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Healthy Coping, Negative Emotions, and Diabetes Management

A Systematic Review and Appraisal

From the Department of Health Behavior and Health Education, School of Public Health, University of North Carolina at Chapel Hill (Dr Fisher, Dr DeVellis, Dr DeVellis), and the Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina (Dr Thorpe).

Correspondence to Edwin B. Fisher, PhD, Department of Health Behavior and Health Education, School of Public Health, University of North Carolina at Chapel Hill, Rosenau Hall, CB #7440, Chapel Hill, NC 27599-7440 (fishere{at}email.unc.edu).

	Abstract

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
Purpose

The purpose of this systematic review is to assess the literature pertinent to healthy coping in diabetes management and to identify effective or promising interventions and areas needing further investigation.

Methods

A PubMed search identified 186 articles in English published between January 1, 1990, and July 31, 2006, addressing diabetes and emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem solving, couples therapy, or marital therapy.

Results

Connections among psychological variables, behavioral factors, coping, metabolic control, and quality of life are appreciable and multidirectional. Interventions for which well-controlled studies indicate benefits for quality of life and/or metabolic control include general self-management, coping/problem-solving interventions, stress management, support groups, cognitive-behavioral therapy, behavioral family systems therapy, cognitive-analytic therapy, multisystemic therapy, medications for depression, and the Pathways intervention integrating case management, support of medication, and problem-solving counseling.

Conclusions

Psychological, emotional, related behavioral factors, and quality of life are important in diabetes management, are worthy of attention in their own right, and influence metabolic control. A range of interventions that achieve benefits in these areas provide a base for developing versatile programs to promote healthy coping.

Healthy Coping—Health status and quality of life are affected by psychological and social factors. Psychological distress directly affects health and indirectly influences a person's motivation to keep their diabetes in control.... When barriers seem insurmountable, good intentions alone cannot sustain the behavior. Coping becomes difficult and a person's ability to self-manage their diabetes deteriorates. (http://www.diabeteseducator.org/AADE7/index.shtml)

The purpose of this review is to characterize the literature pertinent to healthy coping in diabetes, with a focus on identifying effective or promising interventions as well as areas in need of further investigation. In line with the AADE definition of healthy coping, the first part of this review summarizes evidence showing that diabetes management, health status, quality of life, and psychosocial factors are interrelated. The second part of the review summarizes evidence showing the connections between diabetes and specific psychosocial and emotional issues such as depression. The third part of the review examines evidence for the utility of healthy coping interventions as they improve quality of life and related psychological outcomes as well as metabolic control and clinical status.

With the exception of problem solving, which receives a separate review in this issue,³ no specific area of healthy coping includes sufficient numbers of well-controlled studies to support a meta-analytic review. In addition, the diversity of interventions addressing healthy coping and the need to appraise the general status of this emerging area of diabetes care make it more helpful to survey broadly and include observations from a variety of research approaches, rather than focusing on a relatively few articles that meet specified criteria of rigor. Accordingly, this review used (1) systematic review procedures in defining the terms for search but (2) narrative review procedures for the inclusion of articles identified without a priori inclusion criteria based on study methodology.

Recognizing the role of healthy coping within diabetes management raises questions about the interactions among psychology, behavior, and biology in human health and diseases. Before proceeding with the review of healthy coping, a brief review of how these interactions have been viewed in the past provides context for current thinking and research.

Historical Perspectives
The Freudian, psychoanalytic model that emerged in the 19th century distinguished between (1) biologically based symptoms and (2) functional symptoms, such as some paralyses for which no apparent biological pathology could be identified. It asserted that these functional symptoms were symbolic expressions of repressed conflicts. Only the lifting of repression and working through of underlying conflicts were thought able to alleviate these symptoms. In the first half of the 20th century, this view was extended to illnesses such as asthma, dermatologic disorders, and gastrointestinal problems. In its crudest form, this psychosomatic approach saw such disorders as the symptomatic expression of psychological problems. Understandably, this attribution of illnesses to psychological conflicts was greeted with little enthusiasm by those trained in the biological pathology and medical treatment of disease.

The development of behavior therapy in the 1950s and 1960s^4-6 rejected the Freudian traditions of exploring motivational and repressed dynamics and focused on straightforward approaches to desensitizing anxiety problems,⁷ teaching skills such as assertion or problem solving,⁸ and providing incentives⁹ to help even those with profound disturbance such as schizophrenia lead fuller and more satisfying lives.^10-12 However, parallel to the psychoanalytic movement half a century before, behavior therapy was also extended to address medical problems. The extension of behavior therapy differed in an important way from earlier psychoanalytic approaches. Instead of attributing diseases to underlying or repressed motivations and emotions, behavior therapy carried to health problems its focus on teaching skills—in this case, skills to improve disease management and quality of life. For example, replacing earlier views of obesity as a manifestation of repressed oral fixations, early behavioral approaches focused on teaching people skills for shopping for and preparing healthy meals and minimizing temptations to eat excessively or make unhealthy food choices.¹³

Building on the behavior therapy movement and parallel developments in health education, approaches emerged to teach individuals the skills necessary to manage diseases such as diabetes. Consistent with emphasizing the active role of the patient in diabetes management, this approach projected a view of the individual as a rational collaborator in her or his care.¹⁴ Perhaps in response to lingering tensions between psychosomatic/psychological and medical approaches to disease, the development of self-management during the 1970s through 1990s paid little attention to individuals' emotions or to the ways in which those emotions might complicate self-management.

However, research in the 1980s began to document how stress management might contribute to diabetes care¹⁵ as well as to the role of depression, including its relationships with metabolic control and psychological interventions to treat it.^16-20 This was also fueled by research documenting the roles of stress, hostility, social isolation, and depression in cardiovascular disease.²¹ Unlike earlier approaches that pitted the psychological against the biological, the 1980s' return to exploring psyche and soma was grounded in general models in which psychological, behavioral, emotional, metabolic, genetic, and other biological factors interact in the expression of disease, course, complications, longevity, and quality of life. The American Association of Diabetes Educators has advanced recognition of the many connections among coping, behavior, emotions, and metabolism in diabetes management by identifying healthy coping as 1 of 7 key diabetes management behaviors.

	Methods

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
The literature search for this review identified 186 articles. These are described in a Summary of Healthy Coping Evidence that provided the base for the review. Because of the length of this summary, it is available separately at http://www.diabeteseducator.org/ProfessionalResources/Research/Results.html. This detailed table of methodologies and findings of individual articles should be useful for those seeking to pursue these issues in greater detail. The current review presents highlights, conclusions where possible, and suggestions for future research and practice.

Search Procedures
The relationships among challenges to diabetes management, psychological and social factors, and healthy coping interventions are diverse. As noted above, this review was designed to provide a broad appraisal of the diverse areas and promising approaches in the field. The review used (1) systematic review procedures in specifying the terms and approach to searching for articles but (2) narrative procedures in including articles without a priori criteria based on methods and design. Figure 1 outlines the search that supported the current review. Based on the evidence tables developed through the steps outlined in Figure 1, the authors developed the Summary of Healthy Coping Evidence that is the base for the descriptive review that follows.

View larger version (29K): [in this window] [in a new window]   Figure 1. Outline of Search of Healthy Coping in Diabetes Management, 1990 to 2006.

	Results of Review

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
The review of articles is organized into 3 parts. Part 1 summarizes evidence showing that diabetes management, health status, quality of life, and psychosocial factors are interrelated. Part 2 summarizes evidence showing the connections between diabetes and specific psychosocial and emotional issues such as depression. Part 3 examines evidence for the utility of healthy coping interventions as they improve quality of life and related psychological outcomes as well as metabolic control and clinical status.

	Part 1: General Relationships Among Diabetes Management, Health Status, Quality of Life, and Psychosocial Factors

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
Impacts of Diabetes and Its Treatment on Quality of Life
That disease, itself, may compromise quality of life is suggested by adverse effects on quality of life of diabetic kidney disease²³ and a review concluding that diabetes complications are related to reduced quality of life.²⁴

It is unclear whether treatment with insulin therapy influences quality of life. Cross-sectional studies²⁵ leave unclear whether insulin therapy itself compromises quality of life or whether deteriorating metabolic control and clinical status lead to both insulin therapy and reduced quality of life. Among longitudinal studies following groups switched to insulin treatment, 2 studies^26,27 found improved quality of life, but a third study found improved metabolic control but worsening of emotional fatigue.²⁸

Whether more complex diabetes regimens reduce quality of life also receives mixed support. Several studies have indicated negative impacts on quality of life of complex treatments such as hemodialysis²³ or combination therapies,²⁹ but others indicate no relationship between type of treatment and quality of life.³⁰ For example, the Diabetes Control and Complications Trial³¹ found no ill effects of its intensive therapy on quality of life.³² Two other reports including a review³³ and an individual study³⁴ also found no impact of intensive treatments on quality of life. In contrast to negative effects, some reports indicate benefits of intensive interventions,^29,35-37 including pancreatic transplants.³⁸

Among children, one study found a tendency toward greater recalcitrance among those treated with continuous insulin infusion as opposed to conventional therapy.³⁹ If adolescents were given their choice of either multiple daily injections or insulin infusion pump methods, quality of life improved.⁴⁰

Impacts of other technical enhancements of treatment have included improved quality of life^41,42 but deteriorated metabolic control⁴¹ in several studies of an insulin pen, and improvements in both metabolic control and quality of life with insulin glargine.⁴³

That individuals differ in their reactions to insulin therapy is revealed in qualitative studies. Patterns that have been identified include (1) positive attitudes centered on efficacy, avoidance of complications, and feeling better and more energetic; (2) anxiety about pain, hassles of injections, a sense of not having taken good care of diabetes, and concerns about hypoglycemia, health problems from insulin, disease progression, and the possibility that treatment had failed⁴⁴; or (3) rigidity, insecurity, conformity, fear of addiction, and doubts about the therapy.⁴⁵

That metabolic control itself may enhance quality of life found support in a randomized trial of glipizide. Although it included no psychosocial or educational intervention other than the support of participants that is implicit in a clinical trial, improved metabolic control was associated with improved quality of life.⁴⁶ However, healthy coping may have more impact on quality of life than metabolic control. One study showed that coping styles and personality factors were stronger predictors of quality of life than were clinical aspects of diabetes.⁴⁷

Impacts of Psychosocial Issues on Metabolic Control
The influences of psychosocial and family factors on metabolic control have long been the subject of research, especially among children and youth with type 1 diabetes.^48,49 At the individual level, external locus of control, delayed intellectual and emotional development, impulsive and avoidant coping styles, and number of life events have been associated with poorer metabolic control.^50-52 In addition, literature reviews have indicated that emotional factors, depression, motivational factors, and specific problems such as eating disorders may compromise adherence.^53,54 At the family level, poor communication, low socioeconomic status, low financial resources, and family stress are associated with lower diabetes knowledge and problem-solving knowledge.⁵⁵

More articles in this review identified characteristics associated with adherence and good metabolic control than with poor control. Factors associated with good metabolic control include internal locus of control⁵⁶; coping that is task oriented, problem focused, or rational (in contrast to a wish-fulfillment coping style)^51,57,58; support from friends⁵⁸; positive orientation⁵¹; and making use of past experience to guide management efforts.⁵¹ That basic cognitive ability may underlie some of these relationships is suggested by associations of both metabolic control and hyperglycemia with neuropsychological and intelligence test indicators of problem-solving ability among adults with type 1 diabetes.⁵⁹ It is important to note, however, that relationships of psychosocial factors with metabolic control may be complicated. For example, adolescents have greater problem-solving ability than do children, yet they make more choices that are in line with peer preferences than do younger children.⁶⁰

	Part 2: Specific Problems for Coping

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
Coping and Psychological Challenges Associated With Special Problems
A complete review of the psychological and coping challenges posed by complications is beyond the scope of this article. However, several are highlighted here because of their close relationship with coping and their role in quality of life. Impotence is estimated to be as high as 3 times more prevalent among men with diabetes⁶¹ than among nondiabetic men⁶² or as high as 90% prevalent in a population study of diabetic men between 40 and 79 years old in Japan.⁶³ The present review identified no articles addressing coping and sexual dysfunction among women with diabetes, an apparent oversight in the literature.

As more individuals with diabetes live longer lives, as we learn more about brain and cognitive function across the life span, and as we understand better the relationship between metabolism and cognitive function, our attention to the cognitive impacts of diabetes is likely to grow. Declines in cognitive function have been associated with duration of diabetes, not being on hypoglycemic therapy, and several other complications (proliferative retinopathy, peripheral neuropathy, and peripheral vascular disease), all suggesting a general relationship between adequacy of metabolic control and cognitive decline.^64-68 Several studies have found that declines in diabetes are specific to measures of psychomotor speed⁶⁴ and psychomotor efficiency.⁶⁷ A case-control study of those with type 1 diabetes found a positive relationship between history of severe hypoglycemia and neuropsychologic impacts.⁶⁹ Another study found no such relationship, but this was based on retrospective reports of youth and their parents.⁷⁰

Depression: Epidemiology and Needs Assessment
Among those with diabetes, estimates of the prevalence of depression range from 28% to 44% for self-reported minimal-mild depression.^71-73 Studies also indicate associations between depression and poor metabolic control.^71,74,75 The relationship is not one way; there is increasing evidence that depression may be part of prediabetes or may participate in pathogenesis.⁷⁶ That the relationship between depression and diabetes may be multidirectional was shown in a study of older adults admitted to a psychiatric ward for depression; diabetes and cardiovascular disease were each present in 87% of the sample.

That social as well as physiological factors influence the relationship between diabetes and depression is demonstrated in observed variation among adults with diabetes sampled from the Netherlands, Croatia, and United Kingdom.⁷⁷ The prevalence of depression ranged from 19% among English men to 39% among Croatian men and English women.

A high rate of recurrence is a feature of depression, as high as 92% over 5 years in one follow up of participants in a treatment study.⁷⁸ The importance of ongoing support for healthy coping and diabetes management⁷⁹ is underscored by the fact that none of the participants were treated continuously and prophylactically during follow-up.

Other Emotional Issues: Epidemiology and Needs Assessment
The current review identified no evidence for a diabetic personality, either as the result of diabetes or as a contributor to its pathogenesis. Supporting the general debunking of the myth of the diabetic personality,⁸⁰ one article compared adults with rheumatoid arthritis, osteoarthritis, and diabetes on measures of coping, self-appraisal, and activity levels and found no patterns distinctive to diabetes.⁸¹

Although there is no diabetic personality, substantial literature links diabetes and its treatment with various emotions. General reviews have shown a wide range of associations of diabetes^24,82,83 and its complications⁸⁴ with many different emotions and quality of life. Among children and adolescents with diabetes, research has examined internalizing problems such as anxiety, social withdrawal, or depression⁸⁵; tendencies to attribute events to external rather than personal or internal factors⁵⁰; frequency of adverse life events⁵⁰; and eating disorders.^86,87 Suggestions for treating eating disorders include vigilance by primary care providers and multidisciplinary treatment including the primary care provider, a nutritionist, and a mental health professional.⁸⁶ Eating disorders have been associated with insulin omission among those with type 1 diabetes and with excessive concerns for thinness among those with type 2 diabetes⁸⁸ and with problems of mother-daughter communication around emotional issues.⁸⁹

Although better metabolic control and fewer complications appear related to better quality of life,^23,30,46,84 the relationship between adherence and quality of life may not always be positive. Among adolescents with type 1 diabetes, emotional distress was associated with being "quiet, nonrebellious... [and]... with well controlled diabetes from... supportive famil[ies]."⁹⁰ Number of snacks was associated with a higher level of both physical and social functioning on the SF-36.⁹¹ The authors of the latter study concluded that "constant attendance" through strict self-control may be associated with poorer quality of life.

The impact of diabetes on the family and of the family on diabetes has long been of interest.^48,49 That these impacts may not always be profound is suggested by a finding that 4 weeks after their diagnosis with type 1 diabetes, children and their parents reported low distress and did not differ from a reference group in psychological problems.⁵⁰ Both mothers and fathers of children with type 1 diabetes reported positive reappraisal of stressors and seeking social support as frequent problem-solving strategies; however, mothers reported planful problem-solving approaches more than fathers did, and fathers reported emotional distancing from problems more than mothers did.⁹²

An association between schizophrenia and risk of diabetes appears attributable to weight gain as a side effect of antipsychotic medications,^93,94 raising cautions about antipsychotic medications for those with or at risk for diabetes.⁹⁵

Assessment of Psychosocial Issues
In addition to general measures of psychological well-being and quality of life (eg, WHO QOL-100,⁹⁶ SF-36 general quality-of-life measure, CES-D depression scale of the Centers for Epidemiologic Studies), a wide variety of instruments are now available for measuring emotional and quality-of-life impacts of diabetes among children and youth⁹⁷ as well as adults.^24,98 Additional measures assess strategies for coping with barriers to adherence to diet, exercise, and glucose testing⁹⁹ as well as both self-efficacy and coping related to dietary adherence.¹⁰⁰ Another instrument¹⁰¹ measures receipt of supports for self-management and other key components of Wagner's chronic care model.¹⁰²

	Part 3: Interventions to Promote Healthy Coping

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
Table 1 includes descriptions of key articles documenting interventions to promote healthy coping. As noted earlier, the Summary of Healthy Coping Evidence at http://www.diabeteseducator.org/ProfessionalResources/Research/Results.html provides descriptions of all 186 articles on which this review is based.

The American Association of Diabetes Educators has advanced the centrality of healthy coping in all diabetes self-management and patient education to help individuals and families cope with the challenges posed by diagnosis, the complexity of the regimen, demands of self-management, and the need for social support. As a result of this kind of vision, diabetes self-management education, as well as a variety of supportive interventions, have incorporated healthy coping and have included related measures in their evaluation.

Healthy Coping in Diabetes Self-management Education
A number of studies suggest that general approaches to self-management training appear to benefit quality of life. These include a case study of 20 years' use of intensive insulin administration¹⁰³ and evaluations of group medical visits,¹⁰⁴ community health workers,¹⁰⁵ an education program for dialysis patients,¹⁰⁶ and telephone support for adolescents and young adults with type 1 diabetes.¹⁰⁷

In addition to inclusion of healthy coping in general diabetes self-management education, research has examined the benefits for diabetes management of a number of individual, group, and family interventions. Reviews of psychological interventions for individuals with type 1 diabetes¹⁰⁸ and adults with type 2 diabetes¹⁰⁹ found them to achieve significant decreases in a variety of measures of psychological and psychosocial distress.

Support Groups/Group Counseling
Surprisingly, the review identified few studies evaluating support groups for those with diabetes. One study found that relative to a wait-list control group, those receiving group cognitive-behavior therapy experienced reduced diabetes-related stress and self-blame but, surprisingly, achieved no differences on overall psychological well-being.¹¹⁰ A qualitative description of a support group¹¹¹ emphasized the importance of group members' being able to raise topics for groups discussion, a common practice in support groups for those with chronic illnesses.¹¹²

Problem Solving and Coping Skills
Problem solving is a common ingredient in a variety of patient education, self-management, and healthy coping interventions.^7,113 Reviews^114-116 have suggested that teaching coping and problem-solving skills may improve quality of life and diabetes management. This is supported by a separate article in this issue by Hill-Briggs and Gemmell³ that provides a detailed review of problem-solving interventions for those with diabetes. It found (1) consistent relationships between measures of problem solving and measures of quality of life and metabolic control among adults and mixed evidence among youth, (2) good evidence for benefits of problem-solving interventions on quality-of-life measures, and (3) mixed results for improved metabolic control. Several articles identified in the present review^117-120 found improvements in reported problem-solving skills, self-management patterns, adherence, quality of life, and GHb at follow up as long as 1 year after the intervention.

Problem solving has also been recognized as a key ingredient in psychotherapy. Individuals receiving problem-focused psychotherapy concentrating on modification of thought patterns, behavior, and emotionality as well as on relaxation and social support achieved improvements in psychological problem severity and GHb, in comparison to a wait-list control group.¹²¹

Cognitive-Behavior Therapy and Behavior Therapy Interventions
Several reviews^122,123 concluded that cognitive-behavioral interventions have benefits on mood and GHb, showing promise of improvements in course and outcome. A randomized trial compared patient education alone with patient education followed by 10 weeks of individual cognitive-behavior therapy. Cognitive-behavior therapy achieved greater remission of depression and lower GHb.¹²⁴ Other findings of studies of behavioral approaches to healthy coping have included (1) small reductions of GHb through stress management intervention¹²⁵ and (2) improvements in fear, acceptance of chronic disease, and improved work experience through an intervention that used several cognitive-behavioral strategies in improving dysfunctional health beliefs¹²⁶ but (3) little benefit from biofeedback-assisted relaxation^127,128 despite suggestions of its usefulness.⁸²

Among adolescents, cognitive-behavioral and problem-solving interventions have shown mixed results, including reduced anxiety and stress, improved coping, and improved adherence^129,130 but no improvements in diet, physical activity, or GHb¹³⁰ and, in another study, no differential benefits.¹³¹

Family Therapy
Family approaches to youth with type 1 diabetes have shown promising effects on family communication, problem solving, and clinical outcomes. These approaches include behavioral family systems therapy that focuses on problem-solving skills, communication skills, cognitive restructuring, and general family counseling.^{82,123,132-136} Multisystemic therapy¹³⁷ adds intensity of intervention (2 to 3 home visits per week at outset, average duration = 6.5 months) and additional targeting of peer, school, and community settings. An in-patient program that focused on family relationships and behavioral interventions also achieved improvements in binge eating and purging among a series of cases with both bulimia and diabetes.¹³⁸

Research on family interventions points to the apparent utility of focusing on family factors long shown to be associated with diabetes management among youth.^48,49 However, follow-up assessments have either not been conducted or have shown that benefits dissipate relatively quickly, suggesting the importance of ongoing follow-up and support.⁷⁹

Medication for Psychological Problems
A randomized comparison to placebo¹³⁹ indicated benefits of sertraline for depression among adults with diabetes but no differential benefit on GHb. A review¹⁴⁰ found that fluoxetine is superior to placebo among those with diabetes and depression. In a series of cases with depression and also diabetes or obesity, antidepressant treatment with bupropion and tianeptine was associated with weight loss and increased pharmacotherapy adherence.¹⁴¹

Other Interventions
Several studies have examined mixtures of psychotherapeutic approaches. Inpatient medical management and psychoanalytic therapy 3 to 4 times per week for 5 to 28 weeks achieved improved metabolic control maintained at 1-year follow-up among children with type 1 diabetes.^142,143 In another study, inpatient care including individual, group, and family psychotherapy was associated with improvements in hospitalizations, school attendance, metabolic control, weight gain, changes in insulin, knowledge about diabetes, and attitudes toward diabetes.¹⁴⁴ However, both studies included nonequivalent controls or no controls, rendering them essentially a series of case studies.

Cognitive-analytic therapy identifies past problems and new approaches to thinking about them. Among adults with type 1 diabetes, such therapy led to improvements in interpersonal problems but no advantage in terms of metabolic control.¹⁴⁵

Finally, diabetic ketoacidosis has been examined in several case studies. Inpatient psychotherapy and intensive supervision of insulin administration led to reversal of self-destructive patterns,¹⁴⁶ and outpatient group therapy for up to 24 months achieved improvements in adherence, weight gain, self-reliance, and trust among 4 adolescents.¹⁴⁷

Strategies in Promoting Healthy Coping
The Pathways project of Katon and colleagues at Group Health Cooperative of Puget Sound demonstrates a comprehensive approach to addressing depression and emotional issues in primary care. Set within a large health maintenance organization, Pathways is a case management program that includes support of medication treatment and adherence as well as counseling emphasizing problem solving.¹⁴⁸ Benefits included adequacy of pharmacotherapy doses, reduced depression, satisfaction with care, improvements in overall functioning, and exercise. However, treatments were not found to benefit GHb or self-care behaviors.^149,150

The need for healthy coping is substantial and continuing rather than occasional. This was reflected by the breadth of issues that were identified by participants in one support group: family relationships, parenting issues, depression, eating disorders, occupational concerns, driving with diabetes, management issues, and pregnancy.¹¹¹ Thus, healthy coping should be part of regular diabetes care. This is reflected in calls for inclusion of measures of quality of life and emotional health in studies of diabetes management^116,151 and calls for routine engagement of the family and attention to child-family dynamics as part of treatment for children and youth.^152,153

Despite advocacy for its role, healthy coping receives little attention in routine care. In one study, 23% of patients reported having wanted more emotional support than they received at the time of diagnosis.¹⁵⁴ In another study, only 51% of patients who scored as depressed on the Patient Health Questionnaire (PHQ-9) had been recognized as such by their care providers.¹⁵⁵ Furthermore, only 43% of those recognized as depressed received medication for depression, and only 6.7% received appreciable psychotherapy (4 or more sessions). The limited attention to healthy coping is part of a broader trend to underemphasize patient education in diabetes care as 60% to 70% of patients report not having received education in diabetes self-management.¹⁵⁶

Promoting the centrality of healthy coping in diabetes management needs to take note of complex factors that will govern its acceptance, including patient attitudes toward their own role in self-management and patient-provider communication. These were illustrated in a qualitative study¹⁵⁷ of patients in poor control that identified a tendency to keep disease management at a distance from living one's life. This separation was reinforced by emphases on compliance and expectations of failure in patient-provider communication. In contrast, mutuality between provider and patient and openly addressing the challenge of integrating disease management with the rest of life appeared to promote a more moderate, problem-solving approach.

	Summary of Findings

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
From parts 1 and 2 of this review, it is apparent that

• diabetes influences quality of life,
  
• the type of diabetes treatment influences quality of life,
  
• metabolic control influences quality of life, and
  
• psychosocial factors influence metabolic control.
  

This leads to several questions regarding healthy coping interventions.

Do Healthy Coping Interventions Improve Quality of Life?
Well-controlled studies (randomized trials, multiple baseline, or other adequate control procedures) indicate improved quality of life following a variety of interventions, including cognitive-behavioral treatment of depression,¹²⁴ coping/problem-solving interventions with adolescents and youth^{28,117,118,120} as well as adults,¹²¹ support groups,¹¹⁰ cognitive-analytic therapy,¹⁴⁵ and the Pathways intervention that consisted of coordinated case management, support of medication use, and problem-solving counseling.¹⁴⁸ Multisystemic therapy^158-160 and behavioral family systems therapy^133-135 achieve improvements in family functioning and quality of life, but follow up of multisystemic treatment has not been reported, and 12-month follow up of family systems therapy indicates an appreciable decline in benefits.

A variety of self-management interventions that share support and encouragement along with attention to circumstances and, often, emotional factors that interfere with self-management were found to have quality-of-life benefits in well-controlled evaluations^104,106,107 and a pre-post, within-group evaluation.¹⁰⁵

An observational study indicated quality-of-life benefits of a comprehensive intervention for fear of long-term complications.¹²⁶ One pre-post, within-group evaluation found no benefit of behavioral family systems therapy.¹³²

Do Healthy Coping Interventions Improve Metabolic Control?
Well-controlled studies (randomized trials or other adequate control procedures such as multiple baseline) indicate that improved metabolic control results from cognitive-behavioral interventions for depression,¹²⁴ stress management intervention,¹²⁵ coping/problem-solving interventions with adolescents and youth,^{28,117,118,120} as well as with adults in a wait-list comparison,¹²¹ multisystemic therapy,^158-160 and sertraline.¹³⁹

Evaluation against a nonequivalent comparison group indicates improved metabolic control following inpatient interventions stressing psychoanalytically oriented psychotherapy.^142,143 Several studies indicated benefits of antidepressant medication, and a review indicated benefit of fluoxetine.¹⁴⁰

	Discussion and Conclusions

Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 
From this broad review to identify themes and topics worth pursuing in healthy coping, substantial evidence indicates that psychological and behavioral factors are related to metabolic control in diabetes and that a variety of self-management, as well as more psychological interventions such as cognitive behavior therapy, improve both metabolic control and quality of life.

The relationships among self-management, psychological factors, coping, quality of life, and metabolic control are complex. Psychological factors appear related to self-management and metabolic control, metabolic control is related to quality of life, and improving healthy coping skills improves metabolic control and quality of life. Several of these connections are bidirectional. That is, poor quality of life or depression may interfere with management and compromise metabolic control. At the same time, metabolic control may be related to mood and quality of life. An important development in health behavior research and public health has been recognition of interdependent influences among contexts, behaviors, biological variables, health, and quality of life, as opposed to models of unidirectional causation.¹⁶¹ Healthy coping in diabetes is an area for which such complex models are especially pertinent.

Previous reviews in this field^108,109 indicated a variety of methodological concerns including problems with control for bias and sample size. These kinds of problems remain in many of the studies cited here, several of which compare interventions to groups that are not comparable.^142,143 However, many of the studies reviewed have used randomized experimental designs or other control designs such as multiple baseline or waiting-list controls. The limited results supporting any one intervention should lead to further research refining and comparing these approaches. The complex issues in this field include what interventions may best reach what groups, how cultural factors may influence quality of life and may make one or another approach to healthy coping more or less appropriate, how coping and biological influences interact in their influence on metabolic control and quality of life, and so forth. Research needs to use a variety of methods including those emphasized in the grading of evidence in the other AADE7^TM systematic reviews in this special issue.

As survival among those with diabetes is extended, the range and number of complications will increase. This review identified some attention to cognitive decline and impotence, but innovative healthy coping interventions need to be developed or tailored to meet the needs of those facing a growing range of diabetes complications.

Sixty percent to 70% of patients with diabetes have not received training in diabetes self-management.¹⁶² This challenge leads to a number of considerations for both practice and research. For program planning, the variety of healthy coping interventions is not a mark of disarray in the field but rather an advantage in reaching those who have not been served. A variety of interventions, channels, and modes of engaging individuals may be more effective in reaching audiences than provision of one or a limited number of best practices.^79,163 Thus, program planning should draw from the range of interventions of demonstrated benefit, guided by resources available, organizational strengths vis-à-vis those served, and specific needs and preferences of intended audiences.

Research needs to address how to disseminate these approaches to the large numbers who need them. Because choice among different interventions is likely critical to reaching large numbers, research should investigate programs offering choices. It should also examine how specific interventions contribute to the effectiveness of packages of several intervention types, modes, and channels. It should identify ways of integrating different healthy coping approaches into practice settings to provide a varied, attractive package of services capable of reaching and sustaining involvement of large numbers in need. This research should draw on emerging models for dissemination research.^161,164-166 An example of this kind of research is the Pathways intervention, which combined support for medication as well as counseling in problem solving.^148,167,168

Behavior changes and improvements in self-management or healthy coping are not self-sustaining. This reflects a broad pattern in behavioral and health behavior research.^169-173 That initial benefits may fade by the time of follow-up was a pattern noted in this review.^132-135 In addition, the lifelong and progressive nature of diabetes leads to needs for coping with changes both in disease features (eg, the eventual need to use insulin for management) and circumstances (eg, the impact of retirement or widowhood on patterns of daily living including diet and physical activity). Thus, healthy coping and self-management programs need to provide ongoing follow-up and support,⁷⁹ and research needs to address how to extend interventions for healthy coping into lifelong supports and resources. A promising development is that ongoing self-management support is 1 of 10 standards in the 2007 National Standards for Diabetes Self-management Education.¹⁷⁴

A final important topic for research in this area is the-cost effectiveness of healthy coping interventions. Although not a focus of this review, healthy coping interventions may be surprisingly cost-effective. A community health worker program that included weekly phone contacts and home visits reduced acute care, increased quality of life, and was reported to save an average of $2245 per patient per year.¹⁰⁵ Evaluation of the Pathways comprehensive program for those with depression and diabetes in primary care¹⁷⁵ and another similar program¹⁶⁸ indicated that costs of treating depression tended to be offset by savings in costs of overall care. In fact, the eventual costs of poor self-management and complications among those with diabetes and, especially, among those with both negative emotions and diabetes may accentuate the cost-effectiveness of healthy coping interventions.¹⁶⁸

	Acknowledgments

 
Support for this work was provided through the Diabetes Initiative (www.diabetesinitiative.org) of the Robert Wood Johnson Foundation® in Princeton, New Jersey. Dr Thorpe's work on this article was supported by a postdoctoral fellowship from the VA Office of Academic Affairs. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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Top Abstract Methods Results of Review Part 1: General Relationships... Part 2: Specific Problems... Part 3: Interventions to... Summary of Findings Discussion and Conclusions References

 

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The Diabetes Educator, Vol. 33, No. 6, 1080-1103 (2007)
DOI: 10.1177/0145721707309808


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