The prevalence of comorbid depression in adults with diabetes: a meta-analysis

The unmet needs of the elderly with diabetes in home health care

The implementation of the Prospective Payment System (PPS) in Medicare home health care has raised concern about health outcomes of elderly patients since its intention is to curb spending. This study examines the unmet needs of older diabetic patients while receiving home health care and post-discharge from home health care (N = 129) in order to explore any effects of PPS on patients' need. The study found that a higher proportion of elders had unmet needs 30 days post-discharge compared with while receiving home health care. The specific unmet needs identified by the elderly diabetic patients included social work services, home health aide, homemaker services, and need for medical equipment. The study explores the role of social work to better manage the unmet needs of diabetic elders who live in the community.

Depression and its association with diabetes, cardiovascular disease, and birth weight

BACKGROUND

Diabetes increases the risk for depression.

AIM

To study the independent effects of diabetes mellitus (DM) and cardiovascular disease (CVD) on the prevalence of depression and to examine low birth weight as a possible common explanatory factor.

METHODS

2003 subjects from the Helsinki Birth Cohort Study underwent a 75-g oral glucose tolerance test and filled out the Beck Depression Inventory.

RESULTS

Depressive symptoms were more prevalent among subjects with diabetes (23.5%) than among those with normal glucose tolerance (16.6%) (P < 0.001). A history of CVD also markedly increased the odds of having depressive symptoms (odds ratio (OR) = 2.38, 95% confidence interval (CI) = 1.70-3.32, P < 0.001). The association between DM and depressive symptoms was, however, rendered non-significant when adjusting for the presence of CVD. Being born with a low birth weight doubled the risk for having depressive symptoms (OR = 2.64, 95% CI = 1.42-4.91, P = 0.002) and magnified the association between CVD/DM and depression.

CONCLUSION

Diabetes has only a minor independent effect on concurrent occurrence of depressive symptoms, while cardiovascular disease seems to be a more important underlying factor. The association between disease and depression is in particular characteristic to individuals born with a low birth weight.

Coping and psychosocial adaptation to Type 2 diabetes in older Blacks born in the Southern US and the Caribbean

Older Black men and women (n = 212) with Type 2 diabetes completed questionnaires. Spearman's rho correlation indicated that confrontive coping strategies supported effective psychosocial adaptation for persons originally from Haiti and Jamaica, while emotive coping strategies were related to ineffective psychosocial adaptation for persons originally from Barbados and to increased psychological distress for all participants. Women used more palliative coping; no gender differences were observed for psychosocial adaptation. Health care orientation, extended family relationships, and psychological distress domains distinguished Blacks born in Haiti from Blacks born in Barbados and Jamaica, the Southern US and Jamaica, and the Southern US, Barbados, and Jamaica. Findings from this study may aid in the development of interventions focused on improving diabetes self-management for older Blacks.

Predictors of depression in a sample of 1,021 primary care patients with osteoarthritis

OBJECTIVE

Although there is a strong relationship between depression, chronic pain, and physical activity, there are few findings regarding the prevalence and predictors of depression in patients with osteoarthritis (OA). The goal of the present study was to assess the prevalence and severity of depression in a large sample of patients with OA and to reveal predictors of depression.

METHODS

Patients were approached consecutively in 75 general practices. Of 1,250 distributed questionnaires, 1,021 were returned and analyzed. Besides sociodemographic data, medication and comorbidities, depression, and arthritis were assessed using the Patient Health Questionnaire (PHQ-9) and the Arthritis Impact Measurement Scale. A stepwise multiple linear regression analysis with the PHQ-9 score as the dependent variable was performed.

RESULTS

On the PHQ-9, 19.76% of men and 19.16% of women achieved a score of >or=15, indicating at least a moderately severe depression. Significant sex differences could not be revealed. The strongest predictor for depression severity was perceived pain (beta = 0.243, P < 0.001) and few social contacts (beta = 0.218, P < 0.001). Further predictors were physical limitation of the lower body (beta = 0.157, P < 0.001) and upper body (beta = 0.163, P < 0.001), age (beta = -0.168, P < 0.001), and body mass index (beta = 0.080, P = 0.020).

CONCLUSION

These findings suggest an increased prevalence of depression among patients with OA and emphasize the need for recognition and appropriate treatment. Most of the revealed predictors are influenceable and should be potential targets in a comprehensive treatment of OA to interrupt the vicious circle of pain, physical limitation, and depression.

Screening for depression in a diabetic outpatient population

Depression occurs twice as often in patients with diabetes and is associated with reduced compliance with exercise, diet, and medications. It is also associated with hyperglycemia and increased diabetic complications. Despite evidence that successful treatment is associated with improved glycemic control, many cases of depression are left untreated. Objectives. (1) Evaluate a combination screening strategy in an outpatient population; and (2) explore the association between glycemic control and depressive symptomatology. Methods. Ninety-two patients completed the Patient Health Questionnaire (PHQ-2). Patients with a PHQ-2 score ≥ 1 completed the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16). Using the QIDS-SR16, a score of ≤5 corresponded to normal mood, with scores above 5 corresponding to increasing severity of depressive symptoms. Glycemic control was assessed by glycosylated hemoglobin (HbA1c). Results. Using a PHQ-2 cut-off score of ≥3, 37% of the sample screened positive for major depressive disorder (MDD), with an additional 27% reporting sub-threshold symptoms. The depressed group reported significantly more difficulty with reduced interests, insomnia, concentration, self-criticism, energy/fatigue and depressed mood. In terms of glycemic control, there was a marginally significant effect for race and HbA1c. Conclusion. The combined PHQ-2 and QIDS-SR16 can facilitate prompt detection of MDD and provide a means of monitoring specific symptoms and progress once treatment commences.

[Diabetes and depression--a life-endangering interaction]

In the past decade, research has increasingly discovered the relevance of depressive symptoms for the development and course of diabetes, particularly in diabetes type 2. The present paper provides an update on the present state of empirical research concerning this question.One fourth of all patients with diabetes mellitus suffer from depressive symptoms up to and including states of depressive disorders. The studies reviewed advise that depression in patients with diabetes concur with an unfavourable attitude towards the illness as well as towards treatment, a reduction in quality of life, an increased risk for the development of follow-up diseases as well as an increase in mortality risk. As a cause for the increasing risk in morbidity and mortality in depressive patients with diabetes, both neuroendocrinologic changes as well as unfavourable therapy and illness attitudes are discussed. First studies document that psychotherapeutic interventions are helpful in increasing the quality of life of depressive patients with diabetes and improving therapy behaviour.

Psychosocial and psychiatric challenges of diabetes mellitus

Diabetes mellitus is a chronic endocrine disorder that places considerable psychologic stress on individuals and their families. This article discusses psychosocial issues associated with diabetes and its management, and common psychiatric disorders in diabetes population. Psychosocial challenges and psychiatric disorders in people with diabetes can hinder patients' successful diabetes self-management and well-being. An understanding of mental health issues in diabetes is critical for all health care professionals who provide treatment to people with diabetes.

Brain-derived neurotrophic factor (BDNF) and type 2 diabetes

AIMS/HYPOTHESIS

Decreased levels of brain-derived neurotrophic factor (BDNF) have been implicated in the pathogenesis of Alzheimer's disease and depression. These disorders are associated with type 2 diabetes, and animal models suggest that BDNF plays a role in insulin resistance. We therefore explored whether BDNF plays a role in human glucose metabolism.

SUBJECTS AND METHODS

We included (Study 1) 233 humans divided into four groups depending on presence or absence of type 2 diabetes and presence or absence of obesity; and (Study 2) seven healthy volunteers who underwent both a hyperglycaemic and a hyperinsulinaemic-euglycaemic clamp.

RESULTS

Plasma levels of BDNF in Study 1 were decreased in humans with type 2 diabetes independently of obesity. Plasma BDNF was inversely associated with fasting plasma glucose, but not with insulin. No association was found between the BDNF G196A (Val66Met) polymorphism and diabetes or obesity. In Study 2 an output of BDNF from the human brain was detected at basal conditions. This output was inhibited when blood glucose levels were elevated. In contrast, when plasma insulin was increased while maintaining normal blood glucose, the cerebral output of BDNF was not inhibited, indicating that high levels of glucose, but not insulin, inhibit the output of BDNF from the human brain.

CONCLUSIONS/INTERPRETATION

Low levels of BDNF accompany impaired glucose metabolism. Decreased BDNF may be a pathogenetic factor involved not only in dementia and depression, but also in type 2 diabetes, potentially explaining the clustering of these conditions in epidemiological studies.

Facilitating narrative medical discussions of type 1 diabetes with computer visualizations and photography

OBJECTIVE

Patient-centered approaches to medicine suggest the need for physicians to become more aware of concerns and needs expressed in patient narratives. However, patients and physicians have different goals and discourse styles during consultations. We attempt to bridge these differences by providing patients with ways to collect, visualize, and describe behavioral and biomedical data.

METHODS

We describe an intervention where individuals with type 1 diabetes photograph health-related behaviors. These images and blood glucose records are displayed in computer visualizations and used during patient-physician interviews.

RESULTS

Qualitative analyses of interview data with patients who photographed their lives suggest the range of difficulties associated with diabetes self-management. The visualizations helped them articulate concerns about stress, peer relations, and unhealthy routines.

CONCLUSION

Interventions that combine biomedical and biopsychosocial data during patient-physician consultations may be beneficial for patients, helping them reflect on correlations between behaviors and health. Physicians are provided with contextual evidence to better understand patient issues around diabetes management.

PRACTICE IMPLICATIONS

We suggest that this and similar interventions could be used as an occasional diagnostic to help patients articulate stories of their health-related practices. Annotated archives of photographs and glucose data may also be useful tools for sharing diabetes experiences with newly diagnosed patients.

The prevalence of depression and anxiety in adults with Type 1 diabetes

AIM

The aim of the present study was to determine the prevalence of anxiety and depression in a large UK group of people with Type 1 diabetes.

METHODS

Patients aged 16-60 years were invited to complete self-report questionnaires when they attended outpatient clinic appointments. HbA(1c) was recorded from the clinic database.

RESULTS

Analysis was based on 273 complete questionnaires. The mean scores for both anxiety (mean 6.4, sd 4.5) and depression (mean 3.4, sd 3.5) were consistent with normative data. Females reported significantly higher mean anxiety than males, although neither reached the criterion for 'caseness'. Significant differences to the norm were observed for the percentages reporting moderate to severe levels of depression in males (chi(2) = 6.44; d.f. = 2; P = 0.04) and moderate to severe levels of anxiety in females (chi(2) = 7.47; d.f. = 2; P = 0.02). HbA(1c) was positively correlated with HADS scores (anxiety r = 0.2, P = 0.001, depression r = 0.14, P = 0.02).

CONCLUSIONS

While there is no significant difference in the mean anxiety or depression in this cohort compared with those reported for a non-diabetic, healthy population, the results suggest that there is an increased prevalence of clinically relevant anxiety in females and of depression in males with Type 1 diabetes when compared with the normative data.

Vascular depression in older people with diabetes

AIMS/HYPOTHESIS

Cerebrovascular disease may be causal or a vulnerability factor in late-onset depression and may explain the high rate of depression in older adults with diabetes. We explored a wide range of potential explanatory variables of depression in a longitudinal study of older diabetic subjects to investigate the vascular depression hypothesis in these patients.

METHODS

We recruited 207 subjects with diabetes selected for potential cognitive deficits from an existing observational cohort study (average age 75.7 +/- 4.6 years, 52.2% men) for an assessment of depression using a standardised diagnostic instrument (Cambridge Examination for Mental Disorders of the Elderly -- Revised). All subjects underwent a detailed clinical assessment at baseline and at follow-up (after 7.5 +/- 1.1 years).

RESULTS

Major depression was present in 45 subjects (21.7%) and minor depression in ten (4.8%). A positive history of strokes and the presence of peripheral arterial disease were significantly associated with depression at the time of diagnosis. In a subsample of 93 cases who underwent structural neuroimaging, the presence of cerebral infarcts was also significantly associated with depression. Treatment with glucose-lowering therapy, higher serum cholesterol levels and difficulties with activities of daily living at baseline were significant predictors of depression at follow-up.

CONCLUSIONS/INTERPRETATION

A history of cerebrovascular disease was strongly associated with depression and cerebrovascular risk factors were significant predictors of depression in older diabetic patients. Our findings are consistent with the hypothesis that the excess risk of depression in older diabetic patients is related to underlying cerebrovascular disease.

Vulnerable Populations with Diabetes Mellitus

This review of the literature on vulnerable populations with diabetes identifies trends, summarizes major findings, and recommends strategies to fill gaps in the state of the science. For the purposes of this article "vulnerable populations" refers to members of diverse racial and ethnic groups, people of low-income, and those who live in rural and medically underserved areas.

Baseline characteristics of the randomised cohort from the Look AHEAD (Action for Health in Diabetes) study

OBJECTIVE

The Look AHEAD (Action for Health in Diabetes) study is a 16-centre randomised clinical trial in overweight and obese individuals with type 2 diabetes, designed to evaluate the long-term effects (up to 11.5 years) of intensive weight loss intervention on the time to incidence of major cardiovascular events.

RESEARCH DESIGN AND METHODS

Eligibility requirements are diagnosis of type 2 diabetes (determined by self-report and verification) in individuals aged 4574 years and body mass index (BMI) > 25 kg/m2 (> 27 kg/m2 if currently taking insulin). The intensive lifestyle intervention is designed to achieve and maintain weight loss through decreased caloric intake and increased physical activity. The study is designed to provide 90% probability of detecting an 18% difference in major cardiovascular disease event rates in patients randomised to the intensive lifestyle intervention compared to the control group receiving standard diabetes support and education.

RESULTS

The 5,145 participants who were randomised between 2001 and 2004 were 63.3% white, 15.6% African-American, 13.2% Hispanic, 5.0% American Indian and 1.0% Asian-American, which closely paralleled the ethnic distribution of diabetes in the National Health and Nutrition Examination Survey (NHANES) 1999-2000 survey. Their average age at entry was 59+/-6.8 years (mean+/-SD), and 60% were women. There were 31.5% between 4555 years of age, 51.5% were 5665, and 17.0% were 6676 years of age. Some 15.4% of participants were taking insulin at the time of randomisation and 14.0% had a history of cardiovascular disease. More men (21.3%) than women (9.2%) had a history of cardiovascular disease. Few participants (4.4%) were current cigarette smokers, compared to 16.2% in the NHANES 1999-2000 survey. Furthermore, 65.0% of participants had a first-degree relative with diabetes. Overall, BMI averaged 36+/-5.9 kg/m2 at baseline, with 83.6% of the men and 86.1% of women having a BMI > 30 kg/m2 and 17.9% of men and 25.4% of women having a BMI > 40 kg/m2.

CONCLUSIONS

The Look AHEAD study has successfully randomised a large cohort of participants who have type 2 diabetes with a wide distribution of age, obesity, ethnicity and racial background and will examine the effects of lifestyle intervention on the incidence of major cardiovascular events.

Behavioral Interventions for Diabetes Self-Management

This article synthesizes the research on behavioral interventions aimed at diabetes self-management, describes current trends in diabetes self-management, and proposes future directions for diabetes self-management care and research. Interventions that are multifaceted, tailored to the individual, and provided six months or longer demonstrate modest effects in improving diabetes-related outcomes. Improving access to behavioral interventions, maintaining the effects of behavioral interventions, and addressing the more complex social and environmental factors that contribute to behavior change are current challenges in diabetes self-management that warrant further attention and research.

Co-occurrence of mental and physical illness in US Latinos

BACKGROUND

This study describes the prevalence of comorbid physical and mental health problems in a national sample of US Latinos. We examined the co-occurrence of anxiety and depression with prevalent physical chronic illnesses in a representative sample of Latinos with national origins from Mexico, Cuba, Puerto Rico, and other Latin American countries.

METHOD

We used data on 2,554 Latinos (75.5% response rate) ages 18 years and older from the National Latino and Asian American Study (NLAAS). The NLAAS was based on a stratified area probability sample design, and the sample came from the 50 states and Washington, DC. Survey questionnaires were delivered both in person and over the telephone in English and Spanish. Psychiatric disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI). Physical chronic illness was assessed by self-reported history.

RESULTS

Puerto Ricans had the highest prevalence of meeting criteria for any comorbid psychiatric disorder (more than one disorder). Puerto Ricans had the highest prevalence (22%) of subject-reported asthma history, while Cubans had the highest prevalence (33%) of cardiovascular disease. After accounting for age, sex, household income, number of years in the US, immigrant status, and anxiety or depression, anxiety was associated with diabetes and cardiovascular disease, in the entire sample. Depression and co-occurring anxiety and depression were positively associated with having a history of asthma but not with other physical diseases, in the entire sample. Interestingly, Puerto Ricans with a depressive disorder had a lower odds of having a history of cardiovascular disease than Puerto Ricans without a depressive disorder. The relationship between chronic physical and mental illness was not confounded by immigration status or number of years in the US.

DISCUSSION

Despite previous findings that link acculturation with both chronic physical and mental illness, this study does not find that number of years in the US nor nativity explain the prevalence of psychiatric-medical comorbidities. This study demonstrates the importance of considering psychiatric and medical comorbidity among specific ethnic groups, as different patterns emerge than when using aggregate ethnic measures. Research is needed on both the pathways and the mechanisms of comorbidity for the specific Latino groups.

A psychological approach to providing self-management education for people with type 2 diabetes: the Diabetes Manual

BACKGROUND

The objectives of this study were twofold (i) to develop the Diabetes Manual, a self-management educational intervention aimed at improving biomedical and psychosocial outcomes (ii) to produce early phase evidence relating to validity and clinical feasibility to inform future research and systematic reviews.

METHODS

Using the UK Medical Research Council's complex intervention framework, the Diabetes Manual and associated self management interventions were developed through pre-clinical, and phase I evaluation phases guided by adult-learning and self-efficacy theories, clinical feasibility and health policy protocols. A qualitative needs assessment and an RCT contributed data to the pre-clinical phase. Phase I incorporated intervention development informed by the pre-clinical phase and a feasibility survey.

RESULTS

The pre-clinical and phase I studies resulted in the production in the Diabetes Manual programme for trial evaluation as delivered within routine primary care consultations.

CONCLUSION

This complex intervention shows early feasibility and face validity for both diabetes health professionals and people with diabetes. Randomised trial will determine effectiveness against clinical and psychological outcomes. Further study of some component parts, delivered in alternative combinations, is recommended.

Gender-specific care of the patient with diabetes: review and recommendations

BACKGROUND

Men and women differ in their experience of diabetes mellitus (DM). For optimal prevention and treatment of the disease, these differences must be acknowledged. Unfortunately, most studies of diabetes have focused almost exclusively on men.

OBJECTIVE

The purpose of this review was to survey the literature about the sex-specific features of DM and to make recommendations for the gender-specific care of patients.

METHODS

An initial literature search was performed with Google Scholar and MEDLINE (1995-2005) using the search terms sex/gender, women, diabetes mellitus, and coronary artery disease, and specific topic headings such as polycystic ovary syndrome. The bibliographies of articles were used extensively to augment the search, and more specific search terms were included. The strength of each recommendation was assessed.

RESULTS

: Even when women were included in clinical trials, investigators typically made no attempt to assess the impact of sex differences on the reported results. Existing studies, however, reveal several differences between men and women with diabetes. The prevalence of DM is growing fastest for older minority women. Women with diabetes, regardless of menopausal status, have a 4- to 6-fold increase in the risk of developing coronary artery disease (CAD), whereas men with diabetes have a 2- to 3-fold increase in risk. Women with diabetes have a poorer prognosis after myocardial infarction and a higher risk of death overall from cardiovascular disease than do men with diabetes. Women with type 2 DM experience more symptoms of hyperglycemia than do their male counterparts. Obesity, an important contributor to type 2 DM, is more prevalent in women. Women with diabetes have an increased risk of hypertension compared with men with diabetes. Women have a more severe type of dyslipidemia than do men (low levels of high-density lipoprotein cholesterol, small particle size of low-density lipoprotein cholesterol, and high levels of triglycerides), and these risk factors for CAD have a stronger influence in women. Oxidative stress may confer a greater increase in the risk of CAD for women with diabetes than for men with diabetes. Many other sex differences in DM are due to women's reproductive physiology. Polycystic ovary syndrome is an important correlate of insulin resistance and the metabolic syndrome. Gestational diabetes mellitus (GDM) increases the risk of cardiovascular disease and type 2 DM. Women are less likely than men to receive aggressive treatment for CAD and to achieve treatment goals. Critical recommendations for women include exercise, testing for CAD, daily aspirin to counteract the prothrombotic state, depression screening, careful treatment to avoid weight gain, long-term follow-up of children of women with GDM, control of risk factors for CAD, and aggressive treatment with coronary angioplasty for CAD. Disease management programs for patients with diabetes have been shown to save money and improve outcomes, and should continue to incorporate information about sex-specific differences in DM as it becomes available.

CONCLUSION

Gender-specific care of the patient with diabetes should be informed by evidence-based recommendations.

Correlates of depression in type 2 diabetic elderly patients: a correlational study

OBJECTIVES

This aim of this study was to investigate depression and related factors in elderly patients (65 years) with type 2 diabetics.

METHODS

The study utilized a descriptive-correlational design. Convenience sampling was applied to enroll 156 subjects, aged >or= 65 years from diabetic outpatient clinics at three hospitals in Kaohsiung. This study applied the Personal Resource Questionnaire 2000 (PRQ 2000), Taiwan Geriatric Depression Scale (TGDS), and a form for demographic data.

RESULTS

(1) The mean index score for depression level was 26, indicating that study subjects had a low level of depression. The social support index score was 76. (2) Significant differences in TGDS scores existed for diabetes duration, diabetes complications, and treatment type. (3) Social support and regular exercise were significantly and negatively correlated with depression. (4) Social support and diabetes complications were significant correlates of depression and accounted for 25.9% of variance in depression.

CONCLUSION

Analytical results may assist nurses in understanding depression and related factors for diabetic patients aged >or= 65. Therefore, this study could form a basis for caring older people with diabetes, and provide a reference for further research.

Specific associations of insulin resistance with impaired health-related quality of life in the Hertfordshire Cohort Study

Insulin resistance is a metabolic abnormality that underlies Type 2 diabetes, the metabolic syndrome and cardiovascular disease, but it may also be associated with more global health deficits. This study assessed associations of insulin resistance with health-related quality of life (HRQoL) in different domains of physical and mental health in a large elderly population study. Cross-sectional data of 1212 participants from the Hertfordshire Cohort Study were analysed. Insulin resistance was assessed by the homeostatic model assessment (HOMA-IR), and HRQoL was measured using the SF-36 health survey. Poor HRQoL was defined by a score lower than the sex-specific 10th percentile of each scale, and logistic regressions yielded odds ratios in relation to the HOMA-IR scores. Subsequent analyses adjusted for the influence of age, smoking, alcohol consumption, social class, BMI, coronary heart disease and depression. Results showed an increase in poor HRQoL with an increase in HOMA-IR scores for physical functioning (OR = 2.29; CI: 1.67-3.13), vitality (OR = 1.45; CI: 1.05-2.00), and general health (OR = 1.62; CI: 1.19-2.21). In men, but not in women, associations with physical functioning were independent of confounding variables. The results indicate that insulin resistance is associated with poor HRQoL in domains of physical health, but not in domains of mental health.

Is glycemic variability important to assessing antidiabetes therapies?

Traditionally, statistical estimation of glycemic variability includes computing standard deviation of glucose readings or related statistics (eg, M value, mean amplitude of glucose excursions, and so forth). We advocate an alternative approach using risk measures of variability, which have substantial clinical and numerical advantages. In addition, continuous glucose monitoring (CGM) data have clinically important inherent temporal structure that should be taken into consideration. Thus, temporal variability methods are discussed for the analysis and interpretation of CGM output.

Difficulties of smoking cessation in diabetic inpatients benefiting from a systematic consultation to help them to give up smoking

AIM

To assess the value of systematic smoking cessation consultations for diabetic smokers admitted to hospital.

METHODS

All diabetic smokers admitted to the Diabetes Department of Georges Pompidou European Hospital between February 2003 and February 2004 were systematically offered a consultation with a physician specialised in tobacco cessation. Follow-up visits at three, six and nine months were planned.

RESULTS

Of the 306 diabetic patients admitted, 38 (12.4%) were smokers. There were more men than women in the group of smokers and the diabetic smokers were younger than the non-smokers. The smokers had fewer micro-angiopathic complications than the non-smokers, but there was no difference in the frequency of macro-angiopathic complications. The level of nicotine physical dependence was moderate or high for 60% of the smokers. Although all the smokers agreed to the consultation, less than half agreed to drug-based treatments to help them to give up smoking and only 15% returned for the six-month visit. Only one patient had stopped smoking at the six-month visit.

CONCLUSION

This study demonstrates the difficulties in systematic interventions to help diabetic patients to stop smoking. Diabetic smokers probably constitute a specific population for which the barriers to giving up smoking should be explored.

The role of alexithymia factors in glucose control of persons with type 1 diabetes: a pilot study

OBJECTIVE

To clarify the respective contribution of demographic characteristics, health conditions and three psychological variables (depression, anxiety, alexithymia) for glycaemic control measured by glycated hemoglobin (HbA1c).

MATERIALS AND METHODS

Sixty-four persons diagnosed with type 1 diabetes completed psychological measures and demographic information at admission (T1) to the hospital and in a follow-up (+8 weeks) (T2). Additional information about their health conditions was also considered.

RESULTS

At T1, the alexithymia factor "difficulties describing feelings" (DDF) predicted HbA1c over and above the predictive power of demographic information, health conditions, anxiety, and depression. Additionally, higher decrease in HbA1c from T1 to T2 was predicted by higher scores on the alexithymia factor DDF at admission over and above the other predictors.

CONCLUSION

DDF is an important predictor of glucose control. Scoring higher on this factor is related to poorer glycaemic control at admission. Additionally, people with higher scores on this factor seem to benefit highly from the treatment administered at the hospital.

Prevalent and incident depression in community-dwelling elderly persons with diabetes mellitus: results from the ZARADEMP project

AIMS/HYPOTHESIS

Although several studies have reported on the association between diabetes and depression, none have used both formal psychiatric criteria and a prospective, population-based design. Therefore, it remains unclear whether diabetes is a risk factor for the development of depression. Moreover, it is not clear if this effect is influenced by other chronic diseases and functional disabilities.

METHODS

A large (n=4,803) representative community-based study in Spanish elderly subjects (at least 55 years of age) was conducted. The presence of major depression was assessed by means of a standardised psychiatric diagnostic interview (Automated Geriatric Examination for Computer Assisted Taxonomy). Subjects underwent a baseline assessment and a follow-up assessment after 2 and 5 years to determine the incidence of depression.

RESULTS

At baseline 597 subjects (12.5%) were identified as having diabetes. Prevalence and incidence of depression in cases of diabetes were 15.4% and 16.5% respectively. Diabetes was associated with an increased risk of prevalent (odds ratio [OR]=1.47; 95% CI: 1.16-1.83) and incident (OR=1.40; 95% CI: 1.03-1.90) depression. Controlling for potential confounders did not essentially change these findings (prevalent depression: OR 1.41, 95% CI: 1.08-1.83; incident depression: OR 1.26, 95% CI: 0.90-1.77).

CONCLUSIONS/INTERPRETATION

In a large, representative prospective population-based sample using strict psychiatric criteria, we confirmed previous findings that diabetes is associated with an increased risk of depression. The effect on the incidence of depression suggests that diabetes may play a role in the development of depression in the elderly. The presence of comorbid medical diseases seems to decrease the effects of diabetes on the risk of prevalent depression, but to increase the risk of incident depression.

Inadequate follow-up care for depression and its impact on antidepressant treatment duration among veterans with and without diabetes mellitus in the Veterans Health Administration

OBJECTIVE

Our objective was to describe the adequacy of follow-up care for depression and its association with antidepressant treatment duration among veterans with and without diabetes mellitus (DM).

METHOD

This was a retrospective study (1997-2005) of 2178 veterans (33% with DM) in a Midwestern Veterans Health Administration facility who had a new episode of unipolar depression. Adequate follow-up care was defined by a health care visit within 7 and 14 days, and >/=3 visits following antidepressant treatment initiation. Adequate treatment duration was defined by a medication possession ratio of >/=80%. Multivariate logistic regression was used to calculate odds ratios (ORs) adjusted for demographic, clinical and health care utilization characteristics.

RESULTS

Only 27% received >/=3 follow-up visits within 12 weeks, and <23% received follow-up within 2 weeks of antidepressant initiation. Subjects with DM were 1.36-fold more likely [95% confidence interval (95% CI)=1.05-1.75] to have received >/=3 visits but were similarly likely to have received follow-up within 7 days (OR=1.02; 95% CI=0.74-1.41) or 14 days (OR=1.08; 95% CI=0.83-1.40) of antidepressant initiation. Adequate follow-up care was the most important predictor of adequate treatment duration (OR=2.10; 95% CI=1.54-2.88).

CONCLUSION

DM had little influence on the adequacy of follow-up care for depression, with few exceptions. Follow-up care for depression is underutilized and has a significant impact on antidepressant treatment duration. Strategies to more effectively manage depression treatment are required.

The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis

AIM

To conduct a systematic literature review in order to estimate the prevalence and odds ratio of clinically relevant depression in adults with Type 2 diabetes compared with those without.

METHODS

MEDLINE, EMBASE and PSYCINFO databases were searched using MeSH terms and free text to identify relevant controlled studies. Published reference lists were also examined. Study selection and appraisal were conducted independently by two reviewers and a meta-analysis was performed to synthesize and analyse the data.

RESULTS

Ten controlled studies including a total of 51 331 people were published between January 1980 and May 2005. The prevalence of depression was significantly higher in patients with Type 2 diabetes compared with those without [17.6 vs. 9.8%, OR = 1.6, 95%, confidence interval (CI) 1.2-2.0]. However, in most studies, patients with diabetes differed from those without on variables known to be associated with an increased risk of depression. The prevalence of depression was higher in females with diabetes (23.8%) compared with males (12.8%); however, the odds ratio for depression in patients with Type 2 diabetes compared with those without was higher in males (OR = 1.9, 95% CI 1.7-2.1) than females (OR = 1.3, 95% CI 1.2-1.4). Failure to report potential confounders prevented a more rigorous meta-analysis of risk.

CONCLUSION

We identified raised rates of depression in people with Type 2 diabetes, however, there is a need for well-controlled and better-reported studies to inform the development of effective treatments for depression in these patients.

Resource use among patients with diabetes, diabetic neuropathy, or diabetes with depression

BACKGROUND

Diabetes is often associated with complications and comorbidities. The purpose of this research is to compare medical resources used by patients with the following diagnoses: diabetes mellitus (DM), diabetic neuropathy (DN), and diabetes mellitus combined with comorbid depression (DD).

METHODS

Adult patients who were diagnosed with DM, DN, or DD were included in the study. There were 55,972 patients in the DM cohort, 2,146 in the DN, and 2,379 in the DD. P values for comparisons between the three mutually exclusive cohorts were conducted using the Tukey-Kramer method. Cost comparisons among the cohorts were conducted using a stepwise multivariate regression that controlled for patient characteristics and comorbid conditions.

RESULTS

Individuals in the DM or DN cohorts were generally more likely to use antidiabetic medications than patients in the DD group. Those diagnosed with DN or DD generally used more pain medications than individuals in the DM cohort. The DM cohort had significantly lower diabetes-related total medical costs ($1,297 v $5,125, p < 0.0001) and lower total medical costs ($4,819 v $24,765, p < 0.0001) than the DN cohort. The DM cohort also had significantly lower diabetes-related total medical costs ($1,297 v $3,264, p < 0.0001) as well as significantly lower total medical costs ($4,819 v $19,298, p < 0.0001) than the DD cohort.

CONCLUSION

Results from this study indicated significant differences in demographic characteristics, comorbidities, and medication use among individuals diagnosed with DM, DN, or DD. These differences translated into significant cost differences. Patients diagnosed with DN or DD had higher diabetes-related costs than patients diagnosed with DM.

Quality of life, health status and clinical outcomes in Type 2 diabetes patients

This study examines relationships between patient reported outcomes (PROs) and clinical outcomes in Type 2 diabetes mellitus (T2DM). Patients at the outpatient clinics of a university hospital completed measures of generic health status (SF-12), diabetes-specific quality of life (Audit of Diabetes Dependent Quality of Life - ADDQoL), and depressive symptoms (Center for Epidemiologic Studies Depression - CES-D). Patient reported data were merged with a retrospective collection of clinical and utilization data, including HbA1C, from electronic medical records. A Charlson comorbidity score, diabetes complications score, BMI, and total number of ER and hospital visits were calculated. Usable response rate was 44.3% (n = 385). Patients were dichotomized into glycemic control levels based on the ADA recommended A1C level < 7.0, vs. >or= 7.0. The ADDQoL, PCS-12, and MCS-12 scores were separately examined as dependent variables using hierarchical regression models, with glycemic control as the primary explanatory variable, and controlling for demographics and clinical variables including comorbidities and complications. Glycemic control was not a significant predictor in any regression model. Obesity was a significant predictor leading to poorer PCS-12 and MCS-12 scores, while depressive symptoms significantly resulted in lower PCS-12, MCS-12 and ADDQoL scores. These and other factors related to self-management behaviors may contribute to a greater understanding of how to intervene with patients with T2DM. The use of such PROs alongside biomedical measures such as A1C is recommended.

Mental-physical comorbidity in Te Rau Hinengaro: the New Zealand Mental Health Survey

OBJECTIVE

To estimate the prevalence of chronic physical conditions, and the risk factors for those conditions, among those with 12 month mental disorder; to estimate the prevalence of 12 month mental disorder among those with chronic physical conditions.

METHOD

A nationally representative face-to-face household survey was carried out in October 2003 to December 2004 with 12,992 participants aged 16 years and over, achieving a response rate of 73.3%. Mental disorders were measured with the World Mental Health version of the Composite International Diagnostic Interview (CIDI 3.0). Physical conditions were self-reported. All associations are reported adjusted for age and sex.

RESULTS

People with (any) mental disorder, relative to those without mental disorder, had higher prevalences of several chronic physical conditions (chronic pain, cardiovascular disease, high blood pressure and respiratory conditions) and chronic condition risk factors (smoking, overweight/obesity, hazardous alcohol use). Around a quarter of people with chronic physical conditions had a comorbid mental disorder compared with 15% of the population without chronic conditions. Significant relationships occurred between some mental disorders and obesity, cardiovascular disease and diabetes for females, but not for males.

CONCLUSIONS

This paper provides evidence of substantial comorbidity between mental disorders and chronic physical conditions in New Zealand. This should be borne in mind by clinicians working in both mental health and medical services.

Depressive symptoms and insulin resistance in young adult males: results from the Northern Finland 1966 birth cohort

The association between insulin resistance (IR) and depression is a subject of growing research interest, especially as previous population-based studies have presented conflicting findings. The present study extends our understanding about the putative impact of the severity of depressive symptoms on this association and it provides further epidemiological evidence in support of earlier findings, suggesting that the association between IR and depression is present already in young adult males. To determine the impact of the severity of depressive symptoms on the putative association between IR and depression in young adult males, we were given access to the Northern Finland 1966 Birth Cohort database. During the 31-year follow-up survey of this genetically homogeneous birth cohort, IR was assessed by 'Qualitative Insulin Sensitivity Check Index' (QUICKI), and severity of depressive symptoms by 'Hopkins' Symptom Checklist-25' (HSCL-25). This study involved 2,609 male cohort members with complete variable information. In men, the means of the QUICKI-values decreased (i.e., IR increased) in line with the increased severity of depressive symptoms as assessed by HSCL-25 subgroups (analysis of covariance P-value for trend, P=0.003). In multivariate generalized logistic regression analyses, after adjusting for confounders, IR was positively associated with current severe depressive symptoms, the odds ratio (OR) being over threefold (adjusted OR 3.15, 95% confidence interval 1.48-6.68) and the value of OR increased in parallel with a tighter definition of IR (P-value for trend=0.007). The results indicate that in young males, a positive association exists specifically with severe depressive symptoms.

The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus

OBJECTIVE

To test the hypothesis that poor glycemic control in type 1 diabetes mellitus (T1DM) is associated with depression and poor quality of life (QOL), with a higher prevalence in persons of lower socioeconomic status (SES).

STUDY DESIGN

Subjects with T1DM age 8 to 17 years (n = 222) were evaluated using the Childrens Depression Inventory, the Hollingshead Four-Factor Index to determine SES, and PedsQL questionnaires to ascertain QOL. HbAlC > 8% was considered indicative of poor glycemic control.

RESULTS

A total of 110 well-controlled subjects and 112 poorly controlled subjects (HbA1C 7.1% +/- 0.7% vs 9.9% +/- 1.6%) were recruited. It was found that 9.5% of poorly controlled subjects were depressed, compared with 3% of well-controlled subjects. Logistic regression revealed a 27% increase in probability of depression per unit rise in HbA1C (P < .03). Higher SES was associated with better glycemic control (P < .0005) and QOL (P < .0005); longer duration of illness was not associated with poorer glycemic control. Diabetes QOL deteriorated with poorer glycemic control (P < .002).

CONCLUSIONS

Poor glycemic control in peridatric T1DM is associated with lower SES and depression. The probability of depression increases as glycemic control worsens. Screening for depression should be routinely carried out in patients with T1DM, targeting patients with deteriorating glycemic control.

Improving depression care in patients with diabetes and multiple complications

BACKGROUND

Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications.

OBJECTIVE

To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications.

DESIGN

The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications.

PATIENTS

Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan.

MEASUREMENTS

Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records.

RESULTS

The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care.

CONCLUSION

Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems.

Psychosocial characteristics and cardiovascular risk in African Americans with diabetes

This descriptive study examined the ability of anxiety, depressive symptoms, and perceived social support to predict cardiovascular disease (CVD) risk in African American adults (N = 57) with type 2 diabetes but no prior history of CVD events. All completed a questionnaire packet during structured interviews. Participants had CVD risk profiles that indicated a greater than 20% probability of experiencing a CVD event in the next 2 to 10 years based on diabetes status alone. The variance (10%) in CVD risk accounted for by the variables examined was not statistically significant, suggesting that other variables may be better predictors of CVD risk.

Major depressive disorder viewed as a dysfunction in astroglial bioenergetics

For many years scientists and physicians have pondered upon the apparent connection between depressive disorder and diabetes mellitus. Several epidemiologic studies confirm that diabetics have increased incidence of depression, and vice versa. In addition: depressive, non-diabetic patients have several insulin- and glucose-metabolism disturbances, probably exerting a compensatory reaction to the malfunction in the depressed brain as these disturbances are normalised in remission. After the discovery of PET-scanning, such studies have shown that patients with depressive disorder have reduced glucose metabolism in frontal parts of the brain. The present hypothesis regards the PET findings as observations of the primary pathophysiology of depression. Furthermore: two studies of post mortem samples from depressed patients show reduced numbers of astroglia. This is in accordance to the mentioned insulin disturbances, as only astroglia, not neurons, have insulin-sensitive glucose metabolism. Hence: the astroglia, not necessarily the neurons, are proposed to be the type of cells in which the disease resides. Most probably depressive disorder is a multitude of diseases, explaining the apparent multitude of symptoms, and the fact that different patients do respond to different drugs. Therefore: one can only formulate the hypothesis by mentioning a common denominator to these specific malfunctions, namely: disturbed glucose metabolism in the depressed brain. The present paper reviews several findings and proposes that attenuated cerebral glucose metabolism in frontal parts of the brain, in the astroglia, is the cause of depressive disorder.

Diabetes mellitus as a model of psychosomatic and somatopsychic interrelationships

The article reviews research on the problem of interrelationship between different physical and psychosocial factors in type 1 diabetes mellitus (DM1). The authors consider methodological principles of health-related quality of life (HRQoL) assessment in DM1 patients and stress the need for an integrated biopsychosocial approach to the management of the disease. DM1 is a chronic metabolic disease with an absolute requirement for insulin replacement therapy. The stress-inducing nature of DM1 is associated with its unexpected and dramatic manifestation in juvenile years, life-threatening nature of severe hypo-/hyperglycaemias and long-term complications, with the burden of diabetes self-management, threat of work disability, employment and career problems etc. These features of DM1 increase the likelihood of the development of anxiety and depressive disorders, which, in turn, may negatively influence the course of diabetes and in particular, diabetes self-care. This necessitates early diagnosis of emotional and behavioral disturbances in DM1 using self-report instruments as well as clinical assessment. Evidence suggests that active problem-focused coping behavior and adequate social support promote adherence to diabetes regimes and may act as a buffer against negative effects of the disease on HRQoL in DM1 patients. The core element in the HRQoL structure is personal disease picture (as opposed by objective clinical picture)--the cognitive-affective-behavioral complex reflecting the patient's personal perception of the disease. Examination of the personal disease picture and attitude towards the ailment in DM1 patients may help to improve understanding of the mechanisms of poor adjustment. Problems in disease adjustment can be detected also by diabetes-specific HRQoL assessment. The measures of HRQoL can be applied as screening instruments useful in increasing the effectiveness of patient-provider interactions and diabetes care.

The answer to diabetes prevention: science, surgery, service delivery, or social policy?

The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes.

Qualitative study of an intervention for depression among patients with diabetes: how can we optimize patient-professional interaction?

OBJECTIVES

To describe the communication between the depression care specialist (DCS) nurses and patients with both depression and diabetes in an intervention study. Our aims were to inform both the quantitative findings of the present trial and the design of future primary care intervention studies.

METHODS

Qualitative content analysis of consultations between DCS nurses and patients in nine primary care clinics.

RESULTS

Patients experienced a wide range of physical, social and psychological problems. The DCS nurses employed a range of interventions in addition to the problem-solving and case-management skills that formed the basis of this intervention.

CONCLUSIONS

Patients sometimes posed difficulties in being unable to understand the treatment, unprepared to engage with a new treatment and unready (or even unable) to acquire new skills. To optimize the interaction between patient and professional in the case management of depression and diabetes, training should provide guidance in the use of different models of care (medical and psychological), help case managers to identify and negotiate problem scenarios and combine an active model of therapy such as problem-solving treatment for primary care (PST-PC) with elements from motivational interviewing, ensure effective engagement in treatment, and specifically explore how interaction between depression and diabetes might result in adverse outcomes.

The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity

We examine the impact of the rise in treated disease prevalence on the growth in Medicare beneficiaries' health care spending. Virtually all of this spending growth is associated with patients who are under medical management for five or more conditions. This is traced to both a rise in true disease prevalence and changes in clinical treatment thresholds. Using the metabolic syndrome as a case study, we find that the share of patients treated with medications has increased 11.5 percentage points in less than ten years. This raises important questions about the "fit" of how Medicare pays for services for complex medical management.

Perceived barriers and effective strategies to diabetes self-management

AIM

This paper reports the perceived barriers to and effective strategies for self-management of adults with type 2 diabetes in a rural setting.

BACKGROUND

Worldwide, diabetes is a major public health concern and financial burden. Research shows that, for people with diabetes, adhering to programs of self-care is often problematic. Despite the potential for improved metabolic control and quality of life, little is published on the barriers and effective strategies that people with diabetes successfully use to incorporate plans of care into their lifestyles.

METHODS

Twenty-four adults diagnosed with type 2 diabetes were recruited from a rural primary care practice to participate in one of three audiotaped focus groups. Content analysis was conducted on the focus group transcripts and validity was strengthened through independent rankings of barriers and strategies by an expert panel and by the nurse researchers. The data were collected 2002.

FINDINGS

The most frequently reported barriers were lack of knowledge of a specific diet plan, lack of understanding of the plan of care and helplessness and frustration from lack of glycaemic control and continued disease progression despite adherence. Effective strategies identified were developing a collaborative relationship with a provider, maintaining a positive attitude that prompts proactive learning and having a support person who provides encouragement and promotes accountability.

CONCLUSIONS

These data highlight the importance of barrier and strategy identification in developing and implementing realistic self-management plans and the significance of collaborative alliances between patients and practitioners. Awareness of barriers, identification of strategies to overcome obstacles and the opportunity to problem solve with practitioners assists patients in managing a chronic illness that requires numerous daily decisions.

Association between diabetes and depression: Sex and age differences

OBJECTIVE

To examine the association between diabetes and the prevalence of depression in different sex and age groups by analysing the cross-sectional data from the National Population Health Survey, conducted in Canada in 1996-1997.

STUDY DESIGN

A total of 53072 people aged 20-64 years were included in the analysis. Depression was defined as depression scale 5, based on the Composite International Diagnostic Interview Short-Form (CIDI-SF). Respondents who answered the following question affirmatively were considered to have diabetes: 'do you have diabetes diagnosed by a health professional?'.

METHODS

A multiple logistic regression model was used to adjust for potential confounding effects, and a bootstrap procedure was used to take sampling weights and design effects into account.

RESULTS

The prevalence of diabetes was much higher in people aged 40-64 years than in people aged 20-39 years (men: 4.7% vs. 0.5%; women: 3.5% vs. 0.8%, respectively). In contrast, people aged 20-39 years had a slightly higher prevalence of depression than those aged 40-64 years (men: 3.1% vs. 2.9%; women: 6.6% vs. 5.4%, respectively). Diabetes was significantly associated with depression in women aged 20-39 years (odds ratio [OR]=2.52, 95% confidence interval [CI]=1.19, 5.32), but not in women aged 40-64 years (OR=1.62, and 95% CI=0.65, 4.06). The association was not significant in both age groups in men, but it tended to be stronger in the younger age group.

CONCLUSIONS

The data suggest that diabetes is significantly associated with depression, particularly in young adults.

Cognitive dysfunction is associated with poor diabetes control in older adults

OBJECTIVE

To evaluate the association between cognitive dysfunction and other barriers and glycemic control in older adults with diabetes.

RESEARCH DESIGN AND METHODS

Patients over the age of 70 years presenting to a geriatric diabetes clinic were evaluated for barriers to successful diabetes management. Patients were screened for cognitive dysfunction with the Mini Mental State Examination (MMSE) and a clock-drawing test (CDT) scored by 1) a method validated by Mendez et al. and 2) a modified CDT (clock in a box [CIB]). Depression was evaluated with the Geriatric Depression Scale. Interview questionnaires surveyed activities of daily living (ADLs) and instrumental ADLs (IADLs), as well as other functional disabilities.

RESULTS

Sixty patients (age 79 +/- 5 years, diabetes duration 14 +/- 13 years) were evaluated. Thirty-four percent of patients had low CIB (< or =5), and 38% of patients had low CDT (< or =13). Both CIB as well as CDT were inversely correlated with HbA(1c), suggesting that cognitive dysfunction is associated with poor glycemic control (r = -0.37, P < 0.004 and r = -0.38, P < 0.004, respectively). Thirty-three percent of patients had depressive symptoms with greater difficulty completing the tasks of the IADL survey (5.7 +/- 1.7 vs. 4.6 +/- 2.0; P < 0.03). These older adults with diabetes had a high incidence of functional disabilities, including hearing impairment (48%), vision impairment (53%), history of recent falls (33%), fear of falls (44%), and difficulty performing IADLs (39%).

CONCLUSIONS

Older adults with diabetes have a high risk of undiagnosed cognitive dysfunction, depression, and functional disabilities. Cognitive dysfunction in this population is associated with poor diabetes control.

Understanding the determinants of health for people with type 2 diabetes

OBJECTIVE

We assessed which of a broad range of determinants of health are most strongly associated with health-related quality of life (HRQL) among people with type 2 diabetes.

METHODS

Our analysis included respondents from the Canadian Community Health Survey Cycle 1.1 (2000-2001) who were aged 18 years and older and who were identified as having type 2 diabetes. We used regression analyses to assess the associations between the Health Utilities Index Mark 3 and determinants of health.

RESULTS

Comorbidities had the largest impact on HRQL, with stroke (-0.11; 95% confidence interval [CI] = -0.17, -0.06) and depression (-0.11; 95% CI = -0.15, -0.06) being associated with the largest deficits. Large differences in HRQL were observed for 2 markers of socioeconomic status: social assistance (-0.07; 95% CI=-0.12, -0.03) and food insecurity (-0.07; 95% CI=-0.10, -0.04). Stress, physical activity, and sense of belonging also were important determinants. Overall, 36% of the variance in the Health Utilities Index Mark 3 was explained.

CONCLUSION

Social and environmental factors are important, but comorbidities have the largest impact on HRQL among people with type 2 diabetes.

Post-traumatic stress disorder and diabetes: co-morbidity and outcomes in a male veterans sample

The purpose of this study was to assess the prevalence and correlates of comorbid diabetes and Post-Traumatic Stress disorder(PTSD)and potential relationships between PTSD and diabetes outcomes. Male patients enrolled in a VA primary care database (N = 73,270) were classified as having diabetes from pharmacy records (N = 14,438) and grouped into those with diagnoses of PTSD with depression (N = 649), PTSD-only (N = 480), Depression-only (N = 1696), Other psychiatric diagnosis (N = 736), or No psychiatric diagnosis (N = 10,877) based on the Purpose of Visit diagnoses in the medical record. Outcomes included glycemic control (HbA1c), cholesterol and triglycerides. Correlates were age, substance use disorder, other psychiatric diagnosis, number of primary care encounters, and medications. The prevalence of comorbid diabetes and PTSD was 8% (n = 1129). Of these, 57% (n = 649) had comorbid depression. Patients with PTSD and depression had higher rates of substance use disorder and higher cholesterol and LDL. Patients with depression had poorer glycemic control. Patients with PTSD and depression weighed more and had higher BMI than patients with neither diagnosis. Thus, male diabetes patients with PTSD and depression may be vulnerable to substance use disorders and to weight/lipid problems that can affect health. Depression is a likely contributor to poor glycemic control. Careful screening for mental health comorbidities is needed for diabetes patients.

Type 2 diabetes does not increase risk of depression

BACKGROUND

Although diabetes mellitus has a strong association with the presence of depression, it is unclear whether diabetes itself increases the risk of developing depression. The objective of our study was to evaluate whether people with diabetes have a greater incidence of depression than those without diabetes.

METHODS

We conducted a population-based retrospective cohort study using the administrative databases of Saskatchewan Health from 1989 to 2001. People older than 20 years with newly identified type 2 diabetes were identified by means of diagnostic codes and prescription records and compared with a nondiabetic cohort. Depression was ascertained via diagnostic codes and prescriptions for antidepressants. Cox regression analysis was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) after adjusting for age, sex, frequency of visits to physicians and presence of comorbidities.

RESULTS

We identified 31 635 people with diabetes and 57 141 without. Those with diabetes were older (61.4 v. 46.8 yr; p < 0.001), were more likely to be male (55.4% v. 49.8%; p < 0.001) and had more physician visits during the year after their index date (mean 14.5 v. 5.9; p < 0.001). The incidence of new-onset depression was similar in both groups (6.5 v. 6.6 per 1000 person-years among people with and without diabetes, respectively). Similarity of risk persisted after controlling for age, sex, number of physician visits and presence of prespecified comorbidities (adjusted HR 1.04, 95% CI 0.94- 1.15). Other chronic conditions such as arthritis (HR 1.18) and stroke (HR 1.73) were associated with the onset of depression.

INTERPRETATION

Using a large, population-based administrative cohort, we found little evidence that type 2 diabetes increases the risk of depression once comorbid diseases and the burden of diabetes complications were accounted for.

Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To determine whether psychological interventions have any effect on glycaemic control in people with type 1 diabetes.

DESIGN

Systematic review and meta-analysis of psychological therapies to assess their effectiveness in improving glycaemic control in type 1 diabetes.

DATA SOURCES

Medline, PsycINFO, Embase, and Cochrane central register of controlled trials searched to September 2004.

REVIEW METHODS

All included studies were randomised controlled trials in children (including adolescents) or adults with type 1 diabetes that evaluated the effect of a psychological therapy (counselling, cognitive behaviour therapy, family systems therapy, and psychodynamic therapy) on control of diabetes. Data were extracted on sample size, age, duration of diabetes, type of psychological therapy, its mode of delivery, and type of intervention in control group.

MAIN OUTCOME MEASURES

Glycaemic control measured by percentage of glycated haemoglobin and psychological distress. Pooled standardised effect sizes were calculated.

RESULTS

29 trials were eligible for the systematic review and 21 trials for the meta-analysis. In the 10 studies of children and adolescents included in the meta-analysis, the mean percentage of glycated haemoglobin was significantly reduced in those who had received a psychological intervention compared with those in the control group (pooled standardised mean difference -0.35 (95% confidence interval -0.66 to -0.04), equivalent to a 0.48% (0.05% to 0.91%) absolute reduction in glycated haemoglobin. In the 11 studies in adults the pooled standardised mean difference was -0.17 (-0.45 to 0.10), equivalent to 0.22% (-0.13% to 0.56%) absolute reduction in glycated haemoglobin. Psychological distress was significantly lower in the intervention groups in children and adolescents (pooled standardised effect size -0.46, -0.83 to -0.10) but not in adults (-0.25, -0.51 to 0.01).

CONCLUSION

Psychological treatments can slightly improve glycaemic control in children and adolescents with diabetes but have no effect in adults.

Comorbidity in patients with diabetes mellitus: impact on medical health care utilization

Background

Comorbidity has been shown to intensify health care utilization and to increase medical care costs for patients with diabetes. However, most studies have been focused on one health care service, mainly hospital care, or limited their analyses to one additional comorbid disease, or the data were based on self-reported questionnaires instead of health care registration data. The purpose of this study is to estimate the effects a broad spectrum of of comorbidities on the type and volume of medical health care utilization of patients with diabetes.

Methods

By linking general practice and hospital based registrations in the Netherlands, data on comorbidity and health care utilization of patients with diabetes (n = 7,499) were obtained. Comorbidity was defined as diabetes-related comorbiiabetes-related comorbidity. Multilevel regression analyses were applied to estimate the effects of comorbidity on health care utilization.

Results

Our results show that both diabetes-related and non diabetes-related comorbidity increase the use of medical care substantially in patients with diabetes. Having both diabeterelated and non diabetes-related comorbidity incrases the demand for health care even more. Differences in health care utilization patterns were observed between the comorbidities.

Conclusion

Non diabetes-related comorbidity increases the health care demand as much as diabetes-related comorbidity. Current single-disease approach of integrated diabetes care should be extended with additional care modules, which must be generic and include multiple diseases in order to meet the complex health care demands of patients with diabetes in the future.

Depression, anxiety, and nonalcoholic steatohepatitis

OBJECTIVE

Nonalcoholic steatohepatitis (NASH) is a morbid liver disease with limited treatment. Depression and anxiety have been associated recently with insulin resistance and inflammatory states, factors that are relevant to the development of NASH. We hypothesized that depression and anxiety would be more prevalent in NASH patients and predict more severe histological findings on liver biopsy.

METHODS

Histories of major depressive disorder (MDD) and generalized anxiety disorder (GAD) were determined using a structured interview and DSM-IV criteria in 36 NASH subjects and 36 matched controls without liver disease who had undergone cholecystectomy. Histological changes on liver biopsy in NASH subjects were age-adjusted and compared in subjects with and without psychiatric disorders. A multivariate model incorporating other potential risk factors for NASH (female sex, body mass index, waist-to-hip ratio, and presence of diabetes) was used to determine independent effects of MDD and GAD on severity of histological findings.

RESULTS

NASH subjects had significantly increased lifetime rates of MDD (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4-10.2; p = .018) and GAD (OR 5.0, 95% CI, 1.7-14.9; p = .005). The onset of psychiatric illness preceded diagnosis of liver disease by 18 to 20 years. Each psychiatric disorder was associated with more severe histological features (p < .05 for each), the effect of GAD on fibrosis stage persisting in the multivariate model.

CONCLUSIONS

MDD and GAD are overrepresented in NASH subjects and are associated with more advanced liver histological abnormalities. Additional investigation will be required to determine if depression and anxiety affect the development or progression of NASH and serve as modifiable risk factors.

Impact of diabetes on health-related quality of life in a population study in Japan

Diabetes may impact on health-related quality of life (HRQOL). The aim of this population-based study was to confirm this influence. We examined 2135 residents aged > or =30 years in an entire community, who had no history of cancer or cardiovascular disease and did not require care for daily activity. The response rate was 87.8%. The status of diabetes, other chronic diseases and life practices were assessed by self-reported questionnaires, in which HRQOL was evaluated by the Japanese version SF-36, based on five sub-scales of the domain. Diabetes had been diagnosed in 165 (7.7%) of the study population. Comparison of data, adjusted for sex, age, living alone and employment status between non-diabetics and subjects with diabetes treated by pharmacological therapy had odds ratios (ORs) between the lowest quartiles of sub-scale scores of 1.90 for physical role, 2.51 for general health, and 1.79 for emotional role. The OR for lower general health was also increased in people using only lifestyle modification for treatment of diabetes. Although the OR for mental health was worse in the lifestyle modification group it was not increased in people with diabetes on pharmacological therapy. These associations remained almost unchanged after adjustment for the covariates. The sub-scales of physical and emotional roles and general health were decreased significantly in diabetics with duration of disease between 10 and 19 years or > or =20 years. Our study showed treatment of diabetes clearly influenced HRQOL, with this influence being dependent on the duration of diabetes and primarily affecting physical rather than mental health.

Disease-focused or integrated treatment: diabetes and depression

This article reviewed the literature on the adverse health outcomes of the coexistence of diabetes and depression, the challenges of treating coexisting diabetes and depression in a fragmented health care system, and the need for integrated care as a strategy to improve the quality of care for patients who have complex medical illnesses (eg, patients who have coexisting diabetes and depression).