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VOLUME 11 NUMBER 3 • SEPTEMBER 2014
PATIENT INFORMATION LEAFLET
SA JOURNAL OF DIABETES & VASCULAR DISEASE
management (diet, exercise, coordination of food intake and exercise
to prevent hypoglycaemia).
9
Adherence to these complex regimens is
paramount to delaying and/or preventing the onset of serious diabetes
complications, such as retinopathy, neuropathy and nephropathy.
10
Research indicates that psychological factors such as depression,
anxiety, diabetes-specific distress, fear of hypoglycaemia, and eating-
disordered behaviours play a significant role in adherence to diabetes
regimens.
11,12
In addition to adherence outcomes, research also indicates
that psychological factors can increase the risks of poor glycaemic con-
trol and diabetic keto-acidosis (DKA).
13
The psychological aspects of dia-
betes are overwhelming and should be considered and included in the
treatment of diabetes in order to ensure the effective management of
the illness.
14
DISEASE COURSE AND THE ROLE OF PSYCHOLOGY
The primary reasons for psychological referral of diabetic patients are
poor adherence to treatment regimen, poor adjustment to illness, stress
exacerbating medical symptoms and/or self-care, psychiatric presenta-
tions, and cognitive problems.
15
The mental health of the diabetic patient
is an important consideration as the patient requires considerable mo-
tivation and ego strength to comply with the self-care demands of the
illness.
8
Psychology has a significant role to play throughout the course
of the disease.
At diagnosis, patients are suddenly expected to make significant life-
style changes and integrate complex treatment regimens into their lives.
Individuals diagnosed with type 2 diabetes are faced with challenges
pertaining to the fact that their nutrition and exercise habits are already
deeply entrenched.
9
Patients inevitably respond differently to the diag-
nostic news, some may experience shock which may cause emotional
distress while others may respond indifferently or with relief as the rea-
son for symptom presentation can now be explained.
8
Following diagnosis, depending on the type of diabetes and stage
at diagnosis, a treatment regimen is prescribed. While adherence
can significantly delay the onset of diabetes-related complications,
it does not always translate into immediate good results, and positive
feedback may not be possible in the short term, causing the patient to
have to persist for long periods of time before benefitting from regimen
adherence. This delay in results, despite considerable efforts, may be
frustrating and even demotivating for patients. Patients can therefore
benefit from learning active, problem-focused, and pro-active coping
behaviours, which can be applied across settings and over a long pe-
riod of time.
8
Patients can further benefit from psychological interven-
tions that identify barriers to adherence,
16
and use this information to
develop new healthy behaviours, enhance existing healthy behaviours,
and eliminate unhealthy behaviours as they relate to improved glycaemic
control.
17
PSYCHOLOGICAL PRESENTATIONS AND DIABETES
MANAGEMENT
Depression
Depression is twice as common in diabetic patients as the general
population.
18,19
It has been associated with hyperglycaemia for type 1 and
type 2 diabetes.
20
This co-morbidity is often under-diagnosed and under-
treated in more than a quarter of the diabetic population.
19,21
The clinical
relevance of this under-treatment is significant as depression has been
associated with decreased metabolic control,
19
poor adherence to treat-
ment regimens,
22
diminished quality of life,
19
and early mortality.
23
Poor
glycaemic control can also exacerbate depression and diminish response
to anti-depressant therapy.
19
In addition, the combination of depression
and diabetes has been shown to increase the risk of developing diabetes
complications such as cardiovascular disease.
24
Anxiety
It has been reported that the prevalence of anxiety in diabetic patients is
30 to 40%.
25
Anxiety has been related to poor glycaemic control, poorer
quality of life,
25,26
and decreased self-care behaviours.
27
A number of
explanations exist for this link. It has been postulated that sympathetic
nervous system responses to hyperglycaemia can produce anxiety symp-
toms. Further, endocrine abnormalities resulting from diabetes may be
aggravated by normal physiological stress responses. Lastly, anxiety may
be a response to the complexity of the illness and the associated treat-
ment regimen, which may negatively affect coping ability.
15
Regardless,
the negative effect of anxiety on adherence and quality of life makes this
condition clinically relevant in the effective management of diabetes.
Eating-disordered behaviour
Eating disorders and eating-disordered behaviour are a major concern
in managing diabetes.
28
Eating problems that may be considered mild
in non-diabetic patients can have significant clinical consequences for
diabetic patients.
29
In particular, insulin restriction to lose weight in type
1 diabetes patients increases risk for potentially life-threatening com-
plications of diabetes, including higher HbA
1c
readings, more frequent
DKA episodes, higher risk for developing infections, more frequent use
of medical services, and increased risk of mortality.
29,30
Insulin restriction
has also been related to earlier onset of diabetes-related complications,
retinopathy and neuropathy.
31
Disordered eating behaviour is often well
hidden and therefore diabetes healthcare providers have to ask pertinent
questions to uncover this behaviour.
28
Stress
The link between psychological stress and poor diabetes control is well
known.
32
Stressful life events have been found to be concomitant with an
increased risk of the development of type 1 diabetes in children,
33,34
as
