Wednesday, December 24, 2008

A Whole-Person Approach to Diabetes Health Education Part 2 of 4

In my last post, I presented an overview of the mind-body approach to diabetes health education. In this post I give a more in-depth examination of the psychological factors influencing blood glucose control, starting with the effects of emotional depression.

Psychology of Diabetes: How Mind Affects Health

Diabetes requires extreme changes to many people's lifestyles. They must change from a sedentary to health-conscious lifestyle. Instead of eating junk food and watching television, they have to begin eating healthy food, exercise regularly, monitor their blood sugar level multiple times a day, control their blood pressure and cholesterol, have regular eye and foot exams, stop smoking, and possibly take medications (which may include self-injection). Adopting these lifestyle changes and adhering to these self-management routines requires education and guidance, of course. Many diabetic individuals, however, need more than knowledge and instruction. The reason: Psychological obstacles interfere with their ability and willingness to make such dramatic lifestyle changes.
These psychological obstacles may include maladaptive (inappropriate, detrimental) attitudes, coping skills, and emotions. For example:
  • Lack of self-confidence is enough to deter some people from even trying to change their lifestyle since they expect to fail.
  • Just looking at a sugary snack can cause some people to worry about the life-threatening aspects of their disease, or feel depressed and angry that they must deprive themselves.
  • Failure to keep up their exercise routine or eating poorly can also make them feel those same negative emotions. Unhealthy behavior can also make them feel guilty or ashamed for not doing what they should.
Unfortunately, instead of motivating them to control their diabetes, these attitudes and emotions can have the exact opposite effect; they may cause diabetic people to stop trying because they feel hopeless and helpless. Or equally harmful, they may deal with their painful feelings by ignoring their health through denial and self-deception. Following are some examples of the deleterious effects of these psychological obstacles on diabetic individuals.

Depression and Diabetes Management

Health Effects of Depression
Research shows that depression in diabetic people is associated with poorer diet and medication adherence, functional impairment, and higher health care costs.[1][2] This is often a vicious cycle. When the demands of diabetes care or complications of the disease lead to depression, a person feels overwhelmed, hopeless, helpless, and exhausted. These feelings, in turn, destroy one's motivation, which impairs self-management. Failure to manage one's diabetes results in greater health problems, which exacerbate the depression. And the cycle repeats.

Likewise, depressed people are unlikely to modify their behaviors to extend their lives because the prospect of living longer in chronic emotional pain shatters their willingness to change. Furthermore, depressed diabetic individuals may refuse to acknowledge that their illness can severely harm or kill them because the idea is too emotionally painful to accept. This means that the threat of serious complications or death is not a powerful motivator for some. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Dealing with Depression
Fortunately, there are effective ways to help diabetic people overcome the psychological obstacle of depression. For example, compelling discoveries in the fields of cognitive science, linguistics and neuroscience are demonstrating the promise of "reframing" techniques. One useful reframing method helps depressed people develop a vision of "joy of living" rather than a "fear of dying," since joy can be a more powerful motivator than fear. Incorporating this kind of reframing approach into diabetes health education can promote positive changes in people's way of thinking, resulting in increased motivation to live more healthily.[3]

Diabetic people also need good coping strategies for dealing with depression (and other emotional disturbances). Some coping strategies attempt to reduce one's emotional distress by promoting adaptive (effective, useful) ways of thinking, feeling, and acting when trying to manage their illness (or other problems); other strategies, however, are maladaptive. Ten common strategies people use include five adaptive and five maladaptive coping methods.

The five positive, adaptive coping strategies help a person solve a problem or learn to accept it with minimal distress:
  • Logical Analysis involves trying to understand what caused the health problem and different ways to handle it.
  • Problem Solving involves developing specific plan of action to manage the problem, implementing it, learning from the results, and then modifying the plan and trying again if necessary.
  • Social Support involves explaining the problem to other people and asking them for advice or help; this includes peer group support.
  • Positive Reappraisal involves viewing the problem as helping the person change or grow in a good way, find new faith, or learn valuable lessons.
  • Rational Acceptance involves accepting—without undue emotional distress and without self-defeating behaviors—that nothing can be done to cure one's illness; at the same time, it encourages the person to do what is necessary to prevent complications.
  • The five negative, maladaptive coping strategies fail to resolve one's problems, do not enable healthy acceptance, and may even make the situation worse:
  • Behavioral Distraction involves trying to feel better emotionally by doing enjoyable or interesting things, rather than dealing with the health problem proactively or coping with it through positive reappraisal and rational acceptance. While it may help reduce a person's emotional distress temporarily, this strategy is maladaptive because it will never improve the situation, does nothing to help one cope with it long-term, and can actually make matters worse through inaction. This strategy wastes precise time that could be better spent trying to understand and deal constructively with the problem.
  • Cognitive Avoidance involves acting as if there is no problem, or trying not to think about the problem. As with behavioral distraction, the strategy may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
  • Emotional Discharge involves expressing negative emotions by yelling or crying, taking it out on others, or avoiding certain situations. As with the previous two strategies, this one may help reduce one's upset temporarily, but it will never improve the situation and does nothing to help one cope with it long-term. In addition, this strategy may annoy other people who could have been helpful and push them away.
  • Wishful Thinking involves hoping a miracle will somehow make things better, or that one's wishes or prayers would somehow be answered. This, too, may help reduce one's emotional distress temporarily, but it will never improve the situation, does nothing to help one cope with it long-term, and wastes precise time.
  • Resignation happens when a person determines that nothing can be done to fix a problem, so he or she does nothing, while remaining in an emotionally distressed state of anxiety, depression (hopelessness and helpless), and/or anger. This, too, is obviously maladaptive.
It stands to reason, therefore, that helping depressed persons in diabetes health education programs deal with their depressions—through reframing, coping skill training [4], and other methods—will result in better outcomes (i.e., more effective control of blood glucose, blood pressure, etc.).
In my next post, I discuss how mental stress and personality factors affect diabetes management.

[1] Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. 1: Arch Intern Med. 2000 Nov 27;160(21):3278-85. See

Gonzalez JS, Safren SA, Cagliero E, Wexler DJ, Delahanty L, Wittenberg E, Blais MA, Meigs JB, Grant RW. Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. 1: Diabetes Care. 2007 Sep;30(9):2222-7. See this link

[2] Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001 Jun;24(6):1069-78. See this link

[3] Deutschman, A. Change or Die. 2005 May. See this link

[4] Grey, M. Coping and Diabetes. Diabetes Spectrum. 2000 13(3),167. See this link
Grey, M. & Berry, D. Coping skills training and problem solving in diabetes. Curr Diab Rep. 2004 Apr;4 (2):126-31

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