PSYCHOLOGICAL ISSUES IN PSYCHOLOGICAL ISSUES IN DIABETES DIABETES - - PowerPoint PPT Presentation

PSYCHOLOGICAL ISSUES IN PSYCHOLOGICAL ISSUES IN DIABETES DIABETES

William H. Polonsky, PhD, CDE William H. Polonsky, PhD, CDE

Diabetes in the Real World: Diabetes in the Real World: Poor Self Poor Self-

• Care Is Common

Care Is Common

Follows physician guidelines < 50%: Follows physician guidelines < 50%: NMC NMC KSR KSR TMC TMC

• Healthy meal plan

Healthy meal plan 32% 32% 36% 36% 63% 63%

• Exercise

Exercise 54% 54% 55% 55% 52% 52%

• BG monitoring

BG monitoring 15% 15% 21% 21% 27% 27%

NMC, n = 192; KSR, n = 171; TMC, n = 170

Medication Adherence Medication Adherence

• HMO and PBO databases, 11 retrospective

HMO and PBO databases, 11 retrospective studies: OHA compliance was 36% studies: OHA compliance was 36% – – 93% 93%

• MEMS data, 5 prospective studies (3

MEMS data, 5 prospective studies (3– –6 6 months): OHA compliance was 61% months): OHA compliance was 61% – – 85% 85%

• Thus, similar to studies of other illnesses, the

Thus, similar to studies of other illnesses, the average patient may be missing average patient may be missing approximately 25% of prescribed OHA(s) approximately 25% of prescribed OHA(s)

Cramer JA. Diabetes Care 2004;27:1218-1224

Ralph Ralph’ ’s Story s Story

• Age 54, type 2 diabetes 8 years,

Age 54, type 2 diabetes 8 years, never paid much attention to it. never paid much attention to it.

• Knows he is overweight (BMI 32),

Knows he is overweight (BMI 32), suspects his diabetes is not in the suspects his diabetes is not in the best control. best control.

• Knows he

Knows he’ ’ll be told at next ll be told at next medical visit to exercise and to medical visit to exercise and to stop smoking (been told this stop smoking (been told this many times before). But doesn many times before). But doesn’ ’t t think there is anything he think there is anything he can/wants to do about this. can/wants to do about this.

Ralph Ralph’ ’s Story s Story

• Loves eating, not really

Loves eating, not really concerned about his weight. concerned about his weight.

• Knows diabetes can harm him in

Knows diabetes can harm him in long run, but has plenty of other long run, but has plenty of other things to worry about that seem things to worry about that seem more pressing. more pressing.

• Never checks BG

Never checks BG’ ’s, sees no point s, sees no point to it. Many family members with to it. Many family members with diabetes diabetes− −some some doing well, some doing well, some doing poorly. doing poorly.

• This that luck plays a big role in

This that luck plays a big role in what happens with diabetes. what happens with diabetes.

Why Is Self Why Is Self-

• Management Difficult?

Management Difficult?

( (“ “strong strong” ” endorsements by physicians) endorsements by physicians)

poor self poor self-

• discipline

discipline 53.2% 53.2% poor will poor will-

• power

power 50.0% 50.0% not scared enough not scared enough 36.9% 36.9% not intelligent enough not intelligent enough 16.3% 16.3%

Polonsky WH, et al. Diabetes 1996;45(Supplement 2):14a

Why Is Self Why Is Self-

• Management Difficult?

Management Difficult?

• Almost no one is unmotivated to live a long

Almost no one is unmotivated to live a long and healthy life. and healthy life.

• The rewards for good diabetes care are

The rewards for good diabetes care are

• relatively

relatively subtle subtle

• mostly

mostly long long-

• term

term

Why Is Self Why Is Self-

• Management Difficult?

Management Difficult?

• Poor self

Poor self-

• care occurs when obstacles

care occurs when obstacles

• utweigh possible benefits
• utweigh possible benefits
• There are major medical benefits in diabetes,

There are major medical benefits in diabetes, but also many, many obstacles but also many, many obstacles

Obstacles to Good Self Obstacles to Good Self-

• Care

Care

• Lack of access to care

Lack of access to care

• Lack of knowledge or skill

Lack of knowledge or skill

8 Obstacles to Good Self 8 Obstacles to Good Self-

• Care

Care

• Depression and anxiety disorders

Depression and anxiety disorders

• Eating disorders

Eating disorders

• Substance abuse

Substance abuse

• Inadequate/unclear plans for self

Inadequate/unclear plans for self-

• care

care

• Diabetes

Diabetes-

• related health beliefs

related health beliefs

• Diabetes

Diabetes-

• related social support

related social support

• Common environmental barriers

Common environmental barriers

• Diabetes

Diabetes-

• related distress

related distress

Mood Disorders Mood Disorders

• Depression rates are 1.5

Depression rates are 1.5– –2.0x higher in 2.0x higher in diabetes samples: diabetes samples:

– – In review of controlled studies (n = 21): 20.5% of In review of controlled studies (n = 21): 20.5% of patients vs. 11.4% of controls patients vs. 11.4% of controls – – Recent Kaiser study compared 16,000 Type 2 Recent Kaiser study compared 16,000 Type 2 patients vs. 16,000 matched controls: 17.9% of patients vs. 16,000 matched controls: 17.9% of patients vs. 11.2% of controls patients vs. 11.2% of controls

Anderson RJ, et al. Diabetes Care 2001; 24: 1069-1078. Nicohols GA, et al. Diabetes Care 2003; 26: 744-749.

Mood Disorders Mood Disorders

Nicohols GA, et al. Diabetes Care 2003; 26: 744-749.

Mood Disorders Mood Disorders

• Depressive symptoms are common:

Depressive symptoms are common:

• 32% (Gavard et al, 1993)

32% (Gavard et al, 1993)

• 41% (Peyrot and Rubin, 1997)

41% (Peyrot and Rubin, 1997)

• 45% (Gary et al, 2000)

45% (Gary et al, 2000)

• 37% (Polonsky et al, 2000)

37% (Polonsky et al, 2000)

• 31% (Hermanns et al, 2005)

31% (Hermanns et al, 2005)

Influence of Comorbid Disease Influence of Comorbid Disease

HTN, CAD, chronic arthritis, stroke, COPD, ESRD; n = 1794 HTN, CAD, chronic arthritis, stroke, COPD, ESRD; n = 1794

Egede LE. Psychosomatic Medicine 2005; 67: 46-51

1 2 3 4 5 Plus 1 Plus 2 Plus 3 1 2 3 4 5 Plus 1 Plus 2 Plus 3

Major Depression, Adjusted Odds

Influence of Comorbid Disease Influence of Comorbid Disease

• Large community

Large community-

• based Dutch study (n =

based Dutch study (n = 3107) found that depression prevalence was: 3107) found that depression prevalence was:

– – 20% type 2 diabetes, co 20% type 2 diabetes, co-

• morbid chronic disease

morbid chronic disease – – 8% type 2 diabetes only 8% type 2 diabetes only – – 9% healthy controls 9% healthy controls

Pouwer F, et al. Diabetologia 2003; 46:892-898

Mood Disorders Mood Disorders

Depression makes it harder to initiate and Depression makes it harder to initiate and maintain healthy behavior changes maintain healthy behavior changes

• Poor glycemic control (elevating HbA1C 1.8

Poor glycemic control (elevating HbA1C 1.8– –3.3%) 3.3%)

• Over 3

Over 3− −year period, depression was strongest year period, depression was strongest predictor of rate of hospitalization predictor of rate of hospitalization

• Over 10

Over 10− −year period, 3x higher incidence of CAD year period, 3x higher incidence of CAD and retinopathy and retinopathy

Lustman et al, 2000; Rosenthal et al, 1998; Kovacs et al, 1995; Carney et al, 1994

Depression and Healthcare Costs in Depression and Healthcare Costs in Diabetes, Nationwide Sample Diabetes, Nationwide Sample

(4.5x higher in depressed vs. non (4.5x higher in depressed vs. non-

• depressed)

depressed)

Egede LE, et al. Diabetes Care 2002; 25: 464-470

50 100 150 200 250 Not depressed Depressed 50 100 150 200 250 Not depressed Depressed

Dollars, in millions

Anxiety Disorders Anxiety Disorders

• Recent meta

Recent meta-

• analyses of clinical populations:

analyses of clinical populations:

– – Generalized anxiety disorder, 14% of patients Generalized anxiety disorder, 14% of patients – – Elevated symptoms of anxiety, 40% of patients Elevated symptoms of anxiety, 40% of patients – – Anxiety disorders are associated with Anxiety disorders are associated with hyperglycemia hyperglycemia

• No evidence that anxiety disorder rates are

No evidence that anxiety disorder rates are elevated in diabetes elevated in diabetes

Hermanns et al, 2005; Grigsby et al, 2002; Anderson et al, 2002

Eating Disorders Eating Disorders

• Young women with type 1 diabetes

Young women with type 1 diabetes

– – Though controversial, rates appear to be doubled: Though controversial, rates appear to be doubled: * clinical disorders (10% vs. 4%) * clinical disorders (10% vs. 4%) * subclinical disorders (14% vs. 8%) * subclinical disorders (14% vs. 8%) – – Poorer metabolic control Poorer metabolic control – – Increased prevalence of retinopathy at 4 years Increased prevalence of retinopathy at 4 years

Jones JM, et al. BMJ 2000; 320: 1563-1566. Rydall AC, et al. NEJM 1997; 336: 1849-1854.

Insulin Omission in Type 1 Insulin Omission in Type 1 Diabetes Diabetes

Polonsky et al, Polonsky et al, 1994 1994 341 women 341 women surveyed surveyed 31% omitted insulin; 31% omitted insulin; 9% regularly omitted 9% regularly omitted Jones et al, Jones et al, 2000 2000 361 female 361 female teens surveyed teens surveyed 11% omitted insulin 11% omitted insulin regularly regularly

Polonsky WH, et al. Diabetes Care 1994; 17: 1178-1185. Jones JM, et al. BMJ 2000; 320: 1563-1566.

Eating Disorders Eating Disorders

• Type 2 diabetes

Type 2 diabetes

– – Binge eating disorder is often believed to be more Binge eating disorder is often believed to be more prevalent, but the data is equivocal prevalent, but the data is equivocal – – Note that obesity is NOT an eating disorder Note that obesity is NOT an eating disorder

Mannucci E, et al. International Journal of Obesity 2002; 26: 848-853. Herpertz S, et al. Int J Eat Disord 2000; 28:68-77.

Substance Abuse Substance Abuse

• Alcohol use

Alcohol use

• Illicit drug use

Illicit drug use

• Tobacco

Tobacco

8 Obstacles to Good Self 8 Obstacles to Good Self-

• Care

Care

• Depression and anxiety disorders

Depression and anxiety disorders

• Eating disorders

Eating disorders

• Substance abuse

Substance abuse

• Inadequate/unclear plans for self

Inadequate/unclear plans for self-

• care

care

• Diabetes

Diabetes-

• related health beliefs

related health beliefs

• Diabetes

Diabetes-

• related social support

related social support

• Common environmental barriers

Common environmental barriers

• Diabetes

Diabetes-

• related distress

related distress

8 Obstacles to Good Self 8 Obstacles to Good Self-

• Care

Care

• Depression and anxiety disorders

Depression and anxiety disorders

• Eating disorders

Eating disorders

• Substance abuse

Substance abuse

• Inadequate/unclear plans for self

Inadequate/unclear plans for self-

• care

care

• Diabetes

Diabetes-

• related health beliefs

related health beliefs

• Diabetes

Diabetes-

• related social support

related social support

• Common environmental barriers

Common environmental barriers

• Diabetes

Diabetes-

• related distress

related distress

Unachievable Self Unachievable Self-

• Care Plans

Care Plans

• Unclear

Unclear

• “

“I I’ ’m supposed to start exercising. m supposed to start exercising.” ”

• Unrealistic

Unrealistic

• “

“My doctor told me to lose 10 lbs before the My doctor told me to lose 10 lbs before the next visit. next visit.” ”

• “

“Taking care of my diabetes means I Taking care of my diabetes means I’ ’m m supposed to eat perfectly and never cheat. supposed to eat perfectly and never cheat.” ”

Why Are Self Why Are Self-

• Care Plans

Care Plans Often Unachievable? Often Unachievable?

• Patient

Patient-

• provider communication

provider communication

• 21%, complete disagreement on decisions made

21%, complete disagreement on decisions made

• Poor

Poor “ “health literacy health literacy” ”

Parkin T, et al. Parkin T, et al. Diabetic Medicine Diabetic Medicine 2003; 20: 909 2003; 20: 909-

• 914

914 Schillinger Schillinger D, et al. D, et al. JAMA JAMA 2002; 288: 475 2002; 288: 475-

• 482.

482. Sheeran Sheeran P, et al. P, et al. Health Psychology Health Psychology 2000; 19: 283 2000; 19: 283-

• 289.

289.

Marlene Marlene’ ’s Story s Story

• Age 71, type 2 diabetes 15 years

Age 71, type 2 diabetes 15 years

• Hospital volunteer, info desk

Hospital volunteer, info desk

• Suspects her diabetes is not in the

Suspects her diabetes is not in the best control best control

• Takes more pills whenever BG

Takes more pills whenever BG’ ’s s > 150 mg/dl. Very scared by high > 150 mg/dl. Very scared by high and low BG and low BG’ ’s s

• Following MD

Following MD’ ’s advice, recently s advice, recently went to nurse CDE for help went to nurse CDE for help

• “

“That was pointless That was pointless” ”

Functional Health Literacy Functional Health Literacy in Diabetes in Diabetes

• 408 patients with type 2 diabetes, SF General

408 patients with type 2 diabetes, SF General

• Many don

Many don’ ’t understand recommendations: t understand recommendations:

• 38% inadequate FHL

38% inadequate FHL

• 13% marginal FHL

13% marginal FHL

• Poor FHL linked to poor glycemic control and

Poor FHL linked to poor glycemic control and higher rates of long higher rates of long-

• term complications

term complications

Schillinger D, et al. Archives of Internal Medicine 2003; 13: 83-90.

Why Are Self Why Are Self-

• Care Plans

Care Plans Often Unachievable? Often Unachievable?

• Patient

Patient-

• provider communication

provider communication

• 21%, complete disagreement on decisions made

21%, complete disagreement on decisions made

• Poor

Poor “ “health literacy health literacy” ”

Parkin T, et Parkin T, et al. al.Diabetic Diabetic Medicine Medicine 2003; 20: 909 2003; 20: 909-

• 914

914 Schillinger Schillinger D, et al. D, et al. JAMA JAMA 2002; 288: 475 2002; 288: 475-

• 482

482 Sheeran Sheeran P, et al. P, et al. Health Psychology Health Psychology 2000; 19: 283 2000; 19: 283-

• 289

289

Why Are Self Why Are Self-

• Care Plans

Care Plans Often Unachievable? Often Unachievable?

• Patient

Patient-

• provider communication

provider communication

• 21%, complete disagreement on decisions made

21%, complete disagreement on decisions made

• Poor

Poor “ “health literacy health literacy” ”

• No plan for implementing recommendations

No plan for implementing recommendations

• Enthusiasm of the healthcare provider

Enthusiasm of the healthcare provider

Parkin Parkin T, et T, et al. al.Diabetic Diabetic Medicine Medicine 2003; 20: 909 2003; 20: 909-

• 914

914 Schillinger Schillinger D, et al. D, et al. JAMA JAMA 2002; 288: 475 2002; 288: 475-

• 482

482 Sheeran Sheeran P, et al. P, et al. Health Psychology Health Psychology 2000; 19: 283 2000; 19: 283-

• 289

289

Harmful Beliefs about Diabetes Harmful Beliefs about Diabetes

A.

• A. No big deal

No big deal

• “

“I feel fine, therefore I am fine I feel fine, therefore I am fine” ”

• “

“Look, I Look, I’ ’ll start worrying about diabetes if and ll start worrying about diabetes if and when something goes wrong. when something goes wrong.” ”

• “

“We We’ ’re all going to die anyway. re all going to die anyway.” ”

B.

• B. Hopelessness

Hopelessness

• “

“Diabetes means I am doomed Diabetes means I am doomed” ”

Harmful Beliefs about Diabetes Harmful Beliefs about Diabetes

C.

• C. Treatment is ineffective (or harmful)

Treatment is ineffective (or harmful)

• “

“No matter what I do, these numbers are still high! No matter what I do, these numbers are still high!” ”

• “

“I I’ ’m not so sure that what you m not so sure that what you’ ’re asking me to do re asking me to do will really help me. will really help me.” ”

• “

“Take insulin? That Take insulin? That’ ’ll make my diabetes worse! ll make my diabetes worse!” ”

Treatment Efficacy: Reggie Treatment Efficacy: Reggie’ ’s Tale s Tale

… … thanks for your kind attention to my demise. thanks for your kind attention to my demise. The last The last time I visited an endocrinologist was about 4 years ago. time I visited an endocrinologist was about 4 years ago. My understanding of diabetes is rudimentary, and my My understanding of diabetes is rudimentary, and my problems are rooted in my very first disappointing problems are rooted in my very first disappointing efforts to get it under control shortly after I was efforts to get it under control shortly after I was diagnosed in 1990. Whatever I tried simply did not diagnosed in 1990. Whatever I tried simply did not seem to work. My BG seem to work. My BG’ ’s were highly erratic and there s were highly erratic and there seemed no correlation with what I ate, when I ate, and at seemed no correlation with what I ate, when I ate, and at what time I ate. what time I ate.

Treatment Efficacy: Reggie Treatment Efficacy: Reggie’ ’s Tale s Tale

On occasion, I have taken matters very seriously and On occasion, I have taken matters very seriously and monitored my sugars religiously for 1 monitored my sugars religiously for 1– –2 week periods. 2 week periods. Each time I have been disappointed by the lack of logic Each time I have been disappointed by the lack of logic in the BG readings, to the point where long ago I in the BG readings, to the point where long ago I decided I was not going to become a human pin decided I was not going to become a human pin cushion sticking 4 needles into my body a day and then cushion sticking 4 needles into my body a day and then another 6 or 7 into my fingers to check my levels. another 6 or 7 into my fingers to check my levels. I I decided I would simply exercise discretion, abstinence, decided I would simply exercise discretion, abstinence, and control as required. and control as required.

Treatment Efficacy: Reggie Treatment Efficacy: Reggie’ ’s Tale s Tale

I have reduced my intake of insulin to three times daily I have reduced my intake of insulin to three times daily as opposed to 4 times daily. I have stopped testing as opposed to 4 times daily. I have stopped testing

• altogether. I attempt to exercise control where I can, but
• altogether. I attempt to exercise control where I can, but

I do have the occasional chocolate attack and throw I do have the occasional chocolate attack and throw caution to the wind. caution to the wind. I am fully aware there will be I am fully aware there will be consequences, but there doesn consequences, but there doesn’ ’t seem to be anything I t seem to be anything I can do. can do.

Poor Social Support Poor Social Support

• Isolation

Isolation

• The diabetes police

The diabetes police

Environmental Barriers Environmental Barriers

“ “Life gets in the way Life gets in the way” ”: :

• Stress

Stress

• Daily demands

Daily demands

• Limited finances

Limited finances

• Poor healthcare insurance

Poor healthcare insurance

• Social/cultural influences

Social/cultural influences

Diabetes Diabetes-

• Related Distress

Related Distress

• Anxiety (hypoglycemia, complications)

Anxiety (hypoglycemia, complications)

• Guilt (maybe I did this to myself, maybe I

Guilt (maybe I did this to myself, maybe I’ ’m m not doing enough to keep my BG not doing enough to keep my BG’ ’s in range) s in range)

• Anger (I hate this disease)

Anger (I hate this disease)

• Discouragement (I feel like I am failing with

Discouragement (I feel like I am failing with diabetes) diabetes)

Diabetes Diabetes-

• Related Distress

Related Distress

“ “... And even the constant need for decisions ... And even the constant need for decisions might be tolerable, if only the results were might be tolerable, if only the results were

• predictable. Few things generate burnout like
• predictable. Few things generate burnout like

the awful frustration of having followed the awful frustration of having followed instructions and done everything just right and instructions and done everything just right and still be failing to get diabetes into control. At still be failing to get diabetes into control. At those times it seems no use to continue to try. those times it seems no use to continue to try.” ”

Diabetes Diabetes-

• Related Distress

Related Distress

“ “Think how discouraging it is to fail at something Think how discouraging it is to fail at something you really wanted to do. Then consider what it you really wanted to do. Then consider what it must feel like to have diabetes and be failing at must feel like to have diabetes and be failing at something you never, ever, wanted to do in the something you never, ever, wanted to do in the first place. first place.” ”

Hoover JW. Patient 'burnout' can explain non Hoover JW. Patient 'burnout' can explain non-

• compliance.
• compliance. World Book of Diabetes in

World Book of Diabetes in Practice, Vol. 3 Practice, Vol. 3. 1988. New York: Elsevier Science Publishers. . 1988. New York: Elsevier Science Publishers.

8 Obstacles to Good Self 8 Obstacles to Good Self-

• Care

Care

• Depression and anxiety disorders

Depression and anxiety disorders

• Eating disorders

Eating disorders

• Substance abuse

Substance abuse

• Inadequate/unclear plans for self

Inadequate/unclear plans for self-

• care

care

• Diabetes

Diabetes-

• related health beliefs

related health beliefs

• Diabetes

Diabetes-

• related social support

related social support

• Common environmental barriers

Common environmental barriers

• Diabetes

Diabetes-

• related distress

related distress

What To Do? What To Do?

Strategies That Don Strategies That Don’ ’t Work t Work

• Urging more willpower

Urging more willpower

– – “ “if you would just try harder if you would just try harder…” …”

• Threatening bad outcomes

Threatening bad outcomes

– – “ “you you’ ’ll go blind if you don ll go blind if you don’ ’t do what I tell you t do what I tell you to do to do…” …”

• The gift of advice

The gift of advice

– – “ “maybe if you joined a nice fitness center maybe if you joined a nice fitness center…” …”

The Overarching Approach The Overarching Approach

• READY TO CHANGE. The patient must be

READY TO CHANGE. The patient must be interested interested in diabetes management in diabetes management

• KNOW WHAT TO DO. The patient must

KNOW WHAT TO DO. The patient must have have a clear and achievable plan a clear and achievable plan for self for self-

• management

management

The Overarching Approach The Overarching Approach

• READY TO CHANGE. The patient must be

READY TO CHANGE. The patient must be interested interested in diabetes management in diabetes management

• KNOW WHAT TO DO. The patient must

KNOW WHAT TO DO. The patient must have have a clear and achievable plan a clear and achievable plan for self for self-

• management

management

• Here are six steps towards reaching these

Here are six steps towards reaching these goals goals… …

Psychosocial Interventions Psychosocial Interventions

1.

• 1. Stay alert for depression

Stay alert for depression 2.

• 2. Engage the patient

Engage the patient 3.

• 3. Investigate self

Investigate self-

• care importance and

care importance and confidence confidence 4.

• 4. Address functional health literacy issues

Address functional health literacy issues 5.

• 5. Challenge harmful health beliefs

Challenge harmful health beliefs 6.

• 6. Negotiate behaviorally

Negotiate behaviorally-

• based plans for action

based plans for action

• 1. Stay Alert for Depression
• 1. Stay Alert for Depression
• Screen regularly

Screen regularly

• Promote vigilance in patients

Promote vigilance in patients

TWO QUESTIONS ABOUT DEPRESSION TWO QUESTIONS ABOUT DEPRESSION

“ “During the past month, have you often: During the past month, have you often: a.

• a. been bothered by feeling down, depressed

been bothered by feeling down, depressed

• r hopeless?
• r hopeless?”

” b.

• b. had little interest or pleasure in doing

had little interest or pleasure in doing things? things?

Treatment of Depression Treatment of Depression in Diabetes in Diabetes

Percent in Remission at Treatment Conclusion Percent in Remission at Treatment Conclusion

20 40 60 80 100 Nortryptiline Fluoxetine CBT Treat Control 20 40 60 80 100 Nortryptiline Fluoxetine CBT Treat Control Lustman et al, 1997; 1998; 2000

Treatment of Depression in Diabetes Treatment of Depression in Diabetes

• Improving Mood

Improving Mood– –Promoting Access to Collaborative Promoting Access to Collaborative Treatment (IMPACT) Treatment (IMPACT)

• A collaborative, stepped

A collaborative, stepped− − care management care management intervention intervention

• 417 type 2 patients, usual care vs. IMPACT

417 type 2 patients, usual care vs. IMPACT

• Mean age, 70 years

Mean age, 70 years

Williams JW, et al. Annals of Internal Medicine 2004; 140: 1015-1024.

IMPACT Intervention IMPACT Intervention

The The “ “depression care manager depression care manager” ”: collaborative : collaborative development of development of tx tx plan, SSRI and/or PST plan, SSRI and/or PST

• Treatment intensification as needed

Treatment intensification as needed

• Frequent follow

Frequent follow-

• up for 12 months (mean was 9

up for 12 months (mean was 9 visits, 6 phone contacts) visits, 6 phone contacts)

• Frequent re

Frequent re-

• administration of PHQ

administration of PHQ

• Monthly phone follow

Monthly phone follow-

• up after remission

up after remission

Williams JW, et al. Annals of Internal Medicine 2004; 140: 1015-1024.

The Impact of IMPACT: Depression The Impact of IMPACT: Depression

0.5 1 1.5 2 Baseline 3 Months 6 Months 12 Months Intervention Usual Care

SCL-20 Depression

The Impact of IMPACT: Functional The Impact of IMPACT: Functional Impairment Impairment

3 4 5 6 Baseline 3 Months 6 Months 12 Months Intervention Usual Care

SF-12 Functional Impairment

IMPACT Intervention IMPACT Intervention

Compared to usual care: Compared to usual care:

• Reduced depression

Reduced depression

• Reduced functional impairment

Reduced functional impairment

• More exercise

More exercise

• No other impact on self

No other impact on self-

• care behaviors or glycemic

care behaviors or glycemic control (mean A1C, 7.3%) control (mean A1C, 7.3%)

Williams JW, et al. Annals of Internal Medicine 2004; 140: 1015-1024.

Other Psychopathological Issues Other Psychopathological Issues

• Stay alert for disordered eating

Stay alert for disordered eating

– – especially in young women with type 1 diabetes especially in young women with type 1 diabetes – – These are complex problems, difficult to treat, These are complex problems, difficult to treat, referral is critical referral is critical

• Stay alert for anxiety disorders

Stay alert for anxiety disorders

– – antidepressants and CBT are effective forms of antidepressants and CBT are effective forms of treatment treatment

• Stay alert for substance abuse

Stay alert for substance abuse

• 2. Engage the Patient
• 2. Engage the Patient
• Start with questions, not information:

Start with questions, not information:

– – “ “What questions should we make sure to address today? What questions should we make sure to address today?” ” – – “ “What What’ ’s been driving you crazy about diabetes? s been driving you crazy about diabetes?” ”

• Begin with the patient

Begin with the patient’ ’s concerns s concerns

• Agenda must be personally meaningful for the patient

Agenda must be personally meaningful for the patient

• 3. Address Self
• 3. Address Self-
• Care Importance

Care Importance

“ “How do you feel about exercise now? If How do you feel about exercise now? If ‘ ‘0 0’ ’ was not was not important, and important, and ‘ ‘10 10” ” was very important, what number was very important, what number would you give yourself? would you give yourself?” ” 0_________________________________10 0_________________________________10 not important not important very 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 1999. New York: Churchill Livingstone

Listen Well and Summarize Listen Well and Summarize

“ “It sounds as though you It sounds as though you’ ’re inclined in two different re inclined in two different

• directions. On the one hand, you
• directions. On the one hand, you’

’re worried about the re worried about the possible long possible long-

• term effects of your diabetes if you don

term effects of your diabetes if you don’ ’t t manage it well manage it well– –blindness, amputations, things like blindness, amputations, things like

• that. On the other hand, you
• that. On the other hand, you’

’re young and you feel re young and you feel fairly healthy most of the time. You enjoy eating what fairly healthy most of the time. You enjoy eating what you like, and the long you like, and the long-

• term consequences seem far

term consequences seem far

• away. You
• away. You’

’re concerned, and at the same time you re concerned, and at the same time you’ ’re re not concerned. not concerned.” ”

• 3. Address Self
• 3. Address Self-
• Care Confidence

Care Confidence

“ “How confident are you about starting/staying with an How confident are you about starting/staying with an exercise program? If exercise program? If ‘ ‘0 0’ ’ was not important, and was not important, and ‘ ‘10 10” ” very important, what number would you give yourself? very important, what number would you give yourself?” ” 0_________________________________10 0_________________________________10 not confident not confident very 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
• 4. Address Health Literacy
• Assess patients

Assess patients’ ’ recall or comprehension of recall or comprehension of recommendations recommendations

• D. "So . . . let's make sure. What medications are
• D. "So . . . let's make sure. What medications are

we going to change?" we going to change?"

• P. "I think we're going to stop this one (is it
• P. "I think we're going to stop this one (is it

metformin?) . . . and I'm going to take glipizide metformin?) . . . and I'm going to take glipizide twice a day. . . I think that's the green one." twice a day. . . I think that's the green one."

Schillinger D, et al. Archives of Internal Medicine 2003; 13: 83-90.

Influence of Assessing Recall Influence of Assessing Recall

• n
• n Glycemia

Glycemia

40 50 60 70 80 90 100

Recall assessed Recall not assessed

% with adequate glycemic control Schillinger D, et al. Archives of Internal Medicine 2003; 13: 83-90.

• 5. Challenge Harmful Beliefs
• 5. Challenge Harmful Beliefs
• Recommend ongoing diabetes education

Recommend ongoing diabetes education

• Identify (

Identify (“ “what do you think about diabetes? what do you think about diabetes?” ”) )

• Respectfully challenge:

Respectfully challenge:

• Re

Re-

• calculating complication odds

calculating complication odds

• Talking about treatment effectiveness (the power

Talking about treatment effectiveness (the power

• f personalized feedback)
• f personalized feedback)

Levetan et al, 2002

How Many Are How Many Are “ “A1C Aware A1C Aware” ”? ?

5 10 15 20 25 30 35 40

A1C A1C + plausible result A1C + plausible, accurate result

% reporting 38.0 17.0 9.1 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): A31.

FACTS AND FICTIONS FACTS AND FICTIONS

1.

• 1. Diabetes is the leading cause of adult blindness,

Diabetes is the leading cause of adult blindness, amputation and kidney failure. True or false? amputation and kidney failure. True or false? ________________________________________ ________________________________________ False.

• False. Poorly controlled

Poorly controlled diabetes is the leading diabetes is the leading cause of adult blindness, amputation and kidney cause of adult blindness, amputation and kidney failure. failure.

6 7 8 9 Baseline 3 Months 6 Months 9 Months 12 months

UKPDS Mary Hemoglobin A1c Level

Perceived Treatment Efficacy Perceived Treatment Efficacy

The Power of A1C Feedback The Power of A1C Feedback

• 6. Negotiated Goal Setting
• 6. Negotiated Goal Setting
• Focus on concrete actions to start:

Focus on concrete actions to start:

• not attitudes, numbers, or actions to stop

not attitudes, numbers, or actions to stop

• Only 1

Only 1 − − 2 behavior changes at a time 2 behavior changes at a time

• 6. Negotiated Goal Setting
• 6. Negotiated Goal Setting
• Actions must be achievable and personally

Actions must be achievable and personally meaningful meaningful

• “

“Why would you bother doing this? Why would you bother doing this?” ”

• Develop

Develop “ “implementation intentions implementation intentions” ”

• “

“So what exactly are you going to do tomorrow So what exactly are you going to do tomorrow morning? morning?” ”

Implementation Intentions Implementation Intentions

• Promote cervical cancer screening appointment

Promote cervical cancer screening appointment

• Random assignment to experimental or control

Random assignment to experimental or control procedure (n = 114) procedure (n = 114)

• Control. Lecture about the need for screening
• Control. Lecture about the need for screening
• Experimental. Lecture plus:
• Experimental. Lecture plus:
• “

“You You’ ’re more likely to go for a cervical smear if re more likely to go for a cervical smear if you decide when and where you you decide when and where you’ ’ll go. Please ll go. Please write in when, where and how you write in when, where and how you’ ’ll make ll make appointment. appointment.” ”

Sheeran Sheeran P, et al. P, et al. Health Psychology Health Psychology 2000; 19: 283 2000; 19: 283-

• 289.

289.

The Power of Implementation The Power of Implementation

40 50 60 70 80 90 100

Lecture Lecture plus implementation plan

% attending screening appointment Sheeran Sheeran P, et al. P, et al. Health Psychology Health Psychology 2000; 19: 283 2000; 19: 283-

• 289.

289.

Take Take-

• Home Messages

Home Messages

• Everyone would prefer to live a long, healthy life

Everyone would prefer to live a long, healthy life

• Our patients are

Our patients are not not unmotivated to manage unmotivated to manage diabetes effectively diabetes effectively

• The problem is that diabetes self

The problem is that diabetes self-

• care is

care is tough tough

• Our patients face many obstacles to good self

Our patients face many obstacles to good self-

• care

care

• As a result, diabetes burnout is common

As a result, diabetes burnout is common (in providers as well as patients) (in providers as well as patients)

Take Take-

• Home Messages

Home Messages

• Take hope!

Take hope!

• We

We can can help our help our patients to manage patients to manage diabetes more diabetes more successfully successfully

• As a side effect, we

As a side effect, we can improve our own can improve our own morale morale

Take Take-

• Home Messages

Home Messages

Common barriers include: Common barriers include:

1.

• 1. Depression

Depression and anxiety disorders and anxiety disorders 2.

• 2. Eating disorders

Eating disorders 3.

• 3. Substance abuse

Substance abuse 4.

• 4. Inadequate/unclear plans for self

Inadequate/unclear plans for self-

• care

care 5.

• 5. Diabetes

Diabetes-

• related health beliefs

related health beliefs 6.

• 6. Diabetes

Diabetes-

• related social support

related social support 7.

• 7. Common environmental barriers

Common environmental barriers 8.

• 8. Diabetes

Diabetes-

• related distress

related distress

Take Take-

• Home Messages

Home Messages

Effective treatment strategies include: Effective treatment strategies include:

1.

• 1. Stay alert for depression

Stay alert for depression 2.

• 2. Engage the patient

Engage the patient 3.

• 3. Investigate self

Investigate self-

• care importance and confidence

care importance and confidence 4.

• 4. Address functional health literacy issues

Address functional health literacy issues 5.

• 5. Challenge harmful health beliefs

Challenge harmful health beliefs 6.

• 6. Negotiate behaviorally

Negotiate behaviorally-

• based plans for action

based plans for action

Suggested Readings Suggested Readings

• Anderson BJ, Rubin RR.

Anderson BJ, Rubin RR. Practical Psychology for Practical Psychology for Diabetes Clinicians, 2nd Ed. Diabetes Clinicians, 2nd Ed. Alexandria, Va: ADA; 2002. Alexandria, Va: ADA; 2002.

• Miller WR, Rollnick S.

Miller WR, Rollnick S. Motivational Interviewing, 2nd Ed Motivational Interviewing, 2nd Ed. . New York: Guilford Press; 2002. New York: Guilford Press; 2002.

• Polonsky WH.

Polonsky WH. Diabetes Burnout: What To Do When You Diabetes Burnout: What To Do When You Can Can’ ’t Take It Anymore t Take It Anymore, Washington, DC: ADA; 1999. , Washington, DC: ADA; 1999.

• Rollnick S, et al.

Rollnick S, et al. Health Behavior Change Health Behavior Change. New York: . New York: Churchill Livingstone; 1999. Churchill Livingstone; 1999.

• Snoek FJ, Skinner TC.

Snoek FJ, Skinner TC. Psychology in Diabetes Care Psychology in Diabetes Care. New . New York: Wiley and Sons; 2000. York: Wiley and Sons; 2000.