Psychological aspects: an introduction
Diabetes mellitus presents to the physician as a metabolic or pharmacological problem, but adjustment to the diagnosis and its implications represents a major psychological and social challenge for the person affected, and will have a major influence upon the outcome of their disease. Diagnosis brings the realization that the condition is (usually, but not always) irreversible, typically associated with feelings of grief, anger and denial. The condition is often perceived as both isolating and stigmatizing, and may cause problems with self-image, personal relations and sometimes employment. The day to day demands of self care, including dietary restrictions, blood tests and injections, can weigh heavily, especially when associated with fears of hypoglycaemia or late complications. People with diabetes are also more likely to experience depression. Despite so many challenges, the great majority of people affected enjoy a good quality of life. Successful management of diabetes depends upon successful adjustment to the psychological and social challenges of the condition; conversely psychiatric and psychological disorders may result in inability to manage the condition effectively and result in poorer quality of life, worse outcomes and premature mortality. Recent psychological research has greatly increased our ability to identify psychological problems associated with diabetes and to make use of effective interventions.
Textbooks published before the second half of the last century make little or no reference to the psychological or psychosocial aspects of diabetes. Psycho-analytic theories as to the causation of diabetes appeared around the mid-part of the century and are now considered frankly ludicrous. There was also discussion of the so-called "diabetic personality". Insulin was the only treatment for diabetes at the time, and the introduction of the longer-acting insulins in the 1940s resulted in atypical hypoglycaemic reactions including personality change, outbursts of rage or bizarre behaviour which had a long-lasting (but mercifully now extinct) effect upon the popular perception of people with diabetes.
The biopsychosocial model
The traditional "medical model" of disease considered patients as the passive vehicles for purely biological disorders, limiting the role of the physician to organic diagnosis and physical or pharmacological intervention. The concepts of the medical and biopsychological models, as introduced by George L Engel, represented a turning point.
Thenceforth it became less acceptable for physicians, especially those dealing with chronic disease, to ignore the personal and social context of disease, and the importance of the patients' own perception of their condition for its successful management and outcome. This is particularly true of diabetes, a condition managed almost exclusively on a day-to-day basis by the person affected.
The introduction of multidisciplinary management of diabetes has at best resulted in much greater appreciation of the human dimension and more effective emotional and social support for the person affected. Experience, empathy and intuition have been - and remain - invaluable guides for any health professional working with diabetes, but input from trained psychologists has added a further dimension by identifying and teaching the most effective and evidence-based approaches to intervention.
The best results are typically achieved when the input from a psychologist informs and directs the behaviour of the whole diabetes team. Notwithstanding, there is still a school of medical thinking which treats diabetes as an exercise in applied pharmacology, and views psychologists simply as a referral option for their more intractable patients.
The role of psychology in diabetes management
Although medicine and technology have made impressive advances in recent years, many people with diabetes - perhaps one in three - remain in suboptimal metabolic control, and are likely to lead shorter and less satisfying lives in consequence.
Behavioural research has helped to identify key barriers to diabetes self-management, including dysfunctional health beliefs, low feelings of self-efficacy, emotional distress and mood disorders, problematic eating and lack of social support. Psychology can help to optimize diabetes treatment and educational strategies based on health psychology theories and evidence from research into the role of cognitive, emotional and behavioural processes. There is increasing evidence that group interventions aimed at improving self-management in type 2 diabetes and psychological treatments in type 1 and type 2 diabetes have are effective in improving diabetes outcomes .
Psychology has also proved helpful in developing and evaluating diabetes prevention programs, aimed at helping persons at risk for diabetes to achieve lasting lifestyle changes. The section on Diabetes and mental health in Diapedia covers a broad range of clinically relevant topics, from prevention to coping and measuring quality of life across the life-span.
Diabetes and mental illness.
Both diabetes and psychiatric disorders are common conditions, and therefore a degree of co-occurrence would be expected purely by chance. There is a growing body of evidence, however, that diabetes is associated more frequently than expected with a range of psychiatric morbidity, including mood disorders, distress, cognitive decline and eating disorders. There has been particular recent interest in the association between diabetes and depression.
Furthermore, it appears that people with mood and psychotic disorders are at increased risk of developing diabetes, emphasising the bi-directional relationship of diabetes and mental disorders. Some medications used to treat psychotic disorders may also predispose to weight gain and the development of diabetes.
These issues are explored in much greater detail in the section of Diapedia on Diabetes and mental health.
^ Engel GL. Sounding board - the biopsychosocial model and medical education. Who are to be the teachers? New Engl J Med 1982;306(13):802-5
^ Engel GL. The need for a new medical model. A challenge for biomedicine. Science 1977;196:129-136
^ Deakin TA, et al. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003417. DOI: 10.1002/14651858.CD003417.pub2
^ Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 2004 May 15;363(9421):1589-97.
^ Winkley K et al. Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials. BMJ 2006. http://www.bmj.com/content/333/7558/65?view=long&pmid=16803942