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Association between psychosocial stress and psychosocial support in diabetic patients
International Congress Series 1241 (2002) 51 – 58
Association between psychosocial stress and psychosocial support in diabetic patients S. Herpertz a,*, R. Kra¨mer-Paust a, R. Paust b, B. Schulze Schleppinghoff b, F. Best c, R. Bierwirth d, W. Senf a a
Department of Psychotherapy and Psychosomatics, University of Essen, Postfach 103043, 45030 Essen, Germany b Diabetes Center, Elisabeth Hospital, Essen, Germany c Diabetes Center, St. Joseph Hospital, Essen, Germany d Private practice, Essen, Germany
Abstract Psychosocial stress and the use of various kinds of psychosocial support were evaluated. Using the Questionnaire on Stress in Patients with Diabetes (QSD-R), stress in different facets of daily life was assessed in a sample of 410 patients with type 1 and type 2 diabetes. Sixty-eight diabetics (16.6%) suffered from extreme psychosocial stress, which was defined as a mean global stress score above standard deviation. The use of insulin within the type 2 diabetic sample was especially associated with psychosocial stress. An association of diabetic control and the extent of psychosocial stress was found. With regard to the psychosocial stress profile, depression was predominant in both types of diabetes followed by fear of hypoglycemia in the type 1 subsample and physical complaints in the type 2 subsample. Primary care physicians and diabetologists were the main sources of psychosocial support. Psychosocial stress in diabetic patients is quite frequent and is associated with metabolic control; it should be considered more frequently in diabetes care. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Diabetes mellitus; Type 1 diabetes; Type 2 diabetes; Stress; Psychosocial support
1. Introduction In the last decade, there has been a growing interest in psychosocial aspects of diabetes with an increasing number of epidemiologic studies on the comorbidity of psychiatric *
Corresponding author. Tel.: +49-201-7227-544; fax: +49-201-7227-305. E-mail address: [email protected] (S. Herpertz).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 8 1 - 7
52
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
disorders or psychiatric symptoms [1,2]. Anxiety is one of the main problems of diabetic patients especially with regard to hypoglycemia or late diabetic lesions [3]. There is evidence that compared to diabetics with good metabolic control, diabetics with poor metabolic control and high risk of early diabetic lesions often suffer from psychiatric symptoms and disorders [4,5]. The aim of this multicenter study was to evaluate the association of psychosocial stress and the use of psychosocial support in patients with both types of diabetes. Besides evaluating the need of psychosocial support, another aim of the study was to find out associations between sociodemographic variables, type of diabetes, duration of the illness, metabolic control, diabetic lesions, and the extent of psychosocial burden. Furthermore, both the target group of potential support and the time when the psychosocial intervention was required were of interest.
2. Method 2.1. Sample In cooperation with five diabetic centers (two hospitals and three practices) in the industrial area of the Ruhr in Germany, a sample of 410 diabetic patients (type 1: n = 157, type 2: n = 253) was studied (Table 1). They were drawn from a sample of 484 patients (84.7%) (type 1: n = 157, 38.3%; type 2: n = 253, 61.7%). Three hundred fifty-four patients (73.1%) took part in a 5-day inpatient diabetic training program, 56 (11.4%) frequented the practices. 2.2. Instruments Stress in different facets of daily living was assessed using the revised Questionnaire on Stress in Patients with Diabetes (QSD-R) [6]. The QSD-R is a 45-item self-report measure designed to quantify an individual’s daily stress in living with diabetes. Analyses of reliability and validity have been published recently. Diabetics with a mean global stress score above standard deviation were defined as extremely handicapped and compared to
Table 1 Sample
Age Sex: Male Female Non-insulin-dependent Insulin-dependent Duration of illness (years) BMI (kg/m2)
Type 1 38.3% (n = 157)
Type 2 61.7% (n = 253)
42.17 F 14.80
60.63 F 10.41
51.0% (n = 80) 49.0% (n = 77) 39.7% (n = 100) 100% (n = 157) 15.49 F 11.14 24.22 F 3.65
54.9% (n = 139) 45.1% (n = 114) 60.3% (n = 152) 12.12 F 8.47 28.80 F 4.59
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
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Table 2 Comparison of psychosocial stress (QSD-R global score) of type 1 and type 2 diabetics Average stress
Age Sex: Male Female Duration of the illness Rel. HbA1(c) BMI QSD-R total score
Extreme stress
Type 1 (n = 131)
Type 2 (n = 211)
Type 1 (n = 26)
Type 2 (n = 42)
41.59 F 14.73
60.82 F 10.86
45.12 F 15.11
59.57 F 7.81
66 (50.4%) 65 (49.6%) 15.5 F 10.9 1.6 F 0.4 24.3 F 3.5 0.9 F 0.4
115 (54.5%) 96 (45.5%) 11.7 F 8.2 1.7 F 0.4 28.8 F 4.6 0.9 F 0.5
14 (53.8%) 12 (46.2%) 15.3 F 12.5 1.8 F 0.5 23.9 F 4.3 2.3 F 0.4
24 (57.1%) 18 (42.9%) 14.1 F 9.6 1.7 F 0.4 28.6 F 4.6 2.4 F 0.4
the less handicapped sample. Self-constructed items were used to assess the use of psychosocial support during the course of the illness. A standardisation procedure was applied to adjust for variations among local HbA1/ HbA1c assays. According to the recommendation of the German Diabetic Society, we calculated ‘‘relative HbA1 levels’’ within each assay by dividing every absolute HbA1 or HbA1c level by the average of the reference range [7].
3. Results Of the 410 participants, 187 (45.6%) suffered from diabetic lesions: retinopathy (n = 105, 25.6%), nephropathy (n = 49, 12.0%), neuropathy (n = 99, 24.1%), hypertension (n = 104, 25.4%), diabetic food ulcers (n = 100, 24.4%) and CHD (n = 66, 16.1%). The mean global score of the QSD-R of the total sample (n = 410) was 1.16 ( F 0.693). There was no significant difference between the two types of diabetes (1.17 F 0.658 vs. 1.15 F 0.712, p = 0.835) (Table 2). There was a tendency for insulin-dependent type 2 diabetics to be more handicapped than non-insulin-dependent type 2 diabetics (noninsulin-dependent: 0.99 F 0.639, insulin-dependent: 1.25 F 0.749; p = 0.06) (Table 3). No Table 3 Comparison of psychosocial stress (QSD-R global score) with and without insulin treatment Average stress
Age Sex: Male Female Duration of the diabetes Rel. HbA1(c) BMI QSD-R total score
Extreme stress
Insulindependent (n = 119)
Non-insulindependent (n = 91)
Insulindependent (n = 33)
Non-insulindependent (n = 9)
61.68 F 11.04
59.71 F 10.64
60.85 F 7.58
55.33 F 7.47
59 (49.6%) 60 (50.4%) 14.11 F 8.45 1.68 F 0.39 27.83 F 4.69 0.93 F 0.45
56 (61.5%) 35 (38.5%) 8.48 F 6.60 1.62 F 0.39 30.15 F 4.16 0.85 F 0.45
19 (57.6%) 14 (42.4%) 6.35 F 9.14 1.67 F 0.40 28.75 F 5.11 2.40 F 0.41
5 (55.6%) 4 (44.4%) 6.44 F 7.20 1.81 F 0.39 28.12 F 1.44 2.47 F 0.27
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S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
Fig. 1. Profiles of stress (QSD-R) of type 1 diabetics.
difference could be found between participants with and without the inpatient diabetic training program within the type 1 diabetic sample (1.16 F 0.64 vs. 1.17 F 0.90, p = 0.68). However, type 2 diabetics participating in the training program turned out to be more handicapped compared to non-participating type 2 diabetics (0.92 F 0.70 vs. 1.20 F 0.1,
Fig. 2. Target groups of psychosocial support of patients with type 1 diabetes ( > 5%).
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
55
p = 0.1). Extreme psychosocial stress could be found in 68 diabetics (16.6%). Not the type of diabetes but the use of insulin within the type 2 diabetic sample revealed an impact on psychosocial stress. Both in the total sample and in the type 1 diabetic subsample, diabetics with extreme psychosocial stress showed worse diabetic control compared to less stressed diabetic patients. Diabetic lesions were significantly more frequent in patients with extreme psychosocial stress both in the total as well as in the two subsamples of type 1 and type 2 diabetic patients. Profiles of psychosocial stress evidenced a quantitative instead of a qualitative difference between extremely and less handicapped type 1 and type 2 diabetics (Fig. 1). Maximal stress could be observed with regard to depression in both types of diabetes (only type 1 diabetes is shown in the figure); this was followed by fear of hypoglycemia in the type 1 diabetic subsample and physical complaints in the type 2 diabetic subsample. Fig. 2 illustrates the actual reliance compared to the desired reliance on psychosocial support. Family members, primary care physicians, and diabetologists were the main sources of psychosocial support of stressed and non-stressed diabetics (only type 1 diabetes is shown in the figure). Independent of the type of diabetes and the extent of psychosocial stress, the use of psychosocial support differed more quantitatively than qualitatively (Fig. 3). Compared to less handicapped diabetic patients, extremely stressed diabetics desired more psychosocial support from nearly every target group. Whereas psychologists/psychotherapists had not or hardly been consulted in the past, more than 25% of the extremely stressed diabetics had the request for psychotherapeutic support. Half of the type 1 and one third of the type 2 diabetics (only type 1 diabetes is shown in the figure) requested support in self-help
Fig. 3. Events that made support desirable.
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S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
Table 4 Comparison of metabolic control of type 1 and type 2 diabetics with extreme and average stress Rel. HbA1(c) Total sample
extreme stress (n = 68) average stress (n = 342) pa extreme stress (n = 26) average stress (n = 131) pa extreme stress (n = 42) average stress (n = 211) pa
Type 1 diabetics
Type 2 diabetics
a
1.7 F 0.5 1.6 F 0.4 0.045a 1.8 F 0.5 1.6 F 0.4 0.024a 1.7 F 0.4 1.7 F 0.4 0.546
Mann – Whitney – U-Test.
groups. Psychosocial support was favoured within the medical institutions especially at the time of diagnosing the disease and later on for the diabetic lesions.
4. Discussion Type 2 diabetics participating in the diabetic training programs were significantly more handicapped than diabetic patients consulting the medical practices. The recruitment of type 2 diabetic patients may not be representative because of the fact that the majority of them receive treatment from general practitioners. Furthermore, there may be a considerable number of problem cases among those patients referred to a diabetes center by their general practitioner. Whereas no relationship between the type of diabetes and psychosocial stress could be observed, therapy strategies within the type 2 diabetes subsample were associated with psychosocial stress. Within this subsample, insulin application was significantly more associated with psychosocial stress than diet or oral medication. Prevalence of diabetic lesions in insulin-dependent type 2 diabetics is considerably higher compared to non-insulin-dependent patients. Besides the incriminating treatment strategy of regular injections, which is often accompanied by fear of hypoglycemia, the threatening
Table 5 Comparison of diabetic lesions of extremely stressed and less stressed diabetics
Total sample
Type 1
Type 2
a
chi2-Test.
Diabetic lesions
Extreme stress
Average stress
pa
yes no unknown yes no unknown yes no unknown
47 17 4 14 10 2 35 6 1
141 160 17 44 85 2 109 83 19
0.01**
(70.8%) (23.5%) (4.4%) (53.8%) (38.5%) (7.7%) (82.1%) (15.4%) (2.6%)
(44.3%) (50.3%) (5.3%) (33.3%) (65.1%) (1.6%) (52.1%) (39.9%) (8.9%)
0.05 *
0.01**
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
57
awareness or anxious anticipation of the threatened physical integrity of these patients has to be taken into consideration. Nearly 17% of the type 1 and type 2 diabetics were extremely handicapped according to the defined criteria mentioned above. This is in line with the point prevalence of psychiatric comorbidity of epidemiologic studies [4,8,9]. Irrespective of the type of diabetes, extremely stressed diabetics showed a significant worse metabolic control (Table 4) and more frequent diabetic lesions (Table 5) compared to less stressed diabetics, and regardless of the type of diabetes, depression was the prominent problem with regard to the stress profiles, followed by stressful treatment regimen and diet. Fear of hypoglycemia was more prominent in type 1 diabetics, whereas physical complaints were characteristic of type 2 diabetics. Regardless of the extent of psychosocial stress and type of diabetes, the majority of type 1 and type 2 diabetic patients sought support in familial social relationships, the family doctor, and the diabetologist. Self-help groups were favoured by type 1 diabetics. Although psychotherapy had hardly ever been requested by type 2 diabetics and never been requested by type 1 diabetics in the past, more than 25% of the extremely stressed patients desired psychotherapeutic support for the future. Psychosocial support was favoured within the medical institutions especially at the time of diagnosing the disease and later on for the diabetic lesions. These results underline the need for strengthening patients’ individual support systems, for example, by establishing coping groups for diabetic patients and their families. [10,11,12]. There also seems to be a need for psychosocial aspects to be integrated into diabetic training programs.
References [1] R. Mayou, R. Peveler, B. Davies, J. Mann, C. Fairburn, Psychiatric morbidity in young adults with insulindependent diabetes mellitus, Psychol. Med. 21 (1991) 639 – 645. [2] C. Wilkinson, D.Q. Borsey, P. Leslie, R.W. Newton, C. Lind, C.B. Ballinger, Psychiatric disorder in patients with insulin-dependent diabetes mellitus attending a general hospital clinic: two-stage screening and detection by physicians, Psychol. Med. 17 (1997) 515 – 517. [3] M.K. Popkin, A.L. Callies, R.D. Lentz, E.A. Colon, D.E. Sutherland, Prevalence of major depression, simple phobia, and other psychiatric disorders in patients with long-standing type I diabetes mellitus, Arch. Gen. Psychiatry 45 (1988) 64 – 68. [4] M. deGroot, A.M. Jacobson, J.A. Samxon, Psychiatric illness in patients with type I and type II diabetes mellitus, Psychosom. Med. 56 (1994) 176A. [5] P.J. Lustman, L.S. Griffith, R.E. Clouse, P.E. Cryer, Psychiatric illness in diabetes mellitus. Relationship to symptoms and glucose control, J. Nerv. Ment. Dis. 174 (1986) 736 – 742. [6] P. Herschbach, G. Duran, S. Waadt, A. Zettler, C. Amm, B. Marten-Mittag, Psychometric properties of the Questionnaire on Stress in Patients with Diabetes—Revised (QSD-R), Health Psychol. 16 (1997) 171 – 174. [7] U.A. Mu¨ller, K.M. Reinauer, M. Voss, S. Ko¨hler, Programme zur Verbesserung der Stoffwechseleinstellung (Sekunda¨rpra¨vention) bei Typ-I-Diabetes. Kontinuierliches Qualita¨tsmanagement strukturierter Behandlungs- und Schulungsprogramme fu¨r Typ-I-Diabetes in Deutschland, in: M. Berger, C. Trautner (Eds.), Die Forderungen von St.Vincent—Stand 1996 in Deutschland, Kircheim-Verlag, Mainz, 1996. [8] J.A. Gavard, P.J. Lustman, R.E. Clouse, Prevalence of depression in adults with diabetes, Diabetes Care 16 (1993) 1167 – 1178. [9] P.J. Lustman, L.S. Griffith, J.A. Gavard, R.E. Clouse, Depression in adults with diabetes, Diabetes Care 15 (1992) 1631 – 1639.
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[10] I. Fawzy, N. Fawzy, A structured psychoeducational intervention for cancer patients, Gen. Hosp. Psychiatry 16 (1994) 149 – 192. [11] A. Zettler, G. Duran, S. Waadt, F. Strian, P. Herschbach, Psychologische Ansa¨tze fu¨r Diabetiker mit Folgeerkrankungen, in: F. Petermann (Ed.), Diabetes Mellitus, Hogrefe, Go¨ttingen, 1995. [12] A. Zettler, G. Duran, S. Waadt, P. Herschbach, F. Strian, Coping with fear of long-term complications in diabetes mellitus: a model clinical program, Psychother. Psychosom. 64 (1995) 178 – 184.
Association between psychosocial stress and psychosocial support in diabetic patients S. Herpertz a,*, R. Kra¨mer-Paust a, R. Paust b, B. Schulze Schleppinghoff b, F. Best c, R. Bierwirth d, W. Senf a a
Department of Psychotherapy and Psychosomatics, University of Essen, Postfach 103043, 45030 Essen, Germany b Diabetes Center, Elisabeth Hospital, Essen, Germany c Diabetes Center, St. Joseph Hospital, Essen, Germany d Private practice, Essen, Germany
Abstract Psychosocial stress and the use of various kinds of psychosocial support were evaluated. Using the Questionnaire on Stress in Patients with Diabetes (QSD-R), stress in different facets of daily life was assessed in a sample of 410 patients with type 1 and type 2 diabetes. Sixty-eight diabetics (16.6%) suffered from extreme psychosocial stress, which was defined as a mean global stress score above standard deviation. The use of insulin within the type 2 diabetic sample was especially associated with psychosocial stress. An association of diabetic control and the extent of psychosocial stress was found. With regard to the psychosocial stress profile, depression was predominant in both types of diabetes followed by fear of hypoglycemia in the type 1 subsample and physical complaints in the type 2 subsample. Primary care physicians and diabetologists were the main sources of psychosocial support. Psychosocial stress in diabetic patients is quite frequent and is associated with metabolic control; it should be considered more frequently in diabetes care. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Diabetes mellitus; Type 1 diabetes; Type 2 diabetes; Stress; Psychosocial support
1. Introduction In the last decade, there has been a growing interest in psychosocial aspects of diabetes with an increasing number of epidemiologic studies on the comorbidity of psychiatric *
Corresponding author. Tel.: +49-201-7227-544; fax: +49-201-7227-305. E-mail address: [email protected] (S. Herpertz).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 8 1 - 7
52
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
disorders or psychiatric symptoms [1,2]. Anxiety is one of the main problems of diabetic patients especially with regard to hypoglycemia or late diabetic lesions [3]. There is evidence that compared to diabetics with good metabolic control, diabetics with poor metabolic control and high risk of early diabetic lesions often suffer from psychiatric symptoms and disorders [4,5]. The aim of this multicenter study was to evaluate the association of psychosocial stress and the use of psychosocial support in patients with both types of diabetes. Besides evaluating the need of psychosocial support, another aim of the study was to find out associations between sociodemographic variables, type of diabetes, duration of the illness, metabolic control, diabetic lesions, and the extent of psychosocial burden. Furthermore, both the target group of potential support and the time when the psychosocial intervention was required were of interest.
2. Method 2.1. Sample In cooperation with five diabetic centers (two hospitals and three practices) in the industrial area of the Ruhr in Germany, a sample of 410 diabetic patients (type 1: n = 157, type 2: n = 253) was studied (Table 1). They were drawn from a sample of 484 patients (84.7%) (type 1: n = 157, 38.3%; type 2: n = 253, 61.7%). Three hundred fifty-four patients (73.1%) took part in a 5-day inpatient diabetic training program, 56 (11.4%) frequented the practices. 2.2. Instruments Stress in different facets of daily living was assessed using the revised Questionnaire on Stress in Patients with Diabetes (QSD-R) [6]. The QSD-R is a 45-item self-report measure designed to quantify an individual’s daily stress in living with diabetes. Analyses of reliability and validity have been published recently. Diabetics with a mean global stress score above standard deviation were defined as extremely handicapped and compared to
Table 1 Sample
Age Sex: Male Female Non-insulin-dependent Insulin-dependent Duration of illness (years) BMI (kg/m2)
Type 1 38.3% (n = 157)
Type 2 61.7% (n = 253)
42.17 F 14.80
60.63 F 10.41
51.0% (n = 80) 49.0% (n = 77) 39.7% (n = 100) 100% (n = 157) 15.49 F 11.14 24.22 F 3.65
54.9% (n = 139) 45.1% (n = 114) 60.3% (n = 152) 12.12 F 8.47 28.80 F 4.59
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
53
Table 2 Comparison of psychosocial stress (QSD-R global score) of type 1 and type 2 diabetics Average stress
Age Sex: Male Female Duration of the illness Rel. HbA1(c) BMI QSD-R total score
Extreme stress
Type 1 (n = 131)
Type 2 (n = 211)
Type 1 (n = 26)
Type 2 (n = 42)
41.59 F 14.73
60.82 F 10.86
45.12 F 15.11
59.57 F 7.81
66 (50.4%) 65 (49.6%) 15.5 F 10.9 1.6 F 0.4 24.3 F 3.5 0.9 F 0.4
115 (54.5%) 96 (45.5%) 11.7 F 8.2 1.7 F 0.4 28.8 F 4.6 0.9 F 0.5
14 (53.8%) 12 (46.2%) 15.3 F 12.5 1.8 F 0.5 23.9 F 4.3 2.3 F 0.4
24 (57.1%) 18 (42.9%) 14.1 F 9.6 1.7 F 0.4 28.6 F 4.6 2.4 F 0.4
the less handicapped sample. Self-constructed items were used to assess the use of psychosocial support during the course of the illness. A standardisation procedure was applied to adjust for variations among local HbA1/ HbA1c assays. According to the recommendation of the German Diabetic Society, we calculated ‘‘relative HbA1 levels’’ within each assay by dividing every absolute HbA1 or HbA1c level by the average of the reference range [7].
3. Results Of the 410 participants, 187 (45.6%) suffered from diabetic lesions: retinopathy (n = 105, 25.6%), nephropathy (n = 49, 12.0%), neuropathy (n = 99, 24.1%), hypertension (n = 104, 25.4%), diabetic food ulcers (n = 100, 24.4%) and CHD (n = 66, 16.1%). The mean global score of the QSD-R of the total sample (n = 410) was 1.16 ( F 0.693). There was no significant difference between the two types of diabetes (1.17 F 0.658 vs. 1.15 F 0.712, p = 0.835) (Table 2). There was a tendency for insulin-dependent type 2 diabetics to be more handicapped than non-insulin-dependent type 2 diabetics (noninsulin-dependent: 0.99 F 0.639, insulin-dependent: 1.25 F 0.749; p = 0.06) (Table 3). No Table 3 Comparison of psychosocial stress (QSD-R global score) with and without insulin treatment Average stress
Age Sex: Male Female Duration of the diabetes Rel. HbA1(c) BMI QSD-R total score
Extreme stress
Insulindependent (n = 119)
Non-insulindependent (n = 91)
Insulindependent (n = 33)
Non-insulindependent (n = 9)
61.68 F 11.04
59.71 F 10.64
60.85 F 7.58
55.33 F 7.47
59 (49.6%) 60 (50.4%) 14.11 F 8.45 1.68 F 0.39 27.83 F 4.69 0.93 F 0.45
56 (61.5%) 35 (38.5%) 8.48 F 6.60 1.62 F 0.39 30.15 F 4.16 0.85 F 0.45
19 (57.6%) 14 (42.4%) 6.35 F 9.14 1.67 F 0.40 28.75 F 5.11 2.40 F 0.41
5 (55.6%) 4 (44.4%) 6.44 F 7.20 1.81 F 0.39 28.12 F 1.44 2.47 F 0.27
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S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
Fig. 1. Profiles of stress (QSD-R) of type 1 diabetics.
difference could be found between participants with and without the inpatient diabetic training program within the type 1 diabetic sample (1.16 F 0.64 vs. 1.17 F 0.90, p = 0.68). However, type 2 diabetics participating in the training program turned out to be more handicapped compared to non-participating type 2 diabetics (0.92 F 0.70 vs. 1.20 F 0.1,
Fig. 2. Target groups of psychosocial support of patients with type 1 diabetes ( > 5%).
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
55
p = 0.1). Extreme psychosocial stress could be found in 68 diabetics (16.6%). Not the type of diabetes but the use of insulin within the type 2 diabetic sample revealed an impact on psychosocial stress. Both in the total sample and in the type 1 diabetic subsample, diabetics with extreme psychosocial stress showed worse diabetic control compared to less stressed diabetic patients. Diabetic lesions were significantly more frequent in patients with extreme psychosocial stress both in the total as well as in the two subsamples of type 1 and type 2 diabetic patients. Profiles of psychosocial stress evidenced a quantitative instead of a qualitative difference between extremely and less handicapped type 1 and type 2 diabetics (Fig. 1). Maximal stress could be observed with regard to depression in both types of diabetes (only type 1 diabetes is shown in the figure); this was followed by fear of hypoglycemia in the type 1 diabetic subsample and physical complaints in the type 2 diabetic subsample. Fig. 2 illustrates the actual reliance compared to the desired reliance on psychosocial support. Family members, primary care physicians, and diabetologists were the main sources of psychosocial support of stressed and non-stressed diabetics (only type 1 diabetes is shown in the figure). Independent of the type of diabetes and the extent of psychosocial stress, the use of psychosocial support differed more quantitatively than qualitatively (Fig. 3). Compared to less handicapped diabetic patients, extremely stressed diabetics desired more psychosocial support from nearly every target group. Whereas psychologists/psychotherapists had not or hardly been consulted in the past, more than 25% of the extremely stressed diabetics had the request for psychotherapeutic support. Half of the type 1 and one third of the type 2 diabetics (only type 1 diabetes is shown in the figure) requested support in self-help
Fig. 3. Events that made support desirable.
56
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
Table 4 Comparison of metabolic control of type 1 and type 2 diabetics with extreme and average stress Rel. HbA1(c) Total sample
extreme stress (n = 68) average stress (n = 342) pa extreme stress (n = 26) average stress (n = 131) pa extreme stress (n = 42) average stress (n = 211) pa
Type 1 diabetics
Type 2 diabetics
a
1.7 F 0.5 1.6 F 0.4 0.045a 1.8 F 0.5 1.6 F 0.4 0.024a 1.7 F 0.4 1.7 F 0.4 0.546
Mann – Whitney – U-Test.
groups. Psychosocial support was favoured within the medical institutions especially at the time of diagnosing the disease and later on for the diabetic lesions.
4. Discussion Type 2 diabetics participating in the diabetic training programs were significantly more handicapped than diabetic patients consulting the medical practices. The recruitment of type 2 diabetic patients may not be representative because of the fact that the majority of them receive treatment from general practitioners. Furthermore, there may be a considerable number of problem cases among those patients referred to a diabetes center by their general practitioner. Whereas no relationship between the type of diabetes and psychosocial stress could be observed, therapy strategies within the type 2 diabetes subsample were associated with psychosocial stress. Within this subsample, insulin application was significantly more associated with psychosocial stress than diet or oral medication. Prevalence of diabetic lesions in insulin-dependent type 2 diabetics is considerably higher compared to non-insulin-dependent patients. Besides the incriminating treatment strategy of regular injections, which is often accompanied by fear of hypoglycemia, the threatening
Table 5 Comparison of diabetic lesions of extremely stressed and less stressed diabetics
Total sample
Type 1
Type 2
a
chi2-Test.
Diabetic lesions
Extreme stress
Average stress
pa
yes no unknown yes no unknown yes no unknown
47 17 4 14 10 2 35 6 1
141 160 17 44 85 2 109 83 19
0.01**
(70.8%) (23.5%) (4.4%) (53.8%) (38.5%) (7.7%) (82.1%) (15.4%) (2.6%)
(44.3%) (50.3%) (5.3%) (33.3%) (65.1%) (1.6%) (52.1%) (39.9%) (8.9%)
0.05 *
0.01**
S. Herpertz et al. / International Congress Series 1241 (2002) 51–58
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awareness or anxious anticipation of the threatened physical integrity of these patients has to be taken into consideration. Nearly 17% of the type 1 and type 2 diabetics were extremely handicapped according to the defined criteria mentioned above. This is in line with the point prevalence of psychiatric comorbidity of epidemiologic studies [4,8,9]. Irrespective of the type of diabetes, extremely stressed diabetics showed a significant worse metabolic control (Table 4) and more frequent diabetic lesions (Table 5) compared to less stressed diabetics, and regardless of the type of diabetes, depression was the prominent problem with regard to the stress profiles, followed by stressful treatment regimen and diet. Fear of hypoglycemia was more prominent in type 1 diabetics, whereas physical complaints were characteristic of type 2 diabetics. Regardless of the extent of psychosocial stress and type of diabetes, the majority of type 1 and type 2 diabetic patients sought support in familial social relationships, the family doctor, and the diabetologist. Self-help groups were favoured by type 1 diabetics. Although psychotherapy had hardly ever been requested by type 2 diabetics and never been requested by type 1 diabetics in the past, more than 25% of the extremely stressed patients desired psychotherapeutic support for the future. Psychosocial support was favoured within the medical institutions especially at the time of diagnosing the disease and later on for the diabetic lesions. These results underline the need for strengthening patients’ individual support systems, for example, by establishing coping groups for diabetic patients and their families. [10,11,12]. There also seems to be a need for psychosocial aspects to be integrated into diabetic training programs.
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[10] I. Fawzy, N. Fawzy, A structured psychoeducational intervention for cancer patients, Gen. Hosp. Psychiatry 16 (1994) 149 – 192. [11] A. Zettler, G. Duran, S. Waadt, F. Strian, P. Herschbach, Psychologische Ansa¨tze fu¨r Diabetiker mit Folgeerkrankungen, in: F. Petermann (Ed.), Diabetes Mellitus, Hogrefe, Go¨ttingen, 1995. [12] A. Zettler, G. Duran, S. Waadt, P. Herschbach, F. Strian, Coping with fear of long-term complications in diabetes mellitus: a model clinical program, Psychother. Psychosom. 64 (1995) 178 – 184.