Written by
Megan Hanrahan, former BSc Psychology Student at Teesside University.
The following study was completed as a final year project in partial fulfilment of the BSc Psychology Course at Teesside University.
The project was supervised by Dr Sarah Allen, Lecturer in Psychology at Teesside University; email: s.allen@tees.ac.uk
Why can coping with a chronic health condition be so challenging?
Living with a chronic health condition can be both physically and mentally challenging. When someone first develops a chronic condition, and symptoms begin to appear, their life can change quite suddenly. They may be forced to adjust and adapt to a high-maintenance lifestyle that was previously unknown to them, which can take a mental toll. Type 1 diabetes (T1D) is a chronic autoimmune condition which affects around 400,000 people in the UK alone. T1D occurs when the pancreas produces little to no insulin, a hormone produced in the pancreas that allows your body to use sugar (glucose) from carbohydrates in the food you eat. When your body does not produce enough insulin, blood sugar levels begin to rise and overtime this can cause damage to nerves, blood vessels and organs, causing your body to not function properly.
For someone with T1D, a high degree of self-management is required to maintain adequate blood sugar control in order to prevent short and long-term diabetic complications, such as hyperglycaemia/hypoglycaemia (high/low blood sugar), retinopathy, and heart disease (Van Duinkerken et al., 2020). A typical day in the life of someone with T1D may include regular blood sugar monitoring, taking insulin via injection or pump, and paying close attention to the macronutrients in food items to determine how many insulin units to take. Having to cope with such a constant routine can impact mental health negatively by triggering anxious feelings and causing stress build-up.
Mental health plays a two-way role in diabetes self-management. For example, facing problems with self-management may result in emotional problems, including stress and anxiety. In turn these emotional problems can limit someone’s ability to achieve adequate self-management by reducing treatment adherence (Strandberg et al., 2014). So, it is equally important that the mental health of a person with diabetes is monitored in the same way as their physical health. Unfortunately, current mental health provision for people with chronic conditions such as T1D is generally limited, with adult consultation primarily focusing upon physical management (Chew et al., 2014). Providing mental health support for all patients is a demanding task as this would increase workload and financial strain on an already strained NHS. Therefore, it may be useful to explore who may be more vulnerable to developing mental health issues.
The first steps: investigating age at diabetes onset
When it came to planning my final year research project for my BSc Psychology, I wanted to focus on the relationship between T1D and mental health having witnessed how demanding the daily self-management routine can be through my partner’s personal experience. The routine seemed constant and somewhat overbearing. I was there during the diagnosis stages and many consultations; I noticed a lack of consideration when it came to mental health or available support. He was 18 years old when diagnosed, which I thought may have been an additional challenge with undergoing such a drastic change in routine as an adult, having never experienced something quite like it. When reading up on T1D and the increased risk for mental health issues I came across a research paper, Kühtreiber et al. (2017), that prompted me to explore differences in mental vulnerability based on age at diabetes onset.
From my reading I discovered that the age someone is diagnosed with T1D could completely alter their experience of living with their condition. The literature had suggested that people who were diagnosed later in life were better aided, biologically, to manage their condition (Kühtreiber et al., 2017). Essentially, people diagnosed earlier in life would experience a rapid loss of an internal substance called C-peptide, which is produced alongside insulin in the pancreas. Whereas people diagnosed later in life would experience a slower decline, sometimes occurring over decades. As persistent C-peptide has been associated with fewer diabetic complications and better blood sugar control, those diagnosed later who retain this C-peptide may experience less mental strain caused by their condition.
I decided to investigate the influence of age at diabetes onset on mental health based on these findings. When I was deciding which aspects of mental health to focus on, there were three that had been suggested to be negatively impacted by living with T1D: stress, response to stressful situations (stress reactivity), and anxiety. I decided on these because a lot of research had concluded that poor diabetes self-management and stress were associated with one another (Boden & Gala, 2018; Hillard et al.,2016). Heightened anxiety was also shown in people with T1D; anxiety disorders and symptoms were 1.2-1.5 times more common in people with diabetes than the general population (Grisby et al., 2002; Smith et al., 2013). Although response to stress was less researched, a few studies had found heightened stress responses among people with T1D (Kramer et al., 2000).
I ran an online survey for people who did and didn’t have T1D and organised the respondents into three groups: diagnosed before 18 (early onset), after 18 (late onset), or not at all (non-diabetic controls). Three questionnaires then followed regarding stress and anxiety levels, and responses to stressful situations. I compared the three groups to look for differences between them.
Was there an influence?
With the help and guidance of my supervisor, Dr Sarah Allen, I found that overall people with an early onset experienced higher levels of background stress, and anxiety, and had a heightened response to stressful situations as opposed to people who were diagnosed after 18 years old. People with an early onset also had higher levels of stress and anxiety than those without diabetes. However, stress and anxiety levels did not significantly differ between those with a late onset and the control group. My findings support that of research suggesting those diagnosed later may be better equipped to manage their condition, and possibly experience fewer distressing diabetes-related experiences. It could also be suggested that people diagnosed at a younger age may have experienced more recurrent diabetic complications, thus increasing their stress and anxiety levels.
What next?
It is clear that mental health struggles occur among people with T1D, and this highlights the importance of a much-needed increase in attention towards the mental health needs of adults with chronic conditions. The inclusion of mental health intervention could have an overwhelmingly positive effect on patient wellbeing, reducing stress and anxiety, and leading to lasting behavioural change (e.g., adaptive coping strategies) that could improve diabetes self-management. However, if we cannot currently offer mental health support as a standard to all, we could potentially consider who may be more vulnerable and provide to those people. My research indicated that those diagnosed before the age of 18 may be at most risk of mental health issues, and intervention should be targeted at this population. Introducing collaborative care to mentally vulnerable patients could be beneficial, working with both primary care and mental health specialists to offer the best chance of improving both mental health and physical outcomes, and with a limited additional cost (Naylor et al., 2021). Overall, T1D can be a very difficult condition to live with, and certainly has its mental challenges.
References
Boden, M. T., & Gala, S. (2018). Exploring correlates of diabetes-related stress among adults with Type 1 diabetes in the T1D exchange clinic registry. diabetes research and clinical practice, 138, 211-219. https://doi.org/10.1016/j.diabres.2017.10.012
Chew, B. H., Shariff-Ghazali, S., & Fernandez, A. (2014). Psychological aspects of diabetes care: Effecting behavioral change in patients. World journal of diabetes, 5(6), 796. doi:10.4239/wjd.v5.i6.796
Grigsby, A. B., Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2002). Prevalence of anxiety in adults with diabetes: a systematic review. Journal of psychosomatic research, 53(6), 1053-1060. https://doi.org/10.1016/S0022-3999(02)00417-8
Hilliard, M. E., Joyce, P., Hessler, D., Butler, A. M., Anderson, B. J., & Jaser, S. (2016). Stress and A1c among people with diabetes across the lifespan. Current diabetes reports, 16(8), 1-10. https://doi.org/10.1007/s11892-016-0761-3
Kramer, J. R., Ledolter, J., Manos, G. N., & Bayless, M. L. (2000). Stress and metabolic control in diabetes mellitus: methodological issues and an illustrative analysis. Annals of Behavioral Medicine, 22(1), 17-28. https://doi.org/10.1007/BF02895164
Kühtreiber, W. M., Davis, M., & Faustman, D. L. (2017). Early‐versus late‐onset type 1 diabetes: two different pathophysiological subtypes with implications for therapy. Immunopathogenesis and Immune-based Therapy for Selected Autoimmune Disorders, 27. doi:10.5772/65598
Naylor, C., Parsonage, M., McDaid, D., Knapp, M., Fossey, M. and Galea, A., 2021. Long-term conditions and mental health. TheKingsFund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf [Accessed 11 September 2021].
Smith, K. J., Béland, M., Clyde, M., Gariépy, G., Pagé, V., Badawi, G., … & Schmitz, N. (2013). Association of diabetes with anxiety: a systematic review and meta-analysis. Journal of psychosomatic research, 74(2), 89-99. https://doi.org/10.1016/j.jpsychores.2012.11.013
Strandberg, R. B., Graue, M., Wentzel-Larsen, T., Peyrot, M., & Rokne, B. (2014). Relationships of diabetes-specific emotional distress, depression, anxiety, and overall well-being with HbA1c in adult persons with type 1 diabetes. Journal of psychosomatic research, 77(3), 174-179. https://doi.org/10.1016/j.jpsychores.2014.06.015
Van Duinkerken, E., Snoek, F. J., & de Wit, M. (2020). The cognitive and psychological effects of living with type 1 diabetes: a narrative review. DFpiabetic Medicine, 37(4), 555-563. doi:10.1111/dme.14216