Associations Between Glycemic Control, Depressed Mood, Clinical Depression, and Diabetes Distress Before and After Insulin Initiation: An Exploratory, Post Hoc Analysis

The selective serotonin reuptake inhibitors, sertraline and paroxetine, improve islet beta-cell mass and function in vitro

AIMS

To investigate the effects of the selective serotonin reuptake inhibitors (SSRIs) sertraline and paroxetine at therapeutically relevant concentrations on beta-cell mass and function.

METHODS

Viability was quantified in mouse insulinoma (MIN6) beta cells and mouse islets after 48-h exposure to sertraline (1-10 μM) or paroxetine (0.01-1 μM) using the Trypan blue exclusion test. The effects of therapeutic concentrations of these SSRIs on insulin secretion were determined by static incubation and perifusion experiments, while islet apoptosis was investigated by Caspase-Glo 3/7 assay, TUNEL staining and quantitative PCR analysis. Finally, proliferation of MIN6 and mouse islet beta cells was assessed by bromodeoxyuridine (BrdU) enzyme-linked immunosorbent assay and immunofluorescence.

RESULTS

Sertraline (0.1-1 μM) and paroxetine (0.01-0.1 μM) were well tolerated by MIN6 beta cells and islets, whereas 10 μM sertraline and 1 μM paroxetine were cytotoxic. Exposure to 1 μM sertraline and 0.1 μM paroxetine significantly potentiated glucose-stimulated insulin secretion from mouse and human islets. Moreover, they showed protective effects against cytokine- and palmitate-induced apoptosis of islets, they downregulated cytokine-induced Stat1 and Traf1 mRNA expression, and they significantly increased proliferation of mouse beta cells.

CONCLUSIONS

Our data demonstrate that sertraline and paroxetine act directly on beta cells to enhance glucose-stimulated insulin secretion and stimulate beta-cell mass expansion by increasing proliferation and decreasing apoptosis. These drugs are therefore likely to be appropriate for treating depression in people with type 2 diabetes.

Depression and type 2 diabetes: A causal relationship and mechanistic pathway

Depression is a mood disorder that may increase risk for the development of insulin resistance (IR) and type 2 diabetes (T2D), and vice versa. However, the mechanistic pathway linking depression and T2D is not fully elucidated. The aim of this narrative review, therefore, was to discuss the possible link between depression and T2D. The coexistence of T2D and depression is twice as great compared to the occurrence of either condition independently. Hyperglycaemia and dyslipidaemia promote the incidence of depression by enhancing inflammation and reducing brain serotonin (5-hydroxytryptamine [5HT]). Dysregulation of insulin signalling in T2D impairs brain 5HT signalling, leading to the development of depression. Furthermore, depression is associated with the development of hyperglycaemia and poor glycaemic control. Psychological stress and depression promote the development of T2D. In conclusion, T2D could be a potential risk factor for the development of depression through the induction of inflammatory reactions and oxidative stress that affect brain neurotransmission. In addition, chronic stress in depression may induce the development of T2D through dysregulation of the hypothalamic-pituitary-adrenal axis and increase circulating cortisol levels, which triggers IR and T2D.

Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations.

RESULTS

At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence.

CONCLUSIONS

Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.

Risk of Depression according to Cumulative Exposure to a Low-Household Income Status in Individuals with Type 2 Diabetes Mellitus: A Nationwide Population- Based Study

BACKGRUOUND

We aimed to identify the risk of incident depression according to cumulative exposure to a low-household income status in individuals with type 2 diabetes mellitus (T2DM).

METHODS

For this retrospective longitudinal population-based cohort study, we used Korean National Health Insurance Service data from 2002 to 2018. Risk of depression was assessed according to cumulative exposure to low-household income status (defined as Medical Aid registration) during the previous 5 years among adults (aged ≥20 years) with T2DM and without baseline depression who underwent health examinations from 2009 to 2012 (n=2,027,317).

RESULTS

During an average 6.23 years of follow-up, 401,175 incident depression cases occurred. Advance in cumulative number of years registered for medical aid during the previous 5 years from baseline was associated with an increased risk of depression in a dose-dependent manner (hazard ratio [HR], 1.44 [95% confidence interval (CI), 1.38 to 1.50]; HR, 1.40 [95% CI, 1.35 to 1.46]; HR, 1.42, [95% CI, 1.37 to 1.48]; HR, 1.46, [95% CI, 1.40 to 1.53]; HR, 1.69, [95% CI, 1.63 to 1.74] in groups with 1 to 5 exposed years, respectively). Insulin users exposed for 5 years to a low-household income state had the highest risk of depression among groups categorized by insulin use and duration of low-household income status.

CONCLUSION

Cumulative duration of low-household income status, defined as medical aid registration, was associated with an increased risk of depression in a dose-response manner in individuals with T2DM.

Applying contrastive pre-training for depression and anxiety risk prediction in type 2 diabetes patients based on heterogeneous electronic health records: a primary healthcare case study

OBJECTIVE

Due to heterogeneity and limited medical data in primary healthcare services (PHS), assessing the psychological risk of type 2 diabetes mellitus (T2DM) patients in PHS is difficult. Using unsupervised contrastive pre-training, we proposed a deep learning framework named depression and anxiety prediction (DAP) to predict depression and anxiety in T2DM patients.

MATERIALS AND METHODS

The DAP model consists of two sub-models. Firstly, the pre-trained model of DAP used unlabeled discharge records of 85 085 T2DM patients from the First Affiliated Hospital of Nanjing Medical University for unsupervised contrastive learning on heterogeneous electronic health records (EHRs). Secondly, the fine-tuned model of DAP used case-control cohorts (17 491 patients) selected from 149 596 T2DM patients' EHRs in the Nanjing Health Information Platform (NHIP). The DAP model was validated in 1028 patients from PHS in NHIP. Evaluation included receiver operating characteristic area under the curve (ROC-AUC) and precision-recall area under the curve (PR-AUC), and decision curve analysis (DCA).

RESULTS

The pre-training step allowed the DAP model to converge at a faster rate. The fine-tuned DAP model significantly outperformed the baseline models (logistic regression, extreme gradient boosting, and random forest) with ROC-AUC of 0.91±0.028 and PR-AUC of 0.80±0.067 in 10-fold internal validation, and with ROC-AUC of 0.75 ± 0.045 and PR-AUC of 0.47 ± 0.081 in external validation. The DCA indicate the clinical potential of the DAP model.

CONCLUSION

The DAP model effectively predicted post-discharge depression and anxiety in T2DM patients from PHS, reducing data fragmentation and limitations. This study highlights the DAP model's potential for early detection and intervention in depression and anxiety, improving outcomes for diabetes patients.

Antidepressants and type 2 diabetes: highways to knowns and unknowns

Type 2 diabetes (T2D) is a metabolic disease caused by the development of insulin resistance (IR), relative insulin deficiency, and hyperglycemia. Hyperglycemia-induced neurochemical dysregulation activates the progression of depression in T2D patients. Therefore, management of depression by antidepressant agents improves glucose homeostasis and insulin sensitivity. However, prolong use of antidepressant drugs may increase the risk for the development of T2D. However, there is strong controversy concerning the use of antidepressant drugs in T2D. Therefore, this review try to elucidate the potential effects of antidepressant drugs in T2D regarding their detrimental and beneficial effects.

Health care utilization and its association with sociodemographic factors among slum-dwellers with type 2 diabetes in Tabriz, Iran: A cross-sectional study

Background and Aims

Slums are known as growing underprivileged areas. One of the health adverse effects of slum-dwelling is health care underutilization. Management of type 2 diabetes mellitus (T2DM) requires an appropriate utilization. This study aimed to investigate the extent of health care utilization among slum-dwellers with T2DM in Tabriz, Iran, in 2022.

Methods

We conducted a cross-sectional study on 400 patients with T2DM living in slum areas of Tabriz, Iran. Sampling was conducted using a systematic random sampling method. A researcher-made questionnaire was used for data collection. To develop the questionnaire, we used Iran's Package of Essential Noncommunicable (IraPEN) diseases, in which potential needs and essential health care for patients with diabetes and the appropriate time intervals for use are specified. Data were analyzed using SPSS version 22.

Results

Although 49.8% of patients needed outpatient services, only 38.3% were referred to health centers and utilized health services. The results of the binary logistic regression model showed that women (OR = 1.871, CI 1.170-2.993), those with higher income levels (OR = 1.984, CI 1.105-3.562), and those with diabetes complications (Adjusted OR = 1.7, CI 0.2-0.603) were almost 1.8 times more likely to utilize outpatient services. Additionally, those with diabetes complications (OR = 1.93, CI 0.189-2.031) and those taking oral medication (OR = 3.131, CI 1.825-5.369) were respectively 1.9 and 3.1 times more likely to utilize inpatient care services.

Conclusions

Our study showed that, although slum-dwellers with type 2 diabetes needed outpatient services, a small percentage were referred to health centers and utilized health services. Multispectral cooperation is necessary for improving the status quo. There is a need to take appropriate interventions to strengthen health care utilization among residents with T2DM living in slum sites. Also, insurance organizations should cover more health expenditures and provide a more comprehensive benefits package for these patients.

Depression and diabetes distress in patients with diabetes

We aimed to identify the prevalence of comorbid depression, diabetes, and diabetes distress and assess glycemic control and rates of diabetes-related complications. While the presence of either depression or distress did not predict the level of glycemic control, certain macro- and microvascular complications were more prevalent with depression.

Increased Levels of HbA1c in Individuals with Type 2 Diabetes and Depression: A Meta-Analysis of 34 Studies with 68,398 Participants

Glycosylated hemoglobin is used to diagnose type 2 diabetes mellitus and assess metabolic control. Depression itself has been associated with high levels of HbA1c in individuals with T2DM. The association between diabetes and depression suggests the usefulness of determining HbA1c as a biological marker of depressive symptoms. The aim of this study was to determine HbA1c levels in individuals with T2DM with vs. without depression. Additionally, we analyzed the influence of pharmacological treatments, time of evolution, and complications of disease. We performed a literature search in different databases published up to January 2020. A total of 34 articles were included. Our results showed that individuals with T2DM with depression showed increased levels of HbA1c in comparison to individuals with T2DM without depression (d = 0.18, 95% CI: 0.12−0.29, p(Z) < 0.001; I2 = 85.00). We also found that HbA1c levels remained elevated in individuals with T2DM with depression who were taking hypoglycemic drugs (d = 0.20 95% CI: 0.11−0.30, p(Z) < 0.001; I2 = 86.80), in individuals with less than 10 years of evolution (d = 0.17 95% CI: 0.09−0.26, p(Z) = 0.001; I2 = 66.03) and in individuals with complications of the disease (d = 0.17, 95% CI: 0.07−0.26, p(Z) < 0.001; I2 = 58.41). Our results show that HbA1c levels in individuals with T2DM with depression are significantly increased compared to controls with T2DM without depression. Additionally, these levels remained elevated in individuals who were taking hypoglycemic drugs, those with less than 10 years of disease evolution, and those with complications related to diabetes. It is necessary to examine the existence of a diabetes−HbA1c−depression connection.

The bidirectional longitudinal association between depressive symptoms and HbA1c : A systematic review and meta-analysis

AIM

To investigate whether there is a bidirectional longitudinal association of depression with HbA_1c .

METHODS

We conducted a systematic literature search in PubMed, PsycINFO, CINAHL and EMBASE for observational, longitudinal studies published from January 2000 to September 2020, assessing the association between depression and HbA_1c in adults. We assessed study quality with the Newcastle-Ottawa-Scale. Pooled effect estimates were reported as partial correlation coefficients (r_p ) or odds ratios (OR).

RESULTS

We retrieved 1642 studies; 26 studies were included in the systematic review and eleven in the meta-analysis. Most studies (16/26) focused on type 2 diabetes. Study quality was rated as good (n = 19), fair (n = 2) and poor (n = 5). Of the meta-analysed studies, six investigated the longitudinal association between self-reported depressive symptoms and HbA_1c and five the reverse longitudinal association, with a combined sample size of n = 48,793 and a mean follow-up of 2 years. Higher levels of baseline depressive symptoms were associated with subsequent higher levels of HbA_1c (partial r = 0.07; [95% CI 0.03, 0.12]; I² 38%). Higher baseline HbA_1c values were also associated with 18% increased risk of (probable) depression (OR = 1.18; [95% CI 1.12,1.25]; I² 0.0%).

CONCLUSIONS

Our findings support a bidirectional longitudinal association between depressive symptoms and HbA_1c . However, the observed effect sizes were small and future research in large-scale longitudinal studies is needed to confirm this association. Future studies should investigate the role of type of diabetes and depression, diabetes distress and diabetes self-management behaviours. Our results may have clinical implications, as depressive symptoms and HbA_1c levels could be targeted concurrently in the prevention and treatment of diabetes and depression.

REGISTRATION

PROSPERO ID CRD42019147551.

Association between depressive symptoms and diagnosis of diabetes and its complications: A network analysis in electronic health records

OBJECTIVES

Diabetes and its complications are commonly associated with depressive symptoms, and few studies have investigated the diagnosis effect of depressive symptoms in patients with diabetes. The present study used a network-based approach to explore the association between depressive symptoms, which are annotated from electronic health record (EHR) notes by a deep learning model, and the diagnosis of type 2 diabetes mellitus (T2DM) and its complications.

METHODS

In this study, we used anonymous admission notes of 52,139 inpatients diagnosed with T2DM at the first affiliated hospital of Nanjing Medical University from 2008 to 2016 as input for a symptom annotation model named T5-depression based on transformer architecture which helps to annotate depressive symptoms from present illness. We measured the performance of the model by using the F1 score and the area under the receiver operating characteristic curve (AUROC). We constructed networks of depressive symptoms to examine the connectivity of these networks in patients diagnosed with T2DM, including those with certain complications.

RESULTS

The T5-depression model achieved the best performance with an F1-score of 91.71 and an AUROC of 96.25 compared with the benchmark models. The connectivity of depressive symptoms in patients diagnosed with T2DM (p = 0.025) and hypertension (p = 0.013) showed a statistically significant increase 2 years after the diagnosis, which is consistent with the number of patients diagnosed with depression.

CONCLUSION

The T5-depression model proposed in this study can effectively annotate depressive symptoms in EHR notes. The connectivity of annotated depressive symptoms is associated with the diagnosis of T2DM and hypertension. The changes in the network of depressive symptoms generated by the T5-depression model could be used as an indicator for screening depression.

Psychological Distress and All-Cause, Cardiovascular Disease, Cancer Mortality Among Adults with and without Diabetes

Aim

To examine the association of psychological distress with all-cause, cardiovascular disease (CVD) and cancer mortality in US adults, and verified whether the associations differed between participants with and without diabetes.

Methods

A total of 485,864 adults (446,288 without diabetes and 39,576 with diabetes) who participated in the National Health Interview Survey from 1997 to 2013 were linked to the National Death Index through December 31, 2015. Psychological distress was measured by the Kessler 6 distress scale (K6). Multivariable Cox proportional hazards regression models were performed to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between psychological distress and mortality.

Results

We ascertained 11,746 deaths (mean follow-up, 7. 7 years) among people with diabetes and 51,636 deaths (9.9 years) among those without diabetes. Psychological distress was associated with higher all-cause, CVD, and cancer mortality. Compared to non-diabetic adults without psychological distress, HRs (95% CI) were 1.07 (1.04 to 1.09) for mild, 1.26 (1.22 to 1.30) for moderate and 1.46 (1.38 to 1.55) for severe psychological distress. Compared to the same reference group, in diabetic participants the HRs were 1.39 (1.33 to 1.44) for no psychological distress, 1.59 (1.53 to 1.66) for mild, 1.90 (1.80 to 2.00) for moderate and 1.98 (1.82 to 2.17) for severe psychological distress. Similar associations were also observed for CVD and cancer mortality but with non-statistically significant interaction.

Conclusion

Psychological distress was associated with higher mortality, particularly in participants with diabetes. Strategies to ameliorate psychological distress may be important to reduce mortality in this population.

The Burden of Type 2 Diabetes and the Value of Achieving Near Normoglycemia from the Patient Perspective

INTRODUCTION

Type 2 diabetes (T2D) is extremely burdensome to people with T2D and associated with impaired health-related quality of life. This study explores the impact of T2D and potentially relevant outcomes for new therapies using a unique approach to in-depth qualitative interviews where people with T2D are asked to think about their future with T2D.

METHODS

A cross-sectional qualitative interview study among people with T2D from the USA and UK. Interviews explored their treatment journey, perceptions of their future with T2D, and the value of achieving normoglycemia (explored through presentation of two vignettes with hypothetical medications that reduced hemoglobin A1c [HbA1c] levels < 7% and < 5.7%).

RESULTS

Patients with T2D (N = 50; US n = 25; UK n = 25) were 66.0% male, had a mean body mass index (BMI) of 30.8 ± 6.3 kg/m², and had a mean of 13.0 ± 10.0 years since diagnosis. Current diabetes treatments included diet and exercise only (8.0%), oral medications only (62.0%), oral plus injections (24.0%), and insulin only (6.0%). Despite being treated, participants reported over 25 different unmet needs related to their T2D across a broad range of domains. The most common concerns were diet, diabetes-related complications, weight changes, and psychological and emotional issues. A large majority of participants indicated that achieving lower HbA1c values would change their life. When reflecting on the value of improved glycemic control, patients primarily anticipated physical improvements and improved psychological well-being. When presented with two hypothetical treatments, about 70% of participants preferred the < 5.7% treatment option over the < 7% HbA1c treatment option.

CONCLUSIONS

People with T2D have a high disease burden, a broad range of unmet needs, and extremely varied experiences and expectations on the impacts of T2D on their lives and future. Many patients indicated that achieving near normoglycemia would substantially change their lives primarily in terms of their physical and emotional health.

Evidence of hypoglycemic anhedonia and modulation by bupropion in rats

BACKGROUND

Disorders characterized by dysfunction of glucose metabolism are often comorbid with depression. The current study investigated whether a hypoglycemic state caused by 2-deoxy-d-glucose (2-DG) can result in anhedonic behaviors responsive to stimulation of monoamine activity.

METHODS

In experiment 1, male Sprague-Dawley rats were tested for maintenance of intra-oral self-administration (IOSA) of a sweet solution after pre-treatment with 300 or 500 mg/kg 2-DG, a blocker of glucose metabolism. Experiment 2 determined whether exposure to an environment previously paired with the effects of 2-DG (0, 200 or 300 mg/kg) can influence IOSA, and whether 2-DG can modify taste reactivity to same sweet solution. Finally, experiment 3 examined whether 0 or 30 mg/kg bupropion, a monoamine-reuptake blocker, would attenuate the effect of 300 mg/kg 2-DG on IOSA and taste reactivity.

RESULTS

It was found that 2-DG produced a sustained decrease in IOSA when animals were tested drug-free. This decrease in IOSA did not appear linked to place conditioning or to alterations in taste reactivity, and it was partially normalized by pre-treatment with bupropion.

CONCLUSIONS

Taken together, these results in rats suggest that rapid hypoglycemia can induce an anhedonic state characterized by impaired consummatory responses to nutritional incentive stimuli and that can be alleviated by the antidepressant bupropion.

The joint association of diabetes distress and depressive symptoms with all-cause mortality in Japanese individuals with type 2 diabetes: a prospective cohort study (Diabetes Distress and Care Registry in Tenri [DDCRT 20])

AIMS/HYPOTHESIS

The independent association of depressive symptoms and diabetes distress with mortality risk in individuals with diabetes has not been evaluated. We examined the temporal joint association of diabetes distress and depressive symptoms at baseline and the subsequent risk of all-cause mortality.

METHODS

The longitudinal data of 3118 individuals with type 2 diabetes were obtained from a large Japanese diabetes registry. To assess the joint association of diabetes distress and depressive symptoms at baseline with the subsequent risk of all-cause mortality, the Cox proportional hazards model was used with adjustment for potential confounders.

RESULTS

The mean age, BMI and HbA_1c levels were 64.7 years, 24.6 kg/m² and 58.6 mmol/mol (7.5%), respectively, and 38.1% of the participants were women. In the multivariable-adjusted models evaluating the diabetes distress and depressive symptoms separately, the HRs for all-cause mortality were 1.67 (95% CI 1.14, 2.43; p = 0.008) and 1.40 (95% CI 1.05, 1.85; p = 0.020), respectively. In such models evaluating the joint association of diabetes distress and depressive symptoms, compared with individuals without diabetes distress or depressive symptoms (DD^-/DS^-), the HRs for all-cause mortality for the group without diabetes distress but with depressive symptoms (DD^-/DS⁺), with diabetes distress but without depressive symptoms (DD⁺/DS^-), and with diabetes distress and depressive symptoms (DD⁺/DS⁺) were 1.34 (95% CI 0.99, 1.86; p = 0.056), 1.96 (95% CI 1.10, 3.50; p = 0.023) and 1.71 (95% CI 1.06, 2.77; p = 0.029), respectively. We did not observe a significant interaction between diabetes distress and depressive symptoms with all-cause mortality risk (p = 0.2636). In the stratified analysis by sex, a significant joint association of diabetes distress and depressive symptoms with the risk of all-cause mortality was observed only in men.

CONCLUSIONS/INTERPRETATION

Diabetes distress and depressive symptoms were independently associated with all-cause mortality risk in male participants with type 2 diabetes, but we did not observe a significant interaction between diabetes distress and depressive symptoms in relation to all-cause mortality. Graphical abstract.

Depressive symptoms are not associated with type 2 diabetes in a rural population in China: findings from the Henan rural cohort

BACKGROUND

Depression is one of the most prevalent mental health challenges that affect all groups of persons. This study examines the association between type 2 diabetes and depressive symptoms (using PHQ-2) in a rural population. Other risk factors of depressive symptoms are examined.

METHODS

Data from 30,001 participants from the Henan rural cohort was analyzed. Multivariable logistic regression analyses were performed to examine the associations between depressive symptoms (DS) and type 2 diabetes and other risk factors. Adjusted odds ratios (aOR) with confidence intervals (CI) at 95% are reported.

RESULTS

The prevalence of DS in the study population is 5.86%, 6.69% in women, 4.74% in men, 5.80% in persons without diabetes and 6.81% in persons with diabetes (diagnosed and undiagnosed). DS prevalence was highest in persons with previously diagnosed diabetes (8.27%). No association was found between DS and diabetes (aOR = 0.95, CI at 95% 0.61-1.48; p=0.836). DS was associated with poor glycemic control (aOR=1.43, CI at 95% 1.04- 1.98; p= 0.034) in persons with previously diagnosed diabetes, persons with elevated triglycerides (aOR=1.19, CI at 95% 1.08-1.30; p<0.001), household income (aOR= 0.78, CI at 95% 0.63-0.97; p=0.027), marital status (aOR=1.37, CI at 95% 1.01-1.88, p=0.049) and hypertension treatment with medication (aOR=1.94, CI at 95% 1.48-2.55; p<0.001).

LIMITATIONS

DS was assessed through self-report and may suffer recall or information bias.

CONCLUSIONS

DS was not associated with diabetes in our study population. The association between poor glycemic control and DS calls for the integration of screening for depression among patients with diabetes.

Successful Healthcare Provider Strategies to Overcome Psychological Insulin Resistance in Japanese Patients with Type 2 Diabetes

INTRODUCTION

EMOTION was a multinational, noninterventional study surveying current insulin-using adults with type 2 diabetes mellitus (T2D) who were initially reluctant to begin insulin treatment. In this Japanese population subanalysis of EMOTION, we identify the frequency and level of helpfulness of healthcare provider (HCP) actions, and we analyze life events ('actions/events') that assist T2D patients with psychological insulin resistance in the decision to initiate insulin.

METHODS

Participants were selected from Survey Sampling International and their local partners' market research panels in Japan. Quantitative surveys were administered between December 2016 and August 2017 to patients who met the study criteria. Participants were asked whether 45 actions/events occurred, and to rate the level of helpfulness of the actions/events in contributing to their decision to initiate insulin.

RESULTS

Among the 594 eligible participating adults in the EMOTION study, 99 were from Japan. Despite initial reluctance to begin insulin treatment, 80.8% of the Japanese participants immediately commenced insulin. Practical demonstrations by HCPs on how to use insulin were rated by participants as most helpful. Examples of such practical demonstrations, reported as helping moderately or a lot, were 'HCP walked patient through the process of exactly how to take insulin' (82.8%), 'HCP showed an insulin pen' (79.7%), and 'HCP helped patient to see how simple it was to inject insulin' (79.1%).

CONCLUSION

This study identifies actions that HCPs can use to assist Japanese patients in deciding whether to initiate insulin. These findings may aid the development of clinical interventions addressing reluctance to begin insulin treatment among Japanese patients with T2D.

FUNDING

Eli Lilly and Company and Boehringer Ingelheim. Plain language summary available for this article.

The Importance of Addressing Depression and Diabetes Distress in Adults with Type 2 Diabetes

People with type 2 diabetes often experience two common mental health conditions: depression and diabetes distress. Both increase a patient's risk for mortality, poor disease management, diabetes-related complications, and poor quality of life. The American Diabetes Association and the U.S. Preventive Services Task Force recommend routine evaluations for these conditions in adults for optimal disease management and prevention of life-threatening complications. However, barriers exist within primary care and specialty settings that make screening for depression and diabetes distress challenging. Depression and diabetes distress influence diabetes self-care and diabetes control and barriers in clinical care practice that can hinder detection and management of psychosocial issues in diabetes care. This paper highlights opportunities to increase mental health screenings and provides strategies to help providers address depression and diabetes distress in patients with type 2 diabetes.

The Effect of Depression on Poor Glycemic Control in Adults with Type 2 Diabetes: The Mediating Roles of Self-Efficacy and Self-Management Behaviors

<b><i>Background:</i></b> High levels of depression and poor self-efficacy and self-management are associated with worse glycemic control, but the linkage and pathway between these variables are poorly understood. We conducted this study to investigate the hypothesis that self-efficacy and self-management mediate the influence of depression on poor glycemic control. <b><i>Methods:</i></b> We studied a purposive sample of 142 adults with type 2 diabetes attending a public clinic in Ilam, Iran. Hierarchical linear regression analysis and structural equation modeling were used to explore the relationships among the variables of interest. <b><i>Result:</i></b> Depression directly and negatively affects self-efficacy and indirectly affects self-management behaviors, which in turn have direct effects on hemoglobin A1c (HbA1c). Self-efficacy mediates the relationship between depression and self-management behaviors. Self-efficacy and self-management behaviors partially mediate the effect of depression on HbA1c. These results confirmed that the data fit the hypothesized model very well. <b><i>Conclusion:</i></b> Careful monitoring of glycemic control might be important in those individuals who exhibit clinical signs of depression. Effective treatment programs should probably pay close attention to not only screening and treatment of depression but also skills training to enhance patient self-efficacy and self-management of diabetes to improve HbA1c.

To what extent is the elevated risk of psychological distress in people with diabetes accounted for by physical disability? Findings from a large population-based study

OBJECTIVES

People with diabetes experience an elevated risk of psychological distress compared with people without diabetes. It is unclear how much of this elevated risk is attributable to the greater levels of physical disability in people with diabetes, and how this risk varies according to sociodemographic and health-behavioural characteristics. This study quantified levels of psychological distress in people with and without diabetes, considering these factors.

DESIGN

Cross-sectional analysis of questionnaire data.

SETTING

Men and women aged ≥45 years, in the 45 and Up Study, from New South Wales, Australia.

PARTICIPANTS

236 441 people who completed the baseline postal questionnaire (distributed from 1 January 2006-31 December 2008), with valid data for diabetes status and psychological distress.

PRIMARY OUTCOME MEASURES

High psychological distress (Kessler-10 >22). Modified Poisson regression with robust error variance was used to estimate prevalence ratios (PRs), comparing prevalence of high psychological distress among those with and without diabetes and across physical functional limitation (PFL) levels, adjusting for potential confounders.

RESULTS

Overall, 8.4% (19 803/236 441) of participants reported diabetes. 11.8% (2339) of individuals with diabetes and 7.2% (15 664) without diabetes had high psychological distress: age-adjusted and sex-adjusted PR=1.89 (95% CI 1.81 to 1.97), becoming 1.58 (1.52 to 1.65) and 1.22 (1.17 to 1.27) following additional adjustment for sociodemographic factors, health behaviours and additionally for PFL, respectively. Compared with individuals with neither diabetes nor PFL, the adjusted PRs for high psychological distress were: 1.37 (1.17 to 1.60) with diabetes but no PFL, 7.33 (7.00 to 7.67) without diabetes but with severe PFL and 8.89 (8.36 to 9.46) with both diabetes and severe PFL.

CONCLUSIONS

People with diabetes have a 60% greater risk of high psychological distress than people without diabetes; a substantial proportion of this elevation is attributable to higher levels of disability with diabetes, especially factoring in measurement error. Psychological distress is strongly related to physical impairment.

Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes

AIMS

To determine which barriers to care are associated with type 2 diabetes complications in an area in rural East England.

METHODS

3649 individuals with type 2 diabetes from 62 general practices were contacted via postal invitation which included a 33 item Barriers-to-Diabetes-Care Survey. Barriers were grouped into five priori major categories: educational, physical, psychological, psychosocial, and systems. The associations of reported barriers, both individually and as a group, with self-reported complications were assessed using logistic regression.

RESULTS

39.5% of participants had self-reported diabetes complications. Physical health barriers (OR = 3.3; 95%CI: 2.7, 4.0), systems barriers (OR = 1.6; 95%CI: 1.3, 2.0) and psychological barriers (OR = 1.3 (95%CI: 1.1, 1.5) were associated with diabetes complications. In subcategories, presence of comorbidities (OR = 4.8; 95%CI: 3.9, 5.9), financial difficulties (OR = 1.7; 95%CI: 1.3, 2.1), absence of services (OR = 2.0; 95%CI: 1.4, 3.0), feeling others should bear more financial responsibility for their care (OR = 1.6 (95%CI: 1.1, 2.1), no access to diabetes service (OR = 1.3; 95%CI: 1.1, 1.5), feeling worried about their diabetes (OR = 1.5; 95%CI: 1.2, 2.0) and lack of readiness to exercise (OR = 1.4; 95%CI: 1.2, 1.7) were associated with diabetes complications.

CONCLUSIONS

Barriers to self-care are significantly more common among those with, than those without, diabetes complications. Systematic identification and management of different barriers to self-care could help personalise care for those with diabetes related complications.

Glucose-lowering therapies, adequacy of metabolic control, and their relationship with comorbid depression in outpatients with type 2 diabetes in a tertiary hospital in Kenya

BACKGROUND

Depression and diabetes mellitus are important comorbid conditions with serious health consequences. When depression and diabetes are comorbid, depression negatively affects self-management activities of diabetes with serious consequences. Relationship between treatment regimens of diabetes, the adequacy of glycemic control, and occurrence of comorbid depression is not known among our patients.

PATIENTS AND METHODS

This was a cross-sectional descriptive study at the outpatient diabetes clinic of the Kenyatta National Hospital where 220 ambulatory patients with type 2 diabetes on follow-up were systematically sampled. Sociodemographic data and clinical information were documented. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression. Ethylenediaminetetraacetic acid-anticoagulated blood was used for glycated hemoglobin (HbA1C) assay on automated system, COBAS INTEGRA machine.

RESULTS

Two hundred twenty patients with type 2 diabetes were enrolled. The prevalence of comorbid depression by PHQ-9 was 32.3% (95% confidence interval: 26.4%-38.6%). The majority, 69.5%, had poor glycemic control, HbA1C >7.0%, mean HbA1C was 8.9%±2.4%. Half, 50.4%, of the study subjects were on insulin-containing regimens. Over 8% (84.5%) of the participants with comorbid depression had poor glycemic control, which worsened with increasing severity of depression. There was significant correlation between comorbid depression and poor glycemic control, which is more consistent in the insulin-treated patients. However, patients on oral agents only, both with and without comorbid depression, were similar in their glycemic control.

CONCLUSION

Among our type 2 diabetic population with comorbid depression, a large proportion had poor glycemic control, which worsened with increasing severity of depression. The insulin treatment increased the odds of comorbid depression and poor glycemic control in patients. It is justifiable to screen for comorbid depression in patients with type 2 diabetes who are in poor glycemic control, especially the insulin-treated, and then provide specific and appropriate interventions that are necessary to optimize their metabolic outcomes.

Distress and Its Effect on Adherence to Antidiabetic Medications Among Type 2 Diabetes Patients in Coastal South India

Background:

Distress can bring about an unfavorable attitude among the patients toward tackling their disease which can affect adherence to medications. The purpose of this study was to assess the effect of distress on adherence to medication among patients with diabetes.

Methodology:

In this cross-sectional study, 124 type 2 diabetes patients above 18 years, attending the hospitals affiliated to Kasturba Medical College, Mangalore, selected using nonprobability sampling were interviewed to assess the presence of diabetes-related distress (DRD) and their level of adherence to medications. Distress was assessed using diabetes distress scale. Morisky Adherence Questionnaire was used to assess the level of adherence. Approval was obtained from the Institutional Ethics Committee. Multivariate logistic regression was conducted to assess the influence of domains of distress on adherence to antidiabetic medication and P < 0.05 was considered statistically significant.

Results:

In our study, 41.9% (n = 52) of the participants had high diabetes distress. Exactly 43.5% (n = 54) of the participants had low adherence to antidiabetic medications. On univariate analysis, participants with low regimen distress, low physician distress, and low interpersonal distress were found to have good adherence to antidiabetic medication. However, on multivariate analysis, only low regimen distress was found to be significantly associated with good adherence to medication among the study participants.

Conclusion:

DRD is a problem in our study participants which affects the adherence to medications. Identifying distress at an early stage can help doctors formulate and implement remedial measures, thereby improving adherence to medications.

Psychometric properties of the Chinese version of the Problem Areas in Diabetes scale (SG-PAID-C) among high-risk polypharmacy patients with uncontrolled type 2 diabetes in Singapore

Aims/Introduction

Undetected diabetes distress is a cause of concern. However, the lack of a validated questionnaire is a barrier to screening for diabetes distress. The aim of the present study was to examine the validity and reliability of the Chinese version of the Problem Areas in Diabetes scale (SG‐PAID‐C), and its association with sociodemographic and clinical parameters in patients with type 2 diabetes.

Materials and Methods

This cross‐sectional study was carried out in four outpatient healthcare institutions in Singapore. Chinese‐speaking patients with uncontrolled type 2 diabetes, polypharmacy, and multiple comorbidities were administered the SG‐PAID‐C and European Quality of Life‐5 Dimensions questionnaires as quality of life measures. The factorial construct, convergent validity and internal consistency of SG‐PAID‐C were evaluated.

Results

The exploratory factor analysis resulted in a three‐factor structure of SG‐PAID‐C with subscales on emotional‐ and management‐related problem (11 items), ability to cope with diabetes problem (3 items) and support‐related problem (2 items). The findings also showed good model fit in the confirmatory factor analysis, and provided support for the construct and convergent validity of SG‐PAID‐C. Overall, the internal consistency of SG‐PAID‐C was good (Cronbach's alpha = 0.900). Sex and duration of diabetes were positively associated with the 16‐item SG‐PAID‐C, whereas age and type of antidiabetic agents were inversely associated with the 16‐item SG‐PAID‐C.

Conclusions

The 16‐item SG‐PAID‐C is a valid and reliable instrument for use among patients with uncontrolled type 2 diabetes in Singapore. Future studies on its clinical utility should be carried out.

Depression Screening in Diabetes Care to Improve Outcomes

Purpose

Evidence-based guidelines recommend regular depression screening among individuals with type 2 diabetes mellitus (T2DM). The purpose of this study is to examine depression screening patterns among a primary care population with T2DM, through use of the Patient Health Questionnaire-9 (PHQ-9).

Methods

In total, 1817 patients with T2DM were analyzed through a retrospective observational study at 2 sites, a regional health center and a federally qualified health center (FQHC). The T2DM sample was divided into those with and without a major depressive disorder (MDD) diagnosis. Depression screening rates and depression severity were assessed through the PHQ-9.

Results

Both sites had higher rates of PHQ-9 screening among individuals with a history of MDD (64.82%) vs those without MDD (11.39%). Individuals from the FQHC without a history of depression had a higher mean PHQ-9 score (10.11) than those with a previous MDD diagnosis at both RHS and FQHC (7.16 and 9.85, respectively).

Conclusions

Depression screening rates among individuals with diabetes and no history of MDD were remarkably low. Patients with diabetes but no MDD diagnosis who sought health care at a FQHC clinic had more depressive symptoms than those with a history of MDD at both sites. Individuals with diabetes and who have a MDD diagnosis are much more likely to receive regular depression screening than those without MDD, which leaves a substantial proportion of patients with undetected depression. Depression screening must be enhanced for all individuals with diabetes, particularly for low-income individuals and those without a previous diagnosis of MDD.

The Prevalence and Specificity of Depression Diagnosis in a Clinic-Based Population of Adults With Type 2 Diabetes Mellitus

OBJECTIVE

To estimate the crude prevalence of minor depressive disorder (MinD) in a clinic-based population of adults with type 2 diabetes.

METHODS

We screened a clinical sample of 702 adults with type 2 diabetes for depressive symptoms using the Patient Health Questionnaire-2 and performed a structured diagnostic psychiatric interview on 52 screen-positive and a convenience sample of 51 screen-negative individuals. Depressive disorder diagnoses were made using Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) Text Revised criteria and categorized as MinD, major depressive disorder (MDD), or no depressive disorder. We estimated prevalence of MinD and MDD and derived 95% CIs.

RESULTS

The crude prevalence of current, past, and current or past MinD was 4.3% (95% CI: 0.9-9.2%), 9.6% (95% CI: 3.9-15.9%), and 13.9% (95% CI: 7.7-21.2%), respectively. The crude prevalence of current, past, and current or past MDD was slightly higher-5.0% (95% CI: 1.9-9.4%), 12.0% (95% CI: 6.1-19.5%), and 17.0% (95% CI: 10.1-24.8%), respectively. There was a high prevalence of coexisting anxiety disorders in individuals with MinD (42.2%) and MDD (8.1%). Hemoglobin A1c levels were not significantly different in individuals with MinD or MDD compared to those without a depressive disorder.

CONCLUSIONS

MinD is comparably prevalent to MDD in patients with type 2 diabetes; both disorders are associated with concomitant anxiety disorders. MinD is not included in the DSM-5; however, our data support continuing to examine patients with chronic medical conditions for MinD.