2008 Clinical Practice Guidelines - Canadian Diabetes Association
2008 Clinical Practice Guidelines - Canadian Diabetes Association
2008 Clinical Practice Guidelines - Canadian Diabetes Association
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<strong>2008</strong> CLINICAL PRACTICE GUIDELINES<br />
S82<br />
Psychological Aspects of <strong>Diabetes</strong><br />
<strong>Canadian</strong> <strong>Diabetes</strong> <strong>Association</strong> <strong>Clinical</strong> <strong>Practice</strong> <strong>Guidelines</strong> Expert Committee<br />
The initial draft of this chapter was prepared by Helen Jones RN MSN CDE, Peter Hall PhD,<br />
Barry Simon MD and Beth Mitchell PhD<br />
KEY MESSAGES<br />
• Significant behavioural demands and challenging psychosocial<br />
factors affect nearly all aspects of diabetes<br />
management and subsequent glycemic control.<br />
• All individuals with diabetes and their families should<br />
be regularly screened for symptoms of psychological<br />
distress.<br />
• Preventive interventions such as participative decisionmaking,<br />
feedback and psychological support should be<br />
incorporated into all primary care and self-management<br />
education interventions to enhance adaptation to diabetes<br />
and reduce stress.<br />
INTRODUCTION<br />
Significant behavioural demands and challenging psychosocial<br />
factors affect nearly all aspects of diabetes management<br />
and subsequent diabetes control (1,2). Psychological issues<br />
related to the diagnosis and/or self-care demands may<br />
present anywhere on a continuum from impairment in<br />
quality of life to clinically significant depressive and/or<br />
anxiety disorders.<br />
ADJUSTMENT PROBLEMS<br />
Both adults and children face challenges associated with<br />
adjustment to diabetes. Some children and/or their parents<br />
have adjustment problems soon after the diagnosis of diabetes<br />
(3,4).Those who do not solve these problems within the first<br />
year of diagnosis are at risk for poor adaptation to diabetes,<br />
including regimen adherence problems, poor glycemic control<br />
and continued psychosocial difficulties (5,6). Stress (general<br />
and diabetes-specific) (7,8), inadequate social and family<br />
interactions (9,10), inappropriate beliefs about the nature of<br />
diabetes (10), and poor coping skills (11,12) may have a negative<br />
impact on self-care behaviours and glycemic control.<br />
Adults with type 1 and 2 diabetes across many cultures<br />
report significant psychological distress related to the diagnosis<br />
of diabetes, with a negative impact on diabetes selfmanagement<br />
(13).<br />
The diagnosis of diabetes may precipitate or exacerbate<br />
existing psychological disorders (14,15). As quality of life is<br />
adversely affected by the presence of comorbid psychological<br />
disorders and health complications (14,15), the identifi-<br />
cation of potential psychiatric conditions, such as depression,<br />
anxiety and eating disorders, is critical.<br />
Depression<br />
Depressive symptoms are common in people with diabetes<br />
compared with the general population (14,16,17), and<br />
major depressive disorder is present in approximately 15%<br />
of patients with diabetes (18). Depressive disorders in adults<br />
and children are associated with poorer self-care behaviour<br />
(19,20), poorer glycemic control, health complications,<br />
decreased quality of life and psychological well-being<br />
(14,21), increased family problems, and higher healthcare<br />
costs (22-25).<br />
Anxiety<br />
Emerging evidence suggests that the prevalence of phobic<br />
disorders (24,26) and generalized anxiety disorders (3) is<br />
elevated in people with type 1 diabetes. Generalized anxiety<br />
disorder appears to be increased in individuals with diabetes<br />
compared with the general population (14 vs. 3 to 4%,<br />
respectively) (27). As many as 40% of patients have at least<br />
some anxiety symptoms (27), and fear of hypoglycemia<br />
(28,29) is not uncommon in those with diabetes. A recent<br />
meta-analysis suggested that the presence of clinically significant<br />
anxiety disorders among those with type 1 and 2 diabetes<br />
is associated with poor glycemic control (28).<br />
Eating disorders<br />
Eating disorders are frequently observed in young women<br />
and adolescent females with type 1 diabetes (30,31) and are<br />
associated with poorer glycemic control (31,32) and an<br />
increased risk of long-term complications (33). A metaanalysis<br />
of controlled studies of eating disorders and diabetes<br />
showed a higher prevalence of bulimia in girls with<br />
diabetes compared with healthy controls (34). Other studies<br />
have demonstrated prevalence rates of full syndrome and<br />
subthreshold eating disorders that are twice as high as those<br />
in peers without diabetes (30,35).Young women and adolescent<br />
females with type 1 diabetes should, therefore, be<br />
regularly screened for eating disorders with the Eating<br />
Disorders Inventory (36). Those with an identified or suspected<br />
eating disorder should be referred to a medical team<br />
or mental health professional knowledgeable in treating<br />
such disorders.