Relationship Styles and Mortality in Patients With Diabetes

OBJECTIVE

Prior research has shown that less social support is associated with increased mortality in individuals with chronic illnesses. We set out to determine whether lower propensity to seek support as indicated by relationship style, based on attachment theory, is associated with mortality in patients with diabetes.

RESEARCH DESIGN AND METHODS

A total of 3,535 nondepressed adult patients with type 1 and type 2 diabetes enrolled in a health maintenance organization in Washington State were surveyed at baseline and followed for 5 years. Relationship style was assessed at baseline. Patients with a greater propensity to seek support were classified as having an interactive relationship style and those less inclined to seek support as having an independent relationship style. We collected Washington State mortality data and used Cox proportional hazards models to estimate relative risk (RR) of death for relationship style groups.

RESULTS

The rate of death in the independent and interactive relationship style groups was 39 and 29 per 1,000 individuals, respectively. Unadjusted RR of death was 1.33 (95% CI 1.12–1.58), indicating an increased risk of death among individuals with an independent relationship style. After adjustment for demographic and clinical covariates, those with an independent relationship style still had a greater risk of death compared with those with an interactive relationship style (hazard ratio 1.20 [95% CI 1.01–1.43]).

CONCLUSIONS

In a large sample of adult patients with diabetes, a lower propensity to reach out to others is associated with higher mortality over 5 years. Further research is needed to examine possible mechanisms for this relationship and to develop appropriate interventions.The presence of a supportive social network positively affects health by increasing access to instrumental, informational, and emotional support (1). In patients with diabetes, a higher level of social support is associated with improved treatment adherence, better glycemic control, and greater diabetes knowledge (2). Conversely, lower social support has been associated with higher mortality in patients with various chronic conditions (3,4), including patients with diabetes (5).Clinicians treating patients with chronic conditions generally understand these associations and attempt to encourage patients to seek and receive greater support from patients'' family, friends, peers, and social agencies. Clinicians may also encourage greater collaboration in the patient-provider relationship. Although many patients are receptive to such suggestions and efforts, a significant proportion is less receptive or not receptive at all. For example, regardless of the ready availability of a social network, many patients do not benefit from their support at times of need. Among patients who do not collaborate well with others, many have long-term patterns of not doing so, suggesting the influence of stable characteristics. If there are measurable patient characteristics that predict an individual''s capacity to use supports over time, such information may be useful for shaping approaches and recommendations that providers make in clinical settings.Attachment theory provides a theoretical, evidence-based model for understanding the propensity and ability of individuals to reach out to others for support. This theory posits that all individuals develop a cognitive map based on prior experiences that determines one''s comfort and ability to interact with or reach out to others, particularly at times of distress (6). On the basis of empirical research in infants, children, and adults over the past 30 years, distinct relationship styles arising from these cognitive maps have been identified (7) and demonstrate high levels of stability and continuity between early childhood and adulthood (8). Two of the styles, “dismissing” and “fearful” attachment style, are characterized by difficulty reaching out for support or trusting others, and patients with these styles and characteristics have been described as having an independent relationship style (9). Among clinical populations with diabetes, 48% of patients are typically found to have an independent relationship style (10). The remainder have an interactive relationship style, comprising those with “secure” and “preoccupied” attachment styles. Patients with an interactive relationship style have greater comfort reaching out to others, although individuals with a preoccupied style are often characterized as being highly dependent on others (11).In a large sample of primary care patients with diabetes (9,12), an independent relationship style has been associated with more missed primary care visits, lower satisfaction with care, higher A1C levels, and decreased adherence to exercise, quitting smoking, foot care, diet, and oral hypoglycemic medications. Another study showed that having a relationship style characterized by difficulty trusting or reaching out to others is associated with decreased adherence to glucose monitoring and insulin injections among patients with diabetes (13).In a recent article, we demonstrated that patients with major depression in this epidemiological sample were more likely to die over a 5-year period (hazard ratio [HR] 1.53) (14). In the current study, we set out to determine whether relationship styles are associated with mortality in patients with diabetes. Because depression status is associated with poorer collaboration as measured by relationship style (15), we conducted our analyses in nondepressed patients. In the current study, we hypothesized that among nondepressed patients with diabetes, those with an independent relationship style would have higher mortality over a 5-year period than patients with an interactive relationship style.