How well do patients cope with diabetes?
Questionnaire provides patient perspective
Why don't patients stick to their diets and exercise plans? Don't they have any willpower or self-discipline? Don't they realize diabetes is a serious disease?
When patients have poor control over their diabetes, the cause may be their failure to follow their treatment regimen.
But rather than blaming the patients for their apparent weaknesses, physicians should try to understand the barriers to successful treatment from the patient's point of view, says William H. Polonsky, PhD, CDE, a clinical psychologist in San Diego who specializes in counseling patients with diabetes.
Polonsky developed the Problem Areas in Diabetes (PAID) questionnaire to help physicians gauge how well their patients are coping with the disease. The 20-question survey asks patients about their family and social support; feelings of anxiety, depression, or anger; and other coping issues. (See copy of the PAID instrument, p. 43.)
Stress can be overwhelming
Patients may feel discouraged by the mental and physical effort of managing their disease, he says. "Some of them need to talk to their physicians about easing up or changing their diabetes regimen so it doesn't feel so crushing and overwhelming," says Polonsky, who is an assistant clinical professor in psychiatry at the University of California at San Diego.
In addition to the PAID questionnaire, physicians should use a depression screen with diabetes patients, advises Polonsky. While PAID includes a question about depressed moods and can provide an indication of that problem, it is not intended to screen for depression, he says. Research shows that about a third of diabetes patients suffer from depression.1
The PAID form was designed to be brief and easy to use. It can be used by busy clinicians as a starting point for conversations during office visits, says Garry Welch, PhD, an investigator at the Joslin Diabetes Center in Boston, where the PAID questionnaire was developed. Welch, who is also an assistant professor in the department of psychiatry at Harvard Medical School, says patients generally enjoy filling it out.
"[Patients] find it gives them an opportunity to tell their stories," says Welch. "[The questionnaire] is a comfortable lead-in into what the patients' main issues are."
Survey useful for outcomes management
Yet PAID can become a part of outcomes management, as well. It can be scored manually or with new software that Welch has developed as part of the Diabetes Psychosocial Management Aid.
(That software package includes other assessment tools and instant reports. A new version expected in the spring will include recommendations tied to scoring results on the assessments. See editor's note, below, for contact information.)
With the overall score presented on a 0-100 scale, "you can get a sense for the overall burden of disease and compare the score to norms for diabetes treatment groups," says Welch.
The PAID tool also may pick up some issues before they become apparent clinically, says Polonsky. "There are people who will score high on PAID (indicating multiple coping problems) who are in fact managing their diabetes very well," he says. "We tend to ignore those people."
Patients will likely feel relief that the physician is addressing their psychosocial needs, says Polonsky. Physicians also may find ways to help the patient avoid a burnout from following a strict regimen.
"I hope physicians will realize that the reason their patients are struggling is almost never about willpower," he says. "The reasons always make sense from the patient's perspective. PAID is a way to encourage both the patient and physician to look at that."
Editor's note: For more information about the Diabetes Psychosocial Management Aid or use and scoring of the PAID questionnaire, contact Garry Welch, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215. Telephone: (617) 732-2441. Fax: (617) 732-2451.
Reference
1. Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes: An epidemiological evaluation. Diabetes Care 1993; 16:1,167-1,178.
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