Psychological Barriers To Good Glycaemic Control

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Diabetes A Psychological Perspective

• Prof. Frank J. Snoek
• Medical Psychology
• Diabetes Psychology Research Group
• VU University Medical Centre
• Amsterdam - The Netherlands

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Contents

• Well-being and Self-management
• Coping issues
• Barriers to diabetes self-regulation
• Practice Implications

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Psychological Well-being in Diabetes?

• Well-being is an important outcome in its self
  (SVD, 1995)
• Poor Well-being impedes diabetes self-care

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Adaptational Tasks in Chronic Illness (Coping)

• Maintain emotional balance after diagnosis (loss
  of health, self-esteem)
• Cope with physical complaints and functional
  limitations
• Maintain social roles, cope with negative
  labelling (stigma)
• Cope with medical procedures and
  stresses/uncertainties
• Communicate with and maintain relationships with
  HCPs

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Behavioral Diabetes Model
Well -Being
Medical Outcomes
Self-care
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What makes Self-care Difficult to Maintain

• 365 days-a-year proposition
• Pro-active coping required
• Not pleasant, painful (injections, SMBG)
• Interferes with daily life/flexibility
• Often lack of direct positive feed-back
• Adherence does not always pay off
• Long-term goals immediate frustration
• Polonsky WH, 1999 Rubin,1992

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Diabetes treatment A balancing act
Prevent Hypos
Prevent Hypers
NOW
MY FUTURE
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Barriers to Effective Coping with Diabetes

• Intra-individual (cognitive, emotional,
  behavioral)
• Inter-personal (family/martital conflict, lack of
  social support miscarried helping/ diabetes
  police)
• Environmental/contextual (access health services,
  care climate)

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Two levels of psychological problems

• Normal adaptation/coping problems
• Psychological/psychiatric disorders (ICD-10,
  DSM-IV)

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Top 3 items diabetes-specific emotional
distress(PAID-data Polonsky et al., 1995 Welch
et al, 1997 Snoek et al, 2000)

• Worries about the future and complications
• Feeling worried or guilty when off track with
  the diabetes regimen
• Not knowing if your mood or feelings are related
  to your diabetes

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Adaptational Breakdown Diabetes Burn-out
Negative experiences
Negative attitudes
Poor Self- care
Poor control
Hoover JW, 1988 Polonsky WH, 1999 Seligman,
1997 Snoek, 2000.
Hoover JW, 1988
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Psychological/Psychiatric Disorders in Diabetes

• Depression
• Anxiety
• Eating Disorders

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Prevalence of Depression in DiabetesMeta-analysis
of 39 Studies

• Depression prevalence is
• Higher in women vs. men
• Higher in clinic vs. community samples
• Higher when assessed via self-report vs.
  diagnostic methods
• Similar in patients with type 1 vs. type 2
  diabetes

Nondepressed 69
Significant Symptoms 31.0
11 Major Depression
Anderson et al., 2001
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Odds and Prevalence of Depression in 18
Controlled Studies
2.0 (1.8-2.2)
OR (95 CI)
The odds of depression were doubled in diabetics
compared to controls.
Depression prevalence ()
Nondiabetics
Diabetics
Anderson et al., 2001
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Adverse effects of Depression

• Suffering, reduced QoL
• Associated with hyperglycemia (Lustman et al.,
  2000) and complications (De Groot et., 2001)
• Increased health care use and costs (Black, 1999
  Ciechanowski et al., 2000)

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Anxiety

• General Anxiety Disorder (GAD) and Phobias
  (prevalence? Popkin et al., 1988 Petrak et al.,
  2003)
• Self-injecting/monitoring phobia (Snoek et al.,
  1994 Mollema et al., 2000).
• Fear of Hypoglycaemia (Gonder-Frederick et al.,
  1997 Marrero et al., 1997).
• Fear of Complications (Karlson,Agardh,1997
  Zettler et al., 1995)

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Intra-personal BarriersEating Disorders AN, BN,
ED-NOS (bingeing)

• Common among young diabetic girls (10-30) (Jones
  et al., 2000)
• Eating disorders (Binge Eating) in type 2 ?
  (Kenardy et al., 2000)
• Associated with poor metabolic control
• (insulin omission) and
• Earlier onset of complications (Rydall et al.,
  1997)
• Increased mortality (Nielsen et al., 2002)

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Summary

• Psychological and behavioral factors play key
  role in achieving and maintaining optimal control
  (Glasgow et al, 1999 Snoek, 2000)
• Psychosocial problems are prevalent and deserve
  attention (Cox yet et al., 1992 Rubin,Peyrot,
  1996 Snoek, 2000)
• The patients emotional well-being needs to be
  monitored in diabetes care
• (St Vincent Declaration, 1995)

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How to address psychosocial issues?

• Patient-centred care (communication, evaluation
  of patient-reported outcomes)
• Team approach Multidisciplinary, inlcuding
  behavioral scientist
• Coping-oriented, self-management education and
  counseling

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A new paradigm

• Self-management helps people with long-term
  medical condition to take responsibility for
  their own lives. It addresses the whole person
  and not just their illness or disability.
• It is about people with chronic disease
  becoming able to gain greater independence and
  live healthy, confident lives
• Expert Patients Stakeholder Conference, 2000
  (http//www.doh.gov.uk/healthinequalities)

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More Information.

• Anderson Rubin (eds). Practical Psychology for
  diabetes clinicians, ADA, 1996.
• Snoek Skinner (eds). Psychology in diabetes
  care, Wiley, 2000.
• Psychosocial Aspects of Diabetes study group
  (EASD) www.emgo.nl/psad
• fj.snoek_at_vumc.nl