Like other chronic illnesses, diabetes mellitus poses a wide range of problems for patients and their family members. These problems include pain, hospitalization, changes in lifestyle and vocation, physical disabilities, and threatened survival. Direct psychological consequences can arise from any one of these factors, making it harder for patients to treat their diabetes and live productive, enjoyable lives.
Populations at Risk
Diabetes itself does not cause changes in personality or psychiatric illness, but particular subgroups of the diabetic population appear to be at risk for developing psychosocial problems. Young people with insulin-dependent diabetes mellitus (IDDM) may have a higher prevalence of eating disorders, such as anorexia nervosa and bulimia, and adults with longstanding diabetes and major medical complications have a higher prevalence of symptoms of depression and anxiety. Elderly persons who have non-insulin-dependent diabetes mellitus (NIDDM) and other symptomatic medical conditions may also have a higher risk of developing psychological problems.
Patients with IDDM diagnosed before age 5 and older patients with NIDDM may have associated alterations in cognitive or intellectual functioning. The pathophysiology of these cognitive changes is not well understood. In the young patients, these cognitive changes may be linked to recurring episodes of severe hypoglycemia. In the older patients, both microvascular and artherosclerotic disease are possible factors.
Barriers to self-care
Research has indicated that psychological and social factors can profoundly influence a patient's success at adhering to a prescribed regimen of self-care. Patients may fail to care for themselves if they have certain attitudes or beliefs, including the following:
- Anticipating an early cure.
- Believing that their self-care regimen is too difficult.
- Believing that treatment is unlikely to improve or control their health problems.
Several other psychosocial factors can influence how well patients care for themselves:
- Stressful events in the patient's life.
- Development of a new complication.
- The availability and quality of social support for the patient.
- Psychiatric problems unrelated to the patient's diabetes.
- The health care provider's approach to medical care.
To help anticipate or identify psychosocial problems that could interfere with a patient's self-care regimen, the practitioner should strive to establish an ongoing, therapeutic alliance with the patient. The stronger the alliance, the more likely the patient is to share inner concerns and psychosocial issues. This leads to improved detection and permits more rapid institution of treatment.
This therapeutic alliance will take shape over time, through discussions identifying the patient's expectations of, and feelings about, treatment. Although the patient should not be forced to set particular goals, the practitioner may be able to broaden or refine existing objectives to include improving the patient's adjustment to having diabetes.
Over time, this alliance may lead to better glycemic control by helping the patient address such self-care barriers as low motivation, preconceived judgments about treatment, and fears about diabetes.
The practitioner should be sensitive to possible psychosocial issues when diabetes is first diagnosed and when complications, however minor, first develop.
Some psychosocial barriers stem from personal, family, and cultural beliefs that may conflict with suggested treatment. A patient may resist following a prescribed diet, for instance, because of certain cultural beliefs about weight. Such beliefs should be given their due respect; patients respond best to advice that does not seem to prejudge their beliefs.
Certain medical conditions can be reliable indicators of Psychosocial barriers. Recurrent hypoglycemia, frequent episodes of diabetic ketoacidosis, and very high glycosylated hemoglobin levels should each be recognized as a possible sign of personal or family problems. Although brittle, or unstable, diabetes can sometimes have a metabolic basis, interrupted or erratic self-care is by far a more common cause--and psychosocial problems may underlie this cause.
To help uncover problem areas, the practitioner may want to conduct discussions along the following lines:
Ask patients to describe how they feel about the following issues of self-care:
- The importance of glycemic control.
- The feasibility of adhering to a prescribed diet.
- The importance of self-monitoring of blood glucose.
- The patient's susceptibility to developing complications.
- The efficacy of treating complications.
- The reasonableness of the practitioner's recommendations and expectations.
Ask patients to describe any stressful events or situations, such as changes in job, school, place of residence, and immediate family (for example, death or divorce). Ask whether any other events could be creating barriers to a self-care program.
Determine whether patients have adequate social and family support. Specifically, ask patients to whom they can turn for help in caring for themselves.
- Ask about problems concerning mood, anxiety, and sense of well-being.
- Ask young women who might be at risk for eating disorders whether they have skipped insulin doses, dieted excessively, eaten in binges, or vomited.
- Ask specific questions about topics that patients may hesitate to talk about, such as sexual problems.
- Determine how effectively patients use available information about diabetes. Ask whether they find it difficult to retain or add to such knowledge.
The practitioner may then be able to counsel patients and provide useful solutions.
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Try to actively engage the patient in determining as well as pursuing a course of treatment. Ask the patient both specific and open-ended questions. Open-ended questions may elicit information that can help detect problems as well as tailor the course of treatment. Such discussions may identify individual strengths and problem-solving strategies that have helped the patient successfully face previous challenges.
The practitioner will need to identify, for possible referral, mental health professionals who are knowledgeable about diabetes and who can serve as collaborators in treating the patient. If these individuals are not familiar with diabetes, they can be given materials (such as this guide) that provide basic information.
Refer the following persons:
- Parents of children or adolescents in whom diabetes has recently been diagnosed. A single psychosocial evaluation of the family unit may be important to the overall educational process of raising a child who has diabetes.
- Patients who in one year have had two or more episodes of severe hypoglycemia or diabetic ketoacidosis without obvious causes.
- Patients whom you--the health care professional--find frustrating. The mental health professional may prove a valuable consultant for treating these patients.
Remember that diabetes is a chronic illness. Even if treatment activities fail to bring change within a short time, remaining involved with the patient and the patient's family and providing an accepting atmosphere may lead to increased motivation for change.
Encourage patients and their families to attend group sessions. Medical and psychosocial information can be given at these sessions, which can also provide a forum for discussion of personal concerns. These sessions can be led by health care professionals, including physicians, nurses, and dietitians, and may meet several times a year. Local diabetes organizations may sponsor or know of such groups.
Patient Education Principles:
- Inform patients about the typical personal concerns that come with diabetes, about the problems faced in accepting the disease and adapting to it, and about the impact diabetes has on emotional and social functioning.
- Involve families in treatment and education sessions.
- Encourage parents to help their young children and adolescents who are having problems controlling their diabetes.
- Encourage parents to give adolescents increasing responsibility for their diabetes--but not to force them to take these steps.
- Encourage families to provide help for their older relatives, who may find insulin difficult or frightening to use or who may have trouble changing lifelong dietary habits.
- Encourage families to ensure that school nurses and teachers are educated about the needs of children with diabetes and that nursing homes provide proper treatment to elderly patients with diabetes.
- Bradley C. Psychological aspects of diabetes. In: Alberti KGMM, Krall LP, eds. The Diabetes Annual/1. New York: Elsevier, 1985.
- Feste C. The Physician Within. Minneapolis: Diabetes Center, 1987.
- Jacobson AM, Hauser ST. Behavioral and psychological aspects of diabetes. In: Ellenberg M, Rifkin H, eds. Diabetes Mellitus: Theory and Practice. 3rd ed. Vol. 2. New Hyde Park, New York: Medical Examination, 1983.