A diagnosis of Type 1 or Type 2 Diabetes puts new pressures on patients to manage their disease and change their lifestyle - they must begin to monitor glucose levels, eat a healthier diet, increase physical activity, and remain on top of medication and treatment regimens. Along with these challenges, patients often experience personal, family, or social upheaval.
Although psychosocial problems like as anxiety and depression can greatly impact patients’ outcomes, mental health has gone largely unrecognized in primary care settings that treat diabetes, endocrine, and other hormone-related disorders, such as thyroid disease, Cushing’s disease, and obesity.
In recognition of the mind-body connection and as part of its broader commitment to whole-person health, Montefiore’s Division of Endocrinology has added Stephanie Leung, PhD, its first-ever psychologist, to the team at the Fleischer Institute for Diabetes & Metabolism. As Director of Psychology, Dr. Leung provides an integrated and interdisciplinary approach to endocrine care that helps patients manage stress, anxiety, depression, and other issues that may arise with a medical diagnosis.
A Challenging Condition
“For someone newly diagnosed with a chronic illness, dealing with new fears and the changes required in their daily routine can be a significant adjustment,” said Dr. Leung, who joined Montefiore Einstein in October 2019.
Jill Crandall, MD
Working alongside the endocrinology team that includes attending endocrinologists, nurse practitioners, nurses, and dietitians, Dr. Leung has taken a pioneering approach to overcoming barriers to improved health for adults diagnosed with diabetes and other endocrine disorders. New protocols for on-site psychosocial care help patients learn to manage their fears, practice new behaviors, stay on top of their treatment regimens, and surmount social and societal hurdles.
Creating a Bridge
“The psychologist’s role is to help patients identify and cope with ‘diabetes distress,’ with the goal of improving diabetes control and reducing stress,” said Jill Crandall, MD, Chief, Division of Endocrinology and the Jacob A. and Jeanne E. Barkey Chair in Medicine. Having a psychologist on-site, she said, creates a bridge between a patient’s clinical care and emotional health, and makes it easier for the patient to follow up after an endocrinology visit. Dr. Leung provides cognitive behavioral therapy and other targeted behavioral health treatments that are goal oriented and short term, ideally over 10 to 12 visits.
While insulin therapy and treatments allow people, even young children, with T1D to manage their conditions and live long, healthy lives, their bodies do not produce insulin and there is no cure. Diabetes is associated with a greater risk for kidney failure, heart disease, and strokes, and a diagnosis can immediately transform patients’ day-to-day routines.
Adult and adolescent diabetes patients must shoulder the stress of managing glucose levels and may harbor fears about disease progression and the potential for vision loss or amputation. Anxiety can take over, Dr. Leung said, when a patient sees their numbers are too high or too low. As patients begin managing their disease, social concerns also manifest.
“A diabetes diagnosis can be a blow to a person’s identity,” said Dr. Leung. A patient may go from being an independent person to having to rely on family and friends, or even a home health aide, to help them tackle the extra steps they may have to take just to get through the day, she explained.
Supporting Young Adults
Transitioning from pediatric to adult care poses specific emotional challenges for young adults, Dr. Leung said. To shepherd young adults with T1D through this rocky time, Dr. Leung works closely with Shivani Agarwal, MD, MPH, director of the Supporting Emerging Adults with Diabetes (SEAD) program and Assistant Professor of Medicine (Endocrinology). The partnership weaves psychosocial supports into adolescent care and helps patients develop strategies to deal with bullying, stigma, troubles with housing, employment, and education, and better navigate relationships with parents and/or caregivers.
“Young adults undergo a developmental change from adolescence to adulthood in which their identities start to crystalize,” said Dr. Leung, noting that during this period familial roles may change, with many young adults becoming less dependent on their parents for diabetes care. “Some patients and parents have difficulty navigating this shift in roles.”
In her role, Dr. Leung also provides support to another vulnerable population: pregnant women with diabetes. Uncontrolled diabetes is a risk factor for congenital abnormalities in newborns, so in pregnancy, HbA1c needs tighter management—6 percent as compared to 7 for non-pregnant diabetics, Dr. Leung said. Her work with the team helps patients develop strategies to mitigate anxiety and stay on top of treatment protocols.
Looking Ahead
Dr. Leung has devoted her career to integrating psychosocial supports into clinical settings. Prior to joining Montefiore Einstein, Dr. Leung was a Psychologist Care Manager at Wyckoff Heights Medical Center in Brooklyn, providing psychological services and education in the Women’s Health Center, Adult Medicine Clinic, and Bariatric Surgery Program. She earned a PhD in clinical psychology from Rosalind Franklin University of Medicine and Science in Chicago and interned at the VA Connecticut Healthcare System, where she also completed her postdoctoral fellowship through Yale School of Medicine.
Down the line, Dr. Leung hopes to create support groups for adults with diabetes and will collaborate on research investigating social determinants of health and psychosocial factors related to diabetes with Dr. Agarwal and Jeffrey Gonzalez, PhD, Professor in the departments of Medicine (Endocrinology) and Epidemiology & Population Health. Dr. Leung also hopes to teach and mentor young psychologists.
“I’m excited to be at an academic health center such as Montefiore where we’re at the cutting edge of integrated care, science, and education,” she said.
Posted on: Tuesday, March 03, 2020