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

Cognitive performance, psychological well-being, and brain magnetic resonance imaging in older patients with type 1 diabetes

Modest cognitive impairment has been reported in young-adult patients with type 1 diabetes. In older patients with type 2 diabetes, cognitive impairments are more pronounced, which might be due to age but also to differential effects of type 1 diabetes and type 2 diabetes on the brain. This study therefore assessed cognitive performance and magnetic resonance imaging (MRI) of the brain in older type 1 diabetic patients. Forty type 1 diabetic patients (age >50 years) and 40 age-matched control subjects were included. Neuropsychological assessment included all major cognitive domains, and psychological well-being was assessed with questionnaires. Atrophy, white-matter abnormalities, and infarcts were rated on MRI scans. Type 1 diabetic patients performed slightly (effect sizes <0.4) worse on cognitive tasks, but only "speed of information processing" reached statistical significance. No significant between-group differences were found on any of the MRI parameters. Type 1 diabetic patients tended to report more cognitive and depressive problems than control subjects, but this did not correlate with the performance on cognitive tests. We conclude that cognition in older type 1 diabetic patients is only mildly disturbed. Chronic exposure to hyperglycemia is in itself, even at older age, apparently not sufficient to have considerable impact on the brain.

Intimate partner violence and women's physical, mental, and social functioning

OBJECTIVE

To describe the relationship between women's health and the timing, type, and duration of intimate partner violence (IPV) exposure.

METHODS

A telephone interview was completed by 3429 women aged 18 to 64 randomly selected from a large health plan, to assess IPV exposure and heath status (response rate 56.4%). Questions from the Behavioral Risk Factor Surveillance System and the Women's Experience with Battering scale were used to construct IPV exposures: (1) recent (past 5 years) and remote (before past 5 years only) IPV exposure of any type (physical, sexual, or non-physical); (2) recent (past 5 years) IPV exposure to physical and/or sexual or non-physical only; and (3) IPV duration (0 to 2 years, 3 to 10 years, and >10 years). Health outcomes were measured using the Short Form-36 survey (SF-36), the Center for Epidemiologic Studies Depression scale, and the National Institute of Mental Health Presence of Symptoms survey.

RESULTS

In adjusted models, compared to women with no IPV in their adult lifetime, more-pronounced adverse health effects were observed for women with recent (vs remote) IPV; for physical and/or sexual (vs non-physical) IPV; and for longer IPV exposure. Compared to women who never experienced IPV, women with any recent IPV (physical, sexual, or non-physical) had higher rates of severe (prevalence ratio [PR]=2.6; 95% confidence interval [CI]=1.9-3.6) and minor depressive symptoms (PR=2.3; 95% CI=1.9-2.8); higher number of physical symptoms (mean, 1.0; 95% CI=0.7-1.2); and lower SF-36 mental and social functioning scores (range, 4.3-5.5 points lower across subscales). Women with recent physical and/or sexual IPV were 2.8 times as likely to report fair/poor health, and had SF-36 scores that ranged from 5.3 to 7.8 points lower, increased risk of depressive symptoms (PR=2.6) and severe depressive symptoms (PR=4.0), and more than one additional symptom. Longer duration of IPV was associated with incrementally worse health.

CONCLUSIONS

Women's health was adversely affected by the proximity, type, and duration of IPV exposure.

Physician and nurse use of psychosocial strategies in diabetes care: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study

OBJECTIVE

To determine the use of psychosocial strategies by health care providers in treating patients with diabetes and the factors associated with use of these strategies.

RESEARCH DESIGN AND METHODS

Cross-sectional survey of national samples of generalist and diabetes specialist physicians (n = 2,705) and nurses (n = 1,122) from the multinational study of Diabetes Attitudes, Wishes and Needs. Respondents were from 13 countries in Asia, Australia, Europe, and North America. Two psychosocial strategies were examined: provider psychosocial care, which provides psychosocial support by diabetes care providers to their own patients, and psychosocial specialist care, which refers diabetic patients to psychosocial specialists.

RESULTS

Compared with physicians, nurses perceived significantly higher prevalence and severity of psychosocial problems and used psychosocial strategies significantly more frequently, even though they rated their own psychosocial skills lower. Among both physicians and nurses, diabetes specialists were significantly more likely than generalists to utilize psychosocial strategies. Physicians and nurses used psychosocial strategies significantly more when they believed that more patients have psychosocial problems and that problems interfere more with diabetes control. Referral to psychosocial specialists was significantly more likely when physicians and nurses perceived that professional psychological resources were more available. There were substantial country differences in all factors studied. Compared with other countries, U.S. providers provided more psychosocial care themselves but were less likely to refer to psychosocial specialists.

CONCLUSIONS

Psychosocial strategies are important parts of the diabetes care provider repertoire; understanding their determinants may facilitate efforts to increase their use.

Reduced hippocampal neurogenesis and number of hilar neurones in streptozotocin-induced diabetic mice: reversion by antidepressant treatment

Cerebral dysfunctions, including a high incidence of depression, are common findings in human type 1 diabetes mellitus. An association between depression and defective hippocampal neurogenesis has been proposed and, in rodents, antidepressant therapy restores neuronal proliferation in the dentate gyrus. Hippocampal neurogenesis is also deficient in diabetic mice, which led us to study whether the selective serotonin reuptake inhibitor fluoxetine influences cell proliferation in streptozotocin-diabetic animals. Diabetic and control C57BL/6 mice received fluoxetine (10 mg/kg/day, i.p., 10 days) and dentate gyrus cell proliferation was measured after a single injection of 5-bromo-2'-deoxyuridine (BrdU). Diabetic mice showed reduced cell proliferation. Fluoxetine treatment, although having no effect in controls, corrected this parameter in diabetic mice. The phenotype of newly generated cells was analysed by confocal microscopy after seven daily BrdU injections, using Tuj-1/beta-III tubulin as a marker for immature neurones and glial fibrillary acidic protein for astrocytes. In controls, the proportion of Tuj-1-BrdU-positive cells over total BrdU cells was approximately 70%. In vehicle-treated diabetic mice, immature neurones decreased to 56% and fluoxetine brought this proportion back to control values without affecting astrocytes. Therefore, fluoxetine preferentially increased the proliferation of cells with a neuronal phenotype. In addition, neurones were counted in the hilus of the dentate gyrus; a 30% decrease was found in diabetic mice compared with controls, whereas this neuronal loss was prevented by fluoxetine. In conclusion, fluoxetine treatment restored neuroplasticity-related hippocampal alterations of diabetic mice. These findings may be potentially important to counteract diabetes-associated depression in humans.

Relationship between symptoms of depression, functional health status, and chronic disease among a residential sample of African Americans

Depression and psychological distress often go unrecognized and untreated in primary care settings. The association between depression, socioeconomic status, and chronic disease underscore the importance of incorporating mental health education and screening into community-based health initiatives. This is particularly critical for African Americans who bear a disproportionate burden of poverty and chronic disease. This descriptive study assessed associations between symptoms of depression, socioeconomic status, healthcare utilization, physical and mental health functioning, and reactions to race among a sample of low-income African Americans. Consistent with the findings of previous research, respondents with symptoms of depression reported lower levels of physical and mental health functioning, and perceived that they had been treated worse by others at work, and had worse healthcare experiences than those of other races. Community-based programs for reducing disparities in physical illness may need to address the burden of undiagnosed and untreated depression in order to become optimally effective.

Involvement of diazepam-insensitive benzodiazepine receptors in the suppression of DOI-induced head-twitch responses in diabetic mice

RATIONALE

We previously reported that the head-twitch responses induced by the 5-HT2 receptor agonist (+/-)-2,5-dimethoxy-4-iodoamphetamine (DOI) (DOI-HTRs) were decreased in streptozotocin-induced diabetic mice.

OBJECTIVES

We examined the involvement of gamma-aminobutyric acid (GABA)/benzodiazepine system on the suppression of DOI-HTRs in diabetic mice.

RESULTS

The benzodiazepine receptor antagonist flumazenil (0.1-1 mg/kg, i.v.) dose-dependently and significantly increased DOI-HTRs in diabetic mice to the same levels as in nondiabetic mice. However, flumazenil (0.1-1 mg/kg, i.v.) did not affect DOI-HTRs in nondiabetic mice. The benzodiazepine receptor agonist diazepam (0.1-1 mg/kg, i.p.) had no effect on DOI-HTRs in either nondiabetic or diabetic mice. The GABAA receptor antagonist bicuculline (0.1-1 mg/kg, i.p.) and the benzodiazepine receptor partial inverse agonist Ro 15-4513 (0.1-1 mg/kg, i.v.) dose-dependently and significantly suppressed DOI-HTRs in nondiabetic mice to the same levels as in diabetic mice. Ro 15-4513-induced reduction of DOI-HTRs in nondiabetic mice was completely antagonized by flumazenil (1 mg/kg, i.v.), but not diazepam (0.3 mg/kg, i.p.).

CONCLUSIONS

We suggest that the abnormal diazepam-insensitive benzodiazepine receptor function partly underlies the suppression of DOI-HTRs in diabetic mice.

Health Utilities Index mark 3 demonstrated construct validity in a population-based sample with type 2 diabetes

OBJECTIVE

To assess the cross-sectional construct validity of the Health Utilities Index mark 3 (HUI3) in type 2 diabetes using population health survey data.

STUDY DESIGN AND SETTING

Data used were from 5,134 adult respondents of Cycle 1.1 (2000-2001) of the Canadian Community Health Survey (CCHS) with type 2 diabetes. Analyses of covariance models were used to assess differences in overall and single-attribute HUI3 scores between groups hypothesized a priori to differ in HRQL. The association between health-care resource use (i.e., hospitalizations and physician and emergency room visits) and overall HUI3 scores was assessed using logistic regression models.

RESULTS

For overall HUI3 scores, clinically important and statistically significant differences were observed between all groups expected to differ in HRQL. Depression was the comorbidity associated with the largest deficit (-0.17; 95% confidence interval CI=-0.22, -0.12), followed by stroke (-0.15; 95% CI=-0.21, -0.10) and heart disease (-0.08; 95% CI=-0.11, -0.05). Insulin use and comorbidities were associated with clinically important deficits in pain. Overall HUI3 scores were significantly predictive of all three categories of health-care resource use.

CONCLUSION

Observed differences between groups contribute further evidence of the construct validity of the HUI3 in type 2 diabetes.

Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis

AIMS/HYPOTHESIS

Evidence strongly suggests that depression and type 2 diabetes are associated, but the direction of the association is still unclear. Depression may occur as a consequence of having diabetes, but may also be a risk factor for the onset of type 2 diabetes. This study examined the latter association by reviewing the literature and conducting a meta-analysis of longitudinal studies on this topic.

METHODS

Medline and PsycInfo were searched for articles published up to January 2005. All studies that examined the relationship between depression and the onset of type 2 diabetes were included. Pooled relative risks were calculated using fixed and random effects models. To explore sources of heterogeneity between studies, subgroup analyses and meta-regression analyses were performed.

RESULTS

Nine studies met our inclusion criteria for this meta-analysis. The pooled relative risk was 1.26 (1.13-1.39) using the fixed effects model and 1.37 (1.14-1.63) using the random effects model. Heterogeneity between studies could not be explained by (1) whether studies controlled for undetected diabetes at baseline; (2) the method of diabetes assessment at follow-up; (3) the baseline overall risk of diabetes in the study population; and (4) follow-up duration.

CONCLUSIONS/INTERPRETATION

Depressed adults have a 37% increased risk of developing type 2 diabetes mellitus. The pathophysiological mechanisms underlying this relationship are still unclear and warrant further research. A randomised controlled study is needed to test whether effective prevention or treatment of depression can reduce the incidence of type 2 diabetes and its health consequences.

Limb deficiency and prosthetic management. 4. Comorbidities associated with limb loss

This self-directed learning module highlights common comorbidities found in people with amputations and their impact on functional outcome. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on prosthetic considerations, functional outcome, and potential complications for a woman with the comorbidities of stroke and diabetes who experiences a dysvascular amputation. Formulation of the differential diagnosis, management of limb pain, and evaluation of the potential psychosocial issues arising after amputation are also discussed.

OVERALL ARTICLE OBJECTIVE

To analyze common comorbidities of people with amputations and to delineate their impact on functional outcome.

Assessing psychosocial variables: a tool for diabetes educators

The purpose of this article is to share an educational strategy or tool that is relevant for use in patient and professional diabetes education. The tool offers an opportunity for diabetes educators to screen for psychosocial variables such as depression or emotional distress. A systematic review of the literature was conducted to identify psychological variables that have an impact on individuals living with diabetes and their ability to self-manage their disease. The literature revealed that both depression and emotional distress related to diabetes was experienced by individuals with diabetes along with those individuals who were unable to self-management their disease. The Accu-Check Interview is a computer software program that may assist diabetes educators to provide diabetes education. Use of the Accu-Check Interview software program has been implemented at various sites including the Joslin Clinic (Boston, Mass), Baystate Medical Center (Springfield, Mass), and Emerson Hospital (Concord, Mass). The Diabetes Self Care Profile is a Web-based version of the Accu-Check Interview and can be accessed as a demonstration in English and Spanish. These tools allow diabetes educators to screen for psychosocial variables and address issues with individuals while using a motivational interviewing approach.

Prevalence and correlates of depressed mood among youth with diabetes: the SEARCH for Diabetes in Youth study

OBJECTIVE

The objective of this study was to determine if depressed mood among youth with diabetes was associated with type and duration of diabetes, mean glycosylated hemoglobin (HbA1c) level, and the frequency of diabetic ketoacidosis (DKA) and hypoglycemic episodes, hospitalizations, and emergency department (ED) visits.

METHODS

A total of 2672 youth (aged 10-21 years) who had diabetes for a mean duration of 5 years completed a SEARCH study visit, in which their HbA1c was measured and information about their demographic characteristics, diabetes type and duration, and episodes of DKA, hypoglycemia, hospitalizations, and ED visits over the previous 6 months was collected. Their level of depressed mood was measured using the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Among these youth, 14% had mildly (CES-D 16-23) and 8.6% had moderately or severely (CES-D > or =24) depressed mood. Females had a higher mean CES-D score than males. After adjusting for demographic factors, and duration of diabetes, we found the prevalence of depressed mood to be higher among males with type 2 diabetes than those with type 1 diabetes and to be higher among females with comorbidities than those without comorbidities. Higher mean HbA1c and frequency of ED visits were associated with depressed mood. The prevalence of depressed mood among youth with diabetes was similar to that of published estimates of depressed mood among youth without diabetes.

CONCLUSIONS

Physicians and other health care professionals should consider screening youth with diabetes for depressed mood in clinical settings, particularly youth with poor glycemic control, those with a history of frequent ED visits, males with type 2 diabetes, and females with comorbidities.

The prevalence of co-morbid depression in adults with Type 1 diabetes: systematic literature review

AIM

To review the literature estimating the cross-sectional prevalence of clinical depression in adults with Type 1 diabetes.

METHODS

Electronic databases and published references were used to identify studies published between January 2000 and June 2004, with a previous meta-analysis used to identify studies before 1 January 2000.

RESULTS

Between January 2000 and June 2004, a further five eligible studies were identified. Only one was a controlled study using diagnostic interviewing to determine rates of depression. Taking all of the eligible studies identified by the previous meta-analysis and this search, the prevalence of clinical depression in controlled studies was 12.0% for people with diabetes compared with 3.2% for control subjects. In studies with no control group, the prevalence of clinical depression was 13.4%.

CONCLUSION

There are wide-ranging differences reported in the various studies on the prevalence of depression in Type 1 diabetes. In view of the differing methods of diagnosis and small participant numbers, the results should be viewed with caution. A controlled study using diagnostic interviewing techniques to determine levels of depression is recommended to provide a clearer picture of both the prevalence and characteristics of that depression.

Brain magnetic resonance imaging correlates of impaired cognition in patients with type 2 diabetes

The structural correlates of impaired cognition in type 2 diabetes are unclear. The present study compared cognition and brain magnetic resonance imaging (MRI) between type 2 diabetic patients and nondiabetic control subjects and assessed the relationship between cognition and MRI findings and blood pressure and metabolic control. The study included 113 patients and 51 control subjects. Brain MRI scans were rated for white matter lesions (WMLs), cortical and subcortical atrophy, and infarcts. Neuropsychological test scores were divided into five cognitive domains and expressed as standardized Z values. Type 2 diabetes was associated with deep WMLs (P = 0.02), cortical (P < 0.001) and subcortical (P < 0.05) atrophy, (silent) infarcts (P = 0.06), and impaired cognitive performance (attention and executive function, information-processing speed, and memory, all P < 0.05). Adjustment for hypertension did not affect the results. Within the type 2 diabetic group, cognitive function was inversely related with WMLs, atrophy, and the presence of infarcts (adjusted for age, sex, and estimated IQ), and there was a modest association with HbA1c and diabetes duration. This association was strongest for age, even more so than in control subjects. We conclude that cognitive impairments in patients with type 2 diabetes are not only associated with subcortical ischemic changes in the brain, but also with increased brain atrophy.

Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project

OBJECTIVE

The purpose of the study was to investigate the effect of comorbid depression on glycemic control and on response to a telemedicine case management intervention for elderly, ethnically diverse diabetic patients.

RESEARCH DESIGN AND METHODS

Medicare beneficiaries in underserved areas were participants (n = 1,665) in the Informatics for Diabetes Education and Telemedicine (IDEATel) project and randomized to a telemedicine case management intervention or usual care. The data analyzed include baseline demographics (age, sex, race/ethnicity, marital status, insulin use, years of education, years of diabetes, and pack-years smoked) and measures of glycemic control (HbA(1c) [A1C]), comorbidity, diabetes symptom severity, functional disability and depression, and 1-year (n = 1,578) A1C. The association between depression and glycemic control was analyzed cross-sectionally and prospectively.

RESULTS

At baseline, there was a significant correlation between depression and A1C and a trend for depression to predict A1C when other factors were controlled. However, in prospective analyses, depression did not predict change in A1C, either in the control or intervention group.

CONCLUSIONS

In this large sample of elderly diabetic patients, a weak relationship between depression and A1C was found, but depression did not prospectively predict change in glycemic control. Thus, there is no evidence that depression should be used to exclude patients from interventions. Also, we should evaluate the impact of depression on outcomes other than glycemic control.

Diabetes-related symptoms and negative mood in participants of a targeted population-screening program for type 2 diabetes: The Hoorn Screening Study

OBJECTIVE

To determine the level of diabetes-related symptom distress and its association with negative mood in subjects participating in a targeted population-screening program, comparing those identified as having type 2 diabetes vs. those who did not.

RESEARCH DESIGN AND METHODS

This study was conducted within the framework of a targeted screening project for type 2 diabetes in a general Dutch population (age 50-75 years). The study sample consisted of 246 subjects, pre-selected on the basis of a high-risk profile; 116 of whom were subsequently identified as having type 2 diabetes, and 130 who were non-diabetic subjects. Diabetes-related symptom distress and negative mood was assessed approximately 2 weeks, 6 months, and 12 months after the diagnosis of type 2 diabetes, with the Type 2 Diabetes Symptom Checklist and the Negative well-being sub scale of the Well-being Questionnaire (W-BQ12), respectively.

RESULTS

Screening-detected diabetic patients reported significantly greater burden of hyperglycemic (F = 6.0, df = 1, p = 0.015) and of fatigue (F = 5.3, df = 1, p = 0.023) symptoms in the first year following diagnosis type 2 diabetes compared to non-diabetic subjects. These outcomes did not change over time. The total symptom distress (range 0-4) was relatively low for both screening-detected diabetic patients (median at approximately 2 weeks, 6 months, and 12 months; 0.24, 0.24, 0.29) and non-diabetic subjects (0.15, 0.15, 0.18), and not significantly different. No average difference and change over time in negative well-being was found between screening-detected diabetic patients and non-diabetic subjects. Negative well-being was significantly positive related with the total symptom distress score (regression coefficient beta = 2.86, 95% CI 2.15-3.58).

CONCLUSIONS

The screening-detected diabetic patients were bothered more by symptoms of hyperglycemia and fatigue in the first year following diagnosis type 2 diabetes than non-diabetic subjects. More symptom distress is associated with increased negative mood in both screening-detected diabetic patients and non-diabetic subjects.

Depressive symptoms in elderly patients after a somatic illness event: prevalence, persistence, and risk factors

Elderly patients with somatic illness are at increased risk of depression. The authors studied the prevalence and persistence of depressive symptoms during the first year after the events of myocardial infarction, congestive heart failure, fall-related injury, and the diagnosis of cancer and their putative pre-event risk factors. The GLAS study contains data from 614 patients who experienced post-baseline myocardial infarction, cancer, heart failure, or fall-related injury of the extremities within 5 years after the baseline assessment. Follow-up was conducted 8 weeks, 6 months, and 1 year after the somatic event. The authors studied the relative importance of 21 baseline risk factors for experiencing significant depressive symptoms during follow-up and the persistence of depression. Depressive symptoms were prevalent in 38.3% of the subjects during the post-event year; in about 19.1%, symptoms were mild. For a majority of patients (67.5%), symptoms persisted until the next assessment. Significant pre-event risk factors were depressive symptoms at baseline, age, smoking, poor general health, poor well-being, and neuroticism. Within the depressed group, only neuroticism was related to the persistence of symptoms. Neuroticism increases the risk of experiencing post-event depressive symptoms and is related to their persistence, which suggests the existence of a depression-prone personality.

How to screen for depression and emotional problems in patients with diabetes: comparison of screening characteristics of depression questionnaires, measurement of diabetes-specific emotional problems and standard clinical assessment

AIMS/HYPOTHESIS

We compared the screening performance of different measures of depression: the standard clinical assessment (SCA); the Beck Depression Inventory (BDI); the Center of Epidemiological Studies-Depression Scale (CES-D); and the Problem Areas in Diabetes (PAID) questionnaire, which assesses diabetes-specific distress. We also studied the ability of these measures to detect diabetes-related distress.

MATERIALS AND METHODS

A total of 376 diabetic patients (37.2% type 1; 23.9% type 2 without insulin treatment, 38.8% type 2 with insulin) completed the BDI and CES-D; patients who screened positive participated in a diagnostic interview, the Composite International Diagnostic Interview (CIDI). Also, all patients completed the PAID questionnaire. Results of the SCA that related to depression diagnosis were reviewed to correct for false negative screening results.

RESULTS

The prevalence of clinical depression was 14.1%, with an additional 18.9% of patients receiving a diagnosis of subclinical depression. Sensitivity for clinical depression in SCA (56%) was moderate, whereas BDI, CES-D and the PAID questionnaire showed satisfactory sensitivity (87, 79 and 81%, respectively). For subclinical depression, the sensitivity of the PAID questionnaire (79%) was sufficient, whereas that of SCA (25%) was poor. All methods showed low sensitivity for the detection of diabetes-specific emotional problems (SCA 19%, CIDI 34%, BDI 60%, CES-D 49%).

CONCLUSIONS/INTERPRETATION

The screening performance of SCA for clinical and subclinical depression was modest. Additional screening for depression using the PAID or another depression questionnaire seems reasonable. The ability of depression screening measures to identify diabetes-related distress is modest, suggesting that the PAID questionnaire could be useful when screening diabetic patients for both depression and emotional problems.

Depression treatment and satisfaction in a multicultural sample of type 1 and type 2 diabetic patients

OBJECTIVE

To assess rates of depressive symptoms, depression treatment, and satisfaction in a multicultural sample of individuals with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

This study was conducted with a cross-sectional community-based survey design.

RESULTS

The sample (n = 221) was predominantly female (60.3%), had type 2 diabetes (75%), and was middle class with a mean (+/-SD) age of 54 +/- 12 years. A total of 53% were white. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD) (mean 16.4 +/- 11.3). Using conservative thresholds (CESD score > or =22), 25.3% of participants reported clinically significant depression. Rates of depression did not differ by ethnic group or diabetes type. The majority (76%) of depressed participants reported treatment (52% antidepressants, 63% mental health providers, 19% alternative healers, and 15% herbal remedies). African Americans were less likely to report any depression treatment, to receive antidepressant medications, or receive treatment from a mental health professional compared with whites. Participants with high depressive symptoms reported general satisfaction with depression treatment experiences.

CONCLUSIONS

High rates of depressive symptoms were observed across ethnic groups, yet significant differences in use of depression treatment existed across ethnic groups. Those seeking depression treatment reported satisfaction with a variety of depression treatment modalities. Increased depression screening and treatment may be beneficial for ethnically diverse patients with type 1 and type 2 diabetes.

Ethnic differences in the relationship between depressive symptoms and health-related quality of life in people with type 2 diabetes

OBJECTIVE

To examine ethnic differences in the relationship between depressive symptoms and specific aspects of heath-related quality of life in people with type 2 diabetes.

DESIGN

Cross-sectional data from 190 people with type 2 diabetes of Native Hawaiian (50%), Filipino (16%), Japanese (18%), and mixed-ethnic (16%) ancestries from the rural community of North Kōhala, Hawai'i were examined in this study. Depressive symptoms were measured with the Center for Epidemiological Studies-Depression (CES-D) scale. Health-related quality of life was measured with the Short Form-36 Health Survey (SF-36). Eight health-related quality of life constructs were examined: Physical Functioning, Role-Physical Functioning, Role-Emotional Functioning, Social Functioning, Bodily Pain, Vitality, General Health, and Health Transition.

RESULTS

Hierarchical regression analyses of the interaction between ethnicity and the SF-36 subscales of Physical Functioning, Role-Emotional Functioning, Bodily Pain, Vitality, and General Health indicated statistically significant associations with CES-D scores after controlling for sociodemographic factors, glycemic status, and social support.

CONCLUSION

Ethnicity moderated the relationship between depressive symptoms and the health-related quality of life aspects of physical and role-emotional functioning, bodily pain, vitality, and general health perception in people with type 2 diabetes. This relationship was strongest for Filipinos followed by Native Hawaiians and people of mixed-ethnic ancestries.

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

OBJECTIVE

The aim of this study was to investigate how often emotional problems were recognized and registered by diabetes nurses.

METHODS

We studied medical charts and questionnaire data of 112 diabetes patients. The hospital anxiety, depression scale and the problem areas in diabetes survey were used to measure anxiety, depression and diabetes-specific emotional distress.

RESULTS

In patients with moderate to severe levels of anxiety or depression, the presence of an emotional problem was recorded in the medical chart in 20-25% of the cases. The registration-rate of diabetes-specific emotional distress was also found to be low, ranging from 0% (treatment-related problems) to 29% (diabetes-related emotional problems).

CONCLUSION

Registration-rates of emotional problems by diabetes nurses were found to be low, but quite similar to detection rates of physicians and nurses in studies with non-diabetic samples.

PRACTICE IMPLICATIONS

These findings suggest that recognition-rates of emotional problems in diabetes patients need to be increased. Future studies should investigate whether recognition and subsequent treatment of emotional problems in diabetes patients can be facilitated by utilizing validated, standardized self-report questionnaires.

Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression

OBJECTIVE

To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression.

RESEARCH DESIGN AND METHODS

This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care.

RESULTS

Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found.

CONCLUSIONS

The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care.

Effects of histamine H1 receptor antagonists on depressive-like behavior in diabetic mice

We previously reported that streptozotocin-induced diabetic mice showed depressive-like behavior in the tail suspension test. It is well known that the central histaminergic system regulates many physiological functions including emotional behaviors. In this study, we examined the role of the central histaminergic system in the diabetes-induced depressive-like behavior in the mouse tail suspension test. The histamine contents in the hypothalamus were significantly higher in diabetic mice than in non-diabetic mice. The histamine H(1) receptor antagonist chlorpheniramine (1-10 mg/kg, s.c.) dose-dependently and significantly reduced the duration of immobility in both non-diabetic and diabetic mice. In contrast, the selective histamine H(1) receptor antagonists epinastine (0.03-0.3 microg/mouse, i.c.v.) and cetirizine (0.01-0.1 microg/mouse, i.c.v.) dose-dependently and significantly suppressed the duration of immobility in diabetic mice, but not in non-diabetic mice. Spontaneous locomotor activity was not affected by histamine H(1) receptor antagonists in either non-diabetic or diabetic mice. In addition, the number and affinity of histamine H(1) receptors in the frontal cortex were not affected by diabetes. In conclusion, we suggest that the altered neuronal system mediated by the activation of histamine H(1) receptors is involved, at least in part, in the depressive-like behavior seen in diabetic mice.

The potential role of increased adrenal volume in the pathophysiology of obesity-related type 2 diabetes

The hypothalamic-pituitary-adrenal (HPA) axis seems to play an important role in obesity and Type 2 diabetes (DM). The aim of the present study was to determine the adrenal volume in obese patients with DM in comparison to obese non-diabetic patients. Eleven diabetic obese and 19 non-diabetic obese women were sequentially invited to take part in the study. Computed tomography (CT) scan of the abdomen was performed to determine adrenal volume, visceral (VF) and sc fat (SCF). Daily urinary free cortisol (UFC) was used as a measure of integrated cortisol production. In the diabetic patients, hemoglobin A1c was measured as an index of metabolic control. Compared to nondiabetic controls, patients with diabetes had a significantly higher total adrenal volume (4.29+/-1.50 vs 2.95+/-1.64; p=0.03). A highly significant correlation was detected between VF and VF/SCF ratio and total adrenal volume in the whole group (r=0.36, p=0.04 and r=0.48, p=0.008, respectively). This study, therefore, suggests an association between abdominal obesity, enlarged adrenals and Type 2 diabetes. These findings support the hypothesis that an increased activity of the HPA axis in obese subjects may be involved in the pathogenesis of Type 2 diabetes.

Clinical characteristics of depressed patients with comorbid diabetes mellitus

Both diabetes and depression are highly prevalent. Patients with diabetes experience higher rates of depression compared to the general population. When present, depression is associated with an increase in the morbidity and mortality of diabetes, suggesting the importance of treatment in this population. The objective of the present study was to characterize depressive characteristics in depressed patients with and without comorbid diabetes. Seventeen patients with type 1 or type 2 diabetes were drawn from outpatient clinical trials. Depressed patients without diabetes were identified from the same studies. Unpaired t-tests and multiple chi-square analyses were used to compare demographic and clinical characteristics between the samples. Diabetic patients in our sample were more depressed and reported lower levels of somatic well-being and contentment compared to non-diabetic patients. The samples did not differ significantly along other dimensions of depression, including course of illness, response to previous treatments and comorbid conditions. These findings suggest that depressed diabetic patients are more similar than not to non-diabetic depressed patients, although important differences exist.

Screening for depression in chronic hemodialysis patients: Comparison of the Beck Depression Inventory, primary nurse, and nephrology team

Depression in patients with end-state renal disease (ESRD) is both underdiagnosed and treated, which may contribute to an increase in morbidity and mortality. Efforts aimed at screening, diagnosing, and treating depression could potentially modify outcomes in this population. The purpose of this study was to compare the prevalence of depression, as measured by the Beck Depression Inventory (BDI-II), the primary nurse, and nephrology team, among a cohort of patients receiving chronic hemodialysis (HD). A secondary objective was to identify patient variables associated with depression. Patients were screened for depression at the same time point, using the BDI-II, the primary nurse and the nephrology team. Depression was defined as a BDI-II score > or =14. Agreement between the BDI-II score, nurse, and nephrology team assessment of depression was compared using a kappa score and receiver-operating characteristic (ROC) curves were generated. One hundred and twenty-four of an eligible 154 patients completed the study. Depression as measured by a BDI-II> or =14, the nurse and the team was diagnosed in 38.7%, 41.9%, and 24.2% of patients, respectively. With the BDI-II as the gold standard, the nurses' diagnosis of depression had an agreement of 74.6% vs. only 24.2% agreement with the nephrology team. A previous history of malignancy was the only variable associated with the diagnosis of depression. Depression is common among patients on HD, supporting the need for a routine depression-screening program. The primary dialysis nurse is in a key position to identify patients with depression and should be considered as an integral part of the nephrology team.

Depression in Pregnancy

Women who are already predisposed to depression are at increased risks during pregnancy because of endocrine changes; untreated depression in pregnant women might lead to adverse effects for both mothers and infants. This article examines outcomes associated with the use of antidepressants during pregnancy and identifies how nurses can help depressed pregnant women. It is recommended that pregnant women who have mild depression be treated with nonpharmacologic therapy, such as counseling, cognitive-behavioral therapy, or interpersonal psychotherapy. Current appropriate treatment for pregnant women with moderate and severe depression is antidepressant medication, although there is no consensus on the best antidepressants for use in pregnancy. Thus, the psychotropic drug must be chosen carefully to minimize negative effects on infants and mothers, for some studies have demonstrated deleterious effects on infants. Nurses in multiple settings who interact with pregnant women should be aware of the necessity of screening for depression. Nurses in antenatal care settings can refer appropriately screened women to mental health specialists; psychiatric nurse practitioners can identify suitable interventions based on potential risks and benefits to maternal and infant health.

Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up

OBJECTIVE

To study the relationship of minor depression to first onset of major depressive disorder (MDD) among 1634 individuals over a 15-year follow-up using the Baltimore Epidemiologic Catchment Area cohort.

METHOD

Logistic regression analyses were conducted with minor depression alone and also adjusting for anxiety, sociodemographic, and medical variables, with MDD as the outcome variable. Also, among those with minor depression, depressive symptom categories were studied with both logistic regression and population attributable risk (PAR) to determine if they predicted MDD.

RESULTS

Individuals with a history of minor depression had an odds ratio of more than 5 of having a first lifetime episode of MDD (adjusted OR: 5.37, 95% CI: 2.87, 10.06). Suicidal ideation, appetite/weight issues, and sleep difficulty had the highest PARs.

CONCLUSION

Minor depression strongly predicts MDD. Clinical and public health interventions for individuals with minor depression can potentially impact the pathway leading to MDD.

Living with diabetes: perceptions of Hispanic migrant farmworkers

This study1 focuses on Hispanic migrant farmworkers and their perceptions of living with diabetes. A phenomenological design was utilized with a sample of 12 participants recruited from 2 local migrant health centers. The interview guide was based on questions from Kleinman's Explanatory Model. Data were explored with regard to etiology, onset of symptoms, pathophysiology, and course of illness. Six themes emerged from the analysis: usualness of diabetes, causes of diabetes, symptoms prior to the diagnosis of diabetes, understanding the chronicity of diabetes, impact of diabetes on daily life, and fear of long-term complications related to diabetes. Based on the analysis of the interviews, the individuals' explanations of this chronic disease are compiled within their own perceptions and cultural beliefs. The results of this study can be utilized by providers to adapt their health care and education methods to better meet the needs of this mobile population. In the Hispanic migrant farmworker population, further research is needed to explore the long-term impact of living with diabetes on a daily basis.

Adequate initial antidepressant treatment among patients with chronic obstructive pulmonary disease in a cohort of depressed veterans

OBJECTIVE

Depression is common among patients with chronic obstructive pulmonary disease (COPD). Patients with COPD may be more likely to have inadequate treatment with antidepressant medications. We tested the hypothesis that depressed patients with COPD have lower odds of adequate duration of antidepressant therapy in the first 3 months of treatment compared to those without COPD.

METHOD

Using administrative and centralized pharmacy data from 14 northeastern Veterans Affairs Medical Centers, we identified 778 veterans with depression (ICD-9-CM codes 296.2x, 296.3x, and 311.xx) who were in the acute phase of antidepressant treatment from June 1, 1999, through August 31, 1999. Within this group, we identified those patients with COPD (23%). An adequate duration of antidepressant treatment was defined as ≥ 80% of days on an antidepressant. We used multivariable logistic regression models to determine the adjusted odds of adequate acute phase antidepressant treatment duration.

RESULTS

Those patients with COPD had markedly lower odds of adequate acute phase treatment duration (odds ratio = 0.67, 95% CI = 0.47 to 0.96); this was not observed with other medical diagnoses such as coronary heart disease, diabetes mellitus, or osteoarthritis.

CONCLUSIONS

The first few months of treatment appears to be a critical period for depressed patients with COPD who are started on antidepressants. The causes for early antidepressant treatment inadequacy among patients with COPD require further investigation. More intensive efforts may be necessary early in the course of treatment to assure high-quality pharmacologic therapy of depressed patients with COPD.

[Reduction of endogenous regulation in internal medicine patients]

BACKGROUND

General health-related questionnaires on quality of life do not satisfactorily distinguish between healthy and sick people. One of the reasons cited for this lack is too much mental influence. This is why we developed a questionnaire on endogenous regulation (eR) that reflects the regulatory state of various vegetative functions.

OBJECTIVE

The current study examines whether the short version eR questionnaire is able to distinguish between healthy people and internal medicine patients.

PATIENTS AND METHODS

408 participants were included in the study (284 females, 124 males). Among these were patients with colorectal cancer (n = 49), breast cancer (n = 95), diabetes mellitus (type 1: n = 20, type 2: n = 40), coronary disease (n = 39), rheumatoid illnesses (n = 28) and multimorbid patients (n = 22) as well as a healthy control group (n = 115). In addition to the eR questionnaire the study also used the Hospital Anxiety and Depression Scale (HADS), the short questionnaire on self-regulation and questions on the vegetative status.

RESULTS

The healthy control group showed the highest eR, with an estimated average of M = 29.8. Patients with breast cancer, diabetes mellitus type 2, coronary disease and rheumatoid illnesses reveal a significantly lowered eR. Multimorbid patients show the lowest eR. Patients with cancer of the colon and diabetes type 1 were measured at M = 27.9 and M = 27.3 respectively and showed no significantly lowered estimated average compared to the control group. A high eR significantly correlates (p < 0.002) with the following parameters: low levels of anxiety (r = 49) and depression (r = 0.36), high self-regulation (r = 0.34), morning type (r = 0.40), less congestive perspiration (r = 0.38), less shivering (r = 0.23), dysmenorrhoea (r = 0.38) and allergies (r = 0.17).

CONCLUSION

Healthy people show the highest, multimorbid patients the lowest eR. Consistent relations to health, illness, heat regulation and personality presence have been shown. Further studies to clarify clinical relevance are necessary.

Cognitive decline and dementia in diabetes--systematic overview of prospective observational studies

AIMS/HYPOTHESIS

We systematically reviewed and summarised prospective data relating diabetes status to changes in cognitive function over time.

METHODS

Published reports of longitudinal studies that described assessment of cognitive function in people with diabetes were sought. Studies were included if they assessed cognitive function in participants with diabetes at the beginning and at follow-up. Studies were excluded if they had (1) a follow-up period of less than 1 year, (2) a rate of loss to follow-up in excess of 30%, or (3) described selected subgroups. Change in cognitive function was recorded as either the mean change in score and/or the proportion of individuals developing various degrees of change in cognitive function. A pooled estimate was calculated for the latter.

RESULTS

Of 1,165 abstracts and titles initially identified, 25 articles met the inclusion and exclusion criteria. Individuals with diabetes had a 1.2- to 1.5-fold greater change over time in measures of cognitive function than those without diabetes. When assessed by the Mini-Mental State Exam and the Digit Symbol Span tests, a diagnosis of diabetes increased the odds of cognitive decline 1.2-fold (95% CI 1.05-1.4) and 1.7-fold (95% CI 1.3-2.3), respectively . The odds of future dementia increased 1.6-fold (95% CI 1.4-1.8).

CONCLUSIONS/INTERPRETATION

Compared to people without diabetes, people with diabetes have a greater rate of decline in cognitive function and a greater risk of cognitive decline. Cognitive dysfunction should therefore be added to the list of chronic complications of diabetes.

Empowering patients with diabetes: a qualitative primary care study focusing on South Asians in Leicester, UK

OBJECTIVES

We aimed to explore the experience and attitudes of primary care patients with diabetes living in a UK community with a high proportion of South Asian patients of Indian origin, with particular reference to patient empowerment.

METHODS

Semi-structured interviews were conducted with patients with diabetes attending two general practices in Leicester, UK. Patients were interviewed in English, Gujarati or Punjabi and interviews were transcribed with translation into English where necessary. Broad themes were identified and Framework charting was used to organise data for analysis.

RESULTS

Interviews were conducted with 15 South Asian and 5 white patients. We identified both similar and culturally specific elements within the experience, attitudes and barriers in the two ethnic groups. High regard for education, particularly in South Asians, was associated with a positive attitude to empowerment through knowledge, but also sometimes led to low motivation to become partners in diabetes management. High prevalence of diabetes and strong family networks meant that families were an important source of knowledge for South Asians and that these patients generally had good emotional support. Practical considerations such as the need for a convenient venue for educational initiatives were common to both ethnic groups, but some cultural preferences were also identified, for example for appropriate language provision and separate gender sessions.

CONCLUSIONS

Educational initiatives aimed at promoting self-management in chronic diseases such as diabetes need to be designed with an awareness of the complexity of social and cultural experiences and attitudes in target communities.

A prospective study of depression and mortality in patients with type 2 diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

Depression is associated with excess mortality in patients with type 2 diabetes. We investigated the impact, and possible causal mechanisms, of depression on all-cause and cardiac mortality in patients with type 2 diabetes.

METHODS

We recruited 1,273 patients with type 2 diabetes from a postcode-defined community (average age 64.1+/-11.2 years, 48.7% males, median duration of diabetes 4 years [range 1.0-9.0]) and followed them for 7.8+/-2.4 years. Depression was assessed using data obtained using a quality-of-life questionnaire, and cause and date of death were obtained from the state registry.

RESULTS

Depression was present in 31.5% of subjects at recruitment. Depressed subjects had a longer duration of diabetes, more cardiovascular risk factors, CHD, cerebrovascular disease and diabetic microvascular complications at baseline, and higher all-cause and cardiac mortality rates during follow-up. In Cox proportional hazards models and after adjustment for demographic and diabetes-related variables and cardiovascular risk factors, depression was significantly associated with excess all-cause and cardiac mortality. When diabetic microvascular and macrovascular complications were added to the Cox models, depression was not significantly associated with excess all-cause or cardiac mortality.

CONCLUSIONS/INTERPRETATION

Depression in patients with type 2 diabetes is associated with a greater prevalence of complications but is not an independent predictor of all-cause or cardiac mortality. Depression may contribute to the progression of important prognostic variables in diabetes, particularly macrovascular and microvascular disease.

Gender differences in adherence and metabolic control in urban youth with poorly controlled type 1 diabetes: the mediating role of mental health symptoms

OBJECTIVE

To examine gender differences in adherence and metabolic control and test the mediating role of mental health symptoms in a sample of predominantly African-American, low-income youth with chronically poor metabolic control.

METHODS

Baseline questionnaire data from an intervention study were collected from 119 youth and their primary caregiver.

RESULTS

Boys had worse adherence than girls, but there were no gender differences in hemoglobin A1C (HbA1C). Boys had more externalizing symptoms, whereas girls had more anxiety; there were no gender differences in depression. Externalizing symptoms were associated with poor adherence and metabolic control. Although anxiety was correlated with poor adherence, this relationship was not significant in the invariate analysis. Results of structural equation modeling (SEM) suggested that externalizing symptoms mediated the relationship between gender and adherence.

CONCLUSIONS

Results suggest that gender differences in adherence may be attributed, in part, to gender differences in externalizing symptoms in urban youth with poor metabolic control. Interventions targeting these symptoms may be necessary to improve adherence and HbA1C in both boys and girls.

Management of Diabetes During Acute Stroke and Inpatient Stroke Rehabilitation

OBJECTIVES

To summarize evidence on the impact of hyperglycemia on stroke outcomes and to present therapy algorithms for inpatient management in diabetic stroke patients.

DATA SOURCES

Guidelines for inpatient management of diabetes were reviewed and extracted from a technical review and recommendations from 2 national diabetes and endocrine organizations. MEDLINE database searches were conducted using key words: stroke, diabetes, hyperglycemia, hypoglycemia, inpatient, hospitalized, treatment, outcomes, disability, self-management, and education.

STUDY SELECTION

Studies were selected that specifically addressed the impact of the following in stroke patients: hyperglycemia and diabetes on rehabilitation outcomes, management strategies for hyperglycemia and diabetes, and strategies for facilitating diabetes self-management.

DATA EXTRACTION

Two authors independently extracted data and management practices from selected articles and published practice guidelines.

DATA SYNTHESIS

Diabetes is prevalent in stroke patients and results in poorer inpatient hospital and rehabilitation outcomes. Management of diabetes in stroke patients is further complicated by impairments in mobility and vision, necessitating accommodation strategies and tools for self-management. Optimal management of hyperglycemia using insulin or oral hypoglycemic agents results in reduced morbidity and mortality among diabetic inpatients.

CONCLUSIONS

To achieve inpatient glycemic management targets, use of clinical management algorithms, self-management tools, and systems approaches such as diabetes management teams are useful.

Abnormal benzodiazepine receptor function in the depressive-like behavior of diabetic mice

We previously reported that streptozotocin (STZ)-induced diabetic mice exhibited depressive-like behavior in the tail suspension test. In this study, we examined the involvement of benzodiazepine receptor functions in this diabetes-induced depressive-like behavior in mice. STZ-induced diabetes significantly increased the duration of immobility without affecting spontaneous locomotor activity. This increase was dose-dependently and significantly suppressed by a benzodiazepine receptor antagonist, flumazenil (0.1-1 mg/kg, i.v.). However, flumazenil (0.1-1 mg/kg, i.v.) did not affect the duration of immobility in non-diabetic mice. Furthermore, flumazenil (1 mg/kg, i.v.) had no significant effect on spontaneous locomotor activity in either non-diabetic or diabetic mice. The benzodiazepine receptor inverse agonist methyl beta-carboline-3-carboxylate (beta-CCM; 0.03-0.3 mg/kg, i.v.) dose-dependently and significantly increased the duration of immobility in non-diabetic mice, but not in diabetic mice. beta-CCM (0.3 mg/kg, i.v.) significantly suppressed spontaneous locomotor activity in non-diabetic mice, but not in diabetic mice. These results indicate that diabetic mice may have enhanced negative allosteric modulation by benzodiazepine receptor ligands, such as diazepam binding inhibitors, under stressful conditions, but not free-moving conditions, and this abnormal function of benzodiazepine receptors may cause, at least in part, the expression of depressive-like behavior in diabetic mice.

Association between comorbidity and erectile dysfunction in patients with diabetes

The aims of this study were to determine the prevalence of erectile dysfunction (ED) and its relationship with comorbidity in patients with diabetes. The study population comprised of 312 consecutive patients aged 20 years or over residing in the city of Hamadan in Iran in 2005. Depression was assessed by the modified version of the Beck Depression Inventory (BDI-II) and ED by the short form of the International Index of Erectile Function (IIEF-5) questionnaire. Potential confounding was controlled by stratification and by a logistic regression model. The prevalence of moderate or complete ED (IIEF score <or=11) was 34% and that of moderate or severe depressive symptoms 30%. Each 1-year increment in diabetes duration was associated with a 10% higher risk of ED. The risk of ED was higher in men with depression (odds ratio (OR)=10.7, 95% CI 5.4-21.1) and in those with cardiovascular disease (CVD) (OR=2.0, 95% CI 1.1-3.6). CVD was associated with ED only in elderly men, whereas depression was related to ED in both young and older subjects. The risk of ED was higher in subjects with both depression and CVD (OR=17.2, 95% CI 6.8-43.1 compared with men free from both diseases). Subjects who consumed fruits weekly or seldom had a higher risk of ED (OR=3.2) compared with those who consumed daily. Our study shows a strong association between depressive symptoms and ED. The association is much stronger for older men. Depression and CVD may interact with one another in relation to a higher risk of ED. A diet rich in fruits may have a beneficial effect on erectile function.

Use of antidepressants in older patients with co-morbid medical conditions: guidance from studies of depression in somatic illness

Advanced age and medical complexity are characteristics not often associated with participation in randomised, placebo-controlled trials of antidepressants. Thus, evidence for the efficacy of antidepressant treatment among typical seniors with somatic illness and advanced age is scant. Furthermore, there appears to be no clear empirically based delineation between depressive symptoms and depressive disorders among very old, physically ill adults. The increasing numbers of antidepressants and adjunctive medications add to the practitioner's perplexity when confronted with a very old, very depressed patient. Nonetheless, a growing body of evidence from antidepressant studies in the context of age-related somatic illnesses allows reasonable inferences to guide diagnosis and treatment. Once the practitioner and patient agree upon an antidepressant trial, the benefits of prescribed medication should be assessed within the first days rather than first weeks of treatment. The patient and practitioner should expect to escalate the antidepressant to the established therapeutic range rather than seek the lowest dose that is effective. Patients who experience no benefit whatsoever within the first weeks of treatment despite being within the therapeutic range should be offered an alternative promptly. With the results of studies of depression in co-morbid disorders and analyses of treatment response trajectory, the practitioner can be assured that advanced age, physical illness and depression need not go hand in hand.

The association of comorbid depression with mortality in patients with type 2 diabetes

OBJECTIVE

We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.

RESEARCH DESIGN AND METHODS

In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.

RESULTS

There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.

CONCLUSIONS

Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.

Serious diabetes-specific emotional problems and depression in a Croatian-Dutch-English Survey from the European Depression in Diabetes [EDID] Research Consortium

It has been hypothesized that coverage of diabetes-specific issues (e.g. coping with complications, incapacity, pain) during psychotherapy may optimize the likelihood of treatment success for depression in patients with diabetes. However, it is still unclear how often depression is confounded by diabetes-specific emotional problems. We aim to determine the levels of diabetes-specific emotional problems in diabetic individuals with high versus low levels of depression in a sample of 539 outpatients with diabetes (202 Dutch, 185 Croatian and 152 English). Subjects completed the Center for Epidemiological Studies Depression and the Problem Areas in Diabetes scales. Percentages of patients with high depression scores were: 39 and 34% (Croatian men and women), 19 and 21% (Dutch men and women), 19 and 39% (English men and women). Moreover, 79% (Croatian), 47% (Dutch) and 41% (English) of the patients with a severe depression score reported to have four or more serious diabetes-specific emotional problems. For patients with low depression scores, these percentages were: 29% (Croatian), 11% (Dutch) and 1% (English). Serious diabetes-specific emotional problems are particularly prevalent in depressed diabetes patients. Randomized controlled trials are warranted to test whether coverage of diabetes-specific issues during psychotherapy can further improve the treatment of depression in diabetes.

Increasing lifestyle physical activity in patients with depression or other serious mental illness

People with severe and persistent mental illness are more likely to be overweight and to suffer from obesity-related illnesses such as diabetes and heart disease than healthy individuals. Lifestyle change interventions that emphasize integrating physical activity into daily life have not been studied extensively in people with mental illness. The authors present the results of an initial feasibility study of a lifestyle modification program for individuals with serious mental illness. Thirty-nine individuals with depression or other serious mental illness were recruited from three different mental health facilities to attend an 18-week lifestyle intervention program promoting physical activity and healthy eating. At each session, participants discussed topics related to healthy lifestyle changes and participated in group walks. Data were collected at baseline, 6 weeks, and 18 weeks. The results demonstrated that individuals who have depression and other serious mental illnesses can participate in a lifestyle intervention program. Participants who attended the final follow-up session had lost weight over the course of the intervention. Study retention was a problem. However, the cost of this type of group-based lifestyle intervention was relatively low, so that such an intervention for this high-risk group may still be cost-effective.

Fat food for a bad mood. Could we treat and prevent depression in Type 2 diabetes by means of omega-3 polyunsaturated fatty acids? A review of the evidence

AIMS

Evidence strongly suggests that depression is a common complication of Type 2 diabetes mellitus. However, there is considerable room to improve the effectiveness of pharmacological antidepressant agents, as in only 50-60% of the depressed subjects with diabetes does pharmacotherapy lead to remission of depression. The aim of the present paper was to review whether polyunsaturated fatty acids (PUFA) of the omega-3 family could be used for the prevention and treatment of depression in Type 2 diabetes.

METHODS

MEDLINE database and published reference lists were used to identify studies that examined the associations between omega-3 PUFA and depression. To examine potential side-effects, such as on glycaemic control, studies regarding the use of omega-3 supplements in Type 2 diabetes were also reviewed.

RESULTS

Epidemiological and clinical studies suggest that a high intake of omega-3 PUFA protects against the development of depression. There is also some evidence that a low intake of omega-3 is associated with an increased risk of Type 2 diabetes, but the results are less conclusive. Results from randomized controlled trials in non-diabetic subjects with major depression show that eicosapentaenoic acid is an effective adjunct treatment of depression in diabetes, while docosahexanoic acid is not. Moreover, consumption of omega-3 PUFA reduces the risk of cardiovascular disease and may therefore indirectly decrease depression in Type 2 diabetes, via the reduction of cardiovascular complications.

CONCLUSIONS

Supplementation with omega-3 PUFA, in particular eicosapentaenoic acid, may be a safe and helpful tool to reduce the incidence of depression and to treat depression in Type 2 diabetes. Further studies are now justified to test these hypotheses in patients with Type 2 diabetes.

Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes: the Fremantle Diabetes Study

OBJECTIVE

The purpose of this study was to determine longitudinal predictors of impaired mobility and physical disability in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We studied patients with type 2 diabetes who participated in a prospective, community-based study. A wide range of baseline variables were examined to determine whether they predicted future difficulties with 1) mobility and 2) basic activities of daily living (ADLs) in patients free of ADLs difficulty at baseline. To study mobility impairment, subjects with baseline mobility problems were also excluded.

RESULTS

After an average 4.6 +/- 2.3 and 4.8 +/- 2.3 years of follow-up in 818 and 934 patients, respectively, 28.5% of subjects had developed new mobility impairment and 18.1% had developed new ADL disability. In Cox proportional hazards models, the risk of mobility impairment was significantly increased by older age (6%/year), peripheral neuropathy (40% increase), stroke history (123%), insulin treatment (117%), albuminuria, and arthritis (82%); taking exercise and being married lowered the risk (by 39 and 32%, respectively). The risk of new ADL disability was increased by baseline mobility problems (222% increase), stroke (92%), claudication (67%), and depression (41%) and was also influenced by age, smoking, lack of exercise, non-fluency in English, and indigenous Australian ethnicity.

CONCLUSIONS

Both mobility impairment and ADL disability in type 2 diabetes have multiple causes that are due to diabetes complications and common comorbidities. The specific causes of each functional problem are largely distinct, and different approaches may be required to prevent their onset or progression.

Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study

AIMS

To examine patient- and provider-reported psychosocial problems and barriers to effective self-care and resources for dealing with those barriers.

METHODS

Cross-sectional study using face-to-face or telephone interviews with diabetic patients and health-care providers in 13 countries in Asia, Australia, Europe and North America. Participants were randomly selected adults (n = 5104) with Type 1 or Type 2 diabetes, and providers (n = 3827), including primary care physicians, diabetes specialist physicians and nurses.

RESULTS

Regimen adherence was poor, especially for diet and exercise; provider estimates of patient self-care were lower than patient reports for all behaviours. Diabetes-related worries were common among patients, and providers generally recognized these worries. Many patients (41%) had poor psychological well-being. Providers reported that most patients had psychological problems that affected diabetes self-care, yet providers often reported they did not have the resources to manage these problems, and few patients (10%) reported receiving psychological treatment.

CONCLUSIONS

Psychosocial problems appear to be common among diabetic patients worldwide. Addressing these problems may improve diabetes outcomes, but providers often lack critical resources for doing so, particularly skill, time and adequate referral sources.

Mood and cognitive function in elderly diabetic patients living in care facilities

Community studies found deficits of cognitive function in elderly persons with diabetes. The aim of the present study was to compare diabetes and other age-related diseases among residents of senior citizens' care facilities. Participants were 130 residents with and 130 without a diagnosis of diabetes aged between 65 and 98 years. Measures were neuropsychological tests designed for this age group, questionnaires of mood, quality of life and daily activities and level of glycosylated hemoglobin (HbA(1c)) as an index of metabolic control. Only verbal memory was significantly more impaired in residents with than without diabetes. Otherwise, both groups showed overall impairment of cognitive function and mood. Unexpectedly, a slightly elevated HbA(1c) level (6-8%) was associated with an increased level of cognitive and everyday functioning. In old age, diabetic patients might benefit from a slightly higher level of blood glucose than has hitherto been assumed.