With the onset of January, medical providers can often see unhappy patients dealing with the after effects of the holidays, making beginning-of-the-year diabetes-management resolutions or battling the winter blues in the colder, northern latitudes. Psychotherapist Eliot LeBow, LCSW, discusses how providers can help patients set up realistic expectations and goals for their resolutions and identify patients who might be experiencing the winter blues. 
By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net
The passing of December’s holidays marks the time of year where some people may have succumbed to unhealthy eating habits and have experienced some unwanted weight gain and higher than usual blood sugars.  

Subsequently, people with diabetes may begin to consider a New Year’s resolution involving their self-management. Maybe a person wants to lose weight or eat healthy, and this too can bring its own set of challenges.
Possibly compounding the matter is winter’s chill and the lack of sunlight or the ability to exercise outside, which can alter peoples’ moods and confidences, possibly creating the winter blues (seasonal depression) in some.

While many of these underlying issues may not be given much thought by most patients, medical providers have an opportunity to help patients identify some of the stresses associated with this time of year, and counsel them on proper ways to stay the course for resolutions and take care of their mental health too.

New York City-based psychotherapist Eliot LeBow, LCSW, principal of his own practice, and an advisor for the emotional health and wellbeing segment of the New York chapter of the American Diabetes Association understands the difficulties associated with diabetes self-management during this time of year. He has had type 1 diabetes for 34 years, and in his practice, he specializes in counseling patients with diabetes who are struggling with the emotional challenges associated with having diabetes.
LeBow (pictured, above) believes that while medical providers play an essential role in helping to get a patient’s diabetes under control in a physiological capacity, they can also address their mental health issues. For example, depression has been shown to detrimentally affect glucose control.
LeBow spoke with DiabetesCare.net about the value in New Year’s resolutions, setting the right expectations for reaching resolution goals, and how providers can recognize possible mental health issues and the power of referring patients to mental health specialists.
DiabetesCare.net: This is the time of year when people begin to take on New Year’s resolutions. Although some people say not to do them because you may end up not following through on them, what is your stance on resolutions as they pertain to diabetes self-management?
LeBow: I believe resolutions are a good thing; they make a person feel safe to change. It is the one time of the year people are able to openly admit they have a problem to their family and friends and can expect to get support for their resolution.
For people who have diabetes this might be the first time they admit they haven’t been taking care of themselves, and they are actually empowered to take an action to change that. 
DiabetesCare.net: Some people begin New Year’s resolutions with the best intentions, but after a short period of time they quit. Generally speaking, why is it that people with resolutions end up not completing their goals?
LeBow: Let me start by saying those who do complete their goals are ready for change. The people who don’t may not be ready. They may be contemplating it and they are in the change process, but there is a difference between thinking about stopping a behavior and actually doing it.
One of the reasons people do fail is that they might not have enough emotional support to help them through what is a tough time. After New Year’s, much of the support they had from family and friends eventually disappears and they forget about the resolution of the person with diabetes. Everyone goes on with their lives and the person with the resolution is alone facing the problem or the behavior they are trying to overcome.
Also, many people don’t make plans on how they are going to obtain their goals. For example, maybe someone decides he is going to stop eating junk food and eat only healthy food. On New Year’s Day, he goes out to the grocery store but doesn’t even know what to buy. This patient has not done any planning or prep work like going to see a nutritionist first who could help them with purchasing healthier foods. Patients need to think about having someone help manage the change that occurs with the resolution.
Another of the reasons people fail is that they have a tendency to set their goals too high. I actually encourage people to have a solid long-term goal, but utilize a series of objectives that brings them to the first of many smaller goals untill they reach their solid long-term goal. A good example would be Weight Watchers where a person might have a goal to loss 50 lbs by the end of a year but each week they set a modest goal of 1 pound per week.
DiabetesCare.net: How should providers address their patients when they have an episode or reoccurring episodes where they may have gone back on their resolution, and what are some of the strategies medical providers can employ to help their patients realistically manage their resolutions?
LeBow: People will have cravings for whatever behavior they are trying to correct. If a patient likes donuts, for example, when he sees a donut box in the lunch room in his office, it triggers the patient’s mind to work against them. Cravings can come from an environmental trigger that becomes a cognitive-based craving. So it is simply not a person who chooses not to eat donuts; it’s a person fighting these triggers that have been surrounding them for years without them knowing it. All of a sudden they wake up and they see a donut shop everywhere they go. These triggers can cause people to go back on a resolution. This is something people need to be aware of as they go forth with their resolution.
Most people don’t tell their medical providers when they have gone back on their resolutions, so it is really up to the medical providers to ask their patients what is going on with them and open up a dialogue.
When it comes to someone’s diet, for example, it is sometimes best to be forward and ask them how things are going with it.
In the course of the discussion, the medical provider may feel the patient’s goal is too difficult. In this case, ask the patient, if they think the goal is set too high, and if they agree it is, help them come up with a more reasonable goal. If they do not think the goal is too high, then suggest some objectives that will help them obtain their goal.  
A medical provider who sees these types of patients needs to create accountability with them.
As a psychotherapist, I have people talk about their diabetes at the beginning of each session to create accountability. If patients know they are going to have to talk about it, they are more likely to follow through on their goals. Similarly to preparing for a test and having a classmate meeting every other day to study. 
Instead of scheduling a follow-up appointment for six months or a year down the road, the medical provider could schedule a follow-up visit two weeks later, then a month later, and then two months after that. 
Separately, many people with diabetes don’t address their emotional health. Many of them could benefit from therapy because this is a tough disease to deal with. Also, being in therapy helps a person not feel alone in his or her problems.
A medical provider’s referral to a psychotherapist can be so vital to a patient who is in need of help.
DiabetesCare: Can the failure to reach a New Year’s resolution goal combined with some unanticipated weight gain or uncontrolled blood sugars from the holiday season send someone into a funk or a mild depression?
LeBow: As everyone is different, it is difficult to group people together. There are several types of depression, and there is a wide variety of them. That failure of a resolution may be seen as a trauma, and due to it, it may create a period of depression, but it won’t create a long-term depression, unless the person already has an underlying depression issue.
It is something that should be observed by the medical provider every time a patient is trying to make a change with their diabetes. 
DiabetesCare.net: The holiday season transitions into the long winter season, which can lead to the winter blues. What are the characteristic differences between the winter blues and clinical depression and when should a medical provider recommend a psychotherapist consult versus referring a patient to a psychiatrist?
LeBow: If the patient is normally doing well with their diabetes control during other parts of the year, maybe the patient has an issue with the winter blues. Medical providers can find out how patients cope with their stresses and issues. One of the ways to help someone with the winter blues is to find out what their support mechanisms are. Maybe they handle stress by going out into the world to play sports or doing outside activities, and they don’t have something they do in the winter.
It may be good to refer them to a psychotherapist, perferably one who has experience working with diabetes to rule out chronic high blood sugars. If the patient is already showing signs of chronic mental illness with suicidal ideation, then referral to a psychiatrist first may be more appropriate. Outside of patients exhibiting those symptoms psychotherapists are trained to diagnose the different forms of depression in people and decide whether a psychiatrist consult is needed.
If it is just a mild form of depression like the winter blues also known as seasonal depression, talk therapy will work well without medication.
The winter blues will appear more like a person with dysthmia (low level, chronic depression), which includes a lack of motivation, poor self-esteem and a low capacity for pleasure. This same person will still go outside, still go to work, will still function but they have a tendency to see the world as negative.
For a person who has major depressive disorder, the symptoms will be much more severe. The patient will exhibit issues such as feelings of sadness, irritability over small things, fatigue, insomnia or excessive sleep, reduced sex drive, difficulty getting up in the morning, excessive feelings of guilt, rapid weight gain or loss, problems concentrating, thoughts of suicide, suicide attempts, and loss of interest in pleasure or normal activities.
If a person is depressed, it will affect them on a physical level. If a person with diabetes has the winter blues, maybe their A1c is fine three seasons of the year, and it is the wintertime Hemoglobin A1c screening that is uncharacteristically out of control year after year. This person might be carrying out the same routine with their diabetes management, but if the patient is depressed, their chemical balance changes.
The body adapts to depression (or other stressful emotions) by releasing cortisol into the bloodstream that cause blood sugars to go up.
It can be as simple as they have not adjusted their medications for the depression, and so maybe you increase insulin or adjust medications to adjust for the depression and cortisol release during this period. In the end, it is best to figure out how to stop this from happening year-to-year.
High blood sugars can also increase someone’s likelihood for depression. How we are emotionally impacts our physical well-being. 
If you are interested in finding out more about LeBow`s practice, you can visit his website here or contact him at: eliot.lebow@gmail.com or (917) 272-4829.