Nurses' recognition and registration of depression, anxiety and diabetes-specific emotional problems in outpatients with diabetes mellitus

The effects of a mindfulness-based intervention on emotional distress, quality of life, and HbA(1c) in outpatients with diabetes (DiaMind): a randomized controlled trial

OBJECTIVE

Emotional distress is common in outpatients with diabetes, affecting ∼20-40% of the patients. The aim of this study was to determine the effectiveness of group therapy with Mindfulness-Based Cognitive Therapy (MBCT), relative to usual care, for patients with diabetes with regard to reducing emotional distress and improving health-related quality of life and glycemic control.

RESEARCH DESIGN AND METHODS

In the present randomized controlled trial, 139 outpatients with diabetes (type 1 or type 2) and low levels of emotional well-being were randomized to MBCT (n = 70) or a waiting list group (n = 69). Primary outcomes were perceived stress (Perceived Stress Scale), anxiety and depressive symptoms (Hospital Anxiety and Depression Scale), mood (Profiles of Mood States), and diabetes-specific distress (Problem Areas In Diabetes). Secondary outcomes were health-related quality of life (12-Item Short-Form Health Survey), and glycemic control (HbA(1c)). Assessments were conducted at baseline and at 4 and 8 weeks of follow-up.

RESULTS

Compared with control, MBCT was more effective in reducing stress (P < 0.001, Cohen d = 0.70), depressive symptoms (P = 0.006, d = 0.59), and anxiety (P = 0.019, d = 0.44). In addition, MBCT was more effective in improving quality of life (mental: P = 0.003, d = 0.55; physical: P = 0.032, d = 0.40). We found no significant effect on HbA(1c) or diabetes-specific distress, although patients with elevated diabetes distress in the MBCT group tended to show a decrease in diabetes distress (P = 0.07, d = 0.70) compared with the control group.

CONCLUSIONS

Compared with usual care, MBCT resulted in a reduction of emotional distress and an increase in health-related quality of life in diabetic patients who had lower levels of emotional well-being.

Diagnosis and treatment of depression following routine screening in patients with coronary heart disease or diabetes: a database cohort study

BACKGROUND

Depression is common in chronic illness and screening for depression has been widely recommended. There have been no large studies of screening for depression in routine care for patients with chronic illness.

METHOD

We performed a retrospective cohort study to examine the timing of new depression diagnosis or treatment in relation to annual screening for depression in patients with coronary heart disease (CHD) or diabetes. We examined a database derived from 1.3 million patients registered with general practices in Scotland for the year commencing 1 April 2007. Eligible patients had either CHD or diabetes, were screened for depression during the year and either received a new diagnosis of depression or commenced a new course of antidepressant (excluding those commonly used to treat diabetic neuropathy). Analysis was by the self-controlled case-series method with the outcome measure being the relative incidence (RI) in the period 1-28 days after screening compared to other times.

RESULTS

A total of 67358 patients were screened for depression and 2269 received a new diagnosis or commenced treatment. For the period after screening, the RI was 3.03 [95% confidence interval (CI) 2.44-3.78] for diagnosis and 1.78 (95% CI 1.54-2.05) for treatment. The number needed to screen was 976 (95% CI 886-1104) for a new diagnosis and 687 (95% CI 586-853) for new antidepressant treatment.

CONCLUSIONS

Systematic screening for depression in patients with chronic disease in primary care results in a significant but small increase in new diagnosis and treatment in the following 4 weeks.

Psychometric and screening properties of the WHO-5 well-being index in adult outpatients with Type 1 or Type 2 diabetes mellitus

OBJECTIVE

The 5-item World Health Organization well-being index is a commonly used measure of emotional well-being, but research on psychometric properties in outpatients with diabetes is scarce. We examined psychometric and screening properties for depression of this index in a large sample of Dutch outpatients with diabetes.

METHODS

Patients with Type 1 (n = 384) and Type 2 (n = 549) diabetes from three outpatient clinics completed the WHO-5 index, the nine-item Patient Health Questionnaire, the Problem Areas in Diabetes survey and the Short Form-12 health survey. Internal consistency of the WHO-5 index was determined by Cronbach's alpha. The factor structure was tested by confirmatory factor analysis. Concurrent validity was assessed by correlations with the Patient Health Questionnaire, Problem Areas in Diabetes and the Short Form-12 mental component scores. Sensitivity and specificity of the WHO-5 index as depression screener were tested against two existing Patient Health Questionnaire cut-off scores for depression using receiver operating characteristic curves.

RESULTS

A one-factor structure of the WHO-5 index was verified by confirmatory factor analysis for patients with Type 1 and Type 2 diabetes. Moderate to strong correlations were observed between the WHO-5 index and the Patient Health Questionnaire scores, the Problem Areas in Diabetes scores and the Short Form-12 mental component scores (r = 0.55-0.69, P < 0.001). Receiver operating characteristic curves showed that a WHO-5 index cut-off of < 50 performed best as an indication for likely depression, with sensitivity compared with a Patient Health Questionnaire score ≥ 10 and ≥ 12 of 79% and 88%, respectively, and specificity of 88% and 76%, respectively.

CONCLUSIONS

The WHO-5 index is a short, psychometrically sound measure of emotional well-being that appears suitable for use as screening test for likely depression in outpatients with Type 1 and Type 2 diabetes.

Ethnic aspects of emotional distress in patients with diabetes--the Amsterdam Health Monitor Study

AIMS

Depression and anxiety are relatively common in patients with diabetes, but it is unclear whether migrant patients with diabetes are at increased risk for emotional distress. We determined levels of emotional distress in patients with diabetes with a Turkish, Moroccan or Dutch ethnic background and compare distress levels with healthy control subjects. Among patients with diabetes, we examined demographic and clinical correlates of higher levels of emotional distress.

METHODS

Cross-sectional data were collected within the framework of the population-based Amsterdam Health Monitor Survey. Adult participants were interviewed to assess demographics, presence of chronic disease(s) and ethnic background. Emotional distress was determined with the Kessler psychological distress scale. Blood was drawn to determine HbA(1c) , glucose, HDL and total cholesterol. Anthropometrics and blood pressure were assessed during a medical examination.

RESULTS

The total sample comprised of 1736 participants. The prevalence of emotional distress was significantly higher in participants with diabetes (31%) compared with healthy participants (19%). Increased levels of emotional distress were reported by 38% of the Turkish, 35% of the native Dutch and 29% of the Moroccan patients with diabetes. Among patients with diabetes, the presence of two or more co-morbid chronic diseases was most strongly associated with higher levels of emotional distress, whereas glycaemic control, cholesterol, blood pressure or waist circumference were not.

CONCLUSIONS

Emotional distress affects approximately one third of adult patients with diabetes living in Amsterdam. Having multiple co-morbid diseases seems related to more emotional distress among these patients, while ethnicity and diabetes-related characteristics are not.

Screening for depression and diabetes-related distress in a diabetes outpatient clinic

AIMS

To investigate: (1) the willingness of patients with diabetes to participate in a screening programme; (2) the extent to which patients with diabetes who screen positive endorse need for psychosocial care; (3) the rate of referral to psychosocial care during screening vs. usual care.

METHODS

Four hundred and ninety-nine patients with diabetes were invited to complete the Center for Epidemiologic Studies Depression and the Problem Areas in Diabetes questionnaires. Patients screening positive on either instrument were invited for an interview. One year after screening was withdrawn, rates of referral to psychosocial care were assessed from physician reports of patient referrals.

RESULTS

In total, 349/499 (70%) patients with diabetes completed the questionnaire. Patients who did not take up the screening were younger, smoked more often and had higher HbA(1c) values. 'No-shows' for clinical appointments accounted for 74% of non-participation. Of the 104 (30% of 349) patients screening positive, 45 accepted an invitation for an interview. Finally, 36/104 (35%) would like a referral for psychological care. Seven per cent of patients were referred to psychological care during screening compared with 1% when screening was withdrawn.

CONCLUSIONS

Results raise questions as to whether screening is the most efficient way to identify patients with psychological problems. Many patients did not take up the screening, especially those with low adherence to diabetes care in general. Furthermore, few patients screening positive wanted to be referred. Screening should be evaluated in the context of consideration of alternative ways to identify at-risk patients, including providing resources to deal with patients with already known adjustment and adherence problems.

Diabetes and psychological profile of younger rural African American women with type 2 diabetes

PURPOSE

To describe diabetes self-care behaviors, diabetes-related distress, depressive symptoms, and diabetes-related needs among rural African American women with type 2 diabetes ages 21-50.

METHODS

A cross-sectional survey, including questionnaires and a single, open-ended question, was used to assess constructs of interest.

FINDINGS

Taking medication was the most frequently reported (5.5 days/week) self-care activity and exercise the least (3.0 days/week). Nearly half (44%) reported worrying about diabetes complications. Approximately one-third (31%) felt guilty about inconsistent self-care or fearful about living with diabetes. Seventy percent had a depression score suggestive of significant depressive symptomatology. Most diabetes-related concerns were about diet (34%) (i.e., what to eat), exercise (30%), taking medications (10%), and finances (8%).

CONCLUSIONS

Future research should explore specific diabetes self-care barriers/enablers and interventions should provide women with diabetes education, barrier management, and psychological support. Innovative delivery strategies are needed to provide this support in resource-limited rural communities.

Risk of depression in diabetes is highest for young persons using oral anti-diabetic agents

AIMS

Previous studies report an increased risk of depression in patients with diabetes, but there is little knowledge about if or how the risk varies according to sex, groups of age and different type of treatments for the diabetes. We therefore aimed to investigate the risk of depression in different types of treatment for diabetes and in subgroups of age and sex.

METHODS

Data on the Norwegian population from 20 years of age being prescribed antidepressants (n = 253 668) and anti-diabetic agents (n = 121 392) in 2006 was obtained from the National Register of Prescriptions and analysed in a cross-sectional design.

RESULTS

Individuals using insulin in monotherapy (n = 29 611) had an age- and sex-adjusted odds ratio of 1.47 (95% CI 1.42-1.53) for receiving antidepressants. Corresponding odds ratios for individuals receiving oral anti-diabetic agents in monotherapy (n = 76 387) and for those who received both insulin and oral anti-diabetic agents (n = 15 394) were 1.44 (95% CI 1.41-1.47) and 1.82 (95% CI 1.80-1.97), respectively. No major differences in risk according to age were found for persons receiving insulin in monotherapy, while a marked and inverse association between age and risk of receiving antidepressants was found for those receiving oral anti-diabetic agents. Highest risk of antidepressant treatment [odds ratio 4.15 (95% CI 3.12-5.52)] was found for patients receiving both oral anti-diabetic agents and insulin at 30-39 years. The risk was equally increased among men and women.

CONCLUSIONS

The risk of depression among patients with diabetes varies strongly according to age and type of treatment for diabetes.

The course of depressive symptoms in primary care patients with type 2 diabetes: results from the Diabetes, Depression, Type D Personality Zuidoost-Brabant (DiaDDZoB) Study

AIMS/HYPOTHESIS

The aim of the study was to examine the course (incidence, recurrence/persistence) of depressive symptoms in primary care patients with type 2 diabetes and to identify significant predictors of these different course patterns.

METHODS

A cohort of 2,460 primary care patients with type 2 diabetes was assessed for demographic, clinical and psychological factors in 2005 and followed-up in 2007 and 2008. Depression was defined as a score of ≥ 12 on the Edinburgh Depression Scale. Multivariate logistic regression analyses were used to determine whether several depression-course patterns could be predicted by means of demographics, medical co-morbidities and psychological factors.

RESULTS

A total of 630 patients (26%) met the criterion for depression at one or more assessments. In the subgroup with no baseline depression, incident depression at follow-up was present in 14% (n = 310), while recurrence/persistence in those with baseline depression was found in 66% (n = 212).The presence of any depression was associated with being female, low education, non-cardiovascular chronic diseases, stressful life events and a self-reported history of depression. Incident depression was predicted by female sex, low education and depression history, while patients with a history of depression had a 2.5-fold increased odds of recurrent/persistent depression.

CONCLUSIONS/INTERPRETATION

Depression is common in primary care patients with type 2 diabetes, with one in seven patients reporting incident depression during a 2.5 year period. Once present, depression often becomes a chronic/recurrent condition in this group. In order to identify patients who are vulnerable to depression, clinicians can use questionnaire data and/or information about the history of depression.

Screening tools used for measuring depression among people with Type 1 and Type 2 diabetes: a systematic review

BACKGROUND

Depression is common in patients with Type 1 or Type 2 diabetes, has a strong negative impact on the quality of life of patients and is associated with poor outcomes and higher mortality rates. Several guidelines encourage screening of patients with diabetes for depression. It is unclear which depression screening tools are currently being used in people with diabetes and which are most appropriate.

METHODS

A systematic review was conducted to examine which depression screening instruments are currently being used in diabetes research, and the operating characteristics of these tools in diabetes populations. Literature searches for the period January 1970 to October 2010 were conducted using MEDLINE, PSYCH-INFO, ASSIA, SCOPUS, ACADEMIC SEARCH COMPLETE, CINAHL and SCIENCE DIRECT.

RESULTS

Data are presented for the 234 published studies that were examined. The Beck Depression Inventory and the Centre for Epidemiologic Studies Depression Scale were the most popular screening tools (used in 24% and 21% of studies). Information on the cultural applicability of screening tools was mostly unavailable and, where reported, included only details of the language translation process. A small number of studies reported reliability data, most of which showed moderate-good sensitivity and specificity but a high rate of false positives.

CONCLUSIONS

Although a range of depression screening tools have been used in research, there remains few data on their reliability and validity. Information on the cultural applicability of these instruments is even scantier. Further research is required in order to determine the suitability of screening tools for use in clinical practice and to address the increasing problem of co-morbid diabetes and depression.

Is a severe clinical profile an effect modifier in a Web-based depression treatment for adults with type 1 or type 2 diabetes? Secondary analyses from a randomized controlled trial

Background

Depression and diabetes are two highly prevalent and co-occurring health problems. Web-based, diabetes-specific cognitive behavioral therapy (CBT) depression treatment is effective in diabetes patients, and has the potential to be cost effective and to have large reach. A remaining question is whether the effectiveness differs between patients with seriously impaired mental health and patients with less severe mental health problems.

Objective

To test whether the effectiveness of an eight-lesson Web-based, diabetes-specific CBT for depression, with minimal therapist support, differs in patients with or without diagnosed major depressive disorder (MDD), diagnosed anxiety disorder, or elevated diabetes-specific emotional distress (DM-distress).

Methods

We used data of 255 patients with diabetes with elevated depression scores, who were recruited via an open access website for participation in a randomized controlled trial, conducted in 2008–2009, comparing a diabetes-specific, Web-based, therapist-supported CBT with a 12-week waiting-list control group. We performed secondary analyses on these data to study whether MDD or anxiety disorder (measured using a telephone-administered diagnostic interview) and elevated DM-distress (online self-reported) are effect modifiers in the treatment of depressive symptoms (online self-reported) with Web-based diabetes-specific CBT.

Results

MDD, anxiety disorder, and elevated DM-distress were not significant effect modifiers in the treatment of self-assessed depressive symptoms with Web-based diabetes-specific CBT.

Conclusions

This Web-based diabetes-specific CBT depression treatment is suitable for use in patients with severe mental health problems and those with a less severe clinical profile.

ClinicalTrial

International Standard Randomized Controlled Trial Number (ISRCTN): 24874457; http://www.controlled-trials.com/ISRCTN24874457 (Archived by WebCite at http://www.webcitation.org/63hwdviYr)

The reach of depression screening preceding treatment: are there patterns of patients' self-selection?

This study evaluated the reach of depression screening followed by treatment programs for subsyndromal depression and explored demographic and clinical characteristics of patients who were reached versus those who were not. A two-item Patient Health Questionnaire-Depression was sent to 4196 type 2 diabetic patients. Positively screened patients were interviewed to assess the severity of depression, and those with subclinical symptoms were invited to treatment groups. The reach of screening procedure was evaluated by the total response rate, proportion of positive depression screenings, and proportion of eligible patients entering treatment programs. Predictors of responsiveness to screening and of participation in treatment were determined using logistic regression. Of the 34% of patients who returned the questionnaire (n = 1442), 40% reported depressive symptoms and a need for professional help (n = 581). Age (OR = 1.06, 95% CI = 1.05-1.08), BMI (OR = 1.02, 95% CI = 1.00-1.04), HbA1C (OR = .92, 95% CI = .86-.99), and LDL-cholesterol (OR = .90, 95% CI = .81-1.00) correlated with response to screening. Willingness to accept treatment was predicted by professional status (OR = 3.24, 95% CI = 1.53-6.87), education (OR = 1.21, 95% CI = 1.05-1.38), and BMI (OR = .91, 95% CI = .85-.98). Older patients with better diabetes control were more likely to be reached by postal screening for depressive symptoms. Professionally inactive, better-educated persons and those with lower BMI were more likely to participate in the intervention for subsyndromal depression.

Disease management for co-morbid depression and anxiety in diabetes mellitus: design of a randomised controlled trial in primary care

Background

Depression and anxiety are common co-morbid health problems in patients with type 2 diabetes. Both depression and anxiety are associated with poor glycaemic control and increased risk of poor vascular outcomes and higher mortality rates. Results of previous studies have shown that in clinical practice, treatment of depression and anxiety is far from optimal as these symptoms are frequently overlooked and undertreated.

Methods/Design

This randomised controlled trial will examine the effectiveness of a disease management programme treating symptoms of depression and anxiety in primary care patients with Type 2 diabetes. Patients will be randomized on patient level in 1:1 ratio. Random block sizes of 2 and 4 are used. The disease management programme consists of screening, stepped treatment and monitoring of symptoms (n = 80). This will be compared to care as usual (n = 80).

Discussion

The disease management model for co-morbid depression and anxiety in primary care patients with diabetes is expected to result in reduced symptoms of depression and anxiety, improved quality of life, reduced diabetes specific distress and improved glyceamic control, compared to care as usual.

Trial Registration

Dutch Trial Register NTR2626

Validation of the Turkish version of the problem areas in diabetes scale

The Problem Areas in Diabetes (PAID) scale is a widely used self-report measure that can facilitate detection of diabetes-specific emotional distress in clinical practice. The aim of this study was to assess the factor structure and validity of the Turkish version of the PAID. A validation study was conducted among 154 patients with insulin-naïve type 2 diabetes. Participants completed the PAID, Centre for Epidemiological Studies Depression Scale (CES-D), Insulin Treatment Appraisal Scale (ITAS), and World Health Organization-Five Well-Being Index (WHO-5) questionnaires. Exploratory factor analyses yielded a 2-factor structure, identifying a 15-item “diabetes distress” factor and a 5-item “support-related issues” factor. The total PAID-score and the two dimensions were associated with higher levels of depression and poor emotional well-being. In the present study, the Turkish version of the PAID had satisfactory psychometric properties, however, the factorial structure was found to differ from factor solutions from other countries.

Diabetes-related emotional distress in adults: reliability and validity of the Norwegian versions of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS)

BACKGROUND

Regular assessment of diabetes-related emotional distress is recommended to identify high-risk people with diabetes and to further prevent negative effects on self-management. Nevertheless, psychological problems are greatly under diagnosed. Translating and testing instruments for psychosocial assessment across languages, countries and cultures allow for further research collaboration and enhance the prospect of improving treatment and care.

OBJECTIVES

To examine the psychometric properties of the Norwegian versions of the Problem Areas in Diabetes Scale and the Diabetes Distress Scale.

DESIGN

Cross-sectional survey design.

SETTINGS

A sample comprising adults with diabetes (response rate 71%) completed the Problem Areas in Diabetes Scale and the Diabetes Distress Scale, which were translated into Norwegian with standard forward-backwards translation.

PARTICIPANTS

The study included 292 participants with type 1 (80%) and type 2 diabetes (20%) aged 18-69 years, 58% males, mean diabetes duration 17.3 years (11.6), mean HbA(1c) 8.2% (1.6).

METHODS

We used exploratory factor analysis with principal axis factoring and varimax rotation to investigate the factor structure and performed confirmatory factor analysis to test the best fit of a priori-defined models. Convergent and discriminate validity were examined using the Short Form-36 Health Survey, Hospital Anxiety and Depression Scale and demographic and disease-related clinical variables. We explored reliability by internal consistency and test-retest analysis.

RESULTS

Exploratory factor analysis supported a four-factor model for the Diabetes Distress Scale. Confirmatory factor analysis indicated that the data and the hypothesized model for the Diabetes Distress Scale fit acceptably but not for the Problem Areas in Diabetes Scale. Greater distress assessed with both instruments correlated moderately with lower health-related quality of life and greater anxiety and depression. The instruments discriminated between those having additional health conditions or disabilities, foot problems or neuropathy. Women and participants with higher HbA(1c) levels reported significantly higher diabetes-related emotional distress.

CONCLUSIONS

The Norwegian versions of the Problem Areas in Diabetes Scale and the Diabetes Distress Scale have satisfactory psychometric properties and can be used to map diabetes-related emotional distress for diagnostic or clinical use. The Diabetes Distress Scale also contributes to identifying sub-domains of distress and seems promising for use in clinical trials.

Dimensionality and scale properties of the Edinburgh Depression Scale (EDS) in patients with type 2 diabetes mellitus: the DiaDDzoB study

BACKGROUND

Depression is a common complication in type 2 diabetes (DM2), affecting 10-30% of patients. Since depression is underrecognized and undertreated, it is important that reliable and validated depression screening tools are available for use in patients with DM2. The Edinburgh Depression Scale (EDS) is a widely used method for screening depression. However, there is still debate about the dimensionality of the test. Furthermore, the EDS was originally developed to screen for depression in postpartum women. Empirical evidence that the EDS has comparable measurement properties in both males and females suffering from diabetes is lacking however.

METHODS

In a large sample (N = 1,656) of diabetes patients, we examined: (1) dimensionality; (2) gender-related item bias; and (3) the screening properties of the EDS using factor analysis and item response theory.

RESULTS

We found evidence that the ten EDS items constitute a scale that is essentially one dimensional and has adequate measurement properties. Three items showed differential item functioning (DIF), two of them showed substantial DIF. However, at the scale level, DIF had no practical impact. Anhedonia (the inability to be able to laugh or enjoy) and sleeping problems were the most informative indicators for being able to differentiate between the diagnostic groups of mild and severe depression.

CONCLUSIONS

The EDS constitutes a sound scale for measuring an attribute of general depression. Persons can be reliably measured using the sum score. Screening rules for mild and severe depression are applicable to both males and females.

Validation of the Turkish version of the Centre for Epidemiologic Studies Depression Scale (CES-D) in patients with type 2 diabetes mellitus

Background

Depression is a common co-morbid health problem in patients with diabetes that is underrecognised. Current international guidelines recommend screening for depression in patients with diabetes. Yet, few depression screening instruments have been validated for use in this particular group of patients. Aim of the present study was to investigate the psychometric properties of the Turkish version of the Centre for Epidemiologic Studies Depression Scale (CES-D) in patients with type 2 diabetes.

Methods

A sample of 151 Turkish outpatients with type 2 diabetes completed the CES-D, the World Health Organization-Five Well-Being Index (WHO-5), and the Problem Areas in Diabetes scale (PAID). Explanatory factor analyses, various correlations and Cronbach's alpha were investigated to test the validity and reliability of the CES-D in Turkish diabetes outpatients.

Results

The original four-factor structure proposed by Radloff was not confirmed. Explanatory factor analyses revealed a two-factor structure representing two subscales: (1) depressed mood combined with somatic symptoms of depression and (2) positive affect. However, one item showed insufficient factor loadings. Cronbach's alpha of the total score was high (0.88), as were split-half coefficients (0.77-0.90). The correlation of the CES-D with the WHO-5 was the strongest (r = -0.70), and supported concurrent validity.

Conclusion

The CES-D appears to be a valid measure for the assessment of depression in Turkish diabetes patients. Future studies should investigate its sensitivity and specificity as well as test-retest reliability.

Development and reach of a web-based cognitive behavioural therapy programme to reduce symptoms of depression and diabetes-specific distress

OBJECTIVES

There is an urgent need for more effective and efficient depression treatments in diabetes. We developed a diabetes-specific version of the Dutch web-based 'Coping with Depression' (CWD) course. Here, we report on the development, reach, patients' reasons for choosing our intervention and their characteristics.

METHODS

The CWD programme was amended for use in diabetes patients with co-morbid depression. Data were collected using a telephone interview, self-report questionnaires, and medical records.

RESULTS

Adding diabetes-specific topics to an effective web-based depression programme resulted in an 8-lesson intervention ("www.diabetergestemd.nl"), with minimal guidance by coaches. In the framework of a randomised trial, the intervention attracted serious interest of 540 patients. After screening, 255 depressed diabetes patients were enrolled. Less than half had a history of depression treatment; 80% reported the diabetes-specific approach to be an important reason for signing up.

CONCLUSION

We successfully developed a diabetes-specific version of the web-based CWD course, which attracted a large group of patients. Our results affirm the importance of addressing diabetes-specific issues in the context of depression treatment.

PRACTICE IMPLICATIONS

Our intervention could be implemented on a large scale at low costs, and may serve as a model on how to develop other illness-specific online self-help interventions.

The dilemma of diabetic patients living with hypoglycaemia

AIMS

To examine the impact of the threat of hypoglycaemic episodes on people with diabetes in Taiwan.

BACKGROUND

Intensive diabetes treatment in people with diabetes helps them to achieve better glycaemic control. However, it also causes more frequent hypoglycaemic episodes and has an impact on their overall quality of life. Hypoglycaemia is accompanied by various distressing symptoms which may cause excessive fear, affecting decision making in hypoglycaemic management.

DESIGN

Purposive sampling and in-depth, face-to-face interviews were used to collect data.

METHODS

Semi-structured interviews were conducted from July 2008-January 2009 with 17 individuals treated with insulin who had previous hypoglycaemic episodes. Data were analysed using qualitative content analysis.

RESULTS

Four themes were generated from the analysis, 'inability to control fluctuations in health', 'challenges to interpersonal relationships', 'facing the disease alone' and 'finding a balance between competing symptoms'.

CONCLUSIONS

Hypoglycaemia is a major health issue for many people with diabetes. Understanding individuals' experiences with hypoglycaemic episodes should help practitioners become more fully involved in promoting self-management. We identified key areas that health care providers should address, including concerns about patient education and professional support for people with diabetes experiencing hypoglycaemia, to enhance problem solving skills for them and their families.

RELEVANCE TO CLINICAL PRACTICE

We recommend that health care providers make proper use of support groups for family caregivers or other important individuals in the lives of people with diabetes to provide education, clarification, support and guidance. In addition, health care providers also need to provide clients with hypoglycaemia-related emotional support, while enhancing diabetes self-management and problem-solving skills.

Limited effect of screening for depression with written feedback in outpatients with diabetes mellitus: a randomised controlled trial

AIMS/HYPOTHESIS

The aim of this study was to test the effectiveness of a screening procedure for depression (SCR) vs care as usual (CAU) in outpatients with diabetes. The primary outcome measured was depression score and the secondary outcomes were mental healthcare consumption, diabetes-distress and HbA(1c).

MATERIALS AND METHODS

In a multicentre parallel randomised controlled trial, 223 outpatients with diabetes, who had an elevated depression score, were randomly assigned to SCR (n = 116) or CAU (n = 107), using computer generated numbers. SCR-patients were invited for a Composite International Diagnostic Interview (CIDI) to diagnose depression and/or anxiety (interviewers were not blinded for group assignment). As part of the intervention, patients and their physicians were informed of the outcome of the CIDI in a letter and provided with treatment advice. At baseline and 6 month follow-up, depression and diabetes-distress were measured using the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Problem Areas in Diabetes survey (PAID). HbA(1c) levels were obtained from medical charts.

RESULTS

Mean CES-D depression scores decreased from baseline to 6 months in both groups (24 ± 8 to 21 ± 8 [CAU] and 26 ± 7 to 22 ± 10 [SCR] respectively [p < 0.001]), with no significant differences between groups. Neither diabetes-distress nor HbA(1c) changed significantly within and between groups. The percentage of patients receiving mental healthcare increased in the SCR group from 20% to 28%, compared with 15% to 18% in the CAU group.

CONCLUSIONS/INTERPRETATION

Depression screening with written feedback to patient and physician does not improve depression scores and has a limited impact on mental healthcare utilisation, compared with CAU. It appears that more intensive depression management is required to improve depression outcomes in patients with diabetes.

Testing the effectiveness of a mindfulness-based intervention to reduce emotional distress in outpatients with diabetes (DiaMind): design of a randomized controlled trial

BACKGROUND

Approximately 20-40% of outpatients with diabetes experience elevated levels of emotional distress, varying from disease-specific distress to general symptoms of anxiety and depression. The patient's emotional well-being is related to other unfavorable outcomes, like reduced quality of life, sub-optimal self-care, impaired glycemic control, higher risk of complications, and increased mortality rates. The purpose of this study is to test the effectiveness of a new diabetes-specific, mindfulness-based psychological intervention. First, with regard to reducing emotional distress; second, with respect to improving quality of life, dispositional mindfulness, and self-esteem of patients with diabetes; third, with regard to self-care and clinical outcomes; finally, a potential effect modification by clinical and personality characteristics will be explored.

METHODS/DESIGN

The Diabetes and Mindfulness study (DiaMind) is a randomized controlled trial. Patients with diabetes with low levels of emotional well-being will be recruited from outpatient diabetes clinics. Eligible patients will be randomized to an intervention group or a wait-list control group. The intervention group will receive the mindfulness program immediately, while the control group will receive the program eight months later. The primary outcome is emotional distress (anxiety, stress, depressive symptoms), for which data will be collected at baseline, four weeks, post intervention, and after six months follow-up. In addition, self-report data will be collected on quality of life, dispositional mindfulness, self-esteem, self-care, and personality, while complications and glycemic control will be assessed from medical files and blood pressure will be measured. Group differences will be analyzed with repeated measures analysis of covariance.The study is supported by grants from the Dutch Diabetes Research Foundation and Tilburg University and has been approved by a medical ethics committee.

DISCUSSION

It is hypothesized that emotional well-being, quality of life, dispositional mindfulness, self-esteem, self-care, and blood pressure will improve significantly more in the mindfulness group compared to the control group. Results of this study can contribute to a better care for patients with diabetes with lowered levels of emotional well-being. It is expected that the first results will become available in 2012.

TRIAL REGISTRATION

Dutch Trial Register NTR2145.

Does treatment of subsyndromal depression improve depression and diabetes related outcomes: protocol for a randomised controlled comparison of psycho-education, physical exercise and treatment as usual

Background

The prevalence of mood difficulties in persons with diabetes is approximately twice that in the general population, affecting the health outcomes and patients' quality of life in an undesirable way. Although subsyndromal depression is an important predictor of a more serious clinical depression, it is often overlooked. This study aims to compare the effects of two non-pharmacological interventions for subsyndromal depression, psychoeducation and physical exercise, with diabetes treatment as usual on mood- and diabetes-related outcomes.

Methods and Design

Type 2 diabetic patients aged 18-65 yrs. who report mood difficulties and the related need for help in a mail survey will be potential participants. After giving informed consent, they will be randomly assigned to one of the three groups (psychoeducation, physical activity, treatment as usual). Depressive symptoms, diabetes distress, health-related quality of life and diabetes self-care activities will be assessed at baseline, at 6 weeks, 6 months and 12 months. A structured clinical interview for DSM-IV Axis I Disorders (SCID-I) will be performed at baseline and at one-year follow-up in order to determine the clinical significance of the patients' depressive symptoms. Disease-related data will be collected from patients' files and from additional physical examinations and laboratory tests.

The two interventions will be comparable in terms of format (small group work), duration (six sessions) and approach (interactive learning; supporting the participants' active roles). The group treated as usual will be informed about their screening results and about the importance of treating depression. They will be provided with brief re-education on diabetes and written self-help instructions to cope with mood difficulties.

Primary outcomes will be depressive symptoms. Secondary outcomes will be glycaemic control, diabetes-related distress, self-management of diabetes and health-related quality of life. Tertiary outcomes will be biochemical markers reflecting common pathophysiological processes of insulin resistance, inflammation and oxidative damage that are assumed to be intertwined in both diabetes and depression. The mixed-effect linear model will be used to compare the outcome variables.

Power analysis has indicated that the two intervention groups and the control group should comprise 59 patients to enable detection of clinically meaningful differences in depressive symptoms with a power of 80% and alpha = 0.05. Outcomes will be analysed on an intention-to-treat basis.

Trial Registration

ISRCTN: ISRCTN05673017

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.

Psychological risk factors of micro- and macrovascular outcomes in primary care patients with type 2 diabetes: rationale and design of the DiaDDZoB Study

Background

Depression is a common psychiatric complication of diabetes, but little is known about the natural course and the consequences of depressive symptoms in primary care patients with type 2 diabetes. While depression has been related to poor glycemic control and increased risk for macrovascular disease, its association with microvascular complications remains understudied. The predictive role of other psychological risk factors such as Type D (distressed) personality and the mechanisms that possibly link depression and Type D personality with poor vascular outcomes are also still unclear.

Methods/Design

This prospective cohort study will examine: (1) the course of depressive symptoms in primary care patients with type 2 diabetes; (2) whether depressive symptoms and Type D personality are associated with the development of microvascular and/or macrovascular complications and with the risk of all-cause or vascular mortality; and (3) the behavioral and physiological mechanisms that may mediate these associations. The DiaDDZoB Study is embedded within the larger DIAZOB Primary Care Diabetes study, which covers a comprehensive cohort of type 2 diabetes patients treated by over 200 primary care physicians in South-East Brabant, The Netherlands. These patients will be followed during their lifetime and are assessed annually for demographic, clinical, lifestyle and psychosocial factors. Measurements include an interviewer-administered and self-report questionnaire, regular care laboratory tests and physical examinations, and pharmacy medication records. The DiaDDZoB Study uses data that have been collected during the original baseline assessment in 2005 (M₀; N = 2,460) and the 2007 (M₁; N = 2,225) and 2008 (M₂; N = 2,032) follow-up assessments.

Discussion

The DiaDDZoB Study is expected to contribute to the current understanding of the course of depression in primary care patients with type 2 diabetes and will also test whether depressed patients or those with Type D personality are at increased risk for (further) development of micro- and cardiovascular disease. More knowledge about the mechanisms behind this association is needed to guide new intervention studies.

Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Comorbid depression in diabetes is highly prevalent, negatively impacting well-being and diabetes control. How depression in diabetes is best treated is unknown.

OBJECTIVE

This systematic review and meta-analysis aims to establish the effectiveness of existing anti-depressant therapies in diabetes.

DATA SOURCES

PubMed, Psycinfo, Embase and Cochrane library. Study eligibility criteria, participants, interventions: randomized controlled trials (RCTs) evaluating the outcome of treatment by psychotherapy, pharmacotherapy or collaborative care of depression in persons with Type 1 and Type 2 diabetes mellitus.

STUDY APPRAISAL

risk of bias assessment; data extraction. Synthesis methods: data synthesis, random model meta analysis and publication bias analysis.

RESULTS

Meta analysis of 14 RCTs with a total of 1724 patients show that treatment is effective in terms of reduction of depressive symptoms: -0.512; 95% CI -0.633 to -0.390. The combined effect of all interventions on clinical impact is moderate, -0.370; 95% CI -0.470 to -0.271; it is large for psychotherapeutic interventions that are often combined with diabetes self management: -0.581; 95% CI -0.770 to -0.391, n=310 and moderate for pharmacological treatment: -0.467; 95% CI -0.665 to -0.270, n=281. Delivery of collaborative care, which provided a stepped care intervention with a choice of starting with psychotherapy or pharmacotherapy, to a primary care population, yielded an effect size of -0.292; 95% CI -0.429 to -0.155, n=1133; indicating the effect size that can be attained on a population scale. Pharmacotherapy and collaborative care aimed at and succeeded in the reduction of depressive symptoms but, apart from sertraline, had no effect on glycemic control.

LIMITATIONS

amongst others, the number of RCTs is small.

CONCLUSION

The treatment of depression in people with diabetes is a necessary step, but improvement of the general medical condition including glycemic control is likely to require simultaneous attention to both conditions. Further research is needed.

Detection of depression in patients with low vision

PURPOSE

Depression is common in people with vision impairment and further reduces levels of functioning independent of vision loss. However, depression most often remains undetected and untreated this group. Eye health professionals (EHPs) (ophthalmic nurses, ophthalmologists, optometrists, and orthoptists) and rehabilitation workers (RWs) may be able to play a role in detecting depression. This study aimed to identify current practice and investigate factors associated with depression management strategies.

METHODS

A self-administered cross-sectional survey of EHPs and RWs assessed current practice including confidence in working with depressed people with vision impairment; barriers to recognition, assessment, and management of depression; beliefs about the consequences, duration, and efficacy of treatment for depression in individuals with vision impairment.

RESULTS

Ninety-four participants aged 23 to 69 years took part. Thirty-seven participants (39.8%) stated that they attempted to identify depression as part of patient management, with RWs significantly more likely to do so (n = 17, 60.7%) than EHPs (n = 20, 30.8%; p = 0.007). Intention to identify depression was not associated with sociodemographic factors, professional experience in eye care services, or the length and number of patient consultations, but a significant relationship was found for confidence, barriers, and beliefs about depression (p < 0.05). No consistent depression management strategy emerged and a range of barriers were highlighted.

CONCLUSIONS

Training programs are needed to provide EHPs and RWs with the skills and resources to address depression in people with vision loss under their care and to support the development of procedures by which concerns about depression can be identified objectively, documented, and included as part of a referral to appropriate services.

Prevalence of comorbid depression is high in out-patients with Type 1 or Type 2 diabetes mellitus. Results from three out-patient clinics in the Netherlands

AIMS

Depression is common in diabetes, but the scope of the problem and associated correlates are not well established in specialist diabetes care. We aimed to determine the prevalence of depression among adult outpatients with Type 1 (T1DM) or Type 2 diabetes (T2DM) using both self-report measures and a diagnostic interview, and to establish demographic and clinical characteristics associated with depressive affect.

METHODS

A random sample of 2055 diabetes out-patients from three diabetes clinics was invited to participate. Depressive affect was assessed using the World Health Organization-5 Well Being Index (WHO-5), the Centre for Epidemiologic Studies-Depression scale (CESD) using predefined cut-off scores, and depressive disorder with the Composite International Diagnostic Interview (CIDI). Associations between depression and patient characteristics were explored using regression analyses.

RESULTS

Seven hundred and seventy-two patients completed the depression questionnaires. About one-third of T1DM patients and 37-43% of T2DM patients reported depressive affect (WHO-5). The prevalence of depressive affect (CESD) was 25% and 30% for men and women with T1DM, and 35% and 38% for men and women with T2DM, respectively. Based on the CIDI, 8% of T1DM patients (no gender difference) and 2% of men and 21% of women with T2DM suffered from a depressive disorder. Depressive affect was associated with poor glycaemic control and proliferative retinopathy in T1DM, while non-Dutch descent, obesity and neuropathy were correlates in T2DM.

CONCLUSIONS

Depressive symptoms and major depressive disorder constitute a common comorbid problem among Dutch out-patients with T1DM or T2DM and appear particularly common in migrants and women with T2DM.

Should we screen for emotional distress in type 2 diabetes mellitus?

Emotional problems such as depression, anxiety and diabetes-specific distress are common in patients with type 2 diabetes mellitus (T2DM) but often remain unrecognized and thus untreated. The present Review focuses on the extent of this problem and discusses whether we should screen for depression, anxiety and diabetes-specific distress in patients with this condition. Depression has received by far the greatest attention from researchers. Strong evidence exists that depression affects 10-20% of patients with T2DM, but it is often unrecognized. Several guidelines have therefore recommended periodic assessments of emotional well-being in patients with T2DM. However, this recommendation is not based on strong evidence, as the effects of screening (case-finding) on psychological outcomes and diabetes outcomes have not been tested in a randomized controlled study. Results from studies in patients without T2DM have shown that screening for depression does not improve outcomes. On the other hand, collaborative care approaches for depression in patients with type 1 diabetes mellitus (T1DM) or T2DM seem to be effective. Intervention studies for anxiety or diabetes-specific emotional distress are currently lacking, and further research that can help to optimize antidepressant treatment is also urgently needed.

Serious diabetes-specific emotional problems in patients with type 2 diabetes who have different levels of comorbid depression: a Polish study from the European Depression in Diabetes (EDID) Research Consortium

OBJECTIVE

Depression is a common psychiatric problem in patients with type 2 diabetes (DM2). A common view is that the burden of having DM2 contributes to the development of depression in DM2. Aim of the present study was to compare the levels of diabetes-specific emotional problems of DM2 patients with diagnosed depression with those with a subclinical form of depression and those without depression.

METHODS

A cross-sectional study was conducted in 101 DM2 patients (51 men and 50 women, mean age = 63,17; SD = 10,74) who completed a standardized, structured psychiatric diagnostic interview (MINI), the Beck Depression Inventory, the Hamilton Depression Rating Scale as well as the Problem Areas in Diabetes (PAID) scale (a 20-item measure, with an overall scale measuring diabetes-related emotional distress and four subscales [negative emotions, treatment-related problems, food-related problems, lack of social support]).

RESULTS

A depression diagnosis was made in 35% (n = 35) of the participants, 24% (n = 24) had a subclinical form of depression, 42% (n = 42) were not diagnosed with any kind of depressive disorder. Diabetes-specific emotional problems were most common in DM2 patients with a depressive disorder (significantly highest PAID score: 39) compared to patients with subclinical depression or no depression. In the group of non-depressed patients, only 14% agreed to have four or more (somewhat) serious diabetes-specific problems. In those with subclinical depression, this percentage was 42% and in those with a depressive disorder 49% (P < 0.001).

CONCLUSIONS

Diabetes-related emotional problems are particularly common among DM2 patients with comorbid clinical depression and to a lesser extent in patients with subclinical depression, compared to non-depressed DM2 patients. Male diabetes patients with a depressive disorder are particularly vulnerable to develop high levels of diabetes-specific emotional distress. Major differences between the three groups mainly concern the diabetes-specific problems connected with the illness.

Supporting diabetes self-management in primary care: pilot-study of a group-based programme focusing on diet and exercise

AIMS

To develop and implement a group self-management education programme for people with type 2 diabetes at the community level in primary care. This pilot-study intended to evaluate the feasibility, acceptability and long-term effects (12-18 months) of this programme on emotional distress, HbA1c, BMI and actual behaviour.

METHODS

An empowerment-based, theory-driven education programme was evaluated in a before-after design. The programme focused on behaviour assessment, goal-setting, problem solving and tailored information. A diabetes specialist nurse conjointly with a dietician or psychologist led five 2-hour sessions and a follow-up meeting after 3 months.

RESULTS

Forty-four people participated in 5 groups. BMI decreased with 0.45 kg/m(2) (95%CI 0.01-0.89) at 12-month and with 0.53 kg/m(2) (95%CI 0.02-1.04) at 18-month follow-up. HbA1c declined from 7.4% (+/-1.3) to 6.8% (+/-0.8) (p=0.040) and the PAID-score diminished from 28 (+/-20) to 18 (+/-13) (p=0.006) at 12-month post-intervention. These changes were only partly sustained at 18-month follow-up. Actual behaviour changed modestly.

CONCLUSION

Introducing the group education programme in primary healthcare is worthwhile (feasibility and effectiveness). A detailed description of the intervention is offered. Further research should explore the actual education process in greater depth.

Depression and quality of life in patients with diabetes: a systematic review from the European depression in diabetes (EDID) research consortium

Diabetes patients are known to have a worse quality of life than individuals without diabetes. They also have an increased risk for depressive symptoms, which may have an additional negative effect on their quality of life. This systematic review summarizes the current knowledge on the association between depressive symptoms and quality of life in individuals with diabetes. A systematic literature search using MEDLINE, Psychinfo, Social SciSearch, SciSearch and EMBASE was conducted from January 1990 until September 2007. We identified studies that compared quality of life between diabetic individuals with and without depressive symptoms. Twenty studies were identified, including eighteen cross-sectional and two longitudinal studies. Quality of life was measured as generic, diabetes specific and domain specific quality of life. All studies reported a negative association between depressive symptoms and at least one aspect of quality of life in people with diabetes. Diabetic individuals with depressive symptoms also had a severely lower diabetes specific quality of life. Generic and domain specific quality of life were found to be mild to moderately lower in the presence of depressive symptoms. Therefore, increased awareness and monitoring for depression is needed within different diabetes care settings.

The psychological impact of living with diabetes: women's day-to-day experiences

PURPOSE

The purpose of this study is to understand the feelings of depression, anxiety, and anger experienced by women with type 2 diabetes and the impact these feelings have on their overall quality of life.

METHODS

Four focus groups (2 white, 2 African American) were conducted by ethnically matched professional moderators. Sessions were audiotaped, and transcriptions were analyzed using an inductive approach. Forty-one women (mean age, 55.6 years; SD = 7.9) who had type 2 diabetes for an average of 8.7 years (SD = 6.3) participated. Forty-two percent of the sample was African American.

RESULTS

The themes generated directly from the focus group data are (1) struggling with the changing health situation; (2) encountering challenges in relationships with self, family, and others; (3) worrying about the present and future; (4) bearing multiple responsibilities for self and others; and (5) choosing to take a break. Women also expressed feelings of depression, anxiety, and anger, which were primarily related to having diabetes as well as managing the multiple responsibilities of being a caregiver. There were more similarities than differences noted by race.

CONCLUSIONS

Women with type 2 diabetes experience feelings of depression, anxiety, and anger, which affect their health and overall quality of life. The findings suggest that health care providers should assess the psychological health of women with type 2 diabetes when developing plans of care. By understanding and addressing the emotional health of women with type 2 diabetes, the relationships between the patient, family, and health care provider may improve, allowing for more successful diabetes management.

Monitoring health related quality of life in adolescents with diabetes: a review of measures

Particularly in chronic conditions, monitoring health related quality of life (HRQoL) of adolescents in clinical practice is increasingly advocated. We set out to identify and review the clinical utility of available generic and diabetes specific HRQoL questionnaires suitable for use in adolescents with type 1 diabetes. Four generic and five diabetes specific questionnaires were identified and evaluated. The responsiveness of most instruments warrants further research and standardisation of HRQoL measurement should be sought to facilitate comparisons across centres and countries. The PedsQL and the KINDL-R appear, at this time, to be the most suitable instruments.