Psychology in Diabetes Care

We often diagnose a patient with diabetes, give them a meter and a prescription and send them on their way. Some of us refer for education or even have an educator in our office but our patients fail no matter what we try. We have learned that there is a psychological component associated with diabetes that is even more powerful than the disease itself and often prevents the successes we all strive for. With this in mind our next Clinical Gems will focus on

1) Psychology in Diabetes Care:- 

It is difficult to conceive of a disease more likely to cause psychological problems than diabetes. Both Type 1 and Type 2 diabetes are lifelong incurable conditions with a strong heritable element, giving plenty of time for the development of guilt and recrimination within a family. Children who develop Type 1 diabetes are 'punished' by a series of injections and blood tests, a diet which forces them to eat when they don't want to and the prohibition of chocolate and ice cream, previously used to reward them for being 'good'. Type 2 diabetes develops largely because individuals make the 'wrong' lifestyle choices during their lives. Furthermore, the consequences of failing to follow an arduous and often painful treatment of limited effectiveness are a series of progressive, devastating complications which can result in blindness, amputation and premature death from cardiovascular disease....



Yet for many years, health care professionals failed to understand the psychological needs of those with diabetes under their care. Treatment was based on an acute health care model with patients waiting, often for hours in crowded waiting rooms, to see a doctor for just a few minutes (in some clinics they were not even permitted to sit down during a consultation!), who would adjust the insulin or medication and then send them on their way for another few months.
  
Perhaps the best example of this lack of insight was the debate which raged around 'brittle diabetes' in the early 1980s. Young people with Type 1 diabetes, usually women, appeared to become unresponsive to subcutaneous insulin treatment leading to appalling metabolic control and repeated admissions, with often severe uncontrolled diabetes for which there seemed to be no obvious cause. To many, it was unthinkable that those affected could be so self-destructive; that they would deliberately omit insulin and put their lives in jeopardy by inducing severe diabetic ketoacidosis. Many researchers spent much money searching for the metabolic defect which explained why intravenous insulin was more effective than insulin delivered subcutaneously. Of course, we now know that almost all cases of repeated admission with uncontrolled diabetes are indeed due to non-cooperation and that such behavior, particularly during difficult periods such as adolescence, is common. We also realize that to help those with diabetes manage their condition more successfully, as diabetes health care professionals we need to understand human behavior much more clearly and that means working with experts in that field.
It is difficult to overstate the progress in diabetes care over the last 20 years. We now understand how complex diabetes care is and how important psychological factors are, in determining the success of treatment. We are aware that if individuals with diabetes are to have any chance of managing their disease successfully, they need to have skills as well as knowledge and support from an expert multi-disciplinary team. The progress that has been made is exemplified by this book, edited by two psychologists with wide experience and expertise in the psychological needs of those with diabetes. The appearance of a second edition with chapters ranging from childhood to old age emphasizes the importance of psychological support for diabetes health care professionals when managing patients from the cradle to the grave.

Some of us are lucky to have a clinical psychologist working within our multidisciplinary teams, facilitating inter-professional working as well as providing a clinical service. However, most units are not this fortunate and have to rely on the occasional input from psychologists or liaison psychiatrists, few of whom have any specialist knowledge or experience of working with individuals with diabetes.Those in this situation will find the distilled wisdom in this book particularly useful in guiding them through a wide variety of problems. It will help them to manage difficult cases and explain the modern approach to self management and education. However, the knowledge encapsulated in these pages will prove invaluable to anyone who is privileged to provide a professional service to people with diabetes.                                                                

2) Medication Adherence:-

recently met with a Type 2 patient (Jim/52y/o) with an A1c of 9.5%. The first thing I did was to review his medications: he stated he was on 40u of Lantus BID, Glucophage SR 750mg , 2 tablets BID, and Victoza 1.8mg, Lipitor 20mg, and Aspirin 81mg, each taken once daily....

I asked him what his last fasting blood glucose was and he stated that he had not checked his blood sugars for 3 months. I then asked him when he takes his insulin and he mentioned to me that he tries to take his insulin on a regular basis, but usually forgets to take his evening dose and when his pen gets down to less than 40 units, he just takes what's left in the pen.
When questioning him further, he stated that he was under the impression that since he was taking insulin, he could eat whatever he wanted.
I immediately reduced his metformin to 1000 mg bid, and had him take his insulin on a regular basis. I had him monitor his blood sugars fasting, pre and postprandial 3 times a day and at bedtime for the next three days.

Lesson Learned:

Always confirm with the patient that they are compliant with taking their medications and at the appropriate dosages and times. This needs to be done before adjusting any medication.
Note: According to a recent study¹, when it comes to medicine, as many as half of Americans don't stick to their regimens. They fail to fill about 20% to 30% of prescriptions written by doctors, don't take drugs as directed, and don't refill medications when they run out.
Consequences of non-adherence can be dire. Studies of heart-attack patients show those who don't fill prescriptions to help prevent another heart attack have a higher rate of death one year later. Meanwhile, patients who adhere to their medications have better health outcomes, and require less care, than those with similar conditions and poor adherence, research shows.

Steve Freed, RPh, Publisher

¹PhRMA; National Council on Patient Information and Education; WSJ reporting

Copyright © 2011 Diabetes In Control, Inc.

 

3) DPP-4 inhibitors and GLP-1 analogs:-

source:- Diabetes in Control