The association between depression and health-related quality of life in people with type 2 diabetes: a systematic literature review

Trajectories of depressive symptoms in Korean adults with diabetes: Individual differences and associations with life satisfaction and mortality

OBJECTIVE

We examined trajectories of depressive symptoms and their predictors in adults with diabetes. We assessed whether these trajectories were related to life satisfaction and mortality.

DESIGN

Longitudinal, prospective observational study.

METHODS

We analysed data from 1217 adults with diabetes (aged ≥45 years) in the Korean Longitudinal Study of Aging (2006-2018).

RESULTS

Three trajectories of depressive symptomology were identified in growth mixture models: low/stable (i.e., low and stable levels of symptoms; 85.56%), high/decreasing (i.e., high levels of symptoms with a decreasing trajectory; 7.47%), and moderate/increasing (i.e., moderate levels of symptoms with an increasing trajectory; 6.98%). Participants with poor perceived health status at baseline were more likely to be in the moderate/increasing or high/decreasing classes than in the low/stable class. The moderate/increasing class had the lowest satisfaction with quality of life, followed by the high/decreasing and low/stable classes. The moderate/increasing and the high/decreasing classes had lower satisfaction with relationships with spouse and children than the low/stable class. The high/decreasing class had a higher mortality risk than the low/stable class.

CONCLUSIONS

Long-term monitoring of depressive symptoms in adults with diabetes is warranted given their potential adverse impact on life satisfaction and mortality.

The association of depression and sleep disorders in patients with type 1 diabetes in Taiwan

The association between depression and sleep disorders in patients with type 1 diabetes mellitus (T1DM) in Taiwan is underexplored. We used a nationwide population-based dataset to evaluate the association of T1DM with these conditions in Taiwan from 2001 to 2019. Patients with T1DM were identified as cases, and 2 control groups were used for comparison: patients with type 2 diabetes mellitus (T2DM) and nondiabetic patients. Age, sex, date of diagnosis, and multiple comorbidities were included and matched using propensity score matching between cases and controls. The primary outcome of this study was to identify new occurrences of the first diagnosis of depression or sleep disorders. After matching, this study included 27,029 T1DM cases, 54,058 T2DM controls, and 108,116 nondiabetic controls. Patients with T1DM exhibited a 1.55-fold higher risk of developing depression (hazard ratio [HR] 1.55, 95% confidence intervals [CI] 1.48-1.61) and a 1.41-fold higher risk of experiencing sleep disorders (HR 1.41, 95% CI 1.37-1.46) compared to nondiabetic controls. Similarly, patients with T2DM displayed elevated risks of both depression (HR 1.39, 95% CI 1.34-1.43) and sleep disorders (HR 1.40, 95% CI 1.37-1.44) relative to non-diabetic controls. When comparing the T1DM and T2DM groups, T1DM patients demonstrated a slightly higher risk of depression (HR 1.11, 95% CI 1.07-1.16) but no significant difference in the risk of sleep disorders compared to T2DM patients. These results were consistent regardless of different ages or sexes. This study demonstrates a significant association between diabetes mellitus and the risk of depression and sleep disorders in a large cohort of Taiwanese patients.

A Randomized Controlled Trial Comparing the Quality of Life and Medication Adherence in Patients on Antidepressant Monotherapy

Background and objectives The quality of life declines with the growing severity of major depressive disorder (MDD). In depressed people, medication adherence and the quality of life are mutually corrosive. These concerns spurred the investigation of relationships between treatment outcomes and adherence levels. Limited studies are looking at how vortioxetine, escitalopram, and vilazodone affect these parameters. We aimed to detect how the Short Form-36 (SF-36) had changed 16 weeks after the baseline. The connection between treatment results (as expressed by the Hamilton Depression Rating Scale or HDRS) and medication adherence (as reflected by the Morisky Medication Adherence Scale-8 or MMAS-8) was also explored. Methods An open-label, randomized, three-arm trial with 96 MDD patients was conducted. For 16 weeks, the participants were put into three groups per a 1:1:1 ratio and administered tablets of vilazodone (20-40 mg/day), escitalopram (10-20 mg/day), or vortioxetine (5-20 mg/day). There were two test drugs: vilazodone and vortioxetine; the control was escitalopram. Four weeks apart, follow-up appointments were set after the baseline visit. The HDRS, mental and physical components of SF-36, and MMAS-8 scores were evaluated in the per-protocol (PP) population. Reduced HDRS scores were indicative of improved depression symptoms. Higher MMAS-8 and SF-36 scores indicated high drug adherence and enhanced quality of life. Our analysis used the Kruskal-Wallis test, the Bonferroni correction, and the Sankey diagram. In the Clinical Trial Registry-India (CTRI), we recorded this study prospectively (2022/07/043808). Results One hundred nine (81.34%) of the 134 individuals we examined were eligible. The PP population consisted of 96 (88.07%) of them who wrapped up the 16-week study. The mean age of the group was 46.3 ± 6.2 years. For each of the three groups, the SF-36 physical component scores revealed a median difference of 24.5 (23.8-26.0), 24.0 (22.8-25.3), and 27.0 (25.0-29.0) (p = 0.001). Accordingly, the mental components of their SF-36 scores showed a median difference of 32.0 (31.0-33.3), 31.0 (29.8-34.3), and 36.0 (33.0-38.0) (p = 0.001). A median difference of -15.0 (-16.0 to -14.0), -16.0 (-17.0 to -15.0), and -16.0 (-17.0 to -15.8) was observed in the HDRS scores after 16 weeks, with respect to the baseline (p < 0.001). The median MMAS-8 scores at 16 weeks were 6.0 (6.0-7.0), 6.8 (6.0-7.0), and 7.5 (6.5-8.0) (p = 0.031). The Sankey diagram illustrated the connection between better treatment results, increased medication compliance, and decreased symptoms of depression. Conclusion In comparison to vilazodone and escitalopram, vortioxetine demonstrated a statistically significant decrease in HDRS scores and an improvement in the physical and mental component scores of the SF-36. Clinical improvements were evident in the individuals' drug adherence levels. Larger-scale studies are advised to investigate the effects of these medications on the quality of life, medication adherence, and treatment outcomes.

Network analysis of depressive and anxiety symptoms in older Chinese adults with diabetes mellitus

Background

The move away from investigating mental disorders as whole using sum scores to the analysis of symptom-level interactions using network analysis has provided new insights into comorbidities. The current study explored the dynamic interactions between depressive and anxiety symptoms in older Chinese adults with diabetes mellitus (DM) and identified central and bridge symptoms in the depression-anxiety network to provide potential targets for prevention and intervention for depression and anxiety.

Methods

This study used a cross-sectional design with data from the 2017-2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). A regularized partial correlation network for depressive and anxiety symptoms was estimated based on self-reported scales completed by 1685 older adults with DM aged 65 years or older. Depressive and anxiety symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) and the Seven-Item Generalized Anxiety Disorder Scale (GAD-7), respectively. Expected influence (EI) and bridge expected influence (BEI) indices were calculated for each symptom.

Results

According to cutoff scores indicating the presence of depression and anxiety, the prevalences of depression and anxiety in our sample were 52.9% and 12.8%, respectively. The comorbidity rate of depression and anxiety was 11.5%. The six edges with the strongest regularized partial correlations were between symptoms from the same disorder. "Feeling blue/depressed", "Nervousness or anxiety", "Uncontrollable worry", "Trouble relaxing", and "Worry too much" had the highest EI values. "Nervousness or anxiety" and "Everything was an effort" exhibited the highest BEI values.

Conclusion

Central and bridge symptoms were highlighted in this study. Targeting these symptoms may be effective in preventing the comorbidity of depressive and anxiety symptoms and facilitate interventions in older Chinese adults with DM who are at risk for or currently have depressive and anxiety symptoms.

Using machine learning to forecast symptom changes among subclinical depression patients receiving stepped care or usual care

BACKGROUND

Subclinical depression (SD) is a mental health disorder characterized by minor depressive symptoms. Most SD patients are treated in the primary practice, but many respond poorly to treatment at the expense of provider resources. Stepped care approaches are appealing for tiering SD care to efficiently allocate scarce resources while jointly optimizing patient outcomes. However, stepped care can be time inefficient, as some persons may respond poorly and be forced to suffer with their symptoms for prolonged periods. Machine learning can offer insight into optimal treatment paths and inform clinical recommendations for incident patients.

METHODS

As part of the Step-Dep trial, participants with SD were randomized to receive stepped care (N=96) or usual care (N=140). Machine learning was used to predict changes in depressive symptoms every three months over a year for each treatment group.

RESULTS

Tree-based models were effective in predicting PHQ-9 changes among patients who received stepped care (r=0.35-0.46, MAE=0.14-0.17) and usual care (r=0.34-0.49, MAE=0.15-0.18). Patients who received stepped care were more likely to reduce PHQ-9 scores if they had high PHQ-9 but low HADS-A scores at baseline, a low number of chronic illnesses, and an internal locus of control.

LIMITATIONS

Models may suffer from potential overfitting due to sample size limitations.

CONCLUSION

Our findings demonstrate the promise of machine learning for predicting changes in depressive symptoms for SD patients receiving different treatments. Trained models can intake incident patient information and predict outcomes to inform personalized care.

Differential network interactions between psychosocial factors, mental health, and health-related quality of life in women and men

Psychosocial factors affect mental health and health-related quality of life (HRQL) in a complex manner, yet gender differences in these interactions remain poorly understood. We investigated whether psychosocial factors such as social support and personal and work-related concerns impact mental health and HRQL differentially in women and men during the first year of the COVID-19 pandemic. Between June and October 2020, the first part of a COVID-19-specific program was conducted within the "Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB)" cohort study, a representative age- and gender-stratified sample of the general population of Würzburg, Germany. Using psychometric networks, we first established the complex relations between personal social support, personal and work-related concerns, and their interactions with anxiety, depression, and HRQL. Second, we tested for gender differences by comparing expected influence, edge weight differences, and stability of the networks. The network comparison revealed a significant difference in the overall network structure. The male (N = 1370) but not the female network (N = 1520) showed a positive link between work-related concern and anxiety. In both networks, anxiety was the most central variable. These findings provide further evidence that the complex interplay of psychosocial factors with mental health and HRQL decisively depends on gender. Our results are relevant for the development of gender-specific interventions to increase resilience in times of pandemic crisis.

Quality of Life and Medication Adherence in Patients With Major Depressive Disorder: An Interim Analysis of a Randomized Study

BACKGROUND AND OBJECTIVES

Quality of life and medication adherence worsen in untreated depressed individuals. Studies examining how vilazodone, escitalopram, and vortioxetine affect these factors are few and far between. Our study's objectives were to determine the change in SF-36 at 12 weeks and the association between treatment outcome and medication adherence.

METHODS

This is an interim analysis of a randomized, open-label, three-arm ongoing study. The participants were evaluated at baseline, four, eight, and 12 weeks after being randomly assigned to take either vilazodone (20-40 mg/d), escitalopram (10-20 mg/d), or vortioxetine (5-20 mg/d). This study is registered with CTRI, 2022/07/043808.

RESULTS

Of 71 recruited participants, 49 (69%) completed the 12-week visit. The median scores of physical components of SF-36 for the three groups were 35.5, 35.0, and 35.0 at baseline (p=0.76) and 51.0, 49.5, and 53.0 (p<0.001) at 12 weeks respectively. Their corresponding median SF-36 scores for mental components were 43.0, 43.0, and 44.0 at baseline (p=0.34) and 66.0, 63.5, and 70.0 (p<0.001) at 12 weeks. The post hoc analysis yielded a significant difference (p<0.001) regarding SF-36 scores. MMAS-8 scores among the participants were similar (p=0.22) at 12 weeks. Higher medication adherence was associated with lesser depressive symptoms (r= -0.46, p=0.001).

CONCLUSION

As per this interim analysis, vortioxetine substantially impacted the SF-36 scores, juxtaposed with vilazodone and escitalopram. The participants' clinical improvements were reflected by their adherence levels. These effects need to be probed further.

HCV infection characteristics, treatment uptake and outcomes in patient with diabetes mellitus

BACKGROUND

The interplay between HCV, DM, and DAA therapy is poorly understood. We compared HCV infection characteristics, treatment uptake, and treatment outcomes in patients with and without DM.  METHODS: A retrospective cohort study was conducted using data from The Ottawa Hospital Viral Hepatitis Program. Statistical comparisons between diabetes and non-diabetes were made using χ² and t-tests. Logistic regression analyses were performed to assess predictors of DM and SVR.

RESULTS

One thousand five hundred eighty-eight HCV patients were included in this analysis; 9.6% had DM. Patients with DM were older and more likely to have cirrhosis. HCC and chronic renal disease were more prevalent in the DM group. Treatment uptake and SVR were comparable between groups. Regression analysis revealed that age and employment were associated with achieving SVR. Post-SVR HCC was higher in DM group.

CONCLUSION

The high prevalence of DM in our HCV cohort supports screening. Further assessment is required to determine if targeted, early DAA treatment reduces DM onset, progression to cirrhosis and HCC risk. Further studies are needed to determine if optimization of glycemic control in this population can lead to improved liver outcomes.

Chronic Conditions and Psychological Distress in Older Asian Americans: The Mediating Role of Subjective Health Perception

Given the importance of understanding the connection between physical and mental health in old age, the study examined the mediating role of subjective health perception in the relationship between chronic conditions and psychological distress among older Asian Americans. Using data from 533 Asian Americans aged 60 and over in the 2016 Asian American Quality of Life Study, the direct and indirect effect models were tested with multivariate linear regressions and the PROCESS macro. Results show that chronic conditions pose significant risks to psychological distress and that subjective health perception mediates their association. The observed role of subjective health perception as an intervening step between physical and mental health offers implications for gerontological social work research and practice by highlighting the importance of positive self-appraisals for the health and well-being in later years of life.

Psychosocial factors associated with pain and health-related quality of life in Endometriosis: a systematic review

BACKGROUND AND OBJECTIVE

Endometriosis is associated with pain and impaired health-related quality of life (HRQoL). Psychosocial factors have been associated with pain and HRQoL in other conditions, suggesting their potential relevance in Endometriosis. However, the role of psychosocial factors in this population has not been systematically explored yet. This systematic review aims to explore the association of psychosocial factors with pain intensity/severity and HRQoL in women with Endometriosis.

DATABASES AND DATA TREATMENT

Observational and experimental studies that explored the association of psychosocial factors with pain and HRQoL in women with Endometriosis were eligible. The following databases were searched: Medline, Embase, Cochrane library, Web of Science, PsychInfo and Cumulative index of nursing and allied health literature. The methodological quality was assessed, and findings were synthesised using narrative synthesis.

RESULTS

Twenty-seven studies were eligible for inclusion, which included 5419 women with Endometriosis. Catastrophising and anxiety were the factors most consistently associated with greater pain, whilst depression, anxiety and stress were related to worse HRQoL. Findings regarding depression and pain were mixed, and research on social factors was limited.

CONCLUSIONS

This systematic review highlights the role of psychosocial factors in Endometriosis. Anxiety, depression and catastrophising are suggested as potential treatment targets. The review also indicates the lack of research on other potentially important psychosocial factors, such as avoidance, perceived injustice and social support.

Effects of Family Doctor Contract Services on the Health-Related Quality of Life Among Individuals With Diabetes in China: Evidence From the CHARLS

Background

Family doctor contract services (FDCS) has played a key role in diabetes management in China since 2016. The influence of FDCS on the physiological indexes of individuals with diabetes has been examined. However, little attention has been paid to its effect on the Health-Related Quality of Life (HRQoL). This study aims to fill this knowledge gap by evaluating the effect of FDCS on the HRQoL of individuals with diabetes.

Methods

We identified 382 individuals with diabetes receiving all follow-up surveys in 2013, 2015, and 2018 from the China Health and Retirement Longitudinal Study (CHARLS). The HRQoL of the included individuals was estimated using results from the Short Form 36 (SF-36) questionnaire. The propensity score matching with the difference-in-differences (PSM-DID) approach was applied to quantify the effect of FDCS on the HRQoL among individuals with diabetes. A robust test was performed by setting the 2015 data as the treatment group for the placebo test.

Results

The mean score of role-emotional (RE) increased from 54.25 to 61.63 among those who signed up to receive FDCS, while the corresponding score decreased from 57.77 to 51.04 among those who did not receive FDCS. Results from the regression analysis indicated that the use of FDCS was associated with significant improvement in RE (+14.10, p = 0.04) among individuals with diabetes. We did not find a statistically meaningful association between the FDCS and any of the other HRQoL domains: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), and mental health (MH), respectively. The robustness analysis of the model indicated that the results were robust.

Conclusion

The FDCS for diabetes in China was associated with a significant improvement in RE. Due to a limited time since the launch of FDCS (i.e., 2016), the recipient's physical health did not show marked improvement. In the future, FDCS should pay more attention to the physiological health of individuals with diabetes. Moreover, psychological services also need to be maintained and not slackened. At the same time, it is strongly recommended to pay more attention to the HRQoL of individuals with diabetes and more comprehensive health.

Health-related quality of life in patients with type 2 diabetes initiating a second-line glucose-lowering therapy: The DISCOVER study

AIM

To investigate factors associated with health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus (T2D) at initiation of second-line glucose-lowering therapy.

METHODS

DISCOVER is a 3-year, prospective observational study of patients with T2D initiating second-line glucose-lowering therapy, conducted in 38 countries. HRQoL at baseline was assessed using the physical and mental component summary (PCS; MCS) scores of the 36-Item Short Form Health Survey version 2 (SF-36v2) in 31 countries (n = 8309) and the Hypoglycaemia Fear Survey-II (HFS-II) in 23 countries (n = 6516). Factors associated with differences in HRQoL were assessed using multivariable hierarchical regression models.

RESULTS

Mean PCS and MCS scores were 48.0 (standard deviation [SD]: 7.8) and 45.5 (SD: 10.4), respectively. Factors associated with significantly lower SF-36v2 scores included being female, having a history of macrovascular complications and first-line treatment with oral combinations (vs metformin monotherapy). Mean HFS-II behaviour and worry scores were 8.2 (SD: 9.9) and 7.3 (SD: 11.8), respectively. Increased fear of hypoglycaemia was significantly associated with lower SF-36v2 scores.

CONCLUSIONS

Several patient-, disease- and treatment-related characteristics correlated with HRQoL, indicating that a multifactorial approach is needed to maintain HRQoL in patients with T2D.

Diabetes and health-related quality of life among American Indians: the role of psychosocial factors

PURPOSE

Little is known about the association of psychosocial factors with health-related quality of life (HRQoL) among American Indians with type 2 diabetes (T2D). This study described functional social support, emotional support, coping, resilience, post-traumatic stress disorder, and HRQoL, among American Indians by diabetes status and, among those with diabetes, examined the association of these factors with HRQoL.

METHODS

Using data from the Cherokee Nation Health Survey collected between 2017 and 2019, we evaluated differences in each measure of interest according to diabetes status, using t-test and Chi-squared tests of association. We used weighted multiple logistic regression to examine associations between multiple psychosocial factors and HRQoL among those with diabetes.

RESULTS

Compared to individuals without diabetes, participants with diabetes rated their functional social support (4.62 vs. 4.56, respectively) and coping (2.65 vs. 2.61, respectively) slightly lower and were more likely to report ≥ 15 days of poor physical (14% vs. 26%, respectively) and mental health (14% vs. 17%, respectively) in the past month. Odds of reporting poor overall health increased more than sixfold for those who were dissatisfied/very dissatisfied with life (AOR = 6.70). Resilience scores reduced odds of reporting ≥ 15 days with poor physical health, while experiences of post-traumatic stress doubled these odds.

CONCLUSION

Our study yielded insights into the risk as well as protective factors associated with diabetes outcomes in a large sample of American Indians with T2D. Researchers should design pragmatic trials that deepen understanding of preventive as well as treatment leverage through greater attention to experiences that compromise HRQoL.

Swimming exercise decreases depression-like behaviour and inflammatory cytokines in a mouse model of type 2 diabetes

NEW FINDINGS

What is the central question of this study? Can swimming exercise decrease depression-like behaviour and inflammation in type 2 diabetic mice? What is the main finding and its importance? Swimming exercise decreased depression-like behaviour by reducing inflammation in type 2 diabetic mice. Swimming exercise might be useful for the treatment of depression-related disorders in patients with type 2 diabetes.

ABSTRACT

Clinical and experimental studies have shown that type 2 diabetes is associated with depression-related disorders. Inflammation has been identified as a common mechanism in both type 2 diabetes and depression. Several studies have suggested that swimming exercise might be able to reduce depression-related symptoms. The present study aimed to explore whether swimming exercise can decrease depression-like behaviour in type 2 diabetic mice. To induce type 2 diabetes, male C57BL6 mice were treated with a high-fat diet and streptozocin. Type 2 diabetic animals were subjected to swimming exercise for 4 weeks. Then, depression-like behaviours were evaluated by sucrose preference, novelty-suppressed feeding, social interaction and tail suspension tests. We also measured levels of glucose, insulin and pro-inflammatory cytokines such as interleukin-1β and tumour necrosis factor-α in the serum of animals. The results indicated that type 2 diabetes significantly increased anhedonia- and depression-like behaviours in mice. We also found significant increases in glucose, insulin and inflammatory cytokines in diabetic mice. Moreover, swimming exercise reduced anhedonia- and depression-like behaviour in type 2 diabetic mice. Swimming exercise also decreased glucose and inflammatory cytokines in the serum of mice with type 2 diabetes. Collectively, this study demonstrates that swimming exercise decreased depression-like behaviour by reducing inflammation in type 2 diabetic mice. Further clinical studies are needed to validate these findings in patients with type 2 diabetes.

Cost-effectiveness of a stepped care program to prevent depression among primary care patients with diabetes mellitus type 2 and/or coronary heart disease and subthreshold depression in comparison with usual care

BACKGROUND

Patients with diabetes mellitus type 2 (DM2) and/or coronary heart disease (CHD) are at high risk to develop major depression. Preventing incident major depression may be an important tool in reducing the personal and societal burden of depression. The aim of the current study was to assess the cost-effectiveness of a stepped care program to prevent major depression (Step-Dep) in diabetes mellitus type 2 and/or coronary heart disease patients with subthreshold depression in comparison with usual care.

METHODS

An economic evaluation with 12 months follow-up was conducted alongside a pragmatic cluster-randomized controlled trial from a societal perspective. Participants received care as usual (n = 140) or Step-Dep (n = 96) which consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to a general practitioner. Primary outcomes were quality-adjusted life years (QALYs) and cumulative incidence of major depression. Costs were measured every 3 months. Missing data was imputed using multiple imputation. Uncertainty around cost-effectiveness outcomes was estimated using bootstrapping and presented in cost-effectiveness planes and acceptability curves.

RESULTS

There were no significant differences in QALYs or depression incidence between treatment groups. Secondary care costs (mean difference €1644, 95% CI €344; €3370) and informal care costs (mean difference €1930, 95% CI €528; €4089) were significantly higher in the Step-Dep group than in the usual care group. The difference in total societal costs (€1001, 95% CI €-3975; €6409) was not statistically significant. The probability of the Step-Dep intervention being cost-effective was low, with a maximum of 0.41 at a ceiling ratio of €30,000 per QALY gained and 0.32 at a ceiling ratio of €0 per prevented case of major depression.

CONCLUSIONS

The Step-Dep intervention is not cost-effective compared to usual care in a population of patients with DM2/CHD and subthreshold depression. Therefore, widespread implementation cannot be recommended.

TRIAL REGISTRATION

The trial was registered in the Netherlands Trial Register ( NTR3715 ).

Effects of mindfulness-based intervention on glycemic control and psychological outcomes in people with diabetes: A systematic review and meta-analysis

AIMS/INTRODUCTION

Psychological therapies have showed benefits for both glycemic control and psychological outcomes in people with diabetes. However, the effects of mindfulness-based intervention (MBI) on glycemic control and psychological outcomes are inconsistent across studies, and the evidence for MBI has not been summarized. We aimed to identify the effects of MBI on glycemic control and psychological outcomes in people with diabetes by carrying out a systematic review and meta-analysis.

MATERIALS AND METHODS

Six databases (Pubmed, Embase, CINAHL, Cochrane, Web of science and PsycINFO) were searched from inception to October 2019. Randomized controlled trials of MBI for people with type 1 and type 2 diabetes were included. Two authors independently extracted relevant data and assessed the risk of bias, with a third reviewer as arbitrator. Subgroup analyses and sensitivity analyses were also carried out.

RESULTS

Eight studies with 841 participants met the eligibility criteria. Meta-analysis showed that MBI can slightly improve glycosylated hemoglobin (HbA1c; -0.25%, 95% confidence interval [CI] -0.43 to -0.07) and diabetes-related distress (-5.81, 95% CI -10.10 to -1.52) contribute to a moderate effect size in reducing depression (standardized mean difference -0.56, 95% CI -0.82 to -0.30) and stress (standardized mean difference -0.53, CI -0.75 to -0.31). Subgroup analyses showed greater HbA1c reductions in subgroups with baseline HbA1c levels <8% and follow-up duration >6 months. Mixed effects were observed for anxiety.

CONCLUSIONS

MBI appears to have benefits on HbA1c, depression, stress and diabetes-related distress in people with diabetes. More rigorous studies with longer follow-up duration are warranted to establish the full potential of MBI.

Quality of Life and its Determinants in Patients with Diabetes Mellitus from Two Health Institutions of Sub-himalayan Region of India

BACKGROUND

Diabetes mellitus (DM) causes serious deterioration in general quality of life (QoL) mainly affecting the health-related quality of life (HRQOL). Routine assessment of QoL improves communication with the patient, helps to predict treatment response, and supports clinical decision-making. QoL can predict an individual's capacity to manage the disease and maintain long-term health and wellbeing.

AIMS

To find out the QoL and its socio-demographic, anthropometric, and clinical determinants among DM patients attending health institutions from sub-Himalayan region, catering rural population.

SETTINGS AND DESIGN

This cross-sectional study was conducted in two hospitals mostly catering rural population from 2014 to 2018. Purposive sampling technique was used.

MATERIALS AND METHODS

Socio-demographic, anthropometric, and clinical data of DM patients (N = 300) were collected. They were administeredHindi translation of QoL Instrument for Indian Diabetes Patients (QOLID) and Patient Health Questionnaire-9 (PHQ-9). All statistical analyses were carried out using Statistical Package for Social Sciences (SSPS) (Version 17.0, USA).

RESULTS

About 10% had very poor, 13% poor, 11% average, 16% good, and 50% very good QoL on QOLID. General health (GH) and treatment satisfaction (TS) were the most affected domains. Fatigue was the most common symptom (79%) reported in QOLID. Age more than 55 years, rural background, and PHQ-9 score of more than 7 were predictors of poorer QoL.

CONCLUSION

There is a need for a holistic and collaborative care of DM patients, to maintain a good HRQoL. Screening of depression, fatigue, and regular assessment of QoL should be emphasized.

Social support, depression, anxiety, and quality of life among persons living with type 2 diabetes: a path analysis

Co-morbid mental health problems among persons living with type 2 diabetes have a significant influence on diabetic persons’ self-care and, ultimately, quality of life. However, the mechanisms linking the co-morbid mental health problems of type 2 diabetes patients to the decreased quality of life are not fully understood. This study examined the direct and indirect influences of co-morbid depression and anxiety on the quality of life of 115 persons living with type 2 diabetes, using a cross-sectional survey design. Frequencies and percentages were used to summarize the data, and the Pearson correlation was used to determine the bivariate association between the study variables. PROCESS Macro in SPSS was used for mediation analyses. The findings show that depression and anxiety had significant negative correlations with the quality of life of persons living with type 2 diabetes. However, only depression had a significant negative correlation with social support. On the contrary, social support significantly and positively correlated with quality of life. The mediation analysis shows that social support partially mediated the relationship between depression and quality of life after adjusting for the sex of the participants. However, social support did not have a significant mediation effect on the link between anxiety and quality of life after adjusting for the sex of the participants. The availability of social support, especially peer support, could buffer the negative emotional experiences associated with living with type 2 diabetes and improve the quality of life for persons living with this health condition.

Assessment of Psychological Distress in Adults With Type 2 Diabetes Mellitus Through Technologies: Literature Review

Background

The use of technological devices can support the self-management of individuals with type 2 diabetes mellitus (T2DM), particularly in addressing psychological distress. However, there is poor consistency in the literature regarding the use of psychological instruments for the web-based screening of patients’ psychological distress and subsequent monitoring of their psychological condition during digital interventions.

Objective

This study aims to review previous literature on the types of psychological instruments delivered in digital interventions for assessing depression, anxiety, and stress in patients with T2DM.

Methods

The literature review was conducted using the PsycINFO, CINAHL and PubMed databases, in which the following terms were considered: diabetes mellitus, measure, assessment, self-care, self-management, depression, anxiety, stress, technology, eHealth, mobile health, mobile phone, device, and smartphone.

Results

In most studies, psychological assessments were administered on paper. A few studies deployed self-reporting techniques employing automated telephonic assessment, a call system for screening and monitoring patients’ conditions and preferences, or through telephone interviews via interactive voice response calls, a self-management support program leveraging tailored messages and structured emails. Other studies used simple telephone interviews and included the use of apps for tablets and smartphones to assess the psychological well-being of patients. Finally, some studies deployed mood rating scales delivered through tailored text message–based support systems.

Conclusions

The deployment of appropriate psychological tools in digital interventions allows researchers and clinicians to make the screening of anxiety, stress, and depression symptoms faster and easier in patients with T2DM. Data from this literature review suggest that mobile health solutions may be preferred tools to use in such digital interventions.

Association between mental health comorbidity and health outcomes in type 2 diabetes mellitus patients

Type 2 diabetes mellitus (T2D) is often accompanied by chronic diseases, including mental health problems. We aimed at studying mental health comorbidity prevalence in T2D patients and its association with T2D outcomes through a retrospective, observational study of individuals of the EpiChron Cohort (Aragón, Spain) with prevalent T2D in 2011 (n = 63,365). Participants were categorized as having or not mental health comorbidity (i.e., depression, anxiety, schizophrenia, and/or substance use disorder). We performed logistic regression models, controlled for age, sex and comorbidities, to analyse the likelihood of 4-year mortality, 1-year all-cause hospitalization, T2D-hospitalization, and emergency room visit. Mental health comorbidity was observed in 19% of patients. Depression was the most frequent condition, especially in women (20.7% vs. 7.57%). Mortality risk was higher in patients with mental health comorbidity (odds ratio 1.24; 95% confidence interval 1.16-1.31), especially in those with substance use disorder (2.18; 1.84-2.57) and schizophrenia (1.82; 1.50-2.21). Mental health comorbidity also increased the likelihood of all-cause hospitalization (1.16; 1.10-1.23), T2D-hospitalization (1.51; 1.18-1.93) and emergency room visit (1.26; 1.21-1.32). These results suggest that T2D healthcare management should include specific strategies for the early detection and treatment of mental health problems to reduce its impact on health outcomes.

Design and methods of NYC care calls: An effectiveness trial of telephone-delivered type 2 diabetes self-management support

Although problems with type 2 diabetes (T2D) self-management and treatment adherence often co-occur with emotional distress, few translatable intervention approaches are available that can target these related problems in primary care practice settings. The New York City (NYC) Care Calls study is a randomized controlled trial that tests the effectiveness of structured support for diabetes self-management and distress management, delivered via telephone by health educators, in improving glycemic control, self-management and emotional well-being among predominantly ethnic minority and socioeconomically disadvantaged adults with suboptimally controlled T2D. English- and Spanish-speaking adults treated for T2D in NYC primary care practices were recruited based on having an A1C ≥ 7.5% despite being prescribed medications for diabetes. Participants (N = 812) were randomly assigned to a telephonic intervention condition with a stepped protocol of 6-12 phone calls over 1 year, delivered by a health educator, or to a comparison condition of enhanced usual care. The primary outcome is change in A1C over one year, measured at baseline and again approximately 6- and 12-months later. Secondary outcomes measured on the same schedule include blood pressure, patient-reported emotional distress, treatment adherence and self-management behaviors. A comprehensive effectiveness evaluation is guided by the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to gather data that can inform dissemination and implementation of the intervention, if successful. This paper describes the study rationale, trial design, and methodology.

Health-related quality of life and health utilities in insulin-treated type 2 diabetes: the impact of related comorbidities/complications

OBJECTIVE

To evaluate the impact of multiple comorbidities/complications on health-related quality of life (HRQoL) and health utilities in insulin-treated type 2 diabetes (T2DM).

METHODS

In a non-interventional, epidemiological study, data were collected from medical records and via interviews for 938 subjects from various geographical areas of Greece. HRQoL and health utilities were explored with the EQ-5D-5L. Univariate associations were evaluated with the Mann-Whitney and Kruskal-Wallis tests for continuous and Chi-squared tests for nominal variables, and binary logistic regressions were employed to obtain marginal effects. Employing a split sample approach, various specifications of ordinary least squares regression models were evaluated in terms of goodness of fit, model specification, shrinkage and predictive and discriminative performance, to select the best model for mapping health utilities using the whole dataset.

RESULTS

Overall, the most important factors of impaired HRQoL and health utilities were higher age, female gender, obesity, poor glycemic control and increased duration of insulin treatment. History and increasing concurrence of all complications assessed were associated with exacerbated HRQoL problems, decreased health utilities and diminished health state, although it was not always statistically significant. The highest disutilities were associated with stroke (- 0.082), diabetic retinopathy (- 0.066), diabetic neuropathy (- 0.051) and severe hypoglycemia (- 0.050).

CONCLUSIONS

The deleterious impact of comorbidities on insulin-dependent T2DM subjects' HRQoL has been confirmed and clinicians should adapt the priorities of disease management accordingly. The derived health utility estimates may be valuable for conducting economic evaluations of interventions in the area of T2DM when data are not available.

Anxiety and depression in diabetes care: longitudinal associations with health-related quality of life

Anxiety and depression are commonly found in patients with diabetes, but little is known about how the anxiety and depression symptoms of diabetes patients and the health-related quality of life (HRQoL) over time influence each other. Therefore, we conducted a survey among patients with diabetes (T1) and repeated the survey after 3 months (T2). Linear regression models and cross-lagged structural equation models were used to analyze the associations between anxiety and depression symptoms and HRQoL within and across time intervals. Correcting for baseline index and potential confounders, the HRQoL index at T2 reflected the change in anxiety/depression between T1 and T2 more than anxiety/depression at T1 (P < 0.05). Similarly, anxiety and depression at T2 reflected the change in the EQ-5D index over time more than the index at baseline (P < 0.05). Our longitudinal data fitted well in a cross-lagged model with bi-directional pathways of associations between anxiety and HRQoL, as well as depression and HRQoL, among adult patients with diabetes (x²/df = 1.102, P = 0.256; CFI = 1.000, RMSEA = 0.030). Our findings support early detection of anxiety and depression, as well as comprehensive efforts improving HRQoL for patients with diabetes.

Depression and diabetes: An experience from Kashmir

BACKGROUND

Diabetes mellitus is a common chronic metabolic disorder characterized by hyperglycemia. Minimal attention has been paid toward the relationship between diabetes and depression in developing countries such as India, despite a number of studies in developed countries, exploring casual pathway between the two highly prevalent conditions. The aim of this study was to estimate the prevalence and severity of depression among patients of diabetes attending the endocrinology department of a tertiary care hospital of Kashmir.

METHODOLOGY

A total of 527 patients having diabetes of ≥6 months with age ranging from 18 years to 60 years were screened for major depressive disorder (MDD) using Diagnostic and Statistical Manual IV-based criteria. Severity of depression was assessed by the Montgomery-Asberg Depression Rating Scale.

RESULTS

Depression was present in 39.65% of patients. Depression was more prevalent in the age group of 29-38 years, in females as compared to males, among literates and government employees. Prevalence of depression among Type 1 diabetic patients was 60%, while as in case of Type 2, it was 37.75%. Depressed patients had higher fasting blood glucose levels as compared to nondepressed diabetic patients.

CONCLUSION

MDD is inordinately high among adult diabetic patients, and majority of the depressive patients have moderate intensity of MDD.

Relationship between Illness Perception and Depressive Symptoms among Type 2 Diabetes Mellitus Patients in China: A Mediating Role of Coping Style

OBJECTIVE

The aims of the present study were to investigate the prevalence of depressive symptoms among type 2 diabetes mellitus (T2DM) patients in China and to explore how coping style influences the relationship between illness perception and depressive symptoms.

METHODS

Nine hundred and thirty-nine T2DM patients were recruited from a grade 3 Class A hospital in Harbin, China, and asked to complete a demographic questionnaire as well as the Self-rating Depression Scale (SDS), Brief Illness Perception Questionnaire-Revised (IPQ-R), and Medical Coping Modes Questionnaire (MCMQ). Hierarchical linear regression analysis and the bootstrap method were preformed to examine if coping style influenced the relationship between illness perception and depression.

RESULTS

The majority of patients (73.59%) exhibited depressive symptoms, including 37.27% with moderate and 6.71% with severe depressive symptoms. Depressive symptoms were more frequent in patients with complications (P < 0.05). A resignation coping style partially mediated the influence of illness perception on depressive symptoms.

CONCLUSIONS

Interventions to improve coping style may reduce the prevalence or severity of depressive symptoms among T2DM patients, potentially enhancing treatment adherence and clinical outcome.

Psychosocial health care needs of people with type 2 diabetes in primary care: Views of patients and health care providers

Aims

This study examined (a) psychosocial health care needs of people with type 2 diabetes from the perspective of patients and diabetes healthcare providers in primary care, in terms of topics, attention in diabetes care and preferences and (b) factors associated with a positive attitude towards specialized psychosocial health care.

Design

Qualitative focus group study.

Methods

Using purposive sampling, participants were selected from general practices. In 2012–2013, three focus groups were conducted in people with type 2 diabetes (N = 20) and three with healthcare providers (N = 18).

Results

Opinions differed considerably on whether there was a need for psychosocial health care. Topics focused mainly on diabetes‐specific issues ranging from a need for additional diabetes education to attention and support in regular diabetes care. However, not all healthcare providers felt competent enough to address psychosocial problems. Some participants reported a need for specialized psychosocial help. A positive attitude towards specialized psychosocial health care appeared to be influenced by care setting (e.g., in the primary care practice or ‘outside’ mental health care), care accessibility, proactive discussion of psychosocial issues with and referral by healthcare providers and previous experiences with psychosocial health care.

Conclusion

Although only few participants expressed a need for specialized psychosocial care, attention for psychosocial well‐being in regular diabetes care was generally appreciated.

Impact

People with type 2 diabetes generally felt psychosocial care could be provided as part of regular diabetes care. Suggestions for healthcare providers to meet psychosocial health care needs include training and discussion tools.

Self-rated health and the risk of incident type 2 diabetes mellitus: A cohort study

We aimed to evaluate the association between self-rated health (SRH) and the risk of incident type 2 diabetes mellitus (T2D). This cohort study consisted of 250,805 Korean men and women without T2D at baseline. SRH was assessed at baseline with a self-administered structured questionnaire. Incident T2D was defined as fasting serum glucose ≥126 mg/dL, HbA1C ≥6.5%, or use of medication for T2D during follow-up. After adjustment for possible confounders including age, center, year of screening exam, smoking status, alcohol intake, physical activity, education level, total calorie intake, body mass index, sleep duration, depressive symptoms, family history of diabetes, history of hypertension, and history of cardiovascular disease, the multivariable-adjusted hazard ratios (95% confidence intervals) for incident T2D comparing good, fair, and poor or very poor SRH to very good SRH were 1.20 (0.98-1.48), 1.63 (1.33-1.98), and 1.83 (1.47-2.27), respectively. These associations were consistently observed in clinically relevant subgroups. Fair or poorer SRH was independently and positively associated with the development of T2D in a large-scale cohort study of apparently healthy Korean adults, indicating that SRH is a predictor of metabolic health. Physicians involved in diabetes screening and management should routinely consider SRH when evaluating T2D risk as well as overall health.

Patients' and practice nurses' perceptions of depression in patients with type 2 diabetes and/or coronary heart disease screened for subthreshold depression

BACKGROUND

Comorbid depression is common in patients with type 2 diabetes (DM2) and/or coronary heart disease (CHD) and is associated with poor quality of life and adverse health outcomes. However, little is known about patients' and practice nurses' (PNs) perceptions of depression. Tailoring care to these perceptions may affect depression detection and patient engagement with treatment and prevention programs. This study aimed to explore patients' and PNs' perceptions of depression in patients with DM2/CHD screened for subthreshold depression.

METHODS

A qualitative study was conducted as part of a Dutch stepped-care prevention project. Using a purposive sampling strategy, data were collected through semi-structured interviews with 15 patients and 9 PNs. After consent, all interviews were recorded, transcribed verbatim and analyzed independently by two researchers with Atlas.ti.5.7.1 software. The patient and PN datasets were inspected for commonalities using a constant comparative method, from which a final thematic framework was generated.

RESULTS

Main themes were: illness perception, need for care and causes of depression. Patients generally considered themselves at least mildly depressed, but perceived severity levels were not always congruent with Patient Health Questionnaire 9 scores at inclusion. Initially recognizing or naming their mental state as a (subthreshold) depression was difficult for some. Having trouble sleeping was frequently experienced as the most burdensome symptom. Most experienced a need for care; psycho-educational advice and talking therapy were preferred. Perceived symptom severity corresponded with perceived need for care, but did not necessarily match help-seeking behaviour. Main named barriers to help-seeking were experienced stigma and lack of awareness of depression and mental health care possibilities. PNs frequently perceived patients as not depressed and with minimal need for specific care except for attention. Participants pointed to a mix of causes of depression, most related to negative life events and circumstances and perceived indirect links with DM2/CHD.

CONCLUSION

Data of the interviewed patients and PNs suggest that they have different perceptions about (subthreshold) depressive illness and the need for care, although views on its causes seem to overlap more.

Two-year effectiveness of a stepped-care depression prevention intervention and predictors of incident depression in primary care patients with diabetes type 2 and/or coronary heart disease and subthreshold depression: data from the Step-Dep cluster randomised controlled trial

INTRODUCTION

Major depressive disorders (MDD), diabetes mellitus type 2 (DM2) and coronary heart disease (CHD) are leading contributors to the global burden of disease and often co-occur.

OBJECTIVES

To evaluate the 2-year effectiveness of a stepped-care intervention to prevent MDD compared with usual care and to develop a prediction model for incident depression in patients with DM2 and/or CHD with subthreshold depression.

METHODS

Data of 236 Dutch primary care patients with DM2/CHD with subthreshold depression (Patient Health Questionnaire 9 (PHQ-9) score ≥6, no current MDD according to the Mini International Neuropsychiatric Interview (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria)) who participated in the Step-Dep trial were used. A PHQ-9 score of ≥10 at minimally one measurement during follow-up (at 3, 6, 9, 12 and 24 months) was used to determine the cumulative incidence of MDD. Potential demographic and psychological predictors were measured at baseline via web-based self-reported questionnaires and evaluated using a multivariable logistic regression model. Model performance was assessed with the Hosmer-Lemeshow test, Nagelkerke's R² explained variance and area under the receiver operating characteristic curve (AUC). Bootstrapping techniques were used to internally validate our model.

RESULTS

192 patients (81%) were available at 2-year follow-up. The cumulative incidence of MDD was 97/192 (51%). There was no statistically significant overall treatment effect over 24 months of the intervention (OR 1.37; 95% CI 0.52 to 3.55). Baseline levels of anxiety, depression, the presence of >3 chronic diseases and stressful life events predicted the incidence of MDD (AUC 0.80, IQR 0.79-0.80; Nagelkerke's R² 0.34, IQR 0.33-0.36).

CONCLUSION

A model with 4 factors predicted depression incidence during 2-year follow-up in patients with DM2/CHD accurately, based on the AUC. The Step-Dep intervention did not influence the incidence of MDD. Future depression prevention programmes should target patients with these 4 predictors present, and aim to reduce both anxiety and depressive symptoms.

TRIAL REGISTRATION NUMBER

NTR3715.

Examining the risk of depression or self-harm associated with incretin-based therapies used to manage hyperglycaemia in patients with type 2 diabetes: a cohort study using the UK Clinical Practice Research Datalink

OBJECTIVES

To compare population-based incidence rates of new-onset depression or self-harm in patients initiating incretin-based therapies with that of sulfonylureas (SU) and other glucose-lowering agents.

DESIGN

Population-based cohort study.

SETTING

Patients attending primary care practices registered with the UK-based Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Using the UK-based CPRD, we identified two incretin-based therapies cohorts: (1) dipeptidyl peptidase-4 inhibitor (DPP-4i)-cohort, consisting of new users of DPP-4i and SU and (2) glucagon-like peptide-1 receptor agonists (GLP-1RA)-cohort, consisting of new users of GLP-1RA and SU, between January 2007 and January 2016. Patients with a prior history of depression, self-harm and other serious psychiatric conditions were excluded.

MAIN OUTCOME MEASURES

The primary study outcome comprised a composite of new-onset depression or self-harm. Unadjusted and adjusted Cox proportional hazards regression was used to quantify the association between incretin-based therapies and depression or self-harm. Deciles of High-Dimensional Propensity Scores and concurrent number of glucose-lowering agents were used to adjust for potential confounding.

RESULTS

We identified new users of 6206 DPP-4i and 22 128 SU in the DPP-4i-cohort, and 501 GLP-1RA and 16 409 SU new users in the GLP-1RA-cohort. The incidence of depression or self-harm was 8.2 vs 11.7 events/1000 person-years in the DPP-4i-cohort and 18.2 vs 13.6 events/1000 person-years in the GLP-1RA-cohort for incretin-based therapies versus SU, respectively. Incretin-based therapies were not associated with an increased or decreased incidence of depression or self-harm compared with SU (DPP-4i-cohort: unadjusted HR 0.70, 95% CI 0.51 to 0.96; adjusted HR 0.80, 95% CI 0.57 to 1.13; GLP-1RA-cohort: unadjusted HR 1.36, 95% CI 0.72 to 2.58; adjusted HR 1.25, 95% CI 0.63 to 2.50). Consistent results were observed for other glucose-lowering comparators including insulin and thiazolidinediones.

CONCLUSIONS

Our findings suggest that the two incretin-based therapies are not associated with an increased or decreased risk of depression or self-harm.

Depression Screening Rates and Symptom Severity by Alcohol Use Among Primary Care Adult Patients

BACKGROUND

Hazardous alcohol use with depression may exacerbate health conditions and complicate medical care. We examined the rate of depression screening by alcohol use severity among primary care patients screened for hazardous alcohol use and, among those screened, examined patterns of significant depressive symptoms.

METHODS

Using cross-sectional data from primary care patients (n = 2,894,906), we examined past-90-day alcohol use (number of typical drinking days/week and typical number of drinks consumed daily); depression screening rates (using the Patient Health Questionnaire 9 [PHQ-9]); and symptom severity, demographics, and prevalence of selected psychiatric diagnoses.

RESULTS

Within 30 days of routine, in-clinic alcohol use screening by medical assistants, 2.4% (n = 68,686) of patients also completed a PHQ-9; these patients were more likely to be female, younger, white, Medicaid insured, and to have a nondepressive psychiatric diagnosis and a lower Charlson comorbidity score. Abstainers and moderate drinkers (1 to 7 drinks/week or 1 to 4 drinks/week for women and individuals >65 years or for men ≤65 years, respectively) were less likely than hazardous drinkers (exceeding weekly limits) to complete the PHQ-9 or to have significant depressive symptoms (PHQ-9 score ≥10). Nonwhite patients with higher Charlson comorbidity scores were more likely to endorse significant depressive symptoms.

CONCLUSIONS

Only a small fraction of patients in this cohort were screened for depression. Nonwhite patients and those with higher comorbidity burden were more likely to report depression but less likely to be screened. These discrepancies between depression-screening rates and significant depressive symptoms suggest that screening for depression should be enhanced in these at-risk groups.

General health status in Iranian diabetic patients assessed by short-form-36 questionnaire: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus is one of the most prevalent diseases worldwide. Diabetes is a chronic disease associated with micro- and macro-vascular complications and deterioration in general health status. Therefore, the aim of this study was to estimate general health status among Iranian diabetic patients through a systematic review and meta-analysis of study utilizing the Short-Form-36 questionnaire.

METHODS

Searching the EMBASE, PubMed, ISI/Web of Sciences (WOS), MEDLINE via Ovid, PsycoINFO, as well as Iranian databases (MagIran, Iranmedex, and SID) from January 2000 to December 2017. The methodological quality of the studies was evaluated using the "A Cochrane Risk of Bias Assessment Tool: for Non-Randomized Studies of Interventions" (ACROBAT-NRSI). Random-effect model was used and the means were reported with their 95% confidence interval (CI). To evaluate the heterogeneity between studies, I² test was used. Egger's regression test was used to assess the publication bias.

RESULTS

Fourteen studies were retained in the final analysis. The mean general health status using SF-36 in diabetic patients of Iran was 51.9 (95% CI: 48.64 to 53.54). The mean physical component summary was 52.92 [95% CI: 49.46-56.38], while the mean mental component summary was 51.02 [95% CI: 46.87-55.16].

CONCLUSION

The findings of this study showed that general health status in Iranian diabetic patients is low. Health policymakers should work to improve the health status in these patients and take appropriate interventions.

Clinical and Sociodemographic Predictors of the Quality of Life among Patients with Type 2 Diabetes Mellitus on the East Coast of Peninsular Malaysia

BACKGROUND

The quality of life (QoL) describes the multidimensional self-perceived well-being of a person, which is an important diabetes outcome. This study aimed to measure the QoL scores among patients with type 2 diabetes mellitus (T2DM), as well as their clinical and sociodemographic predictors.

METHODS

This cross-sectional study involved 180 randomly sampled patients at a primary care clinic on the East Coast of Peninsular Malaysia. A self-administered questionnaire containing the Audit of Diabetes Dependent Quality of Life-18 (ADDQoL-18) was used.

RESULTS

Most of the respondents (96.7%) were Malay, with a median (interquartile range, IQR) age of 54.0 (14.0) years old. The majority of them were females (60.0%), married (81.1%) and from low-income families (63.3%), who attained a secondary education or lower (75.6%). Only 49.4% of them were employed. The mean (standard deviation, SD) ADDQoL-18 average weighted impact score was -4.58 (2.21) and all 18 domains were negatively affected, particularly the living condition, family life and working life. The multiple linear regression analysis showed that the age (adjusted B = 0.05, P = 0.004) and insulin use (adjusted B = -0.84, P = 0.011) were QoL predictors.

CONCLUSION

T2DM negatively impacts the patient's QoL in all aspects of their life. The QoL improvement with age suggests that the older patients had accepted and adapted to their illness. The need to improve the QoL among insulin users was also highlighted.

HRQOL in Diverse Ethnic Groups with Diabetes: Findings from the 2014 BRFSS

OBJECTIVE

The study's objective is to examine differences in mental and physical health-related quality of life (HRQOL) in non-Hispanic White, non-Hispanic Black, and Hispanic adults with diabetes.

DESIGN

A secondary analysis of 2014 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted. A total of 26 states participated in the 2014 BRFSS core and optional diabetes models (n = 17,923). HRQOL was measured by the number of mentally and physically unhealthy days during the past month, respectively. A series of regression models were developed to assess differences in HRQOL without and with inclusion of demographic (age, marital status, income, gender, and education) and diabetes-related (depression, sleep time, insulin use, complications, age of diabetes diagnosis, BMI, smoking, and exercise) factors.

RESULTS

In the fully adjusted models (inclusion of demographic and diabetes-related factors), non-Hispanic Whites had more mentally (β = 0.88, p = 0.03) and physically (β = 1.35, p = 0.01) unhealthy days per month compared to Hispanics. Non-Hispanic Blacks (β = 1.42, p < 0.01) also had more mentally unhealthy days per month in relation to Hispanics when adjusting for demographic and diabetes-related factors. Depression emerged as a potent predictor of mentally (β = 8.60; p < 0.0001) and physically (β = 4.43; p < 0.0001) unhealthy days in the multivariate models.

CONCLUSION

Non-Hispanic Black and White adults with diabetes may be more vulnerable to poor HRQOL compared to their Hispanic counterparts. Increased, widened application of diabetes interventions targeting depression appears warranted to improve HRQOL outcomes.

Measurement properties of depression questionnaires in patients with diabetes: a systematic review

Purpose

To conduct a systematic review on measurement properties of questionnaires measuring depressive symptoms in adult patients with type 1 or type 2 diabetes.

Methods

A systematic review of the literature in MEDLINE, EMbase and PsycINFO was performed. Full text, original articles, published in any language up to October 2016 were included. Eligibility for inclusion was independently assessed by three reviewers who worked in pairs. Methodological quality of the studies was evaluated by two independent reviewers using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Quality of the questionnaires was rated per measurement property, based on the number and quality of the included studies and the reported results.

Results

Of 6286 unique hits, 21 studies met our criteria evaluating nine different questionnaires in multiple settings and languages. The methodological quality of the included studies was variable for the different measurement properties: 9/15 studies scored ‘good’ or ‘excellent’ on internal consistency, 2/5 on reliability, 0/1 on content validity, 10/10 on structural validity, 8/11 on hypothesis testing, 1/5 on cross-cultural validity, and 4/9 on criterion validity. For the CES-D, there was strong evidence for good internal consistency, structural validity, and construct validity; moderate evidence for good criterion validity; and limited evidence for good cross-cultural validity. The PHQ-9 and WHO-5 also performed well on several measurement properties. However, the evidence for structural validity of the PHQ-9 was inconclusive. The WHO-5 was less extensively researched and originally not developed to measure depression.

Conclusion

Currently, the CES-D is best supported for measuring depressive symptoms in diabetes patients.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1782-y) contains supplementary material, which is available to authorized users.

Association between reduced quality of life and depression in patients with type 2 diabetes mellitus: a cohort study in a Mexican population

BACKGROUND

Diabetes mellitus is a chronic disease that requires attention and commitment on the part of patients; improving the quality of life of these patients reduces health costs, morbidity, and mortality. We focused on investigating the factors related with the quality of life and depression symptomatology in patients with type 2 diabetes.

PARTICIPANTS AND METHODS

A total of 173 Mexican patients with type 2 diabetes were recruited. An interview face-to-face, a sociodemographic characteristics questionnaire, the Short Form 36 (SF-36), and the Clinical Epidemiological Studies of Depression were applied. The biochemical parameters measured were blood glucose, cholesterol, triacylglycerol levels, and glycated hemoglobin.

RESULTS

In all SF-36 subscales, female patients had lower scores in comparison with male patients; individuals ≥65 years of age showed less physical function. We observed that married patients presented a better quality of life than people who were widowed or divorced (P<0.05). Those with high rates of lipids showed decreased scores all the subscales of SF-36. Finally, we observed that depression was the major factor that decreased quality of life in patients with diabetes.

CONCLUSION

Our results suggest that untreated and unrecognized depression can decrease the quality of life in patients with diabetes mellitus type 2. Therefore, health care professionals need to consider these findings when treating patients with diabetes. Due to the limited number of patients included in the present study, more studies are needed, studying larger samples in order to provide conclusive results.

Effect of psychotherapy for depression via home telehealth on glycemic control in adults with type 2 diabetes: Subgroup analysis of a randomized clinical trial

Objective We evaluated the impact of telemedicine-delivered behaviour activation treatment (BAT) on glycemic control in a subgroup of older adults with diabetes who participated in a randomized controlled trial for depression. Research design and methods We randomized older adults with major depression to same-room or telemedicine BAT. Each group received eight weekly sessions. For the subgroup analysis, we identified individuals with type 2 diabetes and obtained hemoglobin A1c at baseline and 12 months' follow-up. We used mixed-effects models (MEM) for repeated measures analysis to compare the longitudinal mean A1c. We estimated model-derived mean A1c values and considered an adjusted model to account for baseline health status. Results We included 90 individuals with type 2 diabetes of the original 241 in the subgroup analysis (43 in telemedicine and 47 in same room). Treatment groups were not significantly different at baseline for demographics, depression, anxiety or A1c levels (telemedicine 6.9 vs. same room 7.3, p = 0.19). Baseline mean A1c for the telemedicine group remained at 6.9 (55 mmol/mol) at 12 months, whereas baseline mean A1c for the same-room group increased to 7.7 (61 mmol/mol). Longitudinal trajectories of model-derived mean A1c indicated a significant main effect of treatment group on mean A1c value at study end (difference = -0.82, 95% CI -1.41, -0.24). Adjusted analyses gave comparable results. Conclusions Telemedicine-delivered BAT was superior to same room in achieving lower mean A1c values in participants with type 2 diabetes, suggesting BAT-delivered via telemedicine is a viable treatment option for adults with diabetes.

Views of Patients on Using mHealth to Monitor and Prevent Diabetic Foot Ulcers: Qualitative Study

Background

People with diabetes are at risk for diabetic foot ulcers (DFUs), which can lead to limb loss and a significant decrease in quality of life. Evidence suggests that mHealth can be an effective tool in diabetes self-management. mHealth presents an opportunity for the prevention and monitoring of DFUs. However, there is a paucity of research that explores its effectiveness in the DFU patient population, as well as the views and attitudes of these patients toward technology and mHealth.

Objective

This study aimed to explore the views, attitudes, and experiences of a diabetic patient population with or at risk of DFUs regarding technology, mHealth, and the diabetic foot.

Methods

We used a qualitative research approach using in-depth interviews with 8 patients with DFUs. Questions were structured around experience with technology, current health practices related to diabetic foot care, and thoughts on using an mHealth device that prevents and monitors DFUs. We transcribed and thematically analyzed all interviews.

Results

All patients had positive responses for an mHealth intervention aimed at preventing and monitoring DFUs. We found 4 themes in the data: diversity in use of technology, feet-checking habits, 2-way communication with health care professionals (HCPs), and functionality. There were varying levels of familiarity with and dependence on technology within this patient population. These relationships correlated with distinct generations found in North America, including baby boomers and Generation X. Furthermore, we found that most patients performed daily feet checks to monitor any changes in health. However, some did not perform feet checks prior to the development of a DFU. Patients expressed interest in 2-way communication with HCPs that would allow for easier appointment scheduling, sharing of medical data, decreased number of visits, and use of alerts for when medical attention is required. Patients also identified conditions of functionality for the mHealth intervention. These included consideration of debilitating complications because of diabetes, such as retinopathy and decreased mobility; ease of use of the intervention; and implementation of virtual communities to support continued use of the intervention.

Conclusions

Our patient population expressed an interest in mHealth for preventing and monitoring DFUs, although some participants were not frequent users of technology. mHealth continues to show potential in improving patient outcomes, and this study provides a foundation for designing interventions specific to a DFU population. Further research is needed to confirm these findings.

Type 2 diabetes mellitus and psychological stress - a modifiable risk factor

Psychological stress is common in many physical illnesses and is increasingly recognized as a risk factor for disease onset and progression. An emerging body of literature suggests that stress has a role in the aetiology of type 2 diabetes mellitus (T2DM) both as a predictor of new onset T2DM and as a prognostic factor in people with existing T2DM. Here, we review the evidence linking T2DM and psychological stress. We highlight the physiological responses to stress that are probably related to T2DM, drawing on evidence from animal work, large epidemiological studies and human laboratory trials. We discuss population and clinical studies linking psychological and social stress factors with T2DM, and give an overview of intervention studies that have attempted to modify psychological or social factors to improve outcomes in people with T2DM.

Effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: A pragmatic cluster randomized controlled trial

Purpose

Given the public health significance of poorly treatable co-morbid major depressive disorders (MDD) among patients with type 2 diabetes mellitus (DM2) and coronary heart disease (CHD), we need to investigate whether strategies to prevent the development of major depression could reduce its burden of disease. We therefore evaluated the effectiveness of a stepped-care program for subthreshold depression in comparison with usual care in patients with DM2 and/or CHD.

Methods

A cluster randomized controlled trial, with 27 primary care centers serving as clusters. A total of 236 DM2 and/or CHD patients with subthreshold depression (nine item Patient Health Questionnaire (PHQ-9) score ≥ 6, no current MDD according to DSM-IV criteria) were allocated to the intervention group (N = 96) or usual care group (n = 140). The stepped-care program was delivered by trained practice nurses during one year and consisted of four sequential treatment steps: watchful waiting, guided self-help, problem solving treatment and referral to the general practitioner. The primary outcome was the 12-month cumulative incidence of MDD as measured with the Mini International Neuropsychiatric Interview (MINI). Secondary outcomes included severity of depression (measured by PHQ-9) at 3, 6, 9 and 12 months.

Results

Of 236 patients (mean age, 67,5 (SD 10) years; 54.7% men), 210 (89%) completed the MINI at 12 months. The cumulative incidence of MDD was 9 of 89 (10.1%) participants in the intervention group and 12 of 121 (9.9%) participants in the usual care group. We found no statistically significant overall effect of the intervention (OR = 1.21; 95% confidence interval (0.12 to 12.41)) and there were no statistically significant differences in the course or severity of depressive symptoms between the two groups.

Conclusions

This study suggest that Step-Dep was not more effective in preventing MDD than usual care in a primary care population with DM2 and/or CHD and subthreshold depression.

Depressive states among adults with diabetes: Findings from the National Health and Nutrition Examination Survey, 2007-2012

AIMS

To determine (1) the prevalence of SubD states among adults with diabetes, and (2) whether evidence exists of an independent association between diabetes status and SubD, controlling for selected confounders.

METHODS

Data from the 2007-2012 National Health and Nutrition Examination Surveys were combined to estimates of depressive states by diabetes status among the noninstitutionalized U.S. adult population, and to assess the association of diabetes status and depressive states using a polytomous logistic regression model.

RESULTS

An estimated 17%, or 3.7 million, of U.S. adults with diabetes (diagnosed and undiagnosed) met criteria for either mD or ssD. The majority of SubD cases with diabetes were found to be ssD (10.1%) compared with mD (6.9%). After controlling for the effects of age, sex, race and ethnicity, education, body mass index, and poverty as covariates, an independent association persists between diagnosed diabetes and each SubD grouping (ssD: OR=1.82, CIs 1.33, 2.47; mD: OR=1.95, CIs 1.39, 2.74) compared with respondents having no diabetes. No association was found between depression and undiagnosed diabetes or prediabetes compared with those having no diabetes.

CONCLUSION

Milder forms of depression such as ssD and mD are more extant than major depressive episodes among adults with diabetes. The odds that an adult with diagnosed diabetes meets the criteria for ssD or mD are higher by 80% and 95%, respectively, after controlling for age, sex, race and ethnicity, education, body mass index, and poverty factors when compared against adults with no diabetes.

Health-Related Quality of Life in Primary Care: Which Aspects Matter in Multimorbid Patients with Type 2 Diabetes Mellitus in a Community Setting?

BACKGROUND AND OBJECTIVE

Knowledge about predictors of health-related quality of life for multimorbid patients with type 2 diabetes mellitus in primary care could help to improve quality and patient-centeredness of care in this specific group of patients. Thus, the aim of this study was to investigate the impact of several patient characteristics on health-related quality of life of multimorbid patients with type 2 diabetes mellitus in a community setting.

RESEARCH DESIGN AND METHODS

A cross-sectional study with 32 primary care practice teams in Mannheim, Germany, and randomly selected multimorbid patients with type 2 diabetes mellitus (N = 495) was conducted. In order to analyze associations of various patient characteristics with health-related quality of life (EQ-5D index) a multilevel analysis was applied.

RESULTS

After excluding patients with missing data, the cohort consisted of 404 eligible patients. The final multilevel model highlighted six out of 14 explanatory patient variables which were significantly associated with health-related quality of life: female gender (r = -0.0494; p = .0261), school education of nine years or less (r = -0.0609; p = .0006), (physical) mobility restrictions (r = -0.1074; p = .0003), presence of chronic pain (r = -0.0916; p = .0004), diabetes-related distress (r = -0.0133; p < .0001), and BMI (r = -0.0047; p = .0045).

CONCLUSION

The findings of this study suggest that increased diabetes-related distress, chronic pain, restrictions in (physical) mobility, female gender, as well as lower education and, increased BMI have a noteworthy impact on health-related quality of life in multimorbid patients with type 2 diabetes mellitus seen in primary care practices in a community setting. The highlighted aspects should gain much more attention when treating multimorbid patients with type 2 diabetes mellitus.

Psychosocial stress in South African patients with type 2 diabetes

Objective: Diabetes mellitus is considered an emotionally and behaviourally demanding condition which adds to the stress of a patient’s daily living. There is a paucity of literature in South Africa regarding stress and diabetes. This study therefore aims to identify the areas and contributory factors of psychosocial stress in South African patients with diabetes.Method: A cross-sectional study was conducted at two public facilities and five private medical practices on the north coast of KwaZulu-Natal, South Africa. The Questionnaire on Stress in Diabetes – Revised was administered to 401 participants.Results: Eighteen percent of the sample reported having extreme psychosocial stress. Depression, physical complaints and self-medication/diet were the main areas which contributed to high psychosocial stress. Factors that also contributed to high levels of psychosocial stress were low educational level, unemployment, female gender, attending the public sector and high HbA1c levels.Conclusion: Psychosocial stress affects metabolic control in patients with diabetes, thereby increasing the risks of long-term complications.

Comorbid Anxiety and Depression and Their Impact on Cardiovascular Disease in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

BACKGROUND

The aims were to determine whether anxious depression, defined by latent class analysis (LCA), predicts cardiovascular outcomes in type 2 diabetes and to compare the predictive power of anxious depression with Diagnostic & Statistical Manual Versions IV and 5 (DSM-IV/5) categories of depression and generalized anxiety disorder (GAD).

METHODS

Prospective observational study of 1,337 type 2 participants. Baseline assessment with the 9-item Patient Health Questionnaire and the GAD Scale; LCA-defined groups with minor or major anxious depression based on anxiety and depression symptoms. Cox modeling used to compare the independent impact of: (1) LCA anxious depression, (2) DSM-IV/5 depression, (3) GAD on incident cardiovascular events and deaths after 4 years.

RESULTS

LCA minor and major anxious depression was present in 21.9 and 7.8% of participants, respectively, DSM-IV/5 minor and major depression in 6.2 and 6.1%, respectively, and GAD in 4.8%. There were 110 deaths, 31 cardiovascular deaths, and 199 participants had incident cardiovascular events. In adjusted models, minor anxious depression (Hazard ratio (95% confidence intervals): 1.70 (1.15-2.50)) and major anxious depression (1.90 (1.11-3.25)) predicted incident cardiovascular events and major anxious depression also predicted cardiovascular mortality (4.32 (1.35-13.86)). By comparison, incident cardiovascular events were predicted by DSM-IV/5 major depression (2.10 (1.22-3.62)) only and cardiovascular mortality was predicted by both DSM-IV/5 major depression (3.56 (1.03-12.35)) and GAD (5.92 (1.84-19.08)).

CONCLUSIONS

LCA-defined anxious depression is more common than DSM-IV/5 categories and is a strong predictor of cardiovascular outcomes in type 2 diabetes. These data suggest that this diagnostic scheme has predictive validity and clinical relevance.

Psychosocial Factors in Diabetes and Cardiovascular Risk

Type 2 diabetes is a chronic disease that is increasing in prevalence globally. Cardiovascular disease is a major cause of mortality and morbidity in diabetes, and lifestyle and clinical risk factors do not fully account for the link between the conditions. This article provides an overview of the evidence concerning the role of psychosocial stress factors in diabetes risk, as well as in cardiovascular complications in people with existing diabetes. Several types of psychosocial factors are discussed including depression, other types of emotional distress, exposure to stressful conditions, and personality traits. The potential behavioral and biological pathways linking psychosocial factors to diabetes are presented and implications for patient care are highlighted.

Prevalence and determinants of depressive and anxiety symptoms in adults with type 2 diabetes in China: a cross-sectional study

OBJECTIVES

To evaluate the prevalence and determinants of anxiety and depression and to assess their impact on glycaemic control in participants with type 2 diabetes mellitus.

DESIGN

A cross-sectional study.

SETTING

Community-based investigation in Xuzhou, China.

PARTICIPANTS

893 Chinese men and women aged 18-84 years who fulfilled the inclusion criteria.

METHODS

People with type 2 diabetes completed the Pittsburgh Sleep Quality Index and the Zung Self-Rating Anxiety and Depression Scales. Demographic and physiological characteristics were recorded. Multiple logistic regression was used to evaluate the combined effect of factors associated with anxiety and depression and to assess the effects of anxiety and depression on glycaemic control.

RESULTS

The prevalence of depressive symptoms and anxiety symptoms was 56.1% and 43.6%, respectively. Multivariate logistic regression analysis indicated that anxiety symptoms were associated with being woman, low income, chronic disease, depressive symptoms and poor sleep quality. Depressive symptoms were associated with being woman, older age, low education level, being single, diabetes complications, anxiety symptoms and poor sleep quality. Glycaemic control was not related to anxiety symptoms (OR=1.31, 95% CIs 0.94 to 1.67) or depressive symptoms (OR=1.23, 95% CI 0.85 to 1.63). A combination of depressive symptoms and anxiety symptoms was associated with poor glycaemic control (relative excess risk due to interaction: 4.93, 95% CI 2.09 to 7.87; attributable proportion due to interaction: 0.27, 95% CI 0.12 to 0.45).

CONCLUSIONS

There was a high prevalence of depressive and anxiety symptoms in this Chinese sample of participants, although depression and anxiety were not singly associated with glycaemic control. However, a combination of depressive and anxiety symptoms was negatively correlated with glycaemic control in participants with type 2 diabetes.

Association between depression and neuropathy in people with type 2 diabetes: a meta-analysis

OBJECTIVE

Depression and neuropathy are frequent complications of type 2 diabetes. The current meta-analysis aimed to estimate the association between depression and neuropathy in subjects with type 2 diabetes.

METHODS

We systematically searched electronic databases for articles published up to February 2015, providing data on the association between depression and neuropathy in individuals with type 2 diabetes. No language restrictions were applied. The meta-analysis generated random-effect odds ratios with 95% confidence intervals (95% CI). Risk of publication bias and heterogeneity were estimated using the Egger test and I(2) index, respectively. Leave-one-out analysis was performed. Data were analysed using stata.

RESULTS

Thirteen studies were included in the meta-analysis. Data on the association between depression and neuropathy were available for 3898 individuals with type 2 diabetes. Pooled analysis showed an association between depression and neuropathy, with an odds ratio of 2.01 (95% CI: 1.60-2.54; p < 0.001). There was no risk of publication bias (p = 0.064), and heterogeneity was moderate (I(2)  = 44.5%). Leave-one-out analysis confirmed consistency of the findings. The association appeared partly influenced by age, because studies selecting older people (sample mean age > 65 years) showed a slightly higher estimate for the association.

CONCLUSIONS

We found an association between depression and neuropathy among people with type 2 diabetes. Because of the cross-sectional nature of included studies, the relationship between these two conditions might be bidirectional. Further research exploring factors that might moderate or mediate this association is needed. Targeted interventions for comorbid depression and neuropathy should be implemented in clinical practice. Copyright © 2016 John Wiley & Sons, Ltd.

Depression and physical functioning among older Americans with diabesity: NHANES 2009-2010

BACKGROUND

Caring for older adults with diabesity can be challenging for primary care nurse practitioners. The purpose of this study was to examine whether there would be an additive effect of diabesity on depressive symptoms and physical functioning of older adults. We hypothesized that there is an additive effect of diabesity on depressive symptoms and physical functioning among older adults with one or neither condition.

METHODS

We performed a cross-sectional analysis of data from National Health and Nutrition Examination Surveys collected from African-American and Caucasian adults aged 65 and over between 2009 and 2010. Multivariate linear regression models were utilized. The sample consisted of 918 participants. In covariate-adjusted models, participants with diabesity reported more depressive symptoms than people with neither condition. Individuals with diabesity and those with obesity alone reported significantly more difficulty with physical function when compared to participants with neither condition.

CONCLUSION

Findings suggest that diabesity was more burdensome to older adults than either condition alone. More research is needed to understand the interplay between depression, physical function, and diabesity.

IMPLICATIONS FOR PRACTICE

To disrupt the adverse effects of diabesity burden, increased nurse practitioner awareness of this phenomenon may be beneficial in improving and maintaining physical and mental health among older adults.