PSYCHOLOGICAL ISSUES IN DIABETES

Transcription

1 PSYCHOLOGICAL ISSUES IN DIABETES William H. Polonsky, PhD, CDE Diabetes in the Real World: Poor Self-Care Is Common Follows physician guidelines < 50%: NMC KSR TMC Healthy meal plan 32% 36% 63% Exercise 54% 55% 52% BG monitoring 15% 21% 27% NMC, n = 192; KSR, n = 171; TMC, n = 170

2 Medication Adherence HMO and PBO databases, 11 retrospective studies: OHA compliance was 36% 93% MEMS data, 5 prospective studies (3 6 months): OHA compliance was 61% 85% Thus, similar to studies of other illnesses, the average patient may be missing approximately 25% of prescribed OHA(s) Cramer JA. Diabetes Care 2004;27: Ralph s Story Age 54, type 2 diabetes 8 years, never paid much attention to it. Knows he is overweight (BMI 32), suspects his diabetes is not in the best control. Knows he ll be told at next medical visit to exercise and to stop smoking (been told this many times before). But doesn t think there is anything he can/wants to do about this. Ralph s Story Loves eating, not really concerned about his weight. Knows diabetes can harm him in long run, but has plenty of other things to worry about that seem more pressing. Never checks BG s, sees no point to it. Many family members with diabetes some doing well, some doing poorly. This that luck plays a big role in what happens with diabetes.

3 Why Is Self-Management Difficult? ( strong endorsements by physicians) poor self-discipline 53.2% poor will-power 50.0% not scared enough 36.9% not intelligent enough 16.3% Polonsky WH, et al. Diabetes 1996;45(Supplement 2):14a Why Is Self-Management Difficult? Almost no one is unmotivated to live a long and healthy life. The rewards for good diabetes care are - relatively subtle - mostly long-term Why Is Self-Management Difficult? Poor self-care occurs when obstacles outweigh possible benefits There are major medical benefits in diabetes, but also many, many obstacles

4 Obstacles to Good Self-Care Lack of access to care Lack of knowledge or skill 8 Obstacles to Good Self-Care Depression and anxiety disorders Eating disorders Substance abuse Inadequate/unclear plans for self-care Diabetes-related health beliefs Diabetes-related social support Common environmental barriers Diabetes-related distress Mood Disorders Depression rates are x higher in diabetes samples: In review of controlled studies (n = 21): 20.5% of patients vs. 11.4% of controls Recent Kaiser study compared 16,000 Type 2 patients vs. 16,000 matched controls: 17.9% of patients vs. 11.2% of controls Anderson RJ, et al. Diabetes Care 2001; 24: Nicohols GA, et al. Diabetes Care 2003; 26:

5 Mood Disorders Nicohols GA, et al. Diabetes Care 2003; 26: Mood Disorders Depressive symptoms are common: 32% (Gavard et al, 1993) 41% (Peyrot and Rubin, 1997) 45% (Gary et al, 2000) 37% (Polonsky et al, 2000) 31% (Hermanns et al, 2005) Influence of Comorbid Disease HTN, CAD, chronic arthritis, stroke, COPD, ESRD; n = 1794 Major Depression, Adjusted Odds Plus 1 Plus 2 Plus 3 Egede LE. Psychosomatic Medicine 2005; 67: 46-51

6 Influence of Comorbid Disease Large community-based Dutch study (n = 3107) found that depression prevalence was: 20% type 2 diabetes, co-morbid chronic disease 8% type 2 diabetes only 9% healthy controls Pouwer F, et al. Diabetologia 2003; 46: Mood Disorders Depression makes it harder to initiate and maintain healthy behavior changes Poor glycemic control (elevating HbA1C %) Over 3 year period, depression was strongest predictor of rate of hospitalization Over 10 year period, 3x higher incidence of CAD and retinopathy Lustman et al, 2000; Rosenthal et al, 1998; Kovacs et al, 1995; Carney et al, 1994 Depression and Healthcare Costs in Diabetes, Nationwide Sample (4.5x higher in depressed vs. non-depressed) Dollars, in millions Not depressed Depressed Egede LE, et al. Diabetes Care 2002; 25:

7 Anxiety Disorders Recent meta-analyses of clinical populations: Generalized anxiety disorder, 14% of patients Elevated symptoms of anxiety, 40% of patients Anxiety disorders are associated with hyperglycemia No evidence that anxiety disorder rates are elevated in diabetes Hermanns et al, 2005; Grigsby et al, 2002; Anderson et al, 2002 Eating Disorders Young women with type 1 diabetes Though controversial, rates appear to be doubled: * clinical disorders (10% vs. 4%) * subclinical disorders (14% vs. 8%) Poorer metabolic control Increased prevalence of retinopathy at 4 years Jones JM, et al. BMJ 2000; 320: Rydall AC, et al. NEJM 1997; 336: Insulin Omission in Type 1 Diabetes Polonsky et al, women surveyed 31% omitted insulin; 9% regularly omitted Jones et al, female teens surveyed 11% omitted insulin regularly Polonsky WH, et al. Diabetes Care 1994; 17: Jones JM, et al. BMJ 2000; 320:

8 Eating Disorders Type 2 diabetes Binge eating disorder is often believed to be more prevalent, but the data is equivocal Note that obesity is NOT an eating disorder Mannucci E, et al. International Journal of Obesity 2002; 26: Herpertz S, et al. Int J Eat Disord 2000; 28: Alcohol use Illicit drug use Tobacco Substance Abuse 8 Obstacles to Good Self-Care Depression and anxiety disorders Eating disorders Substance abuse Inadequate/unclear plans for self-care Diabetes-related health beliefs Diabetes-related social support Common environmental barriers Diabetes-related distress

9 8 Obstacles to Good Self-Care Depression and anxiety disorders Eating disorders Substance abuse Inadequate/unclear plans for self-care Diabetes-related health beliefs Diabetes-related social support Common environmental barriers Diabetes-related distress Unachievable Self-Care Plans Unclear - I m supposed to start exercising. Unrealistic - My doctor told me to lose 10 lbs before the next visit. - Taking care of my diabetes means I m supposed to eat perfectly and never cheat. Why Are Self-Care Plans Often Unachievable? Patient-provider communication - 21%, complete disagreement on decisions made - Poor health literacy Parkin T, et al. Diabetic Medicine 2003; 20: Schillinger D, et al. JAMA 2002; 288: Sheeran P, et al. Health Psychology 2000; 19:

10 Marlene s Story Age 71, type 2 diabetes 15 years Hospital volunteer, info desk Suspects her diabetes is not in the best control Takes more pills whenever BG s > 150 mg/dl. Very scared by high and low BG s Following MD s advice, recently went to nurse CDE for help That was pointless Functional Health Literacy in Diabetes 408 patients with type 2 diabetes, SF General Many don t understand recommendations: - 38% inadequate FHL - 13% marginal FHL Poor FHL linked to poor glycemic control and higher rates of long-term complications Schillinger D, et al. Archives of Internal Medicine 2003; 13:

11 Why Are Self-Care Plans Often Unachievable? Patient-provider communication - 21%, complete disagreement on decisions made - Poor health literacy Parkin T, et al.diabetic Medicine 2003; 20: Schillinger D, et al. JAMA 2002; 288: Sheeran P, et al. Health Psychology 2000; 19: Why Are Self-Care Plans Often Unachievable? Patient-provider communication - 21%, complete disagreement on decisions made - Poor health literacy No plan for implementing recommendations Enthusiasm of the healthcare provider Parkin T, et al.diabetic Medicine 2003; 20: Schillinger D, et al. JAMA 2002; 288: Sheeran P, et al. Health Psychology 2000; 19: Harmful Beliefs about Diabetes A. No big deal - I feel fine, therefore I am fine - Look, I ll start worrying about diabetes if and when something goes wrong. - We re all going to die anyway. B. Hopelessness - Diabetes means I am doomed

12 Harmful Beliefs about Diabetes C. Treatment is ineffective (or harmful) - No matter what I do, these numbers are still high! - I m not so sure that what you re asking me to do will really help me. - Take insulin? That ll make my diabetes worse! Treatment Efficacy: Reggie s Tale thanks for your kind attention to my demise. The last time I visited an endocrinologist was about 4 years ago. My understanding of diabetes is rudimentary, and my problems are rooted in my very first disappointing efforts to get it under control shortly after I was diagnosed in Whatever I tried simply did not seem to work. My BG s were highly erratic and there seemed no correlation with what I ate, when I ate, and at what time I ate. Treatment Efficacy: Reggie s Tale On occasion, I have taken matters very seriously and monitored my sugars religiously for 1 2 week periods. Each time I have been disappointed by the lack of logic in the BG readings, to the point where long ago I decided I was not going to become a human pin cushion sticking 4 needles into my body a day and then another 6 or 7 into my fingers to check my levels. I decided I would simply exercise discretion, abstinence, and control as required.

13 Treatment Efficacy: Reggie s Tale I have reduced my intake of insulin to three times daily as opposed to 4 times daily. I have stopped testing altogether. I attempt to exercise control where I can, but I do have the occasional chocolate attack and throw caution to the wind. I am fully aware there will be consequences, but there doesn t seem to be anything I can do. Poor Social Support Isolation The diabetes police Environmental Barriers Life gets in the way : Stress Daily demands Limited finances Poor healthcare insurance Social/cultural influences

14 Diabetes-Related Distress Anxiety (hypoglycemia, complications) Guilt (maybe I did this to myself, maybe I m not doing enough to keep my BG s in range) Anger (I hate this disease) Discouragement (I feel like I am failing with diabetes) Diabetes-Related Distress... And even the constant need for decisions might be tolerable, if only the results were predictable. Few things generate burnout like the awful frustration of having followed instructions and done everything just right and still be failing to get diabetes into control. At those times it seems no use to continue to try.

15 Diabetes-Related Distress Think how discouraging it is to fail at something you really wanted to do. Then consider what it must feel like to have diabetes and be failing at something you never, ever, wanted to do in the first place. Hoover JW. Patient 'burnout' can explain non-compliance. World Book of Diabetes in Practice, Vol New York: Elsevier Science Publishers. 8 Obstacles to Good Self-Care Depression and anxiety disorders Eating disorders Substance abuse Inadequate/unclear plans for self-care Diabetes-related health beliefs Diabetes-related social support Common environmental barriers Diabetes-related distress What To Do?

16 Strategies That Don t Work Urging more willpower if you would just try harder Threatening bad outcomes you ll go blind if you don t do what I tell you to do The gift of advice maybe if you joined a nice fitness center The Overarching Approach READY TO CHANGE. The patient must be interested in diabetes management KNOW WHAT TO DO. The patient must have a clear and achievable plan for selfmanagement The Overarching Approach READY TO CHANGE. The patient must be interested in diabetes management KNOW WHAT TO DO. The patient must have a clear and achievable plan for selfmanagement Here are six steps towards reaching these goals

17 Psychosocial Interventions 1. Stay alert for depression 2. Engage the patient 3. Investigate self-care importance and confidence 4. Address functional health literacy issues 5. Challenge harmful health beliefs 6. Negotiate behaviorally-based plans for action 1. Stay Alert for Depression Screen regularly Promote vigilance in patients TWO QUESTIONS ABOUT DEPRESSION During the past month, have you often: a. been bothered by feeling down, depressed or hopeless? b. had little interest or pleasure in doing things?

18 Treatment of Depression in Diabetes Percent in Remission at Treatment Conclusion Nortryptiline Fluoxetine CBT Treat Control Lustman et al, 1997; 1998; 2000 Treatment of Depression in Diabetes Improving Mood Promoting Access to Collaborative Treatment (IMPACT) A collaborative, stepped care management intervention 417 type 2 patients, usual care vs. IMPACT Mean age, 70 years Williams JW, et al. Annals of Internal Medicine 2004; 140: IMPACT Intervention The depression care manager : collaborative development of tx plan, SSRI and/or PST Treatment intensification as needed Frequent follow-up for 12 months (mean was 9 visits, 6 phone contacts) Frequent re-administration of PHQ Monthly phone follow-up after remission Williams JW, et al. Annals of Internal Medicine 2004; 140:

19 The Impact of IMPACT: Depression 2 SCL-20 Depression Intervention Usual Care 0 Baseline 3 Months 6 Months 12 Months The Impact of IMPACT: Functional Impairment SF-12 Functional Impairment Baseline 3 Months 6 Months 12 Months Intervention Usual Care IMPACT Intervention Compared to usual care: Reduced depression Reduced functional impairment More exercise No other impact on self-care behaviors or glycemic control (mean A1C, 7.3%) Williams JW, et al. Annals of Internal Medicine 2004; 140:

20 Other Psychopathological Issues Stay alert for disordered eating especially in young women with type 1 diabetes These are complex problems, difficult to treat, referral is critical Stay alert for anxiety disorders antidepressants and CBT are effective forms of treatment Stay alert for substance abuse 2. Engage the Patient Start with questions, not information: What questions should we make sure to address today? What s been driving you crazy about diabetes? Begin with the patient s concerns Agenda must be personally meaningful for the patient 3. Address Self-Care Importance How do you feel about exercise now? If 0 was not important, and 10 was very important, what number would you give yourself? 0 10 not important very important You rated exercise importance at 4. Why isn t it a 3? (listen for benefits) And why isn t it a 6 or 7? (listen for obstacles) What would it take to raise your importance score up to a 6 or 7? Rollnick S, Mason P, Butler C. Health Behavior Change New York: Churchill Livingstone

21 Listen Well and Summarize It sounds as though you re inclined in two different directions. On the one hand, you re worried about the possible long-term effects of your diabetes if you don t manage it well blindness, amputations, things like that. On the other hand, you re young and you feel fairly healthy most of the time. You enjoy eating what you like, and the long-term consequences seem far away. You re concerned, and at the same time you re not concerned. 3. Address Self-Care Confidence How confident are you about starting/staying with an exercise program? If 0 was not important, and 10 very important, what number would you give yourself? 0 10 not confident very confident You rated exercise confidence at 6. Why isn t it a 4 or 5? (listen for confidence contributors) And why isn t it a 7 or 8? (listen for confidence obstacles) What would it take to raise your confidence score up to a 6 or 7? 4. Address Health Literacy Assess patients recall or comprehension of recommendations D. "So... let's make sure. What medications are we going to change?" P. "I think we're going to stop this one (is it metformin?)... and I'm going to take glipizide twice a day... I think that's the green one." Schillinger D, et al. Archives of Internal Medicine 2003; 13:

22 Influence of Assessing Recall on Glycemia % with adequate glycemic control Recall assessed Recall not assessed Schillinger D, et al. Archives of Internal Medicine 2003; 13: Challenge Harmful Beliefs Recommend ongoing diabetes education Identify ( what do you think about diabetes? ) Respectfully challenge: - Re-calculating complication odds - Talking about treatment effectiveness (the power of personalized feedback) Levetan et al, 2002

23 How Many Are A1C Aware? 38.0 % reporting A1C A1C + plausible result A1C + plausible, accurate result Polonsky WH, Zee J, Ah Yee M, Crosson M, Jackson R. Patients awareness and understanding of their own A1c test results. Diabetes 2003; 52 (Supplement 1): A FACTS AND FICTIONS 1. Diabetes is the leading cause of adult blindness, amputation and kidney failure. True or false? False. Poorly controlled diabetes is the leading cause of adult blindness, amputation and kidney failure. Perceived Treatment Efficacy 9 The Power of A1C Feedback Hemoglobin A 1c Level 8 7 UKPDS Mary 6 Baseline 3 Months 6 Months 9 Months 12 months

24 6. Negotiated Goal Setting Focus on concrete actions to start: - not attitudes, numbers, or actions to stop Only 1 2 behavior changes at a time 6. Negotiated Goal Setting Actions must be achievable and personally meaningful - Why would you bother doing this? Develop implementation intentions - So what exactly are you going to do tomorrow morning? Implementation Intentions Promote cervical cancer screening appointment Random assignment to experimental or control procedure (n = 114) Control. Lecture about the need for screening Experimental. Lecture plus: - You re more likely to go for a cervical smear if you decide when and where you ll go. Please write in when, where and how you ll make appointment. Sheeran P, et al. Health Psychology 2000; 19:

25 The Power of Implementation % attending screening appointment Lecture Lecture plus implementation plan Sheeran P, et al. Health Psychology 2000; 19: Take-Home Messages Everyone would prefer to live a long, healthy life Our patients are not unmotivated to manage diabetes effectively The problem is that diabetes self-care is tough Our patients face many obstacles to good self-care As a result, diabetes burnout is common (in providers as well as patients) Take-Home Messages Take hope! We can help our patients to manage diabetes more successfully As a side effect, we can improve our own morale

26 Take-Home Messages Common barriers include: 1. Depression and anxiety disorders 2. Eating disorders 3. Substance abuse 4. Inadequate/unclear plans for self-care 5. Diabetes-related health beliefs 6. Diabetes-related social support 7. Common environmental barriers 8. Diabetes-related distress Take-Home Messages Effective treatment strategies include: 1. Stay alert for depression 2. Engage the patient 3. Investigate self-care importance and confidence 4. Address functional health literacy issues 5. Challenge harmful health beliefs 6. Negotiate behaviorally-based plans for action Suggested Readings Anderson BJ, Rubin RR. Practical Psychology for Diabetes Clinicians, 2nd Ed. Alexandria, Va: ADA; Miller WR, Rollnick S. Motivational Interviewing, 2nd Ed. New York: Guilford Press; Polonsky WH. Diabetes Burnout: What To Do When You Can t Take It Anymore, Washington, DC: ADA; Rollnick S, et al. Health Behavior Change. New York: Churchill Livingstone; Snoek FJ, Skinner TC. Psychology in Diabetes Care. New York: Wiley and Sons; 2000.