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Psychosociale interventies bij mensen met diabetes

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Psychologie en Gezondheid

Summary

Psychosocial interventions in diabetic patients

Diabetes treatment largely consists of self-care. On a daily basis, and probably life-long, diabetic patients need to balance their medication, diet and exercise. They constantly need to be aware for signs of deregulation of blood glucose levels or emerging complications. Diabetes is regarded a disease with a huge emotional impact. As a result, psychological problems, ranging from adaptation problems to depression and anxiety disorders, are common in diabetic patients.

A large diversity of psychological interventions has been developed for patients with diabetes. In this paper, we will subdivide these interventions in interventions embedded in regular care, additional outpatient psychological care and interventions for diabetes-related psychopathology.

Most intervention studies concern additional outpatient psychological programmes. Research shows no effects to moderate effects of these programmes in improving blood glucose, whereas moderate effects are reported in psychological well-being. Increasing intensity, specificity of the target group for treatment and a sound theoretical underpinning increase the efficacy of these interventions. Most interventions use some form of cognitive behavioural therapy. Limited research focuses on psychological intervention embedded in regular care, but the few publications report positive effects. There is ample research on incidence and aetiology of psychopathology in diabetic patients, but little is known about the efficacy of treatment in this group of patients. In general, both standard medication and psychotherapeutic interventions seem effective, although it is essential that therapists have knowledge in the field of diabetes.

The large majority of studies primarily focus on the efficacy of the interventions, disregarding other aspects like the impact in clinical practice. For example, it is mostly unknown whether the target group is reached and whether the intervention is performed as intended.

We notice main caveats in research on psychological interventions in regular diabetes care and in effect studies on treatment for psychopathology in diabetic patients. Currently, psychological problems are increasingly screened for in clinical practice, which is an important first step for psychological care.

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    J. C. Keers

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  1. J. C. Keers
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  2. F. Pouwer
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Correspondence to J. C. Keers.

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Dr. J.C. Keers is als psycholoog werkzaam bij de Afdeling Endocrinologie van het Universitair Medisch Centrum Groningen. Dr. F. Pouwer is als medisch psycholoog werkzaam bij CoRPS, Center of Research on Psychology in Somatic diseases, Afdeling Medische Psychologie, Universiteit van Tilburg, hij is tevens verbonden aan VU medisch centrum, Afdeling Medische Psychologie.

Correspondentieadres: Dr. J.C. Keers, Afdeling Endocrinologie, UMCG, Postbus 30.001, 9700 RB Groningen

Bijlage 1: Diabetes Mellitus

Bijlage 1: Diabetes Mellitus

Incidentie en prevalentie

Diabetes Mellitus (letterlijk: Honingzoete doorloop) is een veelvoorkomende chronische aandoening met een wereldwijd toenemende prevalentie. In 2003 waren er ruim 600.000 mensen in Nederland bij de huisartsen geregistreerd als diabetespatiënt (Rijksinstituut voor Volksgezondheid en Milieu (RIVM), 2004) en in 2003 was de incidentie van diabetes circa 70.000. Naast deze bekende diabetespatiënten waren er in 2003 naar schatting 250.000 mensen met diabetes zonder dat zij dit wisten. Door gerichte screening neemt deze laatste groep af. De diagnose diabetes wordt gesteld op basis van een nuchter bloedglucosespiegel van boven de 6,9 mmol/l en niet-nuchter boven de 11,0 mmol/l

Typen diabetes

De Wereld Gezondheidsorganisatie (WHO) onderscheidt diverse typen diabetes, waarvan type-1 en type-2 de meest voorkomende vormen zijn. Bij type-1 diabetes worden de insulineproducerende eilandjes van Langerhans vernietigd als gevolg van een auto-immuun reactie. Insuline is nodig om glucose vanuit de bloedbaan op te nemen in spiercellen en de lever. Type-1 diabetes ontstaat meestal vóór de leeftijd van 20 jaar. Circa 10-15% van de mensen met diabetes heeft type-1 diabetes.

Bij type-2 diabetes is er een relatief insulinetekort, meestal omdat de lichaamscellen verminderd gevoelig zijn voor insuline (insulineresistentie). Type-2 diabetes wordt veroorzaakt door een combinatie van een genetische dispositie en leefstijlfactoren, te weten overgewicht en bewegingsarmoede. Type-2 diabetes ontstaat meestal op latere leeftijd, hoewel het door toename in obesitas steeds vaker op jongere en zelfs de kinderleeftijd voorkomt. Ongeveer 85-90% van de diabetespatiënten heeft type-2 diabetes.

Behandeling

Het primaire behandeldoel bij alle typen diabetes is het normaliseren van de bloedglucosewaarden. De standaardbepaling voor bloedglucoseregulatie is het geglycolyseerde hemoglobine (HbA1c), dat idealiter onder de 7% ligt, maar vaak hoger is. Het HbA1c is een belangrijke voorspeller voor het ontwikkelen van complicaties van diabetes (UKPDS, 1998a; Diabetes Control and Complications Trial Research Group (DCCT), 1996), maar ook andere risicofactoren zoals hoge bloeddruk en verhoogde cholesterolwaarden vallen onder de behandeling van diabetes.

De dagelijkse behandeling van type-1 diabetes bestaat uit het toedienen van insuline door middel van subcutane injecties of een insulinepomp. Om de juiste hoeveelheid insuline toe te dienen moet de patiënt regelmatig zijn bloedglucose testen met behulp van een vingerprik. De behandeling van type-2 diabetes wordt na de diagnose meestal behandeld met bloedglucoseverlagende tabletten. Wanneer de orale medicatie niet afdoende werkt moeten type-2 diabetespatiënten ook insuline gebruiken. De behandeling is echter niet alleen medicamenteus, maar bestaat uit een goed evenwicht tussen medicatie, voeding en lichaamsbeweging, zoals we in de inleiding beschrijven.

Langetermijncomplicaties

Bij diabetespatiënten ontstaat na verloop van tijd micro- en macrovasculaire schade als gevolg van verhoogde bloedglucosewaarden. Hierdoor hebben diabetespatiënten een sterk verhoogde kans op hartinfarcten, beroerten en nierfalen. Ook schade aan het netvlies komt vaak voor en kan uiteindelijk tot blindheid leiden. Door een combinatie van een slechte doorbloeding en neuropathie kan schade aan voeten en onderbenen optreden, die zelfs kan leiden tot amputatie. Ook impotentie komt vaker voor. Diabetes kan leiden tot hersenbeschadiging, hoewel de pathogenese hiervan nog grotendeels onduidelijk is (Ryan, 2006). Naarmate de diabetesregulatie beter is, is de kans op complicaties kleiner, maar ook bij strikt gereguleerde patiënten kunnen complicaties ontstaan.

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Keers, J.C., Pouwer, F. Psychosociale interventies bij mensen met diabetes. PSEG 36, 209–220 (2008). https://doi.org/10.1007/BF03077502

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