312 Psychosomatics 44:4, July-August 2003

Coping Styles and Quality of Life in Patients With Non-Insulin-Dependent Diabetes Mellitus

RUI COELHO, M.D., PH.D.ISABEL AMORIM, R.N., M.SC.

JOANA PRATA, M.D.

The authors examined the relationship between coping style and perceived quality of life in pa-tients with non-insulin-dependent diabetes mellitus. Diabetic patients (N�123) and nondiabeticcomparison patients (N�124) treated at a Portuguese health center completed the NottinghamHealth Profile, a quality-of-life measure. The diabetic patients also completed the Coping Re-sponses Inventory, a measure of coping styles. In both groups, female subjects had poorer quality-of-life ratings than male subjects. Diabetic patients were more likely to regard diabetes and theconsequent changes in lifestyle as a threat than as a challenge. A greater proportion of diabeticpatients used avoidance coping styles, which overall were related to worse quality of life, thanused active confrontation coping styles. Coping style was significantly correlated with several di-mensions of quality of life in diabetic patients. (Psychosomatics 2003; 44:312–318)

Received April 30, 2002; revision received Sept. 17, 2002; accepted Oct.24, 2002. From the Department of Psychiatry, Faculty of Medicine,Oporto University, Porto, Portugal. Address reprint requests to Dr.Coelho, Rua Sao Joao de Brito numero 524, sala 5, 4100-453 Porto,Portugal; rmnscoelho@mail.telepac.pt (e-mail).

Copyright � 2003 The Academy of Psychosomatic Medicine.

Diabetes mellitus is a common endocrine disease char-acterized by metabolic abnormalities such as elevated

plasma glucose levels resulting from insufficient insulin orresistance to insulin effects. Long-term complications ofdiabetes include effects on the eyes, kidneys, nerves, andblood vessels that can lead to blindness, neuropathy, andkidney failure. Two types of diabetes are usually described:1) insulin-dependent diabetes mellitus, which results frominsulin deficiency, and 2) non-insulin-dependent diabetes,which results from a reduction in the number of intact in-sulin receptors.1

In a review of studies examining the epidemiology ofdepression in diabetes, Goodnick1 reported prevalencerates of depression in diabetes of 8.5% to 27.3% in con-trolled studies and 11% to 19.9% in uncontrolled studiesthat established the diagnosis of depression by means of

structured diagnostic interview. The same author reportedmean ages at onset of depression of 22.1 years in patientswith insulin-dependent diabetes mellitus and 28.6 years inpatients with non-insulin-dependent diabetes mellitus. Thepresence of depression in diabetic patients has been asso-ciated with a high rate of complications. Sachs et al.2 founddirect correlations between the severity of depressive symp-toms, the incidence of complaints of diabetes, and the levelof hyperglycemia among patients with insulin-dependent di-abetes mellitus.

Eaton et al.3 followed subjects from the Baltimore siteof the Epidemiologic Catchment Area Study who did nothave diabetes at baseline in 1981. Among 76 subjects whomet the criteria for major depressive disorder at baseline,6% to 8% had diabetes at follow-up in 1993–1994, com-pared with 5% of the 1,604 subjects who did not meet thecriteria for major depressive disorder at baseline. The au-thors found the risk for non-insulin-dependent diabetesmellitus to be twice as high in patients with preexistingdepression. This finding is consistent with other resultsshowing a significant correlation between Beck Depression

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Inventory scores and symptoms and signs of diabetic dys-control.

Because the purpose of health care is not only to pro-long life but to improve patients’ quality of life, subjectiveas well as objective measures of clinical outcomes areneeded. In general, older clinical measurement instrumentsdo not provide information about how individuals copewith their health conditions. More recently, health care pro-viders have been paying more attention to patients’ sub-jective feelings of well-being, and some subjective mea-sures of quality of life have been developed.4,5 Quality oflife involves several dimensions, and it is generally ac-cepted that quality-of-life measures should assess physical,psychological, and social functioning, as well as generalsatisfaction with life.6,7

Diabetes is a chronic and debilitating disease that ne-cessitates several adjustments in the patient’s lifestyle.8 Di-abetic patients vary in their perceptions of quality of lifeand in their coping styles when dealing with everydaystress. Each patient builds his or her own experience of thedisease, including its emotional and cognitive aspects,which in turn determines the patient’s coping strategies.These coping strategies have a fundamental role in the pa-tient’s physical and psychological well-being, but there isno consensus on which coping styles are more effective forproblem solving,9,10 prevention of future difficulties, or re-lief from emotional maladjustment.

Health education is a cornerstone of treatment for di-abetic patients because it is a key means for achieving op-timal glycemic control. The objective of health educationfor diabetic patients is to provide the necessary informationand practice to allow patients to be responsible for theirown treatment and disease control. However, the ability forself-care is affected by the individual adaptation to dis-ease.11 Adaptation to chronic disease is a difficult and com-plex process. The extent of adaptation can be conceptual-ized as the level of physical and psychological adjustmentto the stress of having a long-term disease.12

The purpose of this study was to examine the rela-tionship between coping styles and perceived quality of lifein patients with non-insulin-dependent diabetes mellitus.

METHOD

The study participants were 123 patients with non-insulin-dependent diabetes mellitus who were consecutivelytreated in the nurse consultation program for diabetic pa-tients at a health care center in northern Portugal (Centrode Saude de Darque–Viana de Castelo) between November

1998 and January 1999. The patients were classified asdiabetic according to the World Health Organization di-agnostic criteria for diabetes mellitus. The nurse consul-tation program is operated under the guidelines of the Por-tuguese Directorate-General for Primary Health Care.13

Patients are evaluated by nurse professionals every 3months, at which time patients’ blood glucose and urineglucose levels are tested, patients’ weight and blood pres-sure are measured, and health-promoting diet and exercisestrategies are encouraged.

The comparison group consisted of 124 individualswho had a health care visit at the health care center duringthe same period. The majority of these individuals (72%)had a chronic disease other than diabetes. Although thecomparison subjects were selected without regard to theirhealth problem, they were not in an acute stage of illnessand were not seeking acute medical treatment when theywere recruited for the study.

A structured, self-evaluation questionnaire developedby the authors was used to obtain demographic data andillness information to allow assignment of patients to thediabetic or comparison group. Demographic and clinicalcharacteristics for which data were collected included age,gender, marital status, educational level, occupation, du-ration of illness, type of treatment undertaken, and asso-ciated medical problems (data not shown).

No statistically significant differences in age and gen-der were found between the diabetic patients and the com-parison group. The diabetic patients had a mean age of 61.9years (SD�10.6, range�37–84), and 52.0% were female.The mean age of the comparison group was 60.2 years(SD�11.2, range�37–84), and 53.2% of the comparisonsubjects were female. No statistically significant differ-ences in the socioeconomic variables of marital status, oc-cupational status, and educational level were found be-tween the groups. The majority of individuals in bothgroups were married (78% of the diabetic patients and 79%of the comparison subjects). Information on socioeconomicstatus was obtained indirectly from measures of occupa-tional status and educational level. We used the occupa-tional categories of the Portuguese National Classificationof Professions,14 which groups occupations according toprimary (agriculture and other extraction of raw materials),secondary (industry and other processing of raw materials),and tertiary (retailing and personal services) sectors of eco-nomic activity. We also included a separate category forhousewives, as this occupation was not included in the Na-tional Classification categories. The greatest percentages ofsubjects had occupations in the primary sector (24.6% of

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the diabetic patients and 29% of the comparison subjects)or the secondary sector (30.1% of the diabetic patients and29% of the comparison subjects) or were housewives(31.7% of the diabetic patients and 29.8% of the compar-sion subjects). The majority of the subjects had 3–4 yearsof education beyond basic compulsory education (90.2%of the diabetic patients and 82.3% of the comparison sub-jects).

The Nottingham Health Profile15 was used as a mea-sure of quality of life. The Nottingham Health Profile is aself evaluation questionnaire used to measure quality of lifeon the basis of personal perceptions of actual health status.It provides information on the following six dimensions ofquality of life: pain, energy, social isolation, physical mo-bility, emotional reactions, and sleep. The NottinghamHealth Profile had been used previously in Portugal16 andvalidated for use with the Portuguese population.

In addition, diabetic patients completed the CopingResponses Inventory—Adult Form,17 which provided dataon coping styles. The Coping Responses Inventory—AdultForm measures the extent of use of eight styles of copingwith stressful life events (in the present study, diabeteswas the stressful life event): logical analysis, positive re-appraisal, search for guidance and support, problem solv-ing, cognitive avoidance, acceptance or resignation, seek-ing alternative rewards, and emotional discharge. The firstfour coping styles are considered examples of active con-frontation strategies, and the last four are examples of de-fensive or avoidance strategies. Within each group of fourcoping styles, the first two styles consist of cognitive strat-egies and the last two are behavioral strategies. Patientsrated 48 items using a 4-point scale ranging from “not atall” to “fairly often” to indicate how often they rely on thevarious coping strategies, and the items were scored andweighted according to the Coping Responses Inventory—

Adult Form Professional Manual.17 The Coping ResponsesInventory is being validated for the Portuguese populationin collaboration with Professor Moos, the developer of theinstrument.

The results of statistical tests were considered signifi-cant when p�0.05.

RESULTS

As Table 1 shows, no statistically significant differenceswere found between the diabetic patients and the compar-ison subjects on the six dimensions of the NottinghamHealth Profile. However, for the dimensions of energy,physical mobility, emotional reactions, and social isolation,diabetic patients had higher scores than the comparisonsubjects. Higher scores indicate worse quality of life.

Gender was associated with differences in quality oflife in both the diabetic group and the comparison group.Within the diabetic group, female patients had significantlyhigher scores on every dimension of the NottinghamHealth Profile, compared to male patients. In the compar-ison group, female subjects had higher scores than malesubjects, but only the differences for the dimensions ofpain, physical mobility, and sleep were statistically signifi-cant (Table 2).

In the diabetic group, the proportions of patients withthe various types of complications of diabetes were as fol-lows: eye/vision (52.8%), sexual dysfunction (44.7%), sen-sory/motor (26.8%), renal function (15.4%), bladder con-trol (15.4%), and gastrointestinal (16.3%). No significantdifferences in the distribution of complications were foundbetween female and male patients, except that sexual dys-function was more likely to occur in male patients(p�0.05).

TABLE 1. Scores on Dimensions of the Nottingham Health Profile of Patients With Non-Insulin-Dependent Diabetes and NondiabeticComparison Patientsa

Diabetic Patients(N�123)

Comparison Patients(N�124)

Nottingham Health Profile Dimension Mean SD Mean SD p (Mann-Whitney test)

Energy 41.46 39.20 34.68 36.42 0.19Pain 31.20 32.89 33.27 33.20 0.64Physical mobility 27.74 23.33 25.10 23.40 0.31Emotional reactions 30.08 27.80 27.96 21.04 0.87Sleep 37.40 37.19 39.52 33.88 0.63Social isolation 11.06 17.96 9.19 15.60 0.54

aHigher scores indicate worse quality of life.

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TABLE 3. Effects of Gender and Diagnostic Group on Scores on Dimensions of the Nottingham Health Profile of Patients With Non-Insulin-Dependent Diabetes (N�123) and Nondiabetic Comparison Subjects (N�124)

p (Analysis of Variance)

Nottingham Health Profile Dimension Gender Diagnostic GroupInteraction of Genderand Diagnostic Group

Energy 0.001 0.14 �0.001Pain �0.001 0.65 �0.001Physical mobility 0.001 0.34 �0.001Emotional reactions �0.02 0.48 �0.001Sleep �0.001 0.64 �0.001Social isolation 0.22 0.38 �0.001

TABLE 2. Scores on Dimensions of the Nottingham Health Profile of Male and Female Patients With Non-Insulin-Dependent Diabetesand Nondiabetic Comparison Subjectsa

Diabetic Patients Comparison Subjects

Male (N�59) Female (N�64) Male (N�58) Female (N�66)

Nottingham HealthProfile Dimension Mean SD Mean SD

p (Mann-Whitney test) Mean SD Mean SD

p (Mann-Whitney test)

Energy 31.63 38.86 50.52 37.55 0.004 28.16 34.08 40.40 37.67 0.06Pain 18.85 26.19 42.57 34.48 �0.001 22.62 30.11 42.61 33.17 �0.001Physical mobility 21.61 23.30 33.39 22.05 0.002 20.90 22.26 28.78 23.91 �0.05Emotional reactions 23.72 22.17 35.93 31.16 0.04 26.24 19.93 29.46 22.00 0.51Sleep 28.81 28.35 45.31 35.49 �0.02 31.03 33.54 46.96 32.62 0.007Social isolation 8.13 16.65 8.78 14.08 �0.03 9.65 17.26 8.78 14.08 0.89

aHigher scores indicate worse quality of life.

Table 3 shows results of an analysis of variance of theeffects of the dependent variables of gender, diagnosticgroup, and the interaction of gender and diagnostic groupon scores on the dimensions of the Nottingham Health Pro-file. Gender was significantly related to scores on all di-mensions of the Nottingham Health Profile except socialisolation, and the interaction of gender and diagnosticgroup was significantly related to scores on all dimensions.Diagnostic group had no significant effects.

The first 10 items of the Coping Responses Inven-tory—Adult Form measure respondents’ overall evaluationof a stressful life event, which in the present study is thediagnosis of diabetes and consequent changes in lifestyle.More patients in this study regarded diabetes and the con-sequent lifestyle changes as a threat (42.3%) than as a chal-lenge (26.8%).

Table 4 shows the diabetic patients’ scores on the Cop-ing Responses Inventory—Adult Form scales measuringthe use of eight coping styles. Overall, the patients hadhigher scores for the avoidance coping styles (cognitiveavoidance, acceptance or resignation, seeking alternativerewards, and emotional discharge) than for active confron-tation coping strategies. Male patients had significantly

higher scores that female patients for the coping style ofseeking alternative rewards (p�0.02) (data not shown).

Table 5 shows the Spearman correlation coefficientsfor the relationships between the diabetic patients’ scoreson the dimensions of the Nottingham Health Profile qualityof life and on the eight scales of the Coping ResponsesInventory–Adult Form. The coping style of seeking alter-native rewards was significantly and positively correlatedwith the Nottingham Health Profile quality-of-life dimen-sions of energy, physical mobility, and emotional reactions.

TABLE 4. Scores on Scales of the Coping ResponsesInventory—Adult Form of Patients With Non-Insulin-Dependent Diabetes (N�123)

Coping Responses Inventory Scale Mean SD

Active confrontation coping stylesLogical analysis 32.91 5.82Positive reappraisal 38.54 5.53Seeking guidance and support 46.39 8.41Problem solving 44.53 8.44

Avoidance coping stylesCognitive avoidance 46.94 5.73Acceptance or resignation 48.76 7.80Seeking alternative rewards 48.00 7.94Emotional discharge 48.32 7.12

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The coping style of emotional discharge was significantlyand negatively correlated with the quality-of-life dimen-sions of emotional reactions, sleep, and social isolation.The coping style of cognitive avoidance was significantlyand negatively correlated with the quality-of-life dimen-sions of pain and physical mobility. Overall, avoidancecoping styles appeared to be associated with worse qualityof life, with the exception of the coping style of seekingalternative rewards, which was associated with better qual-ity of life.

DISCUSSION

Measures of health-related quality of life evaluate the ill-ness experience rather than the disease process. The illnessexperience includes the patient’s perception of symptoms(how symptoms are labeled by the patient and communi-cated to others), the experience of being unable to functionnormally, and the efforts made to cope and control the dis-ease.18

Diabetic patients are subject to various stresses thatcan lead to potential losses and changes in lifestyle. Sub-jective symptoms and medical complications can lead tofunctional limitations and changes in quality of life. Treat-ment outcome depends not only on medical interventionbut also on the patient’s ability to change his or her lifestyleto encompass health-promoting diet and exercise strageiesand blood glucose monitoring. Difficulties in adapting tothe illness can negatively influence metabolic control.

In this study, a generic instrument for measuring qual-ity of life, the Nottingham Health Profile, was used to iden-tify the general effects of illness in the lives of patientswith diabetes, relative to nondiabetic comparison subjectswho were similar to the diabetic patients in age, gender,and socioeconomic status. The Nottingham Health Profile

has been validated for the Portuguese population and is areliable and simple method of evaluating quality of life invarious situations.19–21 The results showed worse qualityof life in the diabetic group than in the comparison groupfor the dimensions of energy, physical mobility, emotionalreactions, and social isolation. However, no statisticallysignificant differences between the groups were found.

Female diabetic patients had significantly worse qual-ity of life, compared to male diabetic patients. The patientsin this study had various types of diabetes complications,including eye/vision, sexual dysfunction, sensory/motor,renal function, bladder control, and gastrointestinal com-plications. However, we did not find significant differencesbetween female and male diabetic patients in the distribu-tion of complications, except that sexual dysfunction wasmore common among male patients. Therefore, differencesin medical complications do not seem to account for thelower quality-of-life measures among female diabetic pa-tients.

We also found significant differences in quality of lifebetween male and female subjects in the comparison group.Quality of life appears to vary significantly according togender independently of whether the person has diabetes,which is in accordance with the finding that women gen-erally have worse scores than men on quality-of-life mea-sures.20

There is increasing evidence of an association betweenstressful life events and physical and psychological mor-bidity. Also, there has been growing interest in the factorsthat modulate the relationship between stress and illness,which include coping strategies. An important aspect ofour study was to determine how diabetic patients evaluateand react to stressful life events. The way a diabetic indi-vidual reacts to stress can be an important predictor of theperson’s success in adapting to the challenges of diabetes,

TABLE 5. Correlation of Scores on Dimensions of the Nottingham Health Profile With Scores on Scales of the Coping ResponsesInventory—Adult Form for Patients With Non-Insulin-Dependent Diabetes (N�123)

r(s)

Nottingham HealthProfile Dimension

LogicalAnalysis

PositiveReappraisal

Seeking Guidanceand Support

ProblemSolving

CognitiveAvoidance

Acceptance orResignation

SeekingAlternative

RewardsEmotionalDischarge

Energy 0.11 0.09 –0.07 0.14 –0.11 –0.02 0.20* –0.07Pain –0.01 –0.07 –0.08 0.07 –0.18* 0.07 0.11 –0.11Physical mobility 0.02 0.02 0.02 0.05 –0.23* –0.05 0.18* –0.08Emotional reactions 0.03 –0.13 –0.12 0.12 –0.08 –0.004 0.19* –0.38**Sleep 0.01 –0.03 0.00 0.11 –0.10 –0.02 0.15 –0.18*Social isolation –0.03 –0.16 –0.18 0.04 0.07 –0.02 0.11 –0.24**

*p�0.05. **p�0.01.

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as an adaptive coping process is considered to be a stabi-lizing factor.9

The results of this study show that diabetic patients tendto deal with the disease by using avoidance coping strategiesrather than by using active confrontation strategies. Eventhough previous studies have shown a consistent relation-ship between avoidance coping strategies and negative in-dicators of functioning, the relationship between confron-tation methods and functioning is not as consistent.22 Also,there appears to be no consensus regarding which type ofstrategy is more effective in problem solving, prevention offuture difficulties, or relief from emotional distress.10

The efficacy of coping strategies centered on the prob-lem or the emotions can not be determined without a care-ful examination of the individual context. Either type ofstrategy is potentially adaptive, as coping is strongly re-lated to cognitive evaluation and the options for copingavailable in the particular context.

When we analyzed the relationship between quality oflife and coping style, avoidance styles of coping overallwere related to worse indexes of quality of life, except forthe coping style of seeking alternative rewards, which wasassociated with better quality of life. The results show thatthere can be several ways to group dimensions of coping.For example, seeking alternative rewards is characterizedas an avoidance coping strategy because it is not directedat changing the problem, but it could also be considered aconfrontation coping strategy in relation to the evaluationof challenge and indexes of psychological well-being. Bothavoidance and active confrontation coping styles can beimportant in specific situations, in relation to specificstressors, or in specific stages of the coping process.

Our study had several limitations, including a smallnumber of subjects and lack of a prospective design. Inaddition, a generic instrument was used to measure quality

of life in patients. Because this instrument did not focus onaspects of life that are specifically affected in diabetes,small but still important differences may have been missed.Nevertheless, we consider our findings to have clinical im-plications for diabetic patients’ treatment compliance andprognosis and for the management of health education andrehabilitation programs for diabetic patients.

CONCLUSIONS

This study highlighted the importance of a biopsychosocialunderstanding of the interactions between the patient, hisor her social support system, and the disease process, be-yond the purely biomedical aspects of the disease. To helpa patient deal with chronic disease, clinicians should beaware of the patient’s coping strategies. Stress and copingare important aspects of everyday life, and there is evi-dence suggesting that coping styles have a major role inphysical, psychological, and social well-being. The dia-betic patients in our study tended to use avoidance strate-gies in dealing with the disease rather than using strategiesdirected at problem solving.

We did not find statistically significant differences inscores on quality-of-life dimensions between diabetic pa-tients and nondiabetic comparison subjects, although thediabetic patients tended to have worse scores. However,avoidance coping strategies were found to be related tolower quality of life scores among the diabetic patients.Improved quality of life for diabetic patients includes bothadequate metabolic control to delay onset of disease com-plications and adequate psychosocial adjustment to dia-betes, which in turn has important implications for com-pliance with treatment. These aspects should be taken intoaccount by health professionals in planning individualizedprograms of health education for diabetic patients.

References

1. Goodnick PJ: Diabetes mellitus and depression: issues in theoryand treatment. Psychiatr Annals 1997; 27:353–359

2. Sachs G, Spiess K, Moser G, Prager R, Kunz A, Schernthaner G:[Glycosylated hemoglobin and diabetes—self-monitoring (com-pliance) in depressed and non-depressed type I diabetic patients].Psychother Psychosom Med Psychol 1991; 41:306–312 (German)

3. Eaton WW, Armenian H, Gallo J, Pratt L, Ford DE: Depressionand risk for onset of type II diabetes: a prospective population-based study. Diabetes Care 1996; 19:1097–1102

4. Ware JE: Measuring functioning, well-being, and other generichealth concepts, in Effect of Cancer on Quality of Life. Edited byOsoba D. Boca Raton, Fla, CRC Press, 1999, pp 17–23

5. Guyatt GH, Jaeshke R: Measurements in clinical trials: choosingthe appropriate approach, in Quality of Life Assessments in Clini-

cal Trials. Edited by Spilker B. New York, Raven Press, 1990, pp37–46

6. Schipper H, Chinch J, Powell V: Definitions and conceptual issues.Ibid, pp 11–24

7. Esteve M, Roca J: Calidad de vida relacionada con la salud: unnuevo parametro a tener en cuenta. Med Clin 1997; 108:458–459

8. Brannon L, Feist J: Living with chronic illness, in Health Psy-chology: An Introduction to Behavior and Health. Pacific Grove,Calif, Brooks/Cole, 1997, pp 265–300

9. Holahan C, Moos RH: Personal and contextual determinants ofcoping strategies. J Pers Soc Psychol 1987; 52:946–955

10. Aldwin CM, Revenson TA: Does coping help? a reexaminationof the relation between coping and mental health. J Pers Soc Psy-chol 1987; 53:337–348

Coping and Quality of Life in Diabetic Patients

318 Psychosomatics 44:4, July-August 2003

11. Correia JM: Adulto diabetico: o que ensinar. Nursing 1996; 9:18–20

12. Grey M, Lipman T, Cameron ME, Thurber FW: Coping behav-iours at diagnosis and in adjustment one year later in children withdiabetes. Nurs Res 1997; 46:312–317

13. Controlo da Diabetes Mellitus: Orientacoes tecnicas. Lisbon, Di-reccao Geral dos Cuidados de Saude Primarios (DGCSP), 1992

14. Classificacao Nacional das Profissoes (CNP). Lisbon, Ministeriodo Trabalho/Secretaria de Estado do Emprego, 1980

15. Hunt SM, McEwen J, McKenna SP: Measuring health status: anew tool for clinicians and epidemiologists. J R Coll Gen Pract1985; 35:185–188

16. Coelho R, Santos A, Ribeiro L, Gama G, Prata J, Barros H, PoloniaJ: Differences in behaviour profile between normotensive subjectsand patients with white-coat and sustained hypertension. J Psy-chosom Res 1999; 46:15–27

17. Moos RH: Coping Responses Inventory—Adult Form ProfessionalManual. Odessa, Fla, Psychological Assessment Resources, 1993

18. Swenson JR, Clinch JJ: Assessment of quality of life in patientswith cardiac disease: the role of psychosomatic medicine. J Psy-chosom Res 2000; 48:405–415

19. Coelho R, Ramos E, Prata J, Maciel MJ, Barros H: Acute myo-cardial infarction: psychosocial and cardiovascular risk factors inmen. J Cardiovasc Risk 1999; 6:157–162

20. Lukkarine H, Hentinen M: Assessment of quality of life with theNottingham Health Profile among patients with coronary heart dis-ease. J Adv Nurs 1997; 26:73–84

21. Keinanen-Kiukaanniemi S, Ohinma A, Pajunpaa H, KoivunkajarP: Health related quality of life in diabetic patients measured bythe Nottingham Health Profile. Diabet Med 1996; 13:382–388

22. Ebata AT, Moos RH: Coping and adjustment in distressed andhealthy adolescents. J Appl Dev Psychol 1991; 12:33–54