PSYCHOLOGICAL IMPACT IN DIABETICS TYPE II

Diabetes is a chronic health care condition that affects millions of people in the United States. Beyond the physical demands of this condition, diabetes is one of the most psychologically and behaviorally demanding of chronic medical illnesses (Cox, !!"# and ca$ses distress and stress, depression, and anxiety disorders. %hese psychological and psychosocial iss$es are often $ndiagnosed and $ntreated in diabetic individ$als. &ealth care providers m$st assess the psychological health of type '' diabetics (hen developing plans of care. Understanding and addressing the psychological health of the diabetic individ$al (ill allo( for more s$ccessf$l diabetes management. Distress is common among diabetics, and may lead to depression and anxiety disorders, as (ell as negatively impact the physical health of diabetics. %he rigoro$s lifestyle demands associated (ith diabetes, in con)$nction (ith the ris* of hypoglycemia and severe hyperglycemia, creates stress in a diabetic+s life (,einger, -. . /ee, 0., "112#. 3nother ca$se of stress can be the diabetic+s relationship to his or her family and friends. 4riends and family may be frightened by the possibility of the serio$s complications of diabetes and may not *no( ho( to help. %herefore family members and friends may react negatively by nagging, doing too m$ch for the person, not letting the person learn ho( to care for themselves, or treating the diabetic ad$lt li*e a child. %hese stressors can lead the diabetic to feel fr$strated, over(helmed, b$rned o$t, and chronically angry, g$ilty, or fearf$l. %hese forms of distress ca$se disco$ragement and red$ce a patient+s self5care motivation, res$lting in poor decisions, less attention to diabetic c$es, and ris*y behaviors li*e food and alcohol binging. 'n t$rn, this lac* of treatment adherence is associated (ith poor metabolic control (C6yen(s*i, !77#.

8hysiological stress itself can directly increase blood gl$cose concentrations thro$gh elevated stress hormones, incl$ding epinephrine, norepinephrine, cortisol, and gro(th hormone (Barglo( et al., !79: C6yen(s*i, !77: 8eyrot . ;c;$rry, !!": 8eyrot et al., !!!: ,einger, -. . /ee, 0. ("112#. Stress also decreases the peripheral effects of ins$lin, stim$lates liver gl$cose secretion, and red$ces pancreatic ins$lin secretion: all of (hich co$ld contrib$te to poor metabolic control (Cox . <onder54rederic*, !!"#. Depression in people (ith diabetes is $nder diagnosed and $ndertreated. 3pproximately one third of depression cases are diagnosed in diabetics. %he presence of diabetes do$bles the odds of comorbid depression. 3dditionally, three5=$arters of diabetic patients (ho recover from an episode of depression s$ffer a relapse (ithin five years (3nderson, >.0, Clo$se, >.?., 4reedland, -.?., /$stman, 8.0., "11 #. Depression directly affects the mental (ell5being of diabetics. Depressed diabetics tend to have greater cognitive impairment relative to non5diabetics individ$als (,atari, et al#. ,hen diabetic individ$als have depression it can also exacerbate existing cognitive deficits. @verall, type '' diabetes has been related to mild cognitive deficits in the areas of verbal memory, processing speed, attention, and exec$tive f$nctioning. Depression is associated (ith compromised self5management, s$bstance ab$se, decreased glycemic control, and diminished emotional and physical (ell5being. Depression is also lin*ed to decreased motivation, lac* of energy, and hopelessness, (hich can interfere (ith the diabetic+s ability to perform demanding self5management tas*s. &o(ever, it is important to recogni6e that diabetes and depression are separate conditions and m$st be treated individ$ally. 't is also important to note that depression

and poor glycemic control are not synonymo$s, many (ith poor control are not depressed and many depressed people manage their diabetes effectively. 'n regard to anxiety disorders, $p to "1A of people s$ffering from anxiety disorders are diabetics (>$bin, >.>. . 8eyrot, >., "11 #. 3nxiety disorders incl$de panic disorders, specific phobias, social phobias, obsessive comp$lsive disorder, ac$te stress disorders, post tra$matic stress disorder, and generali6ed anxiety disorders. 3nxiety disorders are often $nder diagnosed and $ndertreated in primary care, beca$se there is often conf$sion bet(een the physical symptoms of anxiety and hypoglycemia. 3nxiety and anxiety disorders can decrease the =$ality of life for diabetic individ$als and may affect self5care. 3nxiety is associated (ith increased stress, red$ced regimen adherence, and poorer glycemic control (8eyrot, ;c;$rry . -r$ger, !!!#. 3ll of these are dangero$s to the diabetic and may ca$se ha6ardo$s complications. %here are many interventions and therapies to treat distress, stress, depression, and anxiety disorders in diabetic individ$als. Cognitive behavioral therapy may be effective (ith mild to moderate res$lts (/$stman, <riffith, 4reeland, -issel, and Clo$se#. 't helps patients to avoid self5defeating tho$ght patterns and negative behaviors. 'nterpersonal process therapy has also sho(n s$ccess as it helps patients develop comm$nication and social interaction s*ills. Systematic desensiti6ation and cognitive restr$ct$ring may be effective in addressing avoidance behaviors, self5management s*ills, self5destr$ctive patterns, and anxieties. Coping s*ills training may decrease the stress that ca$ses depression. /earning coping s*ills can help diabetic individ$als s$ccessf$lly develop a life (ithin the context of

diabetes instead of )$st managing diabetes. 3nother coping s*ill is problem solving therapy, (hich helps diabetics address their specific lifestyle problems and needs. 8eer gro$p interventions have also sho(n s$ccess in the treatment of stress, distress, and depression. Diabetic peers are more li*ely to provide the emotional s$pport and companionship that non5diabetic family members and family cannot. %his is especially tr$e for adolescent diabetics (ho reported an improvement in self5perception after peer gro$p intervention. ,hen self5perception improved, metabolic control often improved (>$bin, >.>. . 8eyrot, >., "11 #. ;edication is another s$ccessf$l treatment of anxiety and depression. 'n a st$dy by >$bin and 8eyrot, those (ho $sed antidepressant medication, tricyclic nortriptyline, and fl$oxetine (ere more li*ely to experience remission of their depression than those treated (ith placebo. %his resol$tion of depression (as also associated (ith improvement in glycemic control over the eight (ee* st$dy (>$bin . 8eyrot, !!9b#. ;ore treatments for diabetic individ$als s$ffering from anxiety incl$de biofeedbac*, relaxation training, and psychopharmacological agents. ,ith these treatments type '' diabetics reported improved gl$cose tolerance and red$ced long5term hyperglycemia (S$r(it, >oss, ;cCas*ill . 4einglos, !7!#. %he best form of primary care intervention (ith diabetic patients is tal*ing abo$t the specific problems or diffic$lties that they experience (ith this disease. >esolving specific problems (ill lead to positive experiences and (ill improve motivation, self5care and =$ality of life.

%here are five *ey points to a primary care intervention, as sho(n by the acronym B3%&?. B for bac*gro$nd. %he patients are as*ed (hat has been happening in their lives, and enco$raged to identify a specific problem or concern. 3 is for 3ffect. 3fter a specific problem is spotlighted, the patients are as*ed ho( this problem affects them and ma*es them feel. % is for %ro$ble, the patients are as*ed ,hat is it abo$t the sit$ation that tro$bles yo$ the mostB 8atients pa$se and rationali6e abo$t ho( to arrive at a sol$tion. & is for &andling, as in, &o( are yo$ handling thatB @r ho( co$ld yo$ handle thatB 'n this ans(er a negative coping behavior may be fo$nd and the opport$nity to advise a positive coping strategy may be present. ? is for ?mpathy. 't is important to concl$de by recogni6ing the diffic$lty of the sit$ation and providing psychological s$pport to the patient. %he goal of this primary care intervention is to empo(er the patient (ith the right attit$de to adhere to his or her treatment. (St$art, ;.>. . /ieberman ''', 0.3. "11"# 'n concl$sion, the incidence of stress, depression and anxiety is common in people (ith diabetes. %hese conditions can negatively affect diabetes management and control, b$t can be managed (ith a variety of therapies and medications, incl$ding primary care interventions. 8rimary care providers can offer initial interventions that positively treat stress, depression and anxiety in diabetic individ$als. Understanding and addressing the psychological health of the diabetic individ$al (ill allo( for more s$ccessf$l diabetes management.

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