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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
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.
Psychosocial Factors in
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
Psychopathology and Diabetes
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
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
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.
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.
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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
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