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Empowering patient improves compliance
Richard Rubin, PhD, says nearly half of his diabetic patients plunge into clinical depression. "Depression is a severely underdiagnosed and undertreated problem for people with diabetes," explains the assistant professor of medicine and pediatrics at Johns Hopkins School of Medicine in Baltimore. "It’s uniquely devastating because it can lead them into a downward physical spiral."
He says depressed patients with diabetes are more likely to have complications probably because they don’t care for themselves or their disease as well as they should. "Some of them say, To hell with it all,’" Rubin says, remembering a patient in a group therapy session who told him that those with the "hell with it" attitude often wind up in a living hell.
Depression tends to increase with the seriousness of the disease and as complications set in, says Beth Venditti, PhD, licensed psychologist, coordinator of lifestyle resources in the Diabetes Prevention Program at the University of Pittsburgh.
"I see people with borderline diabetes, at the earliest stages, so I don’t see as much depression," Venditti says. "That in itself is another strong argument for prevention of diabetes."
She points out, "A diabetic person isn’t going to automatically be in the mental health system, so it’s important for endocrinologists, clinicians, and diabetes educators to become very familiar with the criteria for depression so they can treat it or make the appropriate referrals." (See box for list of questions to ask your patient, at right.)
Depression should not be treated casually, Rubin adds, and it must be treated as a disease separate from diabetes. Treating diabetes, even with good control, doesn’t necessarily answer the problem of depression, which may require therapy or medication.
Health care professionals who treat diabetic patients should screen them for depression at every visit. "We need to recognize when somebody is depressed and treat them with appropriate medications, counseling, and cognitive behavioral therapy," he says. Among diabetics, Rubin adds, "Depression is common, severe, debilitating, and treatable."
Other emotions are significant as well. "People tell me they are angry they have to deal with this disease," Venditti says. Anger, like depression, lessens the likelihood of patient compliance.
Denial gets in the patient’s way as much as anger or depression and may be triggered by a lack of education among those who have been told they have "a touch of sugar" and think they have "recovered" from diabetes.
Add that to the guilt many patients feel for not sticking with their diets or exercise plans, and compliance suffers even more, she says. It’s tough to urge patients who feel that way to make the lifestyle changes necessary to manage their diabetes without triggering the syndromes of guilt, anger, denial, or even depression.
Rubin’s answer is to reach out to struggling patients by asking, "What’s the hardest thing for you right now?"
He follows that with, "What have you done to change?"
The final question, which Rubin says requires a very specific answer is, "What do you want to change?"
For example, he recalls a patient who told him he was a "grazer" and spent several hours an evening eating a little bit of one thing, then a little bit of another thing. "The key was for me to help him see he had the solution to the problem," Rubin says. "I asked him about the times he didn’t graze and how he felt."
"Inevitably when you ask a patient about the times he was in compliance, he will say something positive," he says. The way to increase the amount of compliance is to be "facilitative rather than directive," says Rubin, who is author of several books, including Practical Psychology for Diabetes Clinicians.
Empowering patients to manage their disease lies at the heart of managing the psychological effects of diabetes, he says. "Engage their expertise. They are experts in their own lives. That’s fundamental. The job is not to manage diabetes, but to help [patients] manage their diabetes. That’s what helps keep them from getting overwhelmed," he says.
[Richard Rubin can be reached at (410) 243-6565 and Beth Venditti at (412) 383-2478.]