State of the art: understanding and integration of the social context in diabetes care.

We review the past 25 years of research addressing challenges people living with diabetes experience in their daily lives related to social contexts, i.e. in their family, at work and in society at large, and identify research gaps. We found that young people with diabetes, as they develop through to adulthood, are exposed to considerable risks to their physical and mental health. Family-system interventions have had mixed outcomes. Research in this area would benefit from attention to ethnic/cultural diversity, and involving fathers and other family members. In adults with diabetes, social support relates to better diabetes outcomes. While family member involvement in care is likely to affect health and psychosocial outcomes of the person with diabetes, key elements and mediators of effective family interventions need to be identified. The challenges of diabetes management at work are under-researched; distress and intentional hyperglycaemia are common. When depression is comorbid with diabetes, there are increased work-related risks, e.g. unemployment, sickness absence and reduced income. Research to support people with diabetes at work should involve colleagues and employers to raise awareness and create supportive environments. Stigma and discrimination have been found to be more common than previously acknowledged, affecting self-care, well-being and access to health services. Guidance on stigma-reducing choice of language has been published recently. Resilience, defined as successful adaptation to adversity such as stigma and discrimination, requires studies relevant to the specific challenges of diabetes, whether at diagnosis or subsequently. The importance of the social context for living well with diabetes is now fully recognized, but understanding of many of the challenges, whether at home or work, is still limited, with much work needed to develop successful interventions.

Two for one? Effects of a couples intervention on partners of persons with Type 2 diabetes: a randomized controlled trial.

AIMS: To compare the outcomes of partners who participated in a telephone couples behavioural intervention to improve glycaemic control in persons with Type 2 diabetes with those of untreated partners of participants in an individual intervention or education; to explore 'ripple effects', i.e. positive behaviour changes seen in untreated partners. METHODS: The Diabetes Support Project was a three-arm randomized telephone intervention trial comparing outcomes of couples calls (CC), individual calls (IC) and diabetes education calls (DE). Couples included one partner with Type 2 diabetes and HbA1c ≥ 58 mmol/mol (7.5%). All arms received self-management education (two calls). CC and IC arms participated in 10 additional behaviour change calls. CC included partners, emphasizing partner communication, collaboration and support. Blinded assessments were performed at 4, 8 and 12 months. Partner outcomes were psychosocial (diabetes distress, relationship satisfaction, depressive symptoms), medical (BMI, blood pressure) and behavioural (fat intake, activity). RESULTS: Partners' (N = 268) mean age was 55.8 years, 64.6% were female and 29.9% were from minority ethnic groups. CC (vs. IC and DE) partners had greater reductions in diabetes distress, greater increases in marital satisfaction (4 and 8 months), and some improvements in diastolic BP. There were no consistent differences among arms in other outcomes. There was no evidence of a dietary or activity behaviour ripple effect on untreated partners, i.e. comparing partners in the IC and DE arms. CONCLUSIONS: A collaborative couples intervention resulted in significant improvements in partner diabetes distress and relationship satisfaction. There were no consistent effects on behavioural or medical partner outcomes, and no evidence of diet or activity behaviour ripple effects, suggesting that partners should be targeted directly to achieve these changes. (Clinical Trial Registry No: NCT01017523).

The marital relationship and psychosocial adaptation and glycemic control of individuals with diabetes.

OBJECTIVE: To explore the relationship between marital relationship domains (i.e., intimacy and adjustment) and glycemic control and psychosocial adaptation to diabetes. RESEARCH DESIGN AND METHODS: A total of 78 insulin-treated adults with both type 1 and type 2 diabetes were assessed on a single occasion. They completed two marital quality measures (Spanier Dyadic Adjustment Scale and Personal Assessment of Intimacy in Relationships Scale) and four quality-of-life measures (Diabetes Quality of Life Scale, Medical Outcomes Study Health Survey, Problem Areas in Diabetes Scale, and Positive and Negative Affect Scale). Glycemic control was assessed by HbA(1c). Demographic data (age, sex, type and duration of diabetes, years married, other medical conditions, family history, disability, and years of education) were gathered from the chart and questionnaires. RESULTS: Concerning psychosocial adaptation, both of the marital quality measures were predictors of aspects of adaptation. Better marital satisfaction was related to higher levels of diabetes-related satisfaction and less impact, as well as less diabetes-related distress and better general quality of life. Higher levels of marital intimacy were related to better diabetes-specific and general quality of life. Concerning glycemic control, there was a nonsignificant trend for marital adjustment scores to relate to HbA(1c) (P = 0.0568). CONCLUSIONS: For insulin-treated adults with diabetes, quality of marriage is associated with adaptation to diabetes and other aspects of health-related quality of life. The suggestive finding that marital adjustment may relate to glycemic control warrants further study. Future work should also explore the impact of couples-focused interventions on adaptation, adherence, and glycemic control.

A prospective study of psychological predictors of lumbar surgery outcome.

STUDY DESIGN: Prospective design in which 102 patients were evaluated with a battery of psychological assessment tests 1-2 weeks before surgery, and outcome was assessed 6 months and 1 year after surgery. OBJECTIVES: The study examined whether three aspects of psychological distress (depression, anxiety, and hostility) predict several surgical outcomes (employment status, subjective pain change ratings, and changes in functional abilities). SUMMARY OF BACKGROUND DATA: Surgery for back pain has been shown to yield poor results in 15-45% of patients. Tools are needed to identify those "at risk" for poor outcome. Aspects of emotional distress, including anxiety, depression, and hostility, have been found to be relevant to various illness outcomes (e.g., cancer, heart disease), but their influence has not been prospectively evaluated for back pain surgical outcome. METHODS: Study patients completed measures of distress before surgery, including the Spielberger Trait Anxiety Inventory, Zung Depression Scale, Modified Somatic Perception Questionnaire, and Cook-Medley Hostility Scale. At 1-year follow-up, patients completed pain change ratings, functional abilities measure (Dallas Pain Questionnaire), and questions about employment status. RESULTS: Multivariate regression analyses, controlling for significant demographic variables, found that failure to return to work was predicted by presurgical anxiety (P < 0.001) and depression (P < 0. 01); failure to report improvement in pain was predicted by presurgical somatic anxiety (P < 0.01) and depression (P < 0.058); and failure to report improved functional abilities was predicted by presurgical somatic anxiety (P < 0.01) and depression (P < 0.05). Hostility did not predict any outcome. Regression analyses found a strong predictor to be a combination of the Zung Depression Scale and Modified Somatic Perception Questionnaire, known as the Distress and Risk Assessment Method (DRAM). CONCLUSIONS: These results indicate that screening for presurgical distress is likely to identify those patients at risk for poor outcome. Studies to evaluate whether presurgical psychological treatment improves outcome are warranted.

Impact of the work environment on glycemic control and adaptation to diabetes.

OBJECTIVE: To evaluate quantitatively whether the work environments of adults with diabetes relate to the adequacy of metabolic control and/or to the individual's adaptation to diabetes and to explore qualitatively the interactions between an individual's life at work and ways of coping with diabetes. RESEARCH DESIGN AND METHODS: A total of 129 insulin-requiring adults who were employed outside of the home were assessed on a single occasion. They completed two work system measures (The Work Environment Scale and The Work Apgar Scale) and two quality-of-life measures (The Diabetes Quality of Life Scale and The Appraisal of Diabetes Scale). Subjects also participated in a semi-structured interview concerning the interaction of work and diabetes. Glycemic control was assessed by using HbAlc results. Demographic data (age, sex, diabetes type, duration of diabetes, number of diabetes-related medical complications) were gathered from the charts. RESULTS: Concerning glycemic control, neither of the work system measures was a significant predictor of HbAlc. Concerning psychosocial adaptation, supervisor support was found to be a significant predictor of positive appraisal and diabetes-related satisfaction. Involvement and coworker cohesion also predicted aspects of diabetes-related quality of life. Interview themes showed that for a minority (18%), diabetes affected choice of work and that for a majority (60%), diabetes affected relationships at work and raised financial/job concerns (49%). Most adjust their diet, blood glucose testing, and exercise regimen through work-related modifications. CONCLUSIONS: For insulin-treated adults with diabetes, work system variables do not directly relate to glycemic control, but they do relate to psychosocial adaptation. Future work should examine further the specific aspects of the workplace that might affect adaptation, with the goal being to develop worksite interventions that target not only the employee with diabetes but also their supervisors and coworkers.

Family environment, glycemic control, and the psychosocial adaptation of adults with diabetes.

OBJECTIVE: To evaluate whether the family system variables of adults with diabetes relate to the adequacy of metabolic control or the psychosocial adaptation to the illness. RESEARCH DESIGN AND METHODS: A total of 150 insulin-requiring adults were assessed on a single occasion. They completed two family system measures (the Family Environment Scale [FES] and the Diabetes Family Behavior Checklist [DFBC]), two quality-of-life measures (the Diabetes Quality of Life Scale and the Medical Outcomes Study Health Survey-36), and one measure of cognitive appraisal (the Appraisal of Diabetes Scale). Glycemic control was assessed using HbA1c results. Demographic data (age, sex, diabetes type, duration of diabetes, and number of diabetes-related medical complications) were gathered from the patients' charts. RESULTS: Concerning glycemic control, none of the family system measures were significant predictors of HbA1c. Older age and longer duration of diabetes predicted higher HbA1c values. For psychosocial adaptation, when family members behaved in ways that supported the diabetes care regimen (measured by the DFBC), the individual with diabetes was more satisfied with his or her adaptation to the illness and reported less interference in role function due to emotional problems. Family cohesion (measured by the FES) also related to better physical function. Women reported higher levels of diabetes satisfaction. The Appraisal of Diabetes Scale predicted glycemic control and psychosocial adaptation. CONCLUSIONS: For insulin-treated adults with diabetes, family system variables do not relate to glycemic control, but they do relate to psychosocial adaptation. Future work should explore the impact of family-centered interventions on adaptation, sex differences in adaptation, and the use of the Appraisal of Diabetes Scale as a first-line clinical screening tool.

Assessing emotional distress of women with breast cancer: a survey of surgical oncologists.

Studies to identify women with breast cancer who are at risk for psychosocial morbidity have identified several predictors, two of which are the focus of this study: 1) prior psychiatric history, and 2) poor initial emotional response to diagnosis. To examine current medical practice a survey was mailed to members of the Society of Surgical Oncology (response rate = 41.21%) asking how often they assess these two factors, reasons for not doing so, and asssessment methods. Results indicate that the majority rarely assess psychiatric history but frequently assess current emotional state, primarily using interview questions. Recommendations are presented to increase the likelihood of psychiatric assessment and enhance its value to the patient and physician.

Counseling needs of women with breast cancer: what the women tell us.

Research has demonstrated that some women treated for breast cancer are at risk for significant and persistent emotional distress and disrupted quality of life. Factors identified that appear to make women psychologically vulnerable include younger age at diagnosis, a history of high life stress or depression prior to diagnosis, and more advanced disease. Research has quickly moved to develop and implement psychological interventions to help these women, although little is known about the patients' perceptions of their need for, and use of, such services. This article presents research that focuses on the perceptions of the women themselves using a survey technique.

Chronic pain and depression: is social support relevant?

This study examined the relationship between social support and depression for 70 patients with chronic back pain. We also explored whether the family environments of these patients related to depression and whether the patients' depression predicted outcome subsequent to involvement in a functional restoration program. The patients completed a battery of psychological questionnaires to assess depression, social support, and family environment. Outcome of a rehabilitation program was measured in terms of physical gains, vocational gains, and progress made toward program goals. Analysis indicated that the 25 depressed and 23 nondepressed patients differed as to perceived social support and quality of family environment; however, no association was found between depression and rehabilitation outcome. Implications for family interventions are discussed.

The potential impact of the Workers' Compensation System on quality of life outcomes: A clinical analysis.

It is widely recognized that the Workers' Compensation System has evolved into a costly adversarial, stress engendering set of interactions. Most prior research has examined the pathology of the individual which contributes to these costs. This paper presents an analysis of the ways that the system itself is pathogenic. Based on a model of factors comprising health-related quality of life, we analyze how the environment of the Workers' Compensation System promotes increased symptom reports, decreased functional status and negative general health perceptions while fostering destructive anxieties. We recommend that future prospective research move from a focus on the individual to a focus on the system and its interaction with the individual.

Rehabilitation of the patient with chronic back pain. A search for outcome predictors.

This prospective study was initiated 3 years ago to evaluate the outcome and to identify predictors of success or failure in patients admitted to a rehabilitation program for chronic low-back pain. Multiple parameters were evaluated, including psychologic data (MMPI, personal interview, pain drawing, etc.), physical measurements (flexibility, strength and endurance), and demographic data concerning the patient's home and working environment. Information was available on each patient admitted to the program prior to his admission, at completion of the program, 6 weeks following completion of the program and 3 months following completion of the program. A telephone interview was carried out 2 1/2 years following the patient's discharge from the program. Linear regression analysis was used to identify the important independent variables with regard to the dependent variables of relief of back pain, return to work and increased activities at home. Demographic data were of no value as a predictor with the exception of age and returning to work. The patients over the age of 50 returned to work with much less frequency than those less than 50. Psychologic information from the MMPI and similar tests were of no value. The personal preadmission interview of a trained psychologist, however, was a good predictor of an individual's eventual return to work and overall improvement. Worker's Compensation and other litigation was a negative factor in a patient's prognosis. The treatment team's prognosis at the time of discharge from the program was the best overall predictor of a patient's chance of success or failure in the longterm.

Functional vs. organic pain: a meaningful distinction?

This study examined the statistical and clinical validity of the distinction frequently made between "functional" pain and "real" pain. Earlier work has relied on the MMPI exclusively and results have been inconclusive, yet the distinction continues to be made and treatment is recommended on the basis of the label. Sixty-seven chronic back pain patients were administered questionnaires that assessed quantity and quality of depression, dimensions of illness behavior, and psychogenic attitudes. Scores of chronic pain patients were compared to normal subjects, and results indicate that the pain subjects experienced high levels of depression, anxiety, and social alienation. However, organic pain subjects did not differ from subjects with no organic findings. The authors suggest that the distinction between organic and functional pain be discarded in favor of an approach that assesses current emotional stressors and available coping mechanisms.

Mastery, stress, and coping in marriage among chronic pain patients.

Marital stress, strain, and coping strategies were investigated in chronic pain patients by administering the Problems of Everyday Life Interview (PEL) to 55 married chronic pain patients. Subjects were assigned to either limited, moderate, or heightened mastery groups based upon PEL mastery scores. The heightened mastery group reported less marital strain, less marital stress, more use of negotiation, less use of selective ignoring, and less use of manage-stress coping strategies than either limited mastery or moderate mastery groups. There were no significant differences between limited mastery and moderate mastery groups on any variables measured. There were no differences between mastery groups on advice seeking. The effects of mastery as a mediator of coping and stress are discussed, as well as the advisability of incorporating treatments that specifically address feelings of lack of control over stressful events into chronic pain programs, especially when marital problems are identified.

Chronic back pain: a tripartite model of outcome.

Studies of patients with chronic low back pain have yielded conflicting results and have been complicated by methodologic differences. This study adopts a tripartite model of outcome, including self-reports, physical measures, and objective indices of success, and examines outcome of a behavioral back rehabilitation program. One hundred thirty-two patients admitted to a back rehabilitation program were assessed physically, behaviorally, and subjectively. Results demonstrate that while 75% of patients provide subjective reports of success and 46% demonstrate significantly improved physical function, only 37% achieve vocational rehabilitation. Relationships between outcome measures are explored and arguments in support of this tripartite model are presented.

The use of the MMPI in a chronic back pain rehabilitation program.

Assessed the usefulness of the MMPI in predicting treatment outcome for chronic low back pain patients. One hundred and thirty-two chronic low back pain patients who participated in a 6-week rehabilitation program were differentiated according to "successful" outcome. Outcome was defined in three major ways: Vocational restoration, significantly improved physical mobility, and patients' subjective evaluations of improved functional level. Pretreatment MMPIs of all outcome groups were compared. Data were analyzed by examining individual scale scores and code-types and by applying multiple regression analyses to the data. Results demonstrate that the MMPI can predict successful outcome. However, the strength of the relationship varies according to the outcome measure employed and the type of analysis completed on the data. It is concluded that, though an interesting research tool, at this time the MMPI is not a consistently valid clinical tool with the chronic back pain population in terms of predicting response to rehabilitation.