Why We Shouldn't Overlook Psychosocial Issues In Patients With Diabetes
Diabetes mellitus is said to be a disorder of glucose metabolism, but it can be so much more for those individuals who have the disease and the families with whom they share their lives. The sequelae of diabetes involve vascular changes in the large and small vessels, and produce disorders of the retina, the kidneys and the coronary arteries, not to mention the peripheral vascular tree. While serum glucose management is critical, it is only one part of the total picture in managing patients with diabetes. In order to adequately protect the patient from the ravages of diabetes, a well-integrated team of specialists is essential. In addition to the internist or endocrinologist, a vascular surgeon, podiatrist, reconstructive foot and ankle surgeon and an infectious disease specialist are required to adequately manage the inpatient issues that may arise when a patient with diabetes is admitted to the hospital. However, even in centers where such integrated team approaches are practiced, there are still certain deficiencies in patient management. I am specifically referring to the lack of understanding and lack of sensitivity toward the psychosocial issues that can influence a patient’s response to intervention. Inherent to these problems are also the effects that chronic disease manifests on the patient’s family and on the interpersonal relationships within that family. As physicians treating patients with a particular disorder, particularly one with as broad a range of complications as diabetes produces, it is essential to be cognizant of the behavioral component of managing these patients.1,2 As with any disease, the initial response from a patient after diagnosis may be denial, mood swings, anger and disbelief. Clinical depression is not uncommon. Physicians and particularly surgeons tend to lose sight of our patients’ psychosocial needs as they pertain to chronic diseases and the impact these diseases have on their interpersonal relationships. Patients with diabetes, particularly those patients who are compliant and try to take care of themselves, engage in a daily battle of balancing tight glycemic levels and a satisfying quality of life. This internal battle can, at times, be devastating. Physicians might be surprised that their patients’ denial and resistance to treatment may be due to their withdrawl from reality and an inability to make emotional adjustments in order to cope with their disease. The fear of potential limb loss, the risk of blindness and the possibility of lower extremity amputation may precipitate a major depression, dysfunctional family relationships and, ultimately, the avoidance of healthcare altogether. Patient education, the prevention of complications and adequate glycemic control are classically regarded as the three pillars in the management of diabetic patients. However, treating physicians should not overlook the management of the fears and anxieties that often accompany chronic diseases. Recognizing And Addressing Patient Fears And Anxieties Following admission to the hospital, patients with diabetes are often transferred to a skilled nursing facility where they might remain for weeks or sometimes months. Remaining at these institutions is never a substitute for their home environment yet rarely are the patients’ psychosocial issues ever considered by the physicians who continue to treat them. The lack of sensitivity on the part of the treating physicians as well as the intrinsic feelings of emotional abandonment on the part of the patient may contribute to a deepening depression, frustration, anger and, finally, withdraw from medical treatment.3 An amputation may be as devastating to the patient with diabetes as it is for his or her family.4 As surgeons who deal with these issues on a daily and objective basis, we can see the benefits of a judicious ablation, knowing that it will permit the patient to resume his or her life in the community. For many patients facing the possibility of an amputation at any level, their perception is far more subjective. One needs to reassure these individuals that the physical loss of part of their extremity is necessary and explain the potential benefits from such an intervention. Surgeons should consider having the patient evaluated and counseled by behavioral health professionals before their amputation. Out of all the team members, it is often psychiatrists and social workers who are underutilized. Preventing complications associated with diabetes is always preferable to treatment. Newly diagnosed diabetics should not only be educated about dietary adjustments, self-monitoring of blood glucose and exercise, but also should be specifically counseled by their primary care physicians on the potential for depression. Physicians should address depression shortly after the diagnosis of diabetes and they should recommend emotional support for the patient and their families far more often than they do. Diabetic foot infection is one of the major reasons for hospital admissions. To the health care provider, it is likely to represent just another admission, one that may result in a trip to the operating room and possible amputation. As surgeons involved with busy inpatient services, it is easy for us to forget the patient’s stress and anxiety associated with such an admission. It is less the potential loss of a leg but rather the way in which it is revealed to the patient that will ultimately determine the patient’s acceptance of events. Even though it is sometimes out of our reach to help save a foot or limb, providing a source of emotional support for patients with diabetes is essential at the beginning of their treatment. Healthcare providers are often astonished by the fact that their diabetic patients refuse to consent to an amputation until the foot is grossly infected and has become frankly septic. Their resistance is often falsely supported by the absence of pain as well as their concerns about living alone as an amputee, their ability to continue to provide for themselves and their families, and other concerns they might not be able to articulate. Final Notes Clearly, the multidisciplinary team approach is the best way of handling the needs of patients with diabetes. Early interventions, such as yearly eye and foot examinations, maintainance of tight glycemic control, urinalysis and screening for microalbuminemia, testing for hyperlipidemia and hypertension, exercise, smoking cessation, application of a healthy diet and weight loss are all essential elements for reducing the complications of diabetes. However, we also should not overlook the importance of an early assessment of the patients’ understanding of their disorder and their ability to cope with the disorder. Dr. Zgonis is an Adjunct Assistant Professor of Surgery at the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa. He is the Associate Director of the PGY-5 Fellowship in Reconstructive Foot And Ankle Surgery at New Britain General Hospital in New Britain, Ct. Dr. Zgonis is an Associate of the American College of Foot and Ankle Surgeons. Dr. Jolly is the President of the American College of Foot and Ankle Surgeons. He is the Chief of Podiatric Surgery and is the Director of the PGY-5 Fellowship in Reconstructive Foot and Ankle Surgery at New Britain General Hospital in New Britain, Ct. Dr. Jolly is a Clinical Professor of Surgery at the College of Podiatric Medicine and Surgery at Des Moines University in Des Moines, Iowa. Dr. Steinberg (pictured) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.
References 1. Rubin RR, Peyrot M. Psychological issues and treatments for people with diabetes. J Clin Psychol. 2001;57(4):457-78 2. Polonsky WH. Emotional and quality-of-life aspects of diabetes management. Curr Diab Rep. 2002;2(2):153-9. 3. Harris MD. Psychosocial aspects of diabetes with an emphasis on depression. Curr Diab Rep. 2003;3(1):49-55. 4. Cox S. How I coped emotionally with diabetes in my family. Prof Care Mother Child. 1994;4(5):139-41.