Psychological effects of blood glucose self-monitoring in diabetic patients

ANDRE DUPUIS, M.D. RO~ERT

L. JONES, M.D.

CHARLES M. PETERSON, M.D.

Psychological effects of blood glucose self-monitoring in diabetic patients ABSTRACT: Psychiatric assessments were done on ten insulin-

dependent diabetic patients who were participating in an eightmonth program aimed at achieving strict carbohydrate control of their disease through self-monitoring of blood glucose levels. Both mean depression scores on the Hamilton Rating Scale and mean hemoglobin Ale levels had decreased twofold after eight months (P<.OO5). Depression did not prevent patients from achieving better carbohydrate control, and no adverse psychological effects were noted. The authors conclude that self-monitoring of blood glucose leads to both better control of diabetes and improved emotional status. While there is general agreement in the literature that many diabetic patients suffer from symptoms of depression and anxiety, I the role of psychological factors as a whole remains controversiaF3 Questions remain regarding the cause of psychological problems in these patients, the incidence of such problems, and their possible contribution to the course of the disease. Some investigators have found no

increase in psychopathology among patients with juvenile diabetes when they were compared with nondiabetic siblings4 and with ma tched con troIs. 1.5 The present study was undertaken to determine whether selfmonitoring of blood glucose would have adverse psychological effects on diabetic patients. Of the criteria used for assessment, it was felt that the psychiatrist's overall clinical

Dr. DupUiS is clinical professor ofpsychiatry at Cornell University Medical College. Dr. Peterson is associate professor and Dr. Jones is assistant professor at The Rockefeller University. Reprint requests to Dr. Dupuis, Department of Psychiatry, The New York Hospital-Cornell Medical Center, 525 East 68th Street, New York. NY jOO21. JULY 1980' VOL 21 • NO 7

evaluation, as rated on a scale for depression such as the Hamilton Rating Scale, would be appropriate for noting any changes that might occur. Symptoms of depression were studied because in the psyc~i­ atric literature, dysphoria, anxiety, inadequate self-perception, hypochondriasis, helplessness, and increased dependence on others have been the emotional manifestations most frequently associated with diabetes mellitus.1.6.11 Background of the study

Self-monitoring of blood glucose is a relatively new technique whose purpose is to allow optimum compliance and carbohydrate control. 12 Certain medical sequelae of diabetes mellitus not only are related to carbohydrate control but also are reversible with strict carbohydrate control. 13•14 The American Diabetes Association has recommended optimal control of blood glucose levels "as close to those in the nondiabetic state as feasible"'s (a position that has been challenged by some I6. IK ). In order to determine whether a 581

Diabetes

program of self-monitoring of blood glucose determinations would optimize compliance and carbohydrate control, we performed a pilot study on young adult and adolescent patidhs with Type I insulin-dependent diabetes mellitus. '9 All had previous, documented histories of ketotic episodes. The medical details of this study have been published elsewhere. 12 Because of an ongoing concern that such a rigorous program might be psychologically harmful to patients with diabetes,20 a psychiatrist assessed and observed the patients throughout the eight months of the study. In particular, the psychological effects of blood glucose self-monitoring in these patients were observed.

Patients Patients were accepted to the study as they arrived in The Rockefeller University Hospital Clinic having been referred by their physicians because of problems in management. Patients ranged in age from

15 to 36, with a mean age of 25 (Table I). They tended to fall in the lower middle-class, and included two unemployed persons. The mean duration of diabetes for this group was ten years and the diabetes would be classified as severe, since there was a mean daily insulin requirement for the group of 0.6 units/kg. '2 Four patients had proliferative retinal disease (two had had photocoagulation) and eight patients were found to have peripheral neuropathy as evidenced by physical examination and/or nerve conduction studies. Of the four patients who at one time had received psychiatric help for emotional problems related to diabetes, two were receiving individual psychotherapy at the time of the study. None were receiving psychotropic medication. The acute onset of diabetes occurred during a period of documented stress in three patients. Following a minimum of two visits to the clinic during which the study was explained, a complete

history taken, and a physical examination performed, ten patients accepted the opportunity to participate. The studies were approved by the Institutional Review Board of The Rockefeller University Hospital. Written consent was obtained from all patients. As a first step, the ten patients were taught to measure their own blood glucose using the Ames Eyetone system. They were encouraged to perform a blood glucose test before and one hour after each meal. These "glucose brackets" have been found to correlate with 24hour glucose monitoring and have also been a useful adjunct to insulin adjustment. 21

Hemoglobin Ale studies Hemoglobin AIC (Hb Alc) levels were measured at the beginning and end of the study,22 since this value as a percentage of total hemoglobin has been shown to correlate with the mean blood glucose . level over the previous three to six weeks. 13 ·23 Normal values comprise

Table 1-Patlent Characteristics

Patient

,

Sex

Age (years)

Years of diabetes

Employed

Stress at onset of diabetes

0

Yes

No

No

No

18

No

17 17

Yes Yes

Yes Yes Yes

Yes Yes

2

F

3

F

4

F

22 34 32 36

5 6

F

19

1

F

19

7

F

4 7

8

F

20

9 10

M

20 25 27

Yes Yes Yes Yes Yes Yes

1

No

M

15

1

Yes

M

No No No

Past Individual psychiatric psychotherapy Interventions during study

No No

Yes

Yes

No No No

No No No

No No No No No No No

PSYCHOSOMATICS

3% to 6% of the total hemoglobin, and higher values are observed with elevated mean glucose levels. The Hb Alc determination thus served as a means of documenting compliance with the study. since the value would be expected to decrease over the eight-month period of observation. Psychiatric assessment At the beginning of the study. one psychiatrist saw each patient for one hour in a semi-structured interview. The interviewer and patients were "blinded" to the patient's Hb AIC values. The psychiatrist elicited information on developmental and family history, adjustment to school and work, peer relationships, information concerning the onset of diabetes, the history of the illness, and the attitude of the patient and his family toward the disease. In addition. the psychiatrist rated the patients on an expanded version of the Hamilton Rating Scale for Depression, a 19-item scale for rating a variety of symptoms associated with depression syndromes; a score above 10 indicates mild to moderate depression, while a score greater than 20 means the patient has significant depression.24 Eight months later, the same psychiatrist conducted an identical interview. This time he also obtained information concerning possible difficulties the patients encountered in monitoring their blood glucose levels. such as obtaining a blood sample or calibrating the reflectance meter. Hamilton Scales were scored and evaluated at the end of the study. Medical results As reported elsewhere, self-monitoring of blood glucose levels did JULY \980· VOL 2\ • NO 7

lead to improved control of diabetes mellitus in these patients.'2 At the beginning of the study, Hb AIC levels were abnormally high in all patients, ranging from 6.5% to 15.0%, with a mean value of 10.3% (see Table 2). After eight months, all patients had decreased Hb AIC levels (mean, 5.4%), and eight out of ten subjects had normal Hb Alc levels (3% to 6%). These beneficial somatic effects were reflected in an improvement in the mental status of these patients. Psychiatric results The main feature that had been noted during the initial psychiatric interview was a persistent dysphoric mood characterized by feelings of sadness and despair. Two patients had suicidal thoughts, and

one had made a suicidal gesture taking an overdose of insulin. Feelings of guilt and self-reproach were frequent. All patients reported a preoccupation with their bodies and their health. Nevertheless, only a few acknowledged having emotional problems. Instead, they attributed their problems to external factors, most commonly to the fact that they had been treated by ineffectual and incompetent physicians. They consistently felt helpless, hopeless, and worthless. A loss of self-esteem permeated their lives. Few felt that they could control their diabetes. Although each patient showed symptoms of depression, none was overtly psychotic. At the beginning of the study, all but one patient had elevated de-

Table 2-Hamllton Depression Scores and Hemoglobin A1C Levels At onset of study Patient

Depression scores-

After 8 months Hb A,ct

Depression scores

(%)

1 2 3 4 5 6 7 8 9 10 Mean

36 35 30 24 19 16 16 14 10 7 207t

Hb Alct (%)

11.9 15.0 110 81 11.3 9.8 106

22 21 16 18 4 6

4.3 9.4 3.5 44 6.9 57

4

52

9.9

7 2 2 102t

4.8 4.2 60 5.4

6.5 8.6 10.3

Total score obta'ned b add,n Ind'Vldua scores 01 each 01 the 1 Ilems Total score lOIS nons,gnllocant tH moglobln AlC (Hb AlC) levels represenl p rcem ollotal hemoglobin ormal values 3~·6~ tOepr 5S'on seor at he 518 and after e gh months dlff r statistically P < 005 by paired I-lest, one ailed

Diabetes

pression scores, as measured by the Hamilton Rating Scale. The mean score was 20.7, indicating the presence of significant depression. Furthermore, when the specific items of the Hamilton Rating Scale were individually rated, it was found that anxiety (psychic and somatic), hypochondriasis, feelings of helplessness and worthlessness, and difficulty functioning at work and in other activities were the predominant symptoms (Table 3). At the end of the eight months of b rvuti n. th p lienL w r b and large pr ud r their abilit t

project them externally. There was a diminished sense of helplessness with a concomitant gain in self-esteem. Four patients admitted feelings of worthlessness, but only on questioning. No patients reported difficulty in obtaining blood samples but some resented having to use the reflectance meter in the presence of employers or peers. They feared that the disclosure of their illness might have negative repercussions. However, all patients found that blood ere glu Ir-det rmin ti n helprul in the management r their

achieve better control of their diabetes. They spontaneously verbalized their feeling of well-being and were enthusiastic about having taken control of their illness. Feelings of depression were reported by three patients, but only on questioning. Self-reproach was absent. They reported being less anxious and not particularly preoccupied with their health and their bodies. The two patients who were unemployed had gained employment. The patients were more inclined to allribute their emotional problem t internal au erath r than t

-

~

Table 3-Depression Scores (Hamilton Rating Scale)

II II Symptoms

Mean score

Score change

Initial After 8 months

Mean ± SE

Number 01 pellenle wllh 8core... Decreased

Increased

Unchanged

1 0 0 0 0

3 6 8

(Score range, 0-4)

10 0.6 0.6 17 00 2.1 15 2.3 1.0 1.0 2.1 1.6 1.6

Depressed mood Feelings of gUilt SUicide Work & activities Retardation AnXiety, psychiC Anxiety. somatic HypochondriasIs Depersonalization Paranoia Helplessness Hopelessness Worthlessness

0.5 0.2 0.0 0.3 00 1.2 0.8 1.4 0.9 0.7 1.1 1.0 0.4

l

I

0,5 ± .22 0.4 :r .16 0,6 ± .43 "1.4±.22 0.0 ± .00 ·0.9 .28 ·0.7 ± .21 ·0.9 ± ,10 ·0.1 ± .10 0.3 .15 ·1,0 ± ,00 ·0,6 ± .16 "1.2 ± ,13

6 4

2 10 0 6 6 9 1 3 10 6 10

a 0 0 0 0 0

a 0

a 10 4 4

I'

1 9

7 0 4 0

I

i

(Score range, 0-2)

0.4 0.0 0.2 0.1 05 0.6

"0.4 0,2 0,6 0,0 0.4 0.2

Obsessive

0.8 0.2 0.8 0.1 09 0.8

• Score change Slgnl iCan 81 P

01 bV paJrOO compaflson Hes ,one 18i1ed

Insomnia Agitation Somatic, general Genital InSight

J LY I

O·

OL 21 .

7

± ± ± ±

,16 .13 ,22 .00 ±37 ± .20

4

2 5

a 4

3

0 0 0 0 1 1

6 8

5 10 5 6

589

Diabetes

illness, especially in the planning of meals and the regulation of insulin dosage. At the end of the study, all ten patients showed a striking decrease in Hamilton depression scores (Table 2). The mean score, 10.2, represents a decrease of 10.5 points from the mean of20.7 at the beginning of the study. Analysis of the symptoms on the scale showed improvement on eight of 19 items. As shown in Table 3, these included work and activities, anxiety (psychic and somatic), helplessness, hopelessness, and worthlessness. All patients showed improved scores in work and activities, helplessness, and worthlessness. Hypochondriasis remained the most severe symptom, but with a mean score of 1.4 as compared with a mean of 2.3 at the beginning of the study. After eight months, the mean values of measurements from both the Hamilton Rating Scale scores and the Hb AIC levels were significantly decreased by one half below those values at the beginning of the study (Table 2). There was a significant relationship between the depression scores and the Hb AIC levels at the beginning of the study (P<.O I). In addition, the patients with the highest depression scores at the beginning of the study (patients I, 2, 3, and 4) achieved carbohydrate control to the same degree as the other patients. Discussion At the beginning of this study, we found poor carbohydrate control concomitant with relatively severe symptoms of depression. Patients with the most poorly controlled diabetes showed evidence of the most severe symptoms of depression. Unexpectedly, the initial seS90

verity of the symptoms of depression did not prevent these patients from successfully participating in a rigorous program of diabetic control. Furthermore, it was found that such a program not only helped the patients achieve better carbohydrate control but also was accompanied by a significant reduction in symptoms of depression. These results concur with the findings of recent studies showing self-monitoring of blood glucose levels to lead to improved carbohydrate control. 25.29 Chronically ill patients often feel helpless and hopeless. As observed in the depressive state, it may be

The initial severity of depression did not prevent patients from successfully participating in a rigorous program ofdiabetic controL the sense that one's actions cannot modify one's circumstances that fosters a state of impotence or passivity.s.3o.J' For insulin-dependent diabetic patients, regulation of insulin dosage is generally made according to glycosuria, which reflects fluctuations of blood glucose levels poorly and belatedly. In spite of conscientious efforts to follow a medical regimen, the patient finds it almost impossible to obtain the results intended. Frequent episodes of hypoglycemia and, later, the appearance of secondary sequelae result in increased anxiety, hypochondriasis, and helplessness. Self-monitoring of blood glucose determinations may result in relief of symptoms of depression because self-administration not only gives patients a more active role in the management of diabetes but also

allows them to control the fluctuations of their blood glucose levels. And they learn how food and exercise influence these levels. Selfmonitoring of blood glucose gives patients the opportunity to assess their own diabetic state at any given moment and makes it difficult for them to use denial mechanisms. As they learn to control their illness, patients develop feelings of competence, self-confidence, and dependability. According to Seligman,31 "The central goal of therapy for depression is the patient's regaining his belief that he can control events important to him." Other factors may have contributed to the improvement in the symptoms of depression in these insulin-dependent diabetic patients and in their positive emotional response to the program. The participation in a research program and the support obtained from training sessions are known to have beneficial influences on patients' moods. These factors could have accounted for the changes we noted. A relationship between hyperglycemia and affective disorders, especially depression, may exist. 32 The possibility that the degree of illness (hyperglycemia) influenced the degree of depression cannot be discounted. Endogenous depression has recently been associated with lowered glucose utilization rates and with insulin resistance.B Thus, it is tempting to speculate that hyperglycemia per se might playa role in affective disorders. In addition, good control of diabetes has been correlated with later onset and shorter duration of illness,S with fewer interpersonal conflicts,34.35 with diminished fear of hypoglycemia,36 and with acceptance of the disease.6.7 Future studies may provide new insight into PSYCHOSOMATICS

the relationship between depression and hyperglycemia as well as the mechanism of depression in chronic illness. 0 The authors wish to thank Patricia Noel, M.A. and Owen Lewis, M.D. for their help at the beginning ofthe study and James Kocsis, M.D. for his advice. This study was supported in part by the New York State Health Research Council.

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