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INTRODUCTION: Disease is defined as a situation resulting in physical and psychological imbalance, and this is more common among individuals with chronic diseases. People attempt to cope with the negative aspects of life caused by the disease by developing different adaptation mechanisms1 . An important consequence of the chronic nature of the disease is that the possibility of mental, emotional, social, and psychosexual problems being experienced is higher than for diseases that are not chronic. In people with Diabetes Mellitus (DM), depression and anxiety may be linked to hyperglycemia and increased levels of HbA1c. Scales and inventories to assess diseasespecific general stress or specific characteristics of distress such as worry or FoP (fear of progression) have been developed in studies to overcome this problem2 . In this study, we intended to research the relationship between DM and the FoP scale, a scale developed by Herschbach et al. based on patients with cancer, diabetes, and rheumatologic diseases, recommended for use by people with chronic disease and used to date on many cancer patients.
MATERIALS AND METHODS: Patients: The sample population of the research was patients with a diagnosis of type 2 DM attending Ordu University Medical FacultyEducation and Research Hospital Diabetes clinic between 1 January and 1 June 2014. The basic inclusion criteria for the study were: no current and/or previous history of psychiatric disease or treatment, age between 18 and 80 years, voluntary participation in the study, and no physical or cognitive obstacles to being interviewed or completing the applied scales. Apart from these participants, the study scanned information in the system to include patients with HbA1c values taken within the previous 3 months. Statistical analysis classified patients into a variety of groups. According to HbA1c value, two groups were formed with HbA1c≤7 and HbA1c>7, respectively. According to BMI value, 4 groups were determined: normal, overweight, obese and morbidly obese. Three groups were classified according to age: 18-40 years, 40-60 years, and above the age of 60. Lastly, patients were grouped according to duration of disease (0-3 years, 3-5 years, 5-10 years, 10-20 years and more than 20 years). The research was completed with 151 patients who fit the criteria stated above. Information was collected with a data collection form prepared by the researchers, the hospital anxiety depression scale, Rosenberg self-esteem scale and the fear of progression questionnaire. Fear of
Progression Questionnaire: The Fear of Progression questionnaire (FoP-Q) was recently created by Herschbach et al. to evaluate fear of a disease advancing in patients with breast cancer, diabetes mellitus, and rheumatic diseases (2). It consists of 43 items and was developed and tested in Germany. It includes 5 subscales of affective reactions (13 items), partnership/family (7), occupation (7), loss of autonomy (7), and coping with anxiety (9). The total score can be calculated by all anxiety subscales, and there is a single total score for the coping subscale. Each item is evaluated with a five-point Likert scale (from 1 [never] to 5 [very often]). Points are given as both subscale and total points. Validity and reliability studies for Turkey have not yet been completed. The English version of the scale was translated to Turkish by Cosar et al.
Statistical Analysis: Descriptive statistics of all data are given as frequency, median, minimum and maximum values. As the data did not follow normal distribution, the Mann Whitney U test was used to compare two groups and the Kruskal-Wallis test was used to compare more than two groups. If a significant difference was found by the Kruskal-Wallis test (p7, the total and sub-parameters of FoP, HADS and sub-parameters, and self-esteem points were compared. Accordingly, while there was no significant difference found between the two groups in terms of total FoP points, the coping subscale in the HbA1c ≤7 group was significantly higher (p=0.0001). The HADS total points (p=0.0023) and both anxiety (p=0.0059) and depression (p=0.0001) subscale points were found to be significantly higher in the HbA1c>7 group compared to the HbA1c ≤7 group. When compared in terms of gender, while there was no difference in FoP total points between the genders, the affective reaction points of women were found to be higher by a significant degree compared to the points for men (p7 group compared to the HbA1c ≤7 group. While no significant difference was found between the HbA1c ≤7 and HbA1c >7 groups in terms of total FoP points and other subscale parameters, the FoP subscale of coping was found to have significantly higher levels in the HbA1c ≤7 group compared to the HbA1c >7 group. When the effect of gender on anxiety and depression is examined, though there was no difference in the total FoP points, women had affective reaction points that were significantly higher than the points for men (p<0.05). In a similar fashion, the HADS total and anxiety and depression points of women were found to be higher than for men at a statistically significant level. Patients with chronic physical diseases, like cancer, rheumatic diseases and diabetes mellitus, have a high incidence of anxiety disorders. Compared with the general population, patients with diabetes mellitus had more than 6 times the rate of generalized anxiety disorders. The criteria developed to aid diagnoses of anxiety disorders are suited to the general population and may not be relevant to patients with chronic physical disease. In order to classify as a mental disorder according to the DSM-4 (or ICD-10) (3), excessive, irrational or inappropriate displays of anxiety should be present DM is a non-contagious chronic disease beginning in middle or advanced age which creates the perception of a real threat in patients due to the disease itself, its high morbidity and mortality, and possible complications. This is different from irrational or psychiatric anxiety because the underlying fear is real and independent. As such, a specific tool is needed to assess it, and this is why the FoP-Q was developed. The coping scale item, separate from other subscales of the FoP-Q, inquires into whether patients can access help from various sources, such as relaxation or pleasant activities, and whether they can talk to doctors about concerns and fears (4). The high coping points obtained by patients with HbA1c ≤7 may indicate that DM patients could benefit from supportive interventions for blood glucose control. This result supports studies in the literature emphasizing the positive relationship between HbA1c levels and anxiety values (5). As a result, we believe that developing the coping skills of DM patients may indirectly provide a protective effect on blood sugar levels and thus on possible complications that may develop in the future. Our study is the first in our country researching the fear of disease progression in DM patients. While we believe it to be an important contribution to the literature, there are some limitations. Our patient numbers are low and it is a single-center study, making it difficult to generalize our findings. This topic requires broader and multi-centered studies. Another limitation is that validity and reliability studies of the scale have not been completed in Turkey. Cosar et al. continue to work on this topic.
CONCLUSION: There is a positive relationship between the stress coping skills of a person and blood sugar control. The FoP-Q coping subscale points of patients with HbA1C ≤7 were higher than in the HbA1C >7 group. This shows that if the coping skills of individuals with a chronic disease like DM can be developed, if the worries of the person related to disease are reduced, this may contribute to blood sugar regulation. In chronic diseases like DM, instead of using scales based on the general population or psychiatric diseases, the use of the FoP-Q scale to identify worries related to situations that are more true to the real life of patients or that affect quality of life may be a good marker of psychiatric interventions for the clinician.