Psychosocial care in diabetes
Psychosocial interventions
Diabetes and behavioral learning principles: Often neglected yet well-known and empirically validated means of optimizing diabetes care behavior
This review article discusses the basic behavioral principles and common barriers to implementation, relevant interventions and presents several examples of applications in clinical settings.
Summary points
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- The authors propose that behavioural learning principles are the key to the vast majority of empirically supported interventions that have demonstrated effectiveness in improving adherence and other aspects of diabetes care.
- Operant conditioning focuses on the ability of reinforcement and punishment to shape human behavior.
- Positive reinforcement increases the likelihood of a behavior occurring by adding something to the environment that the individual finds rewarding.
- Negative reinforcement increases the likelihood of a behavior by removing an adverse stimulus from the environment.
- Punishment decreases the frequency of a behavior by either adding something undesirable to the environment or removing something rewarding.
- Often, a discrepancy exists between patients’ knowledge of desired healthcare and consistently engaging in the behavior necessary to accomplish the healthcare tasks; clinical efforts are often directed at increasing knowledge and ignore the behavioral aspect.
- Examples of behavioral interventions include reinforcement, self-monitoring, contracting and environmental change; existing literature suggests that approaches founded in behavioral learning principles are associated with positive patient and family outcomes.
- Diabetes burnout occurs “when an individual with diabetes has the information (education) necessary to manage diabetes well, yet his or her psychological and emotional state(s) have become barriers to adequately engaging in the behavior necessary to effectively manage diabetes.”
- Positive patient/provider interactions and satisfaction with medical care are critical for effective diabetes management.
- Shaping of the clinical culture in such a way that it values quality engagement in the provision of healthcare may can help to reduce the likelihood of physician burnout.
- The authors offer the following recommendations:
- View regular patient interactions as opportunities for the purposeful application of learning principles, specifically positive reinforcement;
- Emphasize health behaviors, not outcomes;
- Take the punishment out of diabetes care;
- Educate the patient and family about behavioral principles;
- Encourage the continued integration of behavioral health interventions into standard diabetes care delivery.
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Stoeckel M, Duke D. Curr Diab Rep 2015; 15: 39. doi: 10.1007/s11892-015-0615-4
Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions
This study evaluated the Brief Behavioural Activation intervention in patients with chronic conditions and recurrent depression.
Summary points
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- Practice nurses in primary care facilities are in a position to contribute to the management of patients with chronic conditions and recurrent depression.
- A service development project with a nested qualitative study was conducted to:
- Train practice nurses to deliver a brief behavioral activation intervention to patients with depression and one or more long-term health conditions;
- Evaluate the patients and clinicians perspectives and experiences of receiving and delivering the intervention.
- Healthcare professionals (n=10; nurses, general practitioners and a mental health gateway worker) and patients (n=4) were recruited from eight practices in one Primary Care Trust in England.
- Semi-structured qualitative interviews were conducted and four Normalisation Process Theory concepts of coherence, cognitive participation, collective action and reflexive monitoring were used to explore how this intervention could be implemented in practice.
- Both general practitioners and practice nurses found the intervention acceptable in terms of its simplicity and its workability in the long-term management of patients with chronic conditions and recurrent depression.
- Patients believed that the fact that practice nurses were available to listen was valuable.
- The greatest barriers to the implementation of the Brief Behavioural Activation intervention in routine primary care were:
- Competing practice priorities;
- Perceived lack of time and resources;
- Lack of engagement by the whole practice team.
- Lack of understanding of, participation in and support from the whole practice team in the collaborative care model exacerbated the pressures perceived by practice nurses.
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Webster LAD et al. BMC Nurs 2016; 15: 71. doi: 10.1186/s12912-016-0190-2
The psychosocial challenges and care of older adults with diabetes: “Can’t do what I used to do; can’t be who I once was”
This review discusses the current literature on diabetes in older adults, with a focus on psychological and medical challenges and interventions needed to address them.
Summary points
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- Older adults with diabetes have higher rates of diabetes-related complications and are more likely to present with comorbid conditions, which are associated with worsening glycemic control and may interfere with the performance of self-care behaviors.
- Older adults with diabetes experience disproportionately high rates of depression (14–28%) and depressive symptoms.
- Diabetes distress affects 18–35% of older adults and is associated with worsening glycemic control, reduced self-care and increased morbidity; however, only a few validated treatments are available.
- Many people with diabetes and depression also have comorbid anxiety disorders; anxiety disorders and elevated anxiety symptoms have been shown to be associated with increased diabetes complications, worsened blood glucose levels, reduced quality of life, increased depression, increased body mass index and greater disability.
- In older adults with diabetes, quality of life is negatively affected by comorbidity and hypoglycemia; more research into this area is required.
- Older people experience major life challenges whose impact may be exacerbated by diabetes; interventions that include family members and friends can be effective in addressing these challenges.
- The majority of adults over 65 who have diabetes have at least one comorbid condition; the presence of comorbid conditions often presents challenges in the management of diabetes.
- Type 1 and type 2 diabetes and increased age are independent risk factors for cognitive impairment. Older adults with severe hypoglycemia are at greater risk for cognitive impairment; regular screening is recommended.
- Older adults are more vulnerable to hypoglycemia due to diminished counter-regulatory responses and changes in pharmacokinetics and pharmacodynamics; early recognition and treatment of hypoglycemic symptoms, as well as education of patients and family members can help reduce the impact of hypoglycemia in this population.
- Polypharmacy is particularly dangerous in older adults with diabetes due to age-related physiological changes than have an effect on pharmacokinetic and pharamcodynamic parameters.
- Providers should recognize the interdependency of medical, social and mental health issues in the treatment of older patients with diabetes.
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Beverly EA et al. Curr Diab Rep 2016; 16: 48. doi:10.1007/s11892-016-0741-7