According to results of a narrative review published in Diabetes Therapy, clinicians should assess patients with painful diabetic neuropathy (pDN) for psychological health before determining their treatment plans.

This review was largely based on a lecture presented by Dr. Hannah Twiddy from The Walton Centre during the Fourth British Symposium on Diabetic Neuropathy held in November 2019 at the University of Liverpool in the United Kingdom.

Painful diabetic neuropathy is a debilitating condition. The treatment includes pharmacotherapies that target pain generation. Satisfactory outcomes are defined as an improvement in pain of more than 50%. However, a significant proportion of patients do not achieve this landmark.


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Many patients have coexisting psychological conditions, including mental comorbidities and sleep disorders. A bidirectional relationship of pain and psychological symptoms may exacerbate pDN, and clinicians should take much care when designing a treatment plan for these patients.

The Walton Centre Pain Management Programme has developed a 3-item assessment list: 1) improve and enhance quality of life among patients with chronic pain, 2) directly or indirectly alter behaviors with cognitive or behavioral therapy, and 3) assess improvements in the long and short term. This list was designed to encompass 5 areas of the pDN disease: pain, pain beliefs, pain behaviors, emotional distress, and social context.

To ensure treatment plans include all areas of the disease, patients are consulted by 4 clinicians: a pain consultant, a clinical psychologist, a physiotherapist, and an occupational therapist. Following the 4-hour assessment, the clinicians have a multidisciplinary conference to discuss a personalized care package for each patient.

Compared with musculoskeletal pain, neuropathic pain is less predictable and must be considered in the context of existing comorbidities, or in this case, diabetes. Previous studies have associated worsening symptoms of diabetes with increased depression and poor self-care.

The Walton Centre is a proponent of acceptance and commitment therapy (ACT), which is a third wave of cognitive behavioral therapy that focuses on mindfulness strategies in addition to commitment to change adverse behaviors.

In all cases, patients should be assessed for treatment outcomes with established instruments such as Beck’s Depression Inventory Second Edition or Diagnostic and Statistical Manual of Mental Disorders IV, among others.

The authors of the narrative review concluded that in addition to evaluating pain among patients with pDN and creating a treatment plan, clinicians should assess patients to determine whether their expectations are realistic and if they require referral to a mental health or multidisciplinary pain team. In short, a holistic approach is required for all patients with pDN because patients’ mental state can have significant effects on their perception of pain.

Reference

Twiddy H, Frank B, Alam U. A consideration of the psychological aspects to managing patients with painful diabetic neuropathy: an insight into pain management services at a tertiary centre in the UK. Diabetes Ther. 2021;12(2):487-498. doi:10.1007/s13300-020-00983-y