CLINICAL DIABETES
VOL. 16 NO. 2  1998


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T E A M   A P P R O A C H


The Psychologist in Diabetes Care

Michael A. Harris, PhD, and Patrick J. Lustman, PhD


The importance of the mental health expert in the management of medically ill individuals has grown with the proliferation of information linking health and behavior. Seven of the ten leading causes of death in the United States are related to behaviors such as smoking, overeating, and excessive alcohol consumption.1 Psychological problems (e.g., depression, anxiety) also have adverse effects on many physical diseases via a variety of behavioral and physiological pathways.2 The mental health professional intervenes to develop healthful behaviors and remove unhealthful behaviors in all medically ill patients and to relieve emotional distress in the subset of patients with evident psychopathology.

Evidence demonstrating the importance of psychological, behavioral, and social factors in diabetes has been accumulating for more than 20 years,3 and the role of the mental health expert in diabetes care has expanded accordingly.4,5 In this article, we identify these factors and describe their effects on the course of diabetes and the functioning of people with diabetes. The use of psychological treatments to improve diabetes outcomes is also specified. Although the role of mental health provider may be filled by various professionals (e.g., psychologist, medical social worker, or psychiatrist), the term "psychologist" is used in this article to denote a mental health professional.

Role of the Psychologist
in Diabetes Care
Ideally, diabetes treatment is provided by a team of health care professionals that consists of a physician, diabetes nurse educator, dietitian, and psychologist.5 The psychologist provides direct services to the patient via promotion of health behaviors and treatment of psychological problems, and also provides consultation to the medical team on how to incorporate psychological principles into patient care to enhance clinical outcomes.

The bulk of the psychological services in diabetes care are provided to patients who do not have diagnosable psychological problems. For example, nonadherence to the diabetes regimen is the most common reason for psychological referral, although in a statistical sense it represents the norm and not the exception (Table 1). Nonadherence to treatment is not itself evidence of a psychological problem. The objectives of psychological treatment for diabetic patients with and without emotional problems are listed in Table 2.

Table 1. Rates of Nonadherence to Diabetes Regimen Tasks 6-9
Diet—not following meal plan
Insulin—improper administration
Blood glucose testing—inaccurate recording
Foot care—inadequate care
Exercise—inadequate amounts
35–75%
20–80%
30–70%
23–52%
70–81%

Psychosocial Factors in
Diabetes Care
A comprehensive review of the psychosocial barriers to proper diabetes management is beyond the scope of this paper;3 thus, attention will be given to those problems most often encountered in the clinical setting.

Nearly all patients with diabetes evidence lapses in adherence at some point during the course of their illness. The rate of nonadherence fluctuates as a function of the regimen task (see Table 1).6-9 Human nature, the complexity of the regimen, and the chronicity of diabetes also contribute importantly to nonadherence. Nonadherence is a central focus of psychological treatment because of its recognized association with poor metabolic control6,7 and increased risk for diabetes complications.

Nonadherence is often mistakenly attributed to inadequate knowledge about proper diabetes care. Many other psychosocial factors contribute significantly to this problem, such as inadequate social support, time pressures, stress, and health beliefs that are incompatible with the regimen.9-11 The psychologist can provide treatment to develop new healthful behaviors, enhance existing healthful behaviors, and extinguish unhealthy behaviors as they relate to improved glycemic control.

Nonadherence may also be a manifestation of more serious psychological problems, such as depression, anxiety, or eating disorders. These problems may be treated effectively with psychotherapy or psychotropic medication.12-14

Stress is common in diabetes and is brought on by ordinary daily hassles (e.g., driving in traffic, conflict with family members, work deadlines), negative life events (e.g., death of a loved one, financial problems, divorce), and the additional burdens of coping with diabetes. Stress may have direct effects on health via elevated blood glucose values15,16 and indirect effects on health via disruption in behavioral patterns and routines (e.g., eating and sleeping). The psychologist can be a valuable resource in identifying maladaptive reactions to stress and can help patients to develop more useful and effective methods of coping.16

Table 2. Objectives of Psychological Treatment in Diabetes
For All Diabetic Patients
• To improve adherence to the diabetes treatment regimen
• To promote pro-diabetic coping behaviors (e.g., diet and exercise)
• To extinguish high-risk health behaviors (e.g., smoking, high fat intake)
• To improve family functioning as it relates to communication and problem-
   solving about diabetes
• To provide support for subclinical distress related to diabetes

For Diabetic Patients With Psychological Problems
• To evaluate and treat psychopathology, particularly depression, anxiety, and
   eating disorders
• To refer for psychoactive medication as needed

Psychopathology and Diabetes
Approximately one-third of patients with diabetes have diagnosable psychological problems at some point during their lifetime.2 Affective and anxiety disorders are the most common diagnoses and occur significantly more often in patients with diabetes than in the general U.S. population.17 These disorders can lead to poor glycemic control through alterations in neurohormonal and neurotransmitter functioning and through disruption in diabetes self-care.

Major depression affects approximately one of every five patients with diabetes and severely impairs quality of life and all aspects of functioning.17 It has added importance in diabetes because of its association with treatment nonadherence, poor glycemic control, and increased risk for micro- and macrovascular disease complications.18 Depression remains unrecognized and untreated in the majority of cases despite its specific relevance to diabetes.19

Another area of concern is the growing number of documented cases of eating disorders among individuals with diabetes.20,21 Whether these problems are more, less, or equally prevalent in diabetes compared to the general population remains controversial. Regardless, eating disorders are clinically important because of their association with poor glycemic control and an increased risk for retinopathy.21 Eating disorders can be effectively treated with psychotherapy. However, both eating disorders and depression tend to be recurrent and to require repeated treatment.

Psychosocial Issues Unique to
Children and Adolescents
Pediatric and adult patients with diabetes may manifest psychological problems in different ways. Evidence of psychosocial problems related to diabetes in children is often observed in poor school performance, impaired peer relations, or behavioral changes at home, at school, or with friends.22 In addition, conflictual family relations are often clues to psychosocial problems for children with diabetes. Because children rely on their parents for a great deal of their diabetes care, conflictual parent-child relations can impede proper diabetes management.23

Adolescence is a time of rebellion from convention. Convention is represented not only by parents and teachers but also by medical professionals. Adolescent patients may defy the recommendations of health care professionals for reasons related to normal development. However, this defiance can place adolescents at risk for poorer metabolic control even to the point of diabetic ketoacidosis.9,23

With both children and adolescents, the psychologist can provide information to the diabetes treatment team about psychosocial development and how best to resolve some of the struggles between parents and youth that may be an impediment to proper diabetes management.4 In addition, the psychologist can assist parents in negotiating control with their child over the diabetes treatment regimen.

 

Selecting A Mental Health Provider
As previously discussed, a number of individuals may fill the role of psychologist on the diabetes treatment team. However, there are distinct differences in the background, training, and abilities of these individuals.

Clinical psychologists are an appropriate resource to the diabetes treatment team for the diagnosis, assessment, and treatment of mental health problems of patients with diabetes. Psychologists with expertise in reinforcement strategies, learning principles, and behavior modification are highly desirable given the usefulness of these skills for developing health behaviors. While not all psychologists are trained in diabetes, it is recommended that clinical psychologists working with diabetic patients have training in health and/or pediatric psychology and be licensed by the state in which they work. This will provide some degree of quality assurance and will increase the chances that services rendered by a psychologist will be reimbursed by insurance companies.

Medical social workers are another example of individuals with expertise in mental health issues. Medical social workers are unique in that they are trained in case management and identification of community resources for patients. These skills are useful in managed care settings to deal with the financial cost of managing a patient with diabetes not covered by insurance. For example, patients often need assistance in obtaining adequate supplies (e.g., glucose meters, glucose strips, insulin, syringes, oral agents) to properly manage their diabetes.

Side effects and drug interactions must be taken into account when choosing antidepressant medications for diabetic patients.12 In complicated medical illness, psychiatric consultation may be used to clarify appropriate treatment. Psychiatric expertise may also be useful if a patient fails to respond to psychotherapy or to psychoactive agents prescribed by the primary care physician. In most instances, a psychiatric referral is indicated for patients with a history of severe emotional illness or suicidal ideation.

Summary
Evidence that psychological and behavioral factors significantly affect the course and outcomes of diabetes continues to accumulate. As these data are appreciated, psychologists are increasingly being utilized to augment traditional diabetes care.

Effective diabetes management requires adherence to a chronic and complex regimen and, accordingly, nonadherence is the norm rather than the exception. Psychological treatments may be used to improve adherence to the diabetes regimen and, more generally, to develop sustained pro-diabetic lifestyles.

One in every four diabetic patients suffers from recurring problems with depression, anxiety, or eating disorders. These conditions respond well to psychological treatment, and in many cases, relief of distress is associated with improved glycemic control.

Children and adolescents with diabetes present with psychological problems in different ways than adults and require appropriate psychological care to intervene at their specific developmental level.


References

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2Cohen S, Rodriguez MS: Pathways linking affective disturbances and physical disorders. Health Psychol 14:374-80, 1995.

3Rubin RR, Peyrot M: Psychosocial problems and interventions in diabetes. Diabetes Care 15:1640-57, 1992.

4Anderson BJ, Rubin RR (Eds.): Practical Psychology for Diabetes Clinicians: How to Deal With Key Behavioral Issues Faced by Patients & Health Care Teams. Alexandria, Va., American Diabetes Association, 1996.

5Lorenz RA, Bubb J, Davis D, Jacobson A, Jannasch K, Kramer J, Lipps J, Schlundt D: Changing behavior: practical lessons from the Diabetes Control and Complications Trial. Diabetes Care 19:648-52, 1996.

6Kutz SM: Adherence to diabetes regimens: empirical status and clinical applications. Diabetes Educ 16:50-56, 1990.

7Johnson SB: Methodological issues in diabetes research: measuring adherence. Diabetes Care 15:1658-67, 1992.

8McNabb WL: Adherence in diabetes: can we define it and can we measure it? Diabetes Care 20:215-18, 1997.

9Weissberg-Benchell J, Glasgow AM, Tynan WD, Wirtz P, Turek J, Ward J: Adolescent diabetes management and mismanagement. Diabetes Care 18:77-82, 1995.

10Boehm S, Schlenk EA, Funnell MM, Powers H, Ronis DL: Predictors of adherence to nutrition recommendations in people with non-insulin-dependent diabetes mellitus. Diabetes Educ 23:157-65, 1997.

11Schlundt DG, Rea MR, Kline SS, Pichert JW: Situational obstacles to dietary adherence for adults with diabetes. JAMA 94:874-76, 1994.

12Lustman PJ, Clouse RE, Alrakawi A, Rubin EH, Gelenberg AJ: Treatment of major depression in adults with diabetes: a primary care perspective. Clinical Diabetes 16:122-26, 1997.

13Mendez FJ, Belendez M: Effects of a behavioral intervention on treatment adherence and stress management in adolescents with IDDM. Diabetes Care 20:1370-75, 1997.

14Wysocki T, White NH, Bubb J, Harris MA, Greco P: Family adaptation to diabetes: a model for intervention research. In Advances in Pediatric Psychology: Adolescent Health Problems: Behavioral Perspectives. Wallander JL, Siegel LJ, Eds. New York, Guilford Press, 1995, p. 289-304.

15Surwitt RS, Schneider MS, Feinglos MN: Stress and diabetes mellitus. Diabetes Care 15:1413-22, 1992.

16Auslander WF, Bubb J, Rogge M, Santiago JV: Family stress and resources: potential areas of intervention in children recently diagnosed with diabetes. Health Soc Work 18:101-13, 1993.

17Gavard JA, Lustman PJ, Clouse RE: Prevalence of depression in adults with diabetes: an epidemiological evaluation. Diabetes Care 16:1167-78, 1993.

18Lustman PJ, Griffith LS, Clouse RE: Depression in adults with diabetes. Sem Clin Neuropsychiatr 2:15-23, 1997.

19Lustman PJ, Harper GW: Nonpsychiatric physician’ identification and treatment of depression in patients with diabetes. Comp Psychiatr 28:22-27, 1987.

20Pevelier RC, Boller I, Fairburn CG, Dunger D: Eating disorders in adolescents with IDDM. Diabetes Care 15:1356-60, 1992.

21Rydall AC, Rodin GM, Olmsted MP, Devenyi RG, Daneman D: Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus. N Engl J Med 336:1849-54, 1997.

22Eiser C: Psychological effects of chronic disease. J Child Psychol Psychiatr 31:85-98, 1990.

23Wysocki T: Associations among teen-parent relationships, metabolic control, and adjustment to diabetes in adolescents. J Pediatr Psychol 18:441-52, 1993.


Acknowledgment

This article is dedicated to the memory of the late Dr. Julio V. Santiago for his tireless efforts to help individuals overcome the medical, psychological, social, and behavioral challenges presented by diabetes.


Michael A. Harris, PhD, is a clinical psychologist and research associate in the Department of Pediatrics at Washington University School of Medicine in St. Louis, Mo. Patrick J. Lustman, PhD, is an associate professor of medical psychology in the Department of Psychiatry at Washington University School of Medicine and a counseling psychologist at the Department of Veterans Affairs Medical Center in St. Louis, Mo.

Note of disclosure: Dr. Lustman receives research support from Eli Lilly, is a stock shareholder of Pfizer Pharmaceuticals, and has received speaking honoraria from various other companies that manufacture and sell pharmaceutical products for the treatment of depression and/or diabetes.


Copyright 1998 American Diabetes Association
Updated 4/98
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