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- -Care Is Common Care Is Common Poor Self Follows physician guidelines < 50%: Follows physician guidelines < 50%: NMC KSR TMC NMC KSR TMC • Healthy meal plan Healthy meal plan 32% 36% 63% • 32% 36% 63% • Exercise Exercise 54% 55% 52% • 54% 55% 52% • BG monitoring BG monitoring 15% 21% 27% • 15% 21% 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% – – 93% 93% studies: OHA compliance was 36% • MEMS data, 5 prospective studies (3 MEMS data, 5 prospective studies (3– –6 6 • months): OHA compliance was 61% – – 85% 85% months): OHA compliance was 61% • 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’ ’s Story s Story Ralph • 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’ ’ll be told at next ll be told at next • Knows he 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’ ’t t many times before). But doesn think there is anything he think there is anything he can/wants to do about this. can/wants to do about this.

Ralph’ ’s Story s Story Ralph • 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’ ’s, sees no point s, sees no point • Never checks BG to it. Many family members with to it. Many family members with − some diabetes − some doing well, some doing well, some diabetes 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- -Management Difficult? Management Difficult? Why Is Self (“ “strong strong” ” endorsements by physicians) endorsements by physicians) ( poor self- -discipline discipline 53.2% poor self 53.2% poor will- -power power 50.0% poor will 50.0% not scared enough 36.9% not scared enough 36.9% not intelligent enough 16.3% not intelligent enough 16.3% Polonsky WH, et al. Diabetes 1996;45(Supplement 2):14a

Why Is Self- -Management Difficult? Management Difficult? Why Is Self • 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- -Management Difficult? Management Difficult? Why Is Self • Poor self Poor self- -care occurs when obstacles care occurs when obstacles • outweigh possible benefits outweigh 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- -Care Care Obstacles to Good Self • 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- -Care Care 8 Obstacles to Good Self Depression and anxiety disorders • • Depression and anxiety disorders Eating disorders • • Eating disorders • Substance abuse • Substance abuse • Inadequate/unclear plans for self- -care care • Inadequate/unclear plans for self • Diabetes- -related health beliefs related health beliefs • Diabetes • Diabetes- -related social support related social support • Diabetes • Common environmental barriers • Common environmental barriers • Diabetes- -related distress related distress • Diabetes

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 Major Depression, Adjusted Odds 5 5 4 4 3 3 2 2 1 1 0 0 Plus 1 Plus 2 Plus 3 Plus 1 Plus 2 Plus 3 Egede LE. Psychosomatic Medicine 2005; 67: 46-51

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%) • − year period, depression was strongest Over 3 − • Over 3 year period, depression was strongest • predictor of rate of hospitalization predictor of rate of hospitalization − year period, 3x higher incidence of CAD Over 10 − • Over 10 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- -depressed) depressed) (4.5x higher in depressed vs. non 250 250 Dollars, in millions 200 200 150 150 100 100 50 50 0 0 Not depressed Depressed Not depressed Depressed Egede LE, et al. Diabetes Care 2002; 25: 464-470

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.