The term anxiety has become a part of everyday life. The concept of anxiety may differ according to the individual because of anxiety to the individual because of anxiety is an alternating single of depression, its warn of impending danger and enable a person to take measures to overcome treat in life measures to overcome treat in life. The state of psychological factor like joys, sadness, anger fear that seem significant are those provoking feedings of frustration loneliness and dejection (Sadoc 2009).
Anxiety disorders are common and most frequent among all other psychiatric disorders. They were a substantial risk and inability load comparable to what is observed in chronic diseases such as diabetes mellitus (Hattema and Engum (2010). A significant association was observed between anxiety depressions and poor adherence to diet and excise (Diabetes Care 2009)
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Research has shown that relation between anxiety disorders depression and diabetes bound to hyperglycemia, diabetes complication and restraints imposed by diseases. The occurrence of depression individual with diabetes mellitus seem to be related to socio economic status, family status, obesity smoking habits, physical activity, and sedentary life fisher L. Chesla 2001)
Individuals with diabetes mellitus are burdened with personal, socio-demographic and behavioral factor. Which contribute to the manifestation of anxiety and depressive symptoms? (Koylouria and Langana 2004). Women with diabetes mellitus are presented with higher percentage of anxiety and depression when compared to men. Persons who live alone are more vulnerable and face greater risk then persons who live with significant other research results show that past and chronic stress like abusive uncaring family or exposure to physical sexual or emotional abuse can lead low self-esteem pattern of social advance and vulnerability also, may predicable for anxiety and depression, then the stress in the later life it will lead to diabetes mellitus (Eversons Maty Sc 2007).
The combination of anxiety and depression with type 2 diabetes is a public health problem. If diabetes is managed in its initial phase along with stress reduction measures may be prevented. Relaxation techniques and changes of life style are a regular and essential part of health or social miles.
Psychiatric consultation for mental problem, of the anxiety and depression are regarded as a taboo. Usually people follow cultural or religious traditions to address mental illness rather than getting professional help. Untreated anxiety and depression might be responsible for increase the diabetes and co-morbidities because of poor self care (Juarita Hatchen 2009). Non compliance with diet, exercise giddiness lapse in filling prescription for oral diabetes medications are further aggravates the disease condition.
Eventually positive association between diabetes and anxiety and depression has been identified. Exploring this association at the initial stage of type 2 diabetes would help the psychiatric mental health nurse to explore avenue for preventive strategies and also advocacy could be done at policy making level for early reduction of mortality and mortality. Type 2 diabetes and depression are two long course diseases with modifiable risk factor. Diabetes the fourth leading cause of death has affected an estimated 264 million people in the world (Cshazia Parvenn 2009).
Among client with type 2 diabetes depression is found to be strongly associated with increased mortality and mortality. Multiple studies from developed countries have proved positive associates. Type 2 Diabetes with anxiety and depression is high in developing countries of south Asia, the association was significant in rural area of India Bangladesh predominantly among female and young adult. Less physical activity more mental strain and stress will be a predisposing factor for anxiety and depression, These includes socio economic status, past history of gestation diabetes family type body mass index, history of smoking, history of high cholesterol, history of high blood pressure and occupational stress. The health care system of South Asian countries have adequate services for diagnosis and managements of type 2 diabetes mellitus but associated anxiety and depression one not considered.
RISK FACTORS FOR ANXIETY, DEPRESSION AND
TYPE 2 DIABETS MELLITUS
The population of in India has increased susceptibility to diabetes mellitus. The propensity was demonstrated by WHO in a multiple surveys of migrant Indian in 2006.
PSYCHOSOCIAL PROBLEMS
The psychosocial problems arise from works in a working situation failure to adapt to an alien psychosocial environment frustration, lack of job stratifications, insecurity, poor human relationship, emotional tension are some of the psychological factor which may undermine both physical and mental health of all individuals. The capacity to adapt different working environments that influenced by many factor, such as education, cultural, background, family life, social habits and occupational status. The psychological problems when arises it’s contributes to either behavioral change such as hostility. aggressiveness, anxiety, depression, alcoholism, drug abuse, sickness and absenteeism or psychosomatic problems which as fatigue head pain in the neck propensity to Peptic ulcer, Hypertension heart disease and diabetes mellitus
THEORIES OF ANXIETY, AND DEPRESSION RELATED TO DIABETES MELLITUS
Psychological and nursing theories are support the study the researcher gives some theory as evidence as follows.
TRANSACTIONAL STRESS THEORY
Lazarus transactional theory encompasses a set of cognitive, affective (mood) and adaptive coping responses that arise out of person environment transaction. The person and environment are inseparable each effect and affected the others. Stress refers to any event in which environment demand internal or external the adaptive resources of an individual social system or tissue system (Monat and Lazar 1991). The individual respond to perceived environmental changes by adoptive or coping responses.
Stress may be psychological or cognitive factor. Physiological signs and symptoms of stress result from activation of sympathetic and neuroendocrine system of the body. It may lead to cardiac diseases or metabolic disorder such as diabetes psychological manifestation of stress includes anger, fear, anxiety, depression and unconscious ego defense mechanism. Some of the coping mechanism fails the individual tent to may get anxiety and depression and its may lead to diabetes mellitus.
JOHN’S ANXIETY ASSESSMENT MODEL
Anxiety tension, stress and panic are all term used describe wide problem. Anxiety can affect any one, at any time, over -one in ten people experience high level of anxiety. In anxiety the thread or danger being faced it’s often overplayed and builds up in “mind”. Some time usually underplay our own capacity to cope up will the problems. In normally when there is no anxiety we feel able to cope up with problems. But facing the anxiety can produce unbalance mind because of varying thoughts are common in anxiety. When someone feels very low for more than two weeks is called depressive illness. Anxiety and depression often occurs together. Depression can worsen problem such as anxiety.
Figure: 1 – John Five area AssessmentDiabetes and Depression
Diabetes Mellitus and depression is all around the globe, these two words are now more often paired together, regardless of culture or country.
Diabetes is one of the most common chronic conditions in the world; over 285 million people have diabetes worldwide (Diabetes Atlas 2010). The greatest relative increases in diabetes (by 2030) are estimated to occur in the Middle Eastern Crescent, Saharan Africa, and India (Wild et al 2009). Left untreated, diabetes can lead to complications and even death (Richardson et al 2008).
Depression is also a common and serious medical condition all around the globe. Depression matters because it can affect all parts of your life, including changing your appetite, sleep patterns, interest in everyday activities, work productivity, and your relationships with others.
If you have diabetes, you have an increased risk of developing depression (Anderson et al 2001; Hellman 2008); and, if you have depression, you have a greater chance of developing Type 2 diabetes (Rubin et al 2008). There is now evidence that the prevalence of depression together with diabetes is increasing (Katon et al 2009).
Many factors influence the diagnosis of depression in diabetes. Some of these include cultural and economic factors, social and family influences, as well as psychological and behavioral influences. In addition, biological mechanisms, like the hard-wiring’of your brain, will also determine whether or not you may get both disorders (Fisher & Chan 2009). If you are newly diagnosed with diabetes and learning about the disorder when depression strikes, you may feel overwhelmed by trying to manage both disorders day-to-day. Or perhaps you have lived with diabetes for awhile, and you have been struggling to maintain needed lifestyle changes when depression hits.
Whether newly diagnosed, or someone who has had diabetes for a long time, the burden of managing the disorder on a daily basis can be stressful, and the addition of depression can make managing each day more daunting. If you have diabetes and think you might have anxiety and depression, seek help immediately. Depression in diabetes has been associated with poor medication adherence (Kilbourne et al 2005), poor glycemic control (McKellar 2004) and an increased prevalence of complications in Type 2 diabetes. Untreated anxiety and depression in diabetes can increase the risk for diabetes-related complications – such as heart disease, blindness, amputations, stroke, kidney disease, and sexual dysfunction (Groot D et al 2010). By getting early treatment for depression, you can often avoid these serious complications. Though many questions remain about the relationship between diabetes and depression, we know a lot about how depression in diabetes affects the day-to-day lives of those with the disorders (Mayo Clinic 2009):
SIGNIFICANCE AND NEED FOR THE STUDY
Diabetes Mellitus is a chronic metabolic disease characterized by disorder of metabolism of carbohydrates, lipids and amino acids either as a result of decreased insulin secretion or due to a reduction of insulin sensitivity of the cells of the body cells. Its prevalence has increase fivefold during last fifteen years and constitutes one of the major threats to human health in 21st century. Research proved the relation between anxiety and depression and diabetes bound hyperglycemic complication and restarting imposed by the disease the existence of diabetes mellitus doubles of probabilities of depressive episodes, and the depressive symptoms were significantly more in women than men. A proclivity of female sex in anxiety of female sex is anxiety and depressive disorder is observed in general in population as well (Kessles RC and Nelson CB 1996).
Type 2 diabetes and anxiety and depression are two long course diseases with modifiable risk factor. Diabetes is the fourth leading course of death has affected and estimated 246 million people around the world (WHO 2009) resent researcher has shown that, depression and anxiety precede the onset of diabetes or vice versa. Examination mediating factor may be explaining its risk factors of associated symptoms and life style changes.
The research was suggested that diabetes patient screen for anxiety and depression to all and demand early detection and mental health care (Agbir T.M 2010). Because the strong research evidence exist that depression affect 10-20% of client with type 2 diabetes mellitus. Diabetes appear to be associated with an increased prevalence of depression, depression may have special clinical relevance in diabetes. Since the two illness may affect each other in a reciprocal fashion. Fatigue weight loss, insomnia or sexual dysfunction is also found in diabetes. Rapid shift of blood glucose level may also lead to depression. Many diabetes clients have described mood shift associated in blood glucose level. However it is workably that would lead to more permanent state of depression.
Depressive symptometology has been associated with decrease adherent to treatment and deformation glycemic control. (Agarwal RP 2003) Another Biochemical research explains the interaction of diabetes and depression and anxiety on a biological level disequilibrium in the neurotransmitters system has been postulated. Serotonin, nor epinephrine, and GABA are associated with anxiety and depression (Sadock 2009) Alternative in receptor sensitivity play in pathology of anxiety and depression among the type 2 diabetes mellitus (Vyas. In 2002)
WHO (2009) estimate, that at least 180 million individuals suffering from diabetes globally and figure is likely double by 2030. Diabetes related complication such as anxiety and depression are major cause of morbidity and mortality education in diabetes is compared to table top. While diet, exercise (muscle relaxation technique), monitoring, mediation are four legs of the table. This emphasizes how important the education of is the management of diabetes as four legs of the table do not source any purpose without the table top. (Mazycca. B Borne 1986).
Psychological intervention may be help full having anxiety and depression because of education enhances by behavior, and counseling techniques ,relaxation training, supportive counseling based on social learning theory and behavior modification. It can be available adjunct for treatment. Our fast paced society can use people to push their mind and body to the limit. Often at the expense of physical and mental well being .According to the Mind Body Medical Institute at Harvard University 60-90% of all medical and paramedical professional visits United States are for stress related anxiety and depression disorders. Such anxiety and depression have damaging such anxiety and depressions have damaging effect on health and the immune system. Part of stress respond consists of the inhibition of immune functioning by glucocorticoids. This inhibition may reflect a compensatory action of HPA axis (Hypothalamic Pituitary Adrenal) to mitigate other physiological effect of stress. SNS centrally and peripherally increase epinephrine release from adrenal medulla (Sadock 2009).
Relaxation techniques are helpful tools for coping with stress and providing long term health by slowing down the body and quieting mind. A recent nationwide Government survey found that 36% of U.S adults age 18 years and own some alternative medicine. The National Center for Complementary Medicine and Alternative Medicine (NCCAM) at US. Reported that complementary medicine provide, holistic health care those who are suffering from anxiety depression and stress, which deals not only with physical perspective but also emotional and spiritual component (Mary C. Townsend 2007).
Such complementary therapies are Herbal Medicine, Acupuncture, Diet and Nutrition Pet therapy Yoga and relaxation thereby. Many time we hear “Relax, take it easy don’t work so hard don’t worry so much; you will live longs that way” this is good advice. Relaxation is a decrease in tension or intensity resulting in refreshment of body and mind. A state as refreshing tranquility, because relaxation is a exercise for mind and brain. In state as deep relaxation, the respiration rate may slow to as few as four to six breath per minutes and the heart rats to as low 10 to 20 beats per minutes (Pelletren 1999). Blood pressure decreases, the metabolic rates slow down, muscle tension diminishes etc., when deeply relaxed individual are lees attentive to distracting stimuli in external environment. Because as one’s level as consciousness move from beta activity, which occurs whom one is mentally alert and activity thinking to alpha activity as in EEG a state of altered consciousness (Eshelman and Mckay 2009).
Relaxation therapy is associated; with benefits of alpha include an increase creativity memory and ability to concentrate. Ultimately an improvement of adoptive functions also. Such relaxation techniques are autogenic training, breathing, progressive muscle relaxation and meditation. Excellent results have been observed with treatment of progressive muscle relaxation technique for tension, anxiety, insomnia, depression, fatigue, irritable bowel syndrome, muscle spasms, neck and back pain, high level of blood pressure mild Phobia (Davis and Mckey 2009).
Progressive muscle relaxation techniques are useful in many situations such as child birth pain anxiety depression, sleeplessness, anger and other uses are being discovered. Relaxation promotes a body reaction opposite to that of “fight” or “flight” response: respiratory phase, and metabolic rates, blood pressure and energy use are all decreased. Relaxation can be taught to individual or group and is especially helpful because it allows a person to control higher feeling and behavior (Stuart and Laraia 2001).
JACOBSON’S PROGRESSIVE MUSCLE RELAXATION (JPMR)
Progressive muscle relaxation technique is a method of deep muscle relaxation was developed in 1920-1929 by Chicago (US) physician Edmond Jacobson. His technique is based on premise that the body responds to anxiety provoking thoughts and events with muscle tension. Progressive muscle relaxation is a technique for reducing anxiety by altering tensing and relaxing the muscles. Jacobson argued that since muscular tension accompanies anxiety. One can reduce anxiety by learning how to relax the muscular tension. PMR is essential for physician and mental component (Wikilzedia 2010)
The skill of relaxing the JPMR procedure is probably the easiest to teach client for home use. With sufficient instruction and practice proficiency can be acquired by any one. The focus on physical tension and relaxation gives excellent feedback and helps focus the attention. Once learned the JPMR can be streamlined and varied, condensed and muscle portables to wide variety of situation. Although this procedure, has been use clinically, to help the client overcome chronic anxiety and depression those who are treating with type 2 diabetes. This relaxation state is consistent with a state of decrease sympathetic activity.
Generally JPMR training as modified and adopted by Mishre et al(2007) to suit Indian clients is used in everyday clinical practice at NIMHANS, Bangalore. The client is told that would bring deep levels of relaxation and feeling of well being (Chandrashekar C.R. 2003). The practice of JPMR involves 5 stages.
Relaxation of arms
Relaxation of facial area and also neck, shoulders and upper back.
Relaxation of chest, stomach and lower back.
Relaxation of hips, thighs, any toes.
Complete body relaxation.
The number of relaxation, sessions vary in accordance with the difference in the principal problem behavior of the client.
Physiologic reaction, that is opposite of straight response. The relaxation response is proposed to involve decrease arousal of autonomic nervous system and central nervous system as well as increased parasympathetic activity characterized by lower musculoskeletal and cardiovascular tone and altered neuroendocrine function. Relaxation technique may be taught by various complementary practitioners such as, physicians, psychotherapist, hypnotherapists, nurses, clinical psychologist and sports therapists. There is no formal credentialing for relaxation therapies (Herbert Benson 1970).
NURSES ROLE
Nurses work with anxious client in all department of the hospital and community and home health care services. Individual experience stress daily if cannot be eliminated and may produce anxiety and depression, Management of stress must be considered a lifelong function. Nurses can help individuals recognize the sources of stress in their lives and identify methods of adaptive coping. Stress management requires a holistic approach, physical and psychological dimension are considered in determining the individual’s adaptation to stress. So the nurse should assess the patients past experience of living and working conditions, spiritual or religious position and coping of stress and client perception of the stressor adaptation responses. The nurse may assists stress management who are having stress, such as adjustment impairment, anxiety, ineffective coping individual those who are in fear, low self esteem, disturbed sleep, social isolation, pain and those who are having chronic illness like diabetes, hypertension, cancer etc. Nurses must help the individual analyze the usefulness of JPMR technique in the management of stress, anxiety and depression in their daily lives.
STATEMENT OF THE PROBLEM:
A study to assess, the level anxiety and depression and evaluate the effectiveness of Jacobson Progressive Muscle Relaxation (JPMR) Technique, among client with Type 2 Diabetes Mellitus in Government Rajaji Hospital Madurai – 20.
OBJECTIVES OF THE STUDY
To assess the level of anxiety and depression before administering JPMR Techniques.
To assess the level of anxiety depression after administering JPMR Techniques.
Comparison of before and after the effectiveness of JPMR Techniques.
To associate the level of anxiety and depression among client with type 2 diabetes mellitus with selected demographic variable.
HYPOTHESIS
The Hypothesis will be significant at 0.05 levels.
There will be a significant association between level of anxiety and depression and type 2 Diabetes Mellitus.
There will be a significant between level anxiety and depression before and after the Progressive Muscle Relaxation Technique among client with type two Diabetes Mellitus.
There will be a significant association between level of anxiety and depression with in selected demographic variables.
OPERATIONAL DEFINITION
Jacobson Progressive muscle relaxation technique :
Jacobson Progressive muscle relaxation is a method of deep muscle relaxation in which the muscles are tensed for 5 seconds, uphold for 5 seconds and slow excretion with relaxed the muscles for 10 to 15 seconds from the muscles of feet to face.
2. Anxiety
A state of, apprehension or uneasiness arising out of anticipating of danger while taking treatment for Type 2 diabetes mellitus as measured by Hospital anxiety and Depression Scale (HADS).
3. Depression
A state characterized by feeling of sadness, loneliness, despair, low self-esteem and self approach accompanying signs including psychomotor retardation as measured by Hospital anxiety and Depression Scale (HADS).
Effectiveness
Effectiveness relates to how well a Jacobson Progressive Muscle Relaxation works in practice which measures the anxiety and depression of the Type 2 diabetic mellitus clients.
Type 2 diabetes Mellitus
Type 2 diabetes Mellitus is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency. And also the blood glucose level increased by anxiety and depression.
