathic constipation: systematic review and meta-analysis.

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Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome.

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Irritable bowel syndrome is the most frequently diagnosed gastrointestinal (GI) disorder by primary care clinicians. 

Counseling Pearls for IBS Patients

It is that time again: flu season! Starting now, nurse practitioners and physician assistants should prepare for the rush of patients with a variety of clinical presentations. Although influenza is both preventable and treatable, it results in about 200,000 hospitalizations

per year in the United States. Clinicians should remain abreast of the latest recommendations and strengthen their assessment skills as flu season approaches.

The purpose of this article is to review fundamental information about influenza, with a focus on assessment, differential diagnosis, and treatment. The article concludes with additional resources, patient education, and pertinent ICD-10 codes.

A member of the Orthomyxoviridae family, influenza is a single-stranded RNA virus. Infection is caused by one of 3 types of influenza virus: A, B, or C. Influenza A and B are the most prevalent, whereas influenza C causes a mild infection and does not contribute to seasonal epidemics. Minor genetic variations, also called antigenic drift, result in the variations from season to season. Seasonal variation requires the development of unique vaccines each year.

The annual influenza vaccine continues to be the most effective method of reducing infection rates around the world. Administration of the vaccine should be offered by October and continue until April of the following year.

Whereas the vaccine is recommended for everyone older than 6 months, special emphasis should be placed on those with an increased risk for complications, including:

Women who are or may become pregnant during this flu season

Children receiving long-term aspirin therapy

This flu season, US vaccinations are designed to protect against an A/California/ 7/2009 (H1N1)-like virus; an A/ Switzerland/9715293/2013 (H3N2)-like virus; and a B/Phuket/3073/2013-like virus.

This represents changes in the influenza A virus compared with last season.

Interestingly, the seasonal incidence of influenza varies with latitude. Whereas the flu peaks in the winter in temperate climates, it remains consistent throughout the year in tropical climates.

Each year in the temperate climate of the United States, about 200,000 individuals are hospitalized due to the flu and almost two-thirds of these hospitalizations are among those patients older than 65 years.

Real-time influenza activity in the United States can be found on the Centers for Disease Control and Prevention’s (CDC) website FluView (cdc.gov/flu/weekly/).

The transmission of influenza occurs through large-particle respiratory droplets and fomites. These respiratory droplets can travel about 6 feet and survive on dry, inanimate surfaces for a few days.

Common fomites in a convenient care clinic include skin cells, hair, clothing, chairs, door knobs, pens, and clipboards. The incubation period for influenza is about 48 hours, so it is essential that you follow your clinic’s guidelines for cleaning and disinfecting surfaces.

The most common presenting symptoms of influenza include acute onset fever, myalgia, arthralgia, anorexia, headache, dry cough, malaise, fatigue, weakness, and chest discomfort. Symptoms of severe or progressive influenza infection include altered mental status, seizures, hypoxia, tachypnea, and decreased urine output. Due to overlap of influenza symptoms with other illnesses, a clinical diagnosis should be confirmed by a laboratory test (see “Diagnostic Tests” below).

In general, clinicians should assess for fever, myalgia, arthralgia, cough, pharyngitis, and rhinorrhea.

Flushing may be seen on the face and the skin may be hot, dry, or diaphoretic. Rhonchi or scattered rales may be heard upon auscultation of the lungs. Other findings might include conjunctival injection, pain on eye motion, photophobia, and nonexudative pharyngitis.

Upper respiratory infections (URIs) and infectious mononucleosis are frequently confused with influenza. Influenza typically has an acute onset with high fever, headache, dry cough, and achy muscles and joints. In comparison, URIs have a more gradual onset, productive cough, and no fever. Infectious mononucleosis presents with characteristic posterior cervical lymphadenopathy.

Clinicians should consider a diagnostic test if influenza is suspected based on the clinical presentation and physical exam.

Commonly used diagnostic tests for influenza include rapid antigen detection testing, reverse transcriptase- polymerase chain reaction (RT-PCR), and viral culture. Rapid antigen detection tests provide the quickest results; however, the sensitivity of this test is generally low and does not exclude influenza in a symptomatic patient.

An RT-PCR test is the most sensitive and specific test for influenza and can be especially helpful for differentiating between influenza types A and B.

Viral cultures can be used to confirm a diagnosis of influenza; however, they are more frequently used for surveillance during viral outbreaks.

Antiviral treatment is not needed for healthy individuals with an uncomplicated clinical presentation.

This treatment is recommended for any individual with known or suspected influenza who is hospitalized, at a high risk for complications, or who presents with a severe, progressive illness.

summarizes World Health Organization (WHO) recommendations for the use of antiviral treatment for influenza.

If indicated, start antiviral therapy as soon as possible, ideally within 48 hours of symptom onset. There are 2 classes of anti-influenza medications: adamantanes and neuraminidase inhibitors. Neuraminidase inhibitors are recommended as first-line treatment.

includes specific dosing information. Adamantanes are no longer recommended for treatment due to widespread resistance since the 2005- 2006 flu season.

A multitude of clinical resources are available for influenza treatment information. Among these are the CDC’s

, which provides detailed recommendations for the 2015-2016 flu season

; the Department of Health and Human Services website flu.gov, which offers updates on current flu outbreaks across the country; and the CDC’s FluView, which provides weekly geographic updates. Additionally, the American Academy of Family Physicians (AAFP) publishes a point-ofcare guide for diagnosing and treating adults with suspected influenza,15 and the Clinical Infectious Diseases journal provides an updated review of influenza virus resistance to antiviral agents.

A variety of reputable organizations provide free influenza patient education. Both the Mayo Clinic and the Cleveland Clinic offer printable handouts appropriate for all educational levels. The AAFP also provides useful patient information in both English and Spanish. Finally, Patient Plus, a social network connecting health care providers with their patients, has created a handout for patients who are interested in learning technical information about the flu.

The International Statistical Classification of Diseases, 10th Edition (ICD- 10), the updated coding system for disease classification developed by WHO, was recently adopted in the United States after years of postponement. Compared with the previous coding system, ICD-10 codes provide greater specificity and diagnostic detail. For more information on the transition from ICD-9 to ICD-10, check out the

online articles, “Appreciating the Big Picture of ICD- 10” and “The ICD-10 Transition: What You Need to Know.”

Here is a selection of influenza-related codes

J09: influenza due to certain identified influenza virus

J10: influenza due to other identified influenza virus

J10.0: influenza with pneumonia, other influenza virus identified

J10.1: influenza with other respiratory manifestations, other influenza virus identified

J10.8: influenza with other manifestations, other influenza virus identified

J11.0: influenza with pneumonia, virus not identified

J11.1: influenza with other respiratory manifestations, virus not identified

J11.8: influenza with other manifestations, virus not identified

Melissa DeCapua, DNP, PMHNP, is a board-certified psychiatric nurse practitioner who graduated from Vanderbilt University. She has a background in child and adolescent psychiatry, as well as psychosomatic medicine. Dr. DeCapua currently works as the Healthcare Strategist at a Seattle-based health information technology company where she guides product development by combining her clinical background and creative thinking. She is a strong advocate for empowering nurses, and she fiercely believes that nurses should play a pivotal role in shaping modern health care.

For more about Dr. DeCapua, please visit melissadecapua.com or follow her on Twitter @melissadecapua.

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Centers for Disease Control and Prevention. Vaccination: who should do it, who should not and who should take precautions. www.cdc.gov/flu/protect/whoshouldvax.htm. Updated November 4, 2015. Accessed November 6, 2015.

Viboud C, Alonzo WJ, Simonsen L. Influenza in tropical regions.

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Call SA, Vollenweider MA, Hornung CA, Simel DL, McKinney WP. Does this patient have influenza?

Montalto NJ. An office-based approach to influenza: clinical diagnosis and laboratory testing.

Simasek M, Blandino DA. Treatment of the common cold.

Clinicians should remain abreast of the latest recommendations and strengthen their assessment skills as flu season approaches.

Melissa DeCapua, DNP, PMHNP

Articles

Mental Health Counseling for Diabetes Patients

Counseling Pearls for IBS Patients

Influenza: Differential Diagnosis and Treatment

Appreciating the Big Picture of ICD-10