Dr.

Temitope Ilori
Family Medicine Core lectures
04/01/2016

Psychosocial support and the

optimization of team approach
to diabetic care
Introduction

 DM is currently defined as a group of metabolic

disorders of carbohydrate and lipid metabolism
characterized by hyperglycemia which results
from defects in the secretion or action of
INSULIN or both.
 Diabetes mellitus is said to be a disorder of
glucose metabolism, but it can be so much more
for those individuals who have the disease and
the families with whom they share their lives.
Introduction

 Inherent to these problems are also the

effects that chronic disease manifests on the
patient’s family and on the interpersonal
relationships within that family.
 This is due to strained coping with changed
life routine (such as relationships, work-
related and financial issues) right from the
time of diagnosis of DM.
Introduction

 Patients with diabetes, particularly those patients

who are compliant and try to take care of
themselves, engage in a daily battle of balancing
tight glycemic levels and a satisfying quality of life.
 This internal battle can, at times, be devastating.
 Physicians treating patients with diabetes mellitus
with its broad a range of complications should
have understanding and be sensitive toward the
psychosocial issues that can influence a patient’s
response to intervention.
Team Care

 Diabetes treatment should be provided by a team

of health care professionals that consists of
physicians, diabetes nurse educators, dieticians,
psychologists and the patient and family. 
 A multidisciplinary team, made up of members
with expertise in medicine, nursing, and mental
health care, that incorporates group discussions
of psychosocial issues promotes better
adaptation and improves family care.
TEAM WORK

6
Psychopathology and Diabetes

 Patients with diabetes have diagnosable

psychological problems at some point during their
lifetime.
 Affective disorders are the most common diagnoses
and occur significantly more often in patients with
diabetes than in the general population.
 These disorders can lead to poor glycemic control
through alterations in neuro-hormonal and
neurotransmitter functioning and through disruption
in diabetes self-care.
Diabetes and Psychosocial Issues

 Non Adherence
 Stress
 Depression
 Anxiety
 Eating disorders.
 Denial
 Mood swings
 Anger
 Disbelief.
Non-adherence

 Non-adherence is often mistakenly attributed to

inadequate knowledge about proper diabetes
care.
 Many other psychosocial factors contribute
significantly to this problem, such as:
 Inadequate social support
 Time pressure
 Stress
 Health beliefs that are incompatible with the
treatment regimen.
Non-adherence

The physician can provide treatment to:

 Develop new healthful behaviors
 Enhance existing healthful behaviors
 Discourage unhealthy behaviors as they
relate to improved glycemic control.
 Non-adherence may also be a manifestation
of more serious psychological problems, such
as depression, anxiety, or eating disorders.
Non-adherence

 Psychological and behavioral factors significantly

affect the course and outcomes of diabetes mellitus.
 Effective diabetes management requires adherence
to a chronic and complex regimen and, accordingly,
non-adherence is the norm rather than the
exception.
 Psychosocial support may be used to improve
adherence to the diabetes regimen and, more
generally, to develop sustained pro-diabetic
lifestyles.
Stress

 Is common in diabetes and is brought on by

ordinary daily hassles and the additional
burdens of coping with diabetes
 May have direct effects on health via elevated
blood glucose values and indirect effects on
health via disruption in behavioral patterns
and routines (e.g. eating and sleeping)
Stress

 The Family Physician can be a valuable

resource in identifying maladaptive reactions
to stress and can help patients to develop
more useful and effective methods of coping
Stress Management in Diabetes

• Promote pro-diabetic coping behaviors (e.g.

diet and exercise)
• Discourage high-risk health behaviors (e.g.
smoking, high fat intake).
• Improve family functioning as it relates to
communication and problem-solving about
diabetes.
• Provide support for subclinical distress
related to diabetes.
Depression

 Depression affects approximately one of every

five patients with diabetes.
 It severely impairs quality of life and all aspects of
functioning. 
 It usually leads to treatment non-adherence, poor
glycemic control, and increased risk for micro- and
macro-vascular disease complications.
 Depression may lead to cognitive decline and
further aggravate the vicious cycles of self-care
ability
Depression

 In adults, children and adolescents with DM,

depression was related to poorer glycemic
control, a range of diabetes complications,
increased health care costs, worsened functional
disability, re-hospitalization and early mortality.
 Those with psychological distress at the time of
diagnosis had a higher risk of cardiovascular
events (1.7-fold) and death (1.8-fold) than those
without psychological distress.
IDDM

 Patients with insulin-dependent diabetes mellitus

(IDDM) face major changes in lifestyle and the
possibility of debilitating and life-threatening
complications.
 Sometimes resulting in disruptions in family life
and in the ability to function in usual roles due to
the financial, physical, and psychological burdens
of diabetes mellitus.
 Some patients reported their medication
interfered with their ability to live a normal life.
Psychosocial issues of IDDM

 Initial recognition of the disease leads to a

sense of loss that can affect patients of any age.
 The patient and family become aware that they
are entering a new world filled with challenges
and constraints.
 Children and adolescents with IDDM may feel
mild intermittent sadness, a longing for health,
loneliness, apprehension, or crankiness or
irritability and may withdraw socially. 
Psychosocial issues of IDDM

 Outbursts of temper, feelings of guilt, pessimism

about the future, and refusal to take shots or
attend school are ominous signs.
 Parents may feel guilty or worry about their
child's future.
 Early adjustment disorders, sometimes predict
the subsequent development of anxiety and
depression. 
 Initial adjustment problems are more likely to
occur in families where there are signs of strain.
Psychosocial Issues Unique to 
Children with IDDM
 Pediatric and adult patients with diabetes
may manifest psychological problems in
different ways.
 Evidence of psychosocial problems related to
diabetes in children is often observed in:
 poor school performance
 impaired peer relations
 behavioral changes at home, at school, or
with friends.
Psychosocial Issues Unique to 
Children
 Conflictual family relations are often clues to
psychosocial problems for children with
diabetes.
 Because children rely on their parents for a
great deal of their diabetes care, conflictual
parent-child relations can impede proper
diabetes management.
Psychosocial Issues Unique to 
Adolescents
 Adolescence is a time of rebellion from
convention.
 Convention is represented not only by parents
and teachers but also by medical professionals.
 Adolescent patients may defy the
recommendations of health care professionals for
reasons related to normal development.
 However, this defiance can place adolescents at
risk for poorer metabolic control even to the point
of diabetic ketoacidosis.
Psychosocial Issues Unique to 
Adolescents
 Uncertainty about the future can be particularly
upsetting.
 Extreme anger may be directed at the physician or
institution.
 Such anger usually reflects deeper emotions, including
fear of long-anticipated problems, guilt about lapses in
self-care, and sadness about the anticipated losses.
 Untreated psychosocial disorders in DM, may lead to
more physical symptoms, cardiovascular
complications and depression.
Complications of DM and Psychosocial
Issues
 The fear of potential limb loss
 The risk of blindness
 Erectile Dysfunction
 Recurrent infections
 DVT
 CVD
 Fertility issues
These may precipitate a major depression,
dysfunctional family relationships and, ultimately,
the avoidance of healthcare altogether.
Psychosocial support

Psychosocial supports can be through:

 Caring and compassionate family
 Friends
 Health care professional
 Patients support Groups
Also entails encouraging:
 positive Emotions
 resilience
 early screening, evaluation and management of
psychological disorders in people with DM
Psychosocial Support
Emotion has a direct effect on both behaviour and
physiology.
Positive emotions, such as hope, optimism happiness,
vitality ,excitement and contentment result in better
health behaviours and improved adherence to treatment
regimens.
Positive emotion were linked to self-management; strict
diet, improved frequency of blood glucose monitoring,
improved HbA1c, health status and quality of life.
Psychosocial Support

 Negative emotions, Stress, anxiety and

depression are related to impaired immune,
pro-inflammatory cytokines and inflammation
responses that have been linked to DM.
 Emotions such as apathy, guilt feeling, feeling
overwhelmed and disgruntled could
contribute to prolonged infections and
delayed wound healing.
 Such emotions should be discouraged.
Psychosocial Support

 Resilience is defined as an individual’s capacity to

maintain psychological and physical well-being
when faced with adverse life events by drawing
on self-esteem, self-efficacy, self-mastery and
optimism as resources.
 Resilience has been shown to contribute to
relatively successful social functioning in patients
with DM, with an effect that was stronger than
social support and material resources.
The Therapeutic Relationship

 Psychosocial oriented care begins with an

understanding of how to develop and maintain
the therapeutic relationship.
 This relationship can be strengthened by
encouraging patients to participate actively in
setting the goals for their care.
 The physician should attempt to identify
unexpressed goals of the patient and then
negotiate a plan that recognizes any differences
between the patient’s and clinician’s goals.
The Therapeutic Relationship

These steps increase the likelihood of

successful treatment:
 Establish rapport
 Listening to the expressions of anger
 Asking about other worries
 Inform, Educate and Counsel
 Maintainance of tight glycemic control
 Exercise
 Smoking cessation
The Therapeutic Relationship
Healthy diet
Weight loss
are all essential
elements for
reducing the
complications
of diabetes.
General Interventions

 Yearly eye and foot examinations

 Urinalysis and screening for microalbuminemia
 Testing for hyperlipidemia and hypertension
Others include
 Sexual therapy for impotence can help couples
emotionally and can improve erectile function
when psychological problems compound the
physical disorder.
 Short-term group and individual therapy can help
the patient adjust.
Management of diabetes

 The three pillars in the management of

diabetic patients include:
 Patient education
 Prevention of complications
 Adequate glycemic control
However, physicians should not overlook the
management of the fears and anxieties that
often accompany this disease.
Conclusion

 There is need for an early assessment of the

patients’ understanding of their disorder and their
ability to cope with the disorder. 

 The goal of promoting the patient's well-being

while preventing complications requires a
multidisciplinary treatment approach that
incorporates an understanding of the social,
psychological, and psychiatric ramifications of
DM.
Conclusion

 A patient’s physical wellbeing depend on his

psychosocial wellbeing, social structure and
personal relationships.
 Psychosocial support can increase the
patient's sense of wellbeing.
 To provide such a sense of security is the
fundamental basis of successful medical care.
TPALLITTTTTTTTTTTTTTTTTTTTTTTTTTTTTT Thanks for
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