Difficulty trusting and reaching out to others may shorten diabetes patients' lives

Diabetes patients who have a lower propensity to reach out to others have a higher mortality rate than those who feel comfortable seeking support. These are the findings of a five-year study reported by Dr. Paul Ciechanowski, associate professor of psychiatry and behavioral sciences at the University of Washington (UW) and an affiliate investigator at Group Health Research Institute in Seattle.

Ciechanowski also directs the training insitute at the Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP) at Harborview Medical Center, which is part of UW Medicine.

The report was published in this month's Diabetes Care, a professional journal of the American Diabetes Association.

This is the first known study, the research team believes, to examine the association between relationship styles and mortality.

The researchers examined 3,535 adult patients with type 1 and type 2 diabetes enrolled as Group Health Cooperative patients in the Puget Sound area of Washington state. Because depression has been linked to premature death from diabetes, patients with depression were not included to avoid confounding the study results.

The patients completed a relationship questionnaire, developed in 1994 by Griffin and Bartholomew. Based on the results of this survey, patients were divided into two groups: those with an interactive style and those with an independent style in relating to people.

Individuals with an interactive style find it easy to get close to others and rely on them, and in turn are dependable for others. Those with an independent style tend to be either dismissive or fearful of close relationships. Some people with this style would like emotional closeness, but find it hard to trust or depend on others. Others can be indifferent to close relationships, preferring instead to be free and self-reliant.

"These ways of relating often extend to their relationships with health-care providers," the researchers said.

Regardless of their style, most patients Ciechanowski and his colleagues have studied over several projects perceive health care as rushed, impersonal and fragmented. Those with an independent style also reported feeling threatened by the power health-care providers had. Some were highly attuned to signs of rejection; others were sensitive to being controlled, and at the same time worried that help would not be available for them. Those with an independent style in relationships often felt a wall existed between patients and providers.

Interactive patients tended to understand the pressures health professionals were under, and overlooked minor shortcomings, previous research by Ciechanowski and his team has found. Such patients were more likely to value ongoing relationships with their providers, even when circumstances weren't ideal, and respected their training and knowledge.

During the course of the most recent study, diabetes patients who were mistrustful of people, including health-care providers, had a 33 percent higher mortality rate than those who interacted easily with others and sought comfort and support. The researchers found the significantly higher risk of death among diabetes patients who were less likely to seek support still held after controlling for other potential risk factors for mortality such as age, marital status, other medical conditions, complications of diabetes and body mass index.

The exact mechanisms behind the link between an independent relationship style and a higher mortality rate are not yet known, the researchers said, and further research is needed to delineate the reasons and to develop effective interventions.

"Prior studies have shown that lower support seeking is associated with poorer adherence to treatment," Ciechanowski noted. An independent relationship style, he explained, is often played out in missed appointments, higher glucose readings, lower satisfaction with health-care, and poorer home treatment of diabetes in such areas as foot care, exercise, diet, oral and injectible medication use, blood sugar monitoring, and smoking cessation.

"Many self-management behaviors related to diabetes are optimally carried out in collaboration with others -- family, peers and health-care providers," Ciechanowski noted. Planning and cooking diabetic-friendly meals, exercising, and quitting smoking are best undertaken, he added, with motivational support. Also, as diabetes gets more severe or complications arise, a self-reliant attitude that worked in the past may become a liability.

There are approaches, according to Ciechanowski, that health-care providers can try to improve collaboration with diabetes patients who have an independent relationship style, such as directly and non-judgmentally talking about this style. Also, providers might coach patients and help them set simple goals in seeking support in managing their diabetes. However, the effectiveness of such approaches in reducing the higher death rates among such patients has not yet been tested.

"Our research is based on a developmental theory known as attachment theory where earlier experiences often shape an individual's ability to trust later in life," Ciechanowski explains. "As clinicians, we have to keep in mind that what we say and how we say it can make a big difference in trust between clinician and patient -- which has implications for treatment adherence and health outcomes. Bedside manner matters. Also, as stewards of health care, we have to be mindful about what our fast-paced health-care system says to patients to engender trust or not. Long waits, less face-to-face time with providers, rashly delivered health information, and lack of continuous care can reduce trust -- particularly in those with an independent relationship style."

In addition to Ciechanowski, other researchers on the study "Relationship Styles and Mortality in Patients with Diabetes" were Joan Russo and Wayne Katon, UW Department of Psychiatry and Behavioral Sciences; Elizabeth H.B. Lin, Evette Ludman, Susan Heckbert, and Michael Von Korff, Group Health Research Institute, Seattle; Bessie Young, UW Department of Medicine; and Lisa H. Williams, Veterans Administration Puget Sound Health Care System, Seattle. Heckbert also has a faculty appointment in the UW Department of Epidemiology, and Young has a VA Puget Sound appointment as well. Ciechanowski is founder and CEO of Samepage, an educational company dedicated to improving health-care communications for patients and for providers.

The study was supported with a grant from the National Institute of Mental Health at the National Institutes of Health. The principal investigator on the grant is Dr. Von Korff.