Journal of Psychosomatic Research, Vol. 35. No. 2/3. pp. 335-343, Printed m Great Britain.
1991. 0
CNl22-3999/91 $3.oO+.W 1991 Pergamon Press plc
PSYCHOSOCIAL FACTORS AND ADMISSION FOR POOR GLYCAEMIC CONTROL: A STUDY OF PSYCHOLOGICAL AND SOCIAL FACTORS IN POORLY CONTROLLED INSULIN DEPENDENT DIABETIC PATIENTS M. WRIGLEY* and R. MAYOU~ (Received
17 October
1989; accepted in revised
form 3
October
1990)
Abstract-Psychological and social factors were investigated in 89 poorly controlled insulin-dependent diabetic admissions matched with out-patient controls. Those admitted were found to suffer greater current and past psychiatric morbidity, to report more social problems and chronic difficulties and to experience more life events in the six months before interview. The occurrence of significantly more independent events and chronic difficulties among admissions suggests that social stress can lead to poor control. These results emphasize the importance of global assessment of diabetic admissions to include psychological and social aspects as well as medical status.
INTRODUCTION POORLY controlled diabetes is a common cause of hospital admission and there is considerable evidence that a high proportion of such admissions are due wholly or partly to poor self-care [l-31. However, the extent to which poor glycaemic control is associated with psychological and social problems is unknown [41. Several studies have investigated psychological and social factors in insulindependent diabetes. Wilkinson found an excess of psychiatric disorders in diabetic out-patient clinic attenders [51, Mazze found an association between psychiatric disorder and poor control [61 as did two recent studies carried out in Oxford 17, 81. Social problems appear to be common among those with diabetes and have been linked with poor control t9, 101, but not invariably so [Sl. Disturbed family relationships have also been identified in those with poorer control 14, 9, 111. Likewise, acute stress is said to be associated with derangements in metabolic control 1121 as indicated by more episodes of glycosuria, more changes in the diabetic regieme and increased frequency of out-patient visits [ 131. In this study acute admissions for poor diabetic control were compared with matched out-patient clinic attenders with the aim of examining the nature of psychological and social factors in poorly controlled insulin-dependent diabetic patients. Improved understanding of the contribution of such factors to a common clinical problem would lead to better management. ASSESSMENT Adult insulin-dependent Infirmary, John Radcliffe study during the two-year
diabetic patients admitted to the Oxford group of hospitals (Radcliffe Ii), primarily because their diabetes was out of control, were recruited to the period 1984-1986. In all of these patients serious problems in control were
*Author to whom correspondence should be addressed Blanchardstown, Dublin 15, Republic of Ireland, TDepartment of Psychiatry, Warneford Hospital. Oxford
335
at: James OX3
Connolly
7JK, U.K.
Memorial
Hospital,
M. WRIGUY
and R. MAYOU
identified by the attending doctor though in only a few was the presentation as dramatic as diabetic coma. Ninety-one admissions were approached to join the study, one refused and one was judged too confused. The control group consisted of insulin-dependent diabetic patients attending the out-patient clinics in the John Radcliffe II at the same time and the two groups were matched for age, sex and duration of diabetes. A further requirement was that the control group had not been admitted to hospital because of diabete\ during the previous six months (this was the period studied for life events). The 89 admissions were seen in hospital within three days of admission and the controls were seen at home. Both groups were assessed using a semi-structured interview and standard questionnaires covering the following areas:
This was extracted
from the medical notes and covered reasons for admission, diabetic complications blood glucose at the time of admission or clinic attendance, and HbAlc if available. The severity of complications was graded by clinically rating the effect on the individual’s life as follows: 0 = no effect; 1 = mild eff‘ect e.g. need io take medication; 2 = moderate effect e.g. some loss of function because of pain or impairment: 3 = severe effect e.g. blindness or amputation.
[ 141. other medical conditions,
Pre.wwr Stmre Examindon (PSE). The PSE is a standard interview schedule which assesses the presence and severity of psychiatric symptoms over the previous month and for which extensive comparative data are available [15, 161. The associated computer programme ‘CATEGO’ generates diagnoses and grades the severity of psychiatric disorder to produce an Index of Definition (ID). Those rated 5 and above on the ID scale of l-8 are considered to be psychiatric ‘cases’ i.e. they have a psychiatric disorder of similar severity to psychiatric out-patient clinic attenders. Ewmck Personality In~rnro~ (EPI) I 171. The EPI is a self-administered questionnaire measuring two major personality factors extroversion/introversion and stability/instability. Profile ofMood Srutes (POMS). This self-administered questionnaire I181 for assessing mood at the time of interview provides a total score and five sub-factor scores for anger, depression. tension, fatigue and lack of vigour. Pswhicrrric- !lea/th. Four open-ended questions were asked to assess this: I. Are you seeing a doctor for a nervous illness? 2. Have you ever suffered from a nervous illness? 3. Are you on any tablets for your nerves? 4. Have you ever seen a psychiatrist’?
Life elemr. Information about recent stressful events was obtained with the life events schedule devised by Paykel and Mangen 1191. This is a semi-structured interview covering 69 types of events grouped into the following categories: work; education; finance; health and bereavement; migration; and family and social relationships. Results were recorded in two ways: (i) All events occurring in the six month period prior to admission for patients and prior to interview for controls. (ii) Only those events considered to have occurred independently of the person‘s diabetes and also to have had an objectively marked or severe negative impact on the individual. Standard rules were used to categorirr independence and impact of events Il91. For a life event to be rated as ‘independent’ by the inventory it must appear unlikely that the event was a consequence of diabetes or its elfects. The objective negative impact of the event is rated on the degree of unpleasant impact, stress or threat an event might have on someone when its nature and circumstance are considered. The person’s sub_jectivc account of the impact does not influence the rating. Chronic rlifficu1rie.s. Stressful events of longer than six months duration were recorded with a modilied version of the Life Events schedule and grouped into six categories: health; housing; children: marital/ social; work/educational; and financial difficulties. As with life events, first all chronic dithculties and then those occurring independently of diabetes and of marked or severe negative impact were separately identihed. .Socxr/ ~vwbletns. These were identified using a modified form of the self report questionnaire devised by Corney and Glare 1201. The areas covered by it included housing. work. tinancial circumstances. social contact. relattonships, domestic situation. legal matters and ‘others’. C/(E ,!f tr/c&o/. Patients and control\ were screened for drinking problems with the four-question
Psychosocial
factors
12 1I Those scoring
Cage questionnaire problem.
and admission
for poor glycaemic
two or more positive
answers
control
were considered
In those for whom it was relevant. these were identified using four open-ended to the diabetic person specifically rather than their partner. I. Has there been any decrease in sexual activity since developing diabetes? 2. Men-is this due to loss of function? 3. Women-is this due to loss of sensation? 4. Both-is this due to loss of interest in sex? Data
337 to have an alcohol
questions
which refer
analysis
The two groups were compared as matched pairs i.e. each subject with its matched control and the McNemar and Sign Tests applied to test for significance. In instances where this was not possible, the tests used are included in the results.
RESULTS
Admitted
group
Medical conditions such as infections were considered responsible for poor control in one-third of admissions. The remaining two-thirds of admissions had less clearly defined causes of poor control resulting from inadequate self-care e.g. nonadministration of insulin or poor understanding of the diabetic condition. Those with a medical precipitant were more likely to be admitted as emergencies (Table I) whilst the rest of the admitted group generally had a number of clinic visits in which poor control was identified and, despite advice, remained unsatisfactory so eventually culminated in an elective admission for stabilization. Both the admission subgroups described similar psychosocial problems (Table I). Demographic
and medical
characteristics
Fewer admissions were married, in social classes I and II or employed (Table II). Statistically more admissions had diabetic complications and were adversely affected TABLE
I.-CHARACTERISTICS
Emergency admissions Diabetic complications with moderate/severe effect Other condition present with moderate/severe effect Life events Independent life events Chronic difficulties Independent difficulties Social problems Alcohol problems Past/present psychiatric history PSE cases Total PSE score Total POMS and subsections EPI neuroticism *Mann-Whitney
OF ADMITTED
‘Medical’ sub-group
Factor
U-Wilcoxon
N=29 22 26 15 I5 3 2s 8 1s 6 14 3 14 3
(%) (75) (89) (51) (51) (10) (86) (27) (51) (20) (48) (IO) (48) (IO)
rank Sum IV Test Used
GROUP
‘Non-medical’ sub-group N=60 15 58 10 28 5 45 16 40 11 25 9 23 9
(%) (25) (96) (16) (46) (8) (75) (26) (66) (18) (41) (15) (38) (15)
P(x2)
1991. 0
CNl22-3999/91 $3.oO+.W 1991 Pergamon Press plc
PSYCHOSOCIAL FACTORS AND ADMISSION FOR POOR GLYCAEMIC CONTROL: A STUDY OF PSYCHOLOGICAL AND SOCIAL FACTORS IN POORLY CONTROLLED INSULIN DEPENDENT DIABETIC PATIENTS M. WRIGLEY* and R. MAYOU~ (Received
17 October
1989; accepted in revised
form 3
October
1990)
Abstract-Psychological and social factors were investigated in 89 poorly controlled insulin-dependent diabetic admissions matched with out-patient controls. Those admitted were found to suffer greater current and past psychiatric morbidity, to report more social problems and chronic difficulties and to experience more life events in the six months before interview. The occurrence of significantly more independent events and chronic difficulties among admissions suggests that social stress can lead to poor control. These results emphasize the importance of global assessment of diabetic admissions to include psychological and social aspects as well as medical status.
INTRODUCTION POORLY controlled diabetes is a common cause of hospital admission and there is considerable evidence that a high proportion of such admissions are due wholly or partly to poor self-care [l-31. However, the extent to which poor glycaemic control is associated with psychological and social problems is unknown [41. Several studies have investigated psychological and social factors in insulindependent diabetes. Wilkinson found an excess of psychiatric disorders in diabetic out-patient clinic attenders [51, Mazze found an association between psychiatric disorder and poor control [61 as did two recent studies carried out in Oxford 17, 81. Social problems appear to be common among those with diabetes and have been linked with poor control t9, 101, but not invariably so [Sl. Disturbed family relationships have also been identified in those with poorer control 14, 9, 111. Likewise, acute stress is said to be associated with derangements in metabolic control 1121 as indicated by more episodes of glycosuria, more changes in the diabetic regieme and increased frequency of out-patient visits [ 131. In this study acute admissions for poor diabetic control were compared with matched out-patient clinic attenders with the aim of examining the nature of psychological and social factors in poorly controlled insulin-dependent diabetic patients. Improved understanding of the contribution of such factors to a common clinical problem would lead to better management. ASSESSMENT Adult insulin-dependent Infirmary, John Radcliffe study during the two-year
diabetic patients admitted to the Oxford group of hospitals (Radcliffe Ii), primarily because their diabetes was out of control, were recruited to the period 1984-1986. In all of these patients serious problems in control were
*Author to whom correspondence should be addressed Blanchardstown, Dublin 15, Republic of Ireland, TDepartment of Psychiatry, Warneford Hospital. Oxford
335
at: James OX3
Connolly
7JK, U.K.
Memorial
Hospital,
M. WRIGUY
and R. MAYOU
identified by the attending doctor though in only a few was the presentation as dramatic as diabetic coma. Ninety-one admissions were approached to join the study, one refused and one was judged too confused. The control group consisted of insulin-dependent diabetic patients attending the out-patient clinics in the John Radcliffe II at the same time and the two groups were matched for age, sex and duration of diabetes. A further requirement was that the control group had not been admitted to hospital because of diabete\ during the previous six months (this was the period studied for life events). The 89 admissions were seen in hospital within three days of admission and the controls were seen at home. Both groups were assessed using a semi-structured interview and standard questionnaires covering the following areas:
This was extracted
from the medical notes and covered reasons for admission, diabetic complications blood glucose at the time of admission or clinic attendance, and HbAlc if available. The severity of complications was graded by clinically rating the effect on the individual’s life as follows: 0 = no effect; 1 = mild eff‘ect e.g. need io take medication; 2 = moderate effect e.g. some loss of function because of pain or impairment: 3 = severe effect e.g. blindness or amputation.
[ 141. other medical conditions,
Pre.wwr Stmre Examindon (PSE). The PSE is a standard interview schedule which assesses the presence and severity of psychiatric symptoms over the previous month and for which extensive comparative data are available [15, 161. The associated computer programme ‘CATEGO’ generates diagnoses and grades the severity of psychiatric disorder to produce an Index of Definition (ID). Those rated 5 and above on the ID scale of l-8 are considered to be psychiatric ‘cases’ i.e. they have a psychiatric disorder of similar severity to psychiatric out-patient clinic attenders. Ewmck Personality In~rnro~ (EPI) I 171. The EPI is a self-administered questionnaire measuring two major personality factors extroversion/introversion and stability/instability. Profile ofMood Srutes (POMS). This self-administered questionnaire I181 for assessing mood at the time of interview provides a total score and five sub-factor scores for anger, depression. tension, fatigue and lack of vigour. Pswhicrrric- !lea/th. Four open-ended questions were asked to assess this: I. Are you seeing a doctor for a nervous illness? 2. Have you ever suffered from a nervous illness? 3. Are you on any tablets for your nerves? 4. Have you ever seen a psychiatrist’?
Life elemr. Information about recent stressful events was obtained with the life events schedule devised by Paykel and Mangen 1191. This is a semi-structured interview covering 69 types of events grouped into the following categories: work; education; finance; health and bereavement; migration; and family and social relationships. Results were recorded in two ways: (i) All events occurring in the six month period prior to admission for patients and prior to interview for controls. (ii) Only those events considered to have occurred independently of the person‘s diabetes and also to have had an objectively marked or severe negative impact on the individual. Standard rules were used to categorirr independence and impact of events Il91. For a life event to be rated as ‘independent’ by the inventory it must appear unlikely that the event was a consequence of diabetes or its elfects. The objective negative impact of the event is rated on the degree of unpleasant impact, stress or threat an event might have on someone when its nature and circumstance are considered. The person’s sub_jectivc account of the impact does not influence the rating. Chronic rlifficu1rie.s. Stressful events of longer than six months duration were recorded with a modilied version of the Life Events schedule and grouped into six categories: health; housing; children: marital/ social; work/educational; and financial difficulties. As with life events, first all chronic dithculties and then those occurring independently of diabetes and of marked or severe negative impact were separately identihed. .Socxr/ ~vwbletns. These were identified using a modified form of the self report questionnaire devised by Corney and Glare 1201. The areas covered by it included housing. work. tinancial circumstances. social contact. relattonships, domestic situation. legal matters and ‘others’. C/(E ,!f tr/c&o/. Patients and control\ were screened for drinking problems with the four-question
Psychosocial
factors
12 1I Those scoring
Cage questionnaire problem.
and admission
for poor glycaemic
two or more positive
answers
control
were considered
In those for whom it was relevant. these were identified using four open-ended to the diabetic person specifically rather than their partner. I. Has there been any decrease in sexual activity since developing diabetes? 2. Men-is this due to loss of function? 3. Women-is this due to loss of sensation? 4. Both-is this due to loss of interest in sex? Data
337 to have an alcohol
questions
which refer
analysis
The two groups were compared as matched pairs i.e. each subject with its matched control and the McNemar and Sign Tests applied to test for significance. In instances where this was not possible, the tests used are included in the results.
RESULTS
Admitted
group
Medical conditions such as infections were considered responsible for poor control in one-third of admissions. The remaining two-thirds of admissions had less clearly defined causes of poor control resulting from inadequate self-care e.g. nonadministration of insulin or poor understanding of the diabetic condition. Those with a medical precipitant were more likely to be admitted as emergencies (Table I) whilst the rest of the admitted group generally had a number of clinic visits in which poor control was identified and, despite advice, remained unsatisfactory so eventually culminated in an elective admission for stabilization. Both the admission subgroups described similar psychosocial problems (Table I). Demographic
and medical
characteristics
Fewer admissions were married, in social classes I and II or employed (Table II). Statistically more admissions had diabetic complications and were adversely affected TABLE
I.-CHARACTERISTICS
Emergency admissions Diabetic complications with moderate/severe effect Other condition present with moderate/severe effect Life events Independent life events Chronic difficulties Independent difficulties Social problems Alcohol problems Past/present psychiatric history PSE cases Total PSE score Total POMS and subsections EPI neuroticism *Mann-Whitney
OF ADMITTED
‘Medical’ sub-group
Factor
U-Wilcoxon
N=29 22 26 15 I5 3 2s 8 1s 6 14 3 14 3
(%) (75) (89) (51) (51) (10) (86) (27) (51) (20) (48) (IO) (48) (IO)
rank Sum IV Test Used
GROUP
‘Non-medical’ sub-group N=60 15 58 10 28 5 45 16 40 11 25 9 23 9
(%) (25) (96) (16) (46) (8) (75) (26) (66) (18) (41) (15) (38) (15)
P(x2)
