Prof. Frank J. Snoek
Medical Psychology
Diabetes Psychology Research Group
VU University Medical Centre
Amsterdam - The Netherlands
Contents
Well-being and Self-management
Coping issues
Barriers to diabetes self-regulation
Practice Implications
Psychological Well-being in Diabetes?
Well-being is an important outcome in its self (SVD, 1995)
Poor Well-being impedes diabetes self-care
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 HCP’s
Behavioral Diabetes Model
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
Diabetes treatment: A balancing act
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)
Two levels of psychological problems
‘Normal’ adaptation/coping problems
Psychological/psychiatric disorders (ICD-10, DSM-IV)
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
Adaptational Breakdown: ‘Diabetes Burn-out’
Psychological/Psychiatric Disorders in Diabetes
Depression
Anxiety
Eating Disorders
Prevalence of Depression in Diabetes Meta-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
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)
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)
Intra-personal Barriers Eating 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)
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 patient’s emotional well-being needs to be monitored in diabetes care
(St Vincent Declaration, 1995)
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
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)
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
