GPs can help their patients adjust to chronic illness
Around 30% of patients with a chronic illness struggle to adjust to their condition. GPs have an important role to play in guiding patients towards a new equilibrium and preventing the detrimental emotional and functional consequences of maladjustment.
Four key components of successful adjustment have been identified: maintenance of physical activity, emotional expression, taking control and finding a positive dimension to the illness.1
Proinflammatory cytokines have a role in producing fatigue, depressive symptoms and inactivity, and patients face the challenge of undertaking graded exercise in spite of these symptoms. In patients with diabetes, cytokines are produced by adipose tissue. However, the recent evidence that diabetes only becomes psychologically harmful after it has been diagnosed suggests that cognitive factors may be more important.2
Patients who believe that it is weak or unacceptable to show strong feelings may suppress their negative emotions.3 This emotional repression may activate the sympathetic nervous system, and inhibit patients from working with health professionals to manage their condition. Interventions that facilitate the release of emotions can result in improved physical and psychological functioning.4
The relationship between psychological wellbeing and effective self-management is bidirectional. A vicious cycle may occur, whereby depressed patients lack the motivation and self-confidence to make the necessary changes to their lifestyle, resulting in further damage to their self-esteem. In contrast, patients who successfully engage in self-management are likely to feel more confident and experience improvements in their mood and sense of wellbeing.
Not all the consequences of chronic illness are negative: patients may start to appreciate life more and relationships may be strengthened. Some studies have suggested that adjustment is better in those patients who are able to find a benefit from their condition.3
Data from the English Longitudinal Study of Ageing (ELSA) suggest that the quality of chronic disease management is not as good as the high QOF scores would suggest.5 Overall, participants reported that they had received 65% of 32 quality indicators developed by the study. However, in the first year of the ‘pay for performance' contract, a median 83% of the QOF clinical indicators were achieved.6 This difference largely reflects substantially lower achievement rates for conditions excluded from the QOF.
The QOF does not measure how well we facilitate adjustment to chronic illness. The most important contribution GPs can make is to encourage patients to take control of the implementation of their treatment: they are the experts on what is feasible.7
The ELSA survey asked seven questions on the quality of patient-centred care. The mean score for these indicators was a disappointing 58%, which, when combined with the achievement rates of the clinical indicators, reduced the overall score to 62%.5
The recognition by the DH of the importance of patient self-care is welcome.8 However, the Expert Patients Programme has only produced a small improvement in self-efficacy (effect size 0.44),9 and there are fears that it will lead to further fragmentation of patient care.7 Group interventions may have a role but should be provided within general practice.
By working in partnership with our patients to help them remain as active as possible, express and process their emotions, gain competence in self-management and discover positive consequences of their illness, there is much that we can do to facilitate a healthy adjustment to their new circumstances.Author
Dr Phillip Bland
BA BM BCh MRCGP DRCOG
The most important contribution GPs can make is to encourage patients to take control of the implementation of their treatment