Cath Lab Digest

Poorly managed diabetes can have devastating consequences and there are challenges in getting patients to do their part in following treatment regimens. With these things in mind, this author offers key insights into the psychology of non-adherent behavior and how to get patients back on the right path.

   It is estimated that over 23 million people in the United States are living with diabetes.¹ In recent decades, our knowledge about the importance of early and aggressive treatment of diabetes, and the availability of effective treatments has increased dramatically. Yet the number of people who are managing their diabetes well remains a very small minority and the outcomes of poorly managed diabetes continue to be devastating.

   Those of us who work with people with diabetes have likely had patients who are engaging in behaviors that are endangering their life and limbs. Efforts to help these patients change their behavior can often be frustrating, disappointing and unrewarding. As a result of these discouraging experiences, healthcare professionals may develop beliefs about these high-risk patients and have responses to them that actually contribute to the problem.

   It is commonly believed that non-adherent patients are unmotivated, lack adequate willpower, are not scared enough and are perhaps incapable of making necessary change. These assumptions about these patients, though understandable, are incorrect. As a result, we may try to motivate them by using tactics that simply do not work for most people. These tactics may include urging more willpower, offering unwanted advice and threatening them with the scary outcomes of continued non-adherence.

   Unfortunately, these tactics can cause these high-risk patients to become even more frustrated and disengaged, immobilized with fear, and hopeless about their ability ever to manage diabetes well.

   People do not follow through with recommended changes when their perceptions of the obstacles outweigh the understood benefits. In order to employ more effective strategies to facilitate adherence, it may be necessary first to consider a new framework for understanding non-adherent behaviors. Denial, willpower and ability are not the factors that explain why a patient is not following through with self-care recommendations.

   The person’s non-adherent behavior will often make sense when you understand the barriers behind it. To do this, it is important to look at how the individual patient views his or her own situation. One can evaluate the benefit versus the cost by answering two important questions. Does the patient think the self-care recommendation is worthwhile? Does the patient view it as achievable?

Does The Patient View Self-Care Recommendations As Worthwhile?

   With every new behavior, patients must decide for themselves, “Is this worth it?” There are three major factors that can negatively affect whether the patient sees a particular recommendation as worthwhile. These factors include: the presence of depression; the belief that there are no real benefits; and the perception that the costs are too high (i.e. unpleasant side effects, too expensive, embarrassment).

   Depression can make a person feel like nothing is worthwhile, including self-care. The prevalence of a significant problem with depression is about twice as likely in people with diabetes (like other chronic illnesses) and has a powerfully negative effect on self-care. It can disable the energy, concentration and interest required to follow through with the many important self-care behaviors necessary to manage diabetes well. Therefore, these patients perceive an increased “cost” of the recommendation, which reduces their confidence in achievement.