Depression and incident diabetic retinopathy: a prospective cohort study

Experts' perspectives on the impact of visual impairment and comorbid mental disorders on functioning in essential life domains

BACKGROUND

Visual impairment (VI) with comorbid mental disorders (MDs) are expected to have a major impact on people's daily functioning, for which tailored support is needed. However, this has been barely investigated. Therefore, this study aimed to (1) determine the impact of VI and comorbid MDs on functioning in essential life domains, (2) gain insight into best-practices that are currently used to support this target group, and (3) determine strategies to optimize care in the future.

METHODS

A four-step qualitative Delphi method was used to obtain input from 31 Dutch professionals who work with this target group (84% female, mean age 46 years, on average 11 years of experience in working with the target group). The Self-Sufficiency Matrices were used to determine the impact on various aspects of daily living, for people with VI and (1) autism spectrum disorder, (2) psychotic disorders, (3) obsessive-compulsive disorder, (4) antisocial personality disorder, (5) borderline personality disorder, (6) dependent personality disorder.

RESULTS

Experts describe a frail and vulnerable population, in which the VI and MD often have a cumulative negative impact on people's physical and mental health. People frequently experience anxiety, depression, fatigue and sleep disturbances. Also, many tend to neglect self-care and substance abuse is common. They often experience difficulty in trusting others while at the same time being dependent on them. Social interaction and relationships are complicated because of communication restrictions (e.g. no facial recognition) and social incompetence or withdrawal. Experts advise taking transdiagnostic factors into account, using evidence-based psychological treatment options based on an intermittent approach, and offering multidisciplinary care. They stress the importance of building trust, showing patience and empathy, stimulating empowerment, involving the informal network and building on positive experiences.

CONCLUSION

VI and comorbid MD have a major impact on people's daily functioning on a mental, physical, social and environmental level. This study provides insight into best-practices to support this target group. According to experts, more research is needed which could be aimed at investigating tailored diagnostic approaches and treatment options and include clients' perspectives.

Validation of Chinese version of the 5-item WHO well-being index in type 2 diabetes mellitus patients

BACKGROUND

For better disease management and improved prognosis, early identification of co-morbid depression in diabetic patients is warranted. the WHO-5 well-being index (WHO-5) has been used to screen for depression in diabetic patients, and its Chinese version (WHO-5-C) has been validated. However, its psychometric properties remain to be further validated in the type 2 diabetes patient population. The aim of our study was to examine the reliability and validity of the WHO-5-C in patients with type 2 diabetes mellitus.

METHODS

The cross-sectional study was conducted on 200 patients from July 2014 to March 2015. All patients should complete the WHO-5-C, the Patient Health Questionnaire-9 (PHQ-9), the 20-item Problem Areas in Diabetes Scale (PAID-20), the Mini International Neuropsychiatric Interview (M.I.N.I), and Hamilton Rating Scale for Depression (HAM-D). Internal consistency of WHO-5 was revealed by Cronbach's alpha, and constructive validity by confirmatory factor analysis (CFA). Relationship with PHQ-9, HAM-D, and PAID-20 was examined for concurrent validity, and ROC analysis was performed for criterion validity.

RESULTS

The WHO-5-C presented satisfactory reliability (Cronbach's alpha = 0.88). CFA confirmed the unidimensional factor structure of WHO-5-C. The WHO-5-C had significant negative correlation with HAM-D (r = -0.610), PHQ-9 (r = -0.694) and PAID-20 (r = -0.466), confirming good concurrent validity. Using M.I.N.I as the gold standard, the cut-off value of WHO-5-C was 42, with a sensitivity of 0.83 and specificity of 0.75.

CONCLUSION

The WHO-5-C holds satisfactory reliability and validity that is suitable for depression screening in type 2 diabetes patients as a short and convenient instrument.

Longitudinal bidirectional associations between diabetic retinopathy and diagnosed depression: Results from a Danish nationwide registry-based cohort study

OBJECTIVE

Diabetic retinopathy (DR) is a feared complication and a leading course of visual impairment, but the connection between DR and depression including the direction has never been studied in a nationwide cohort. We aimed to assess, whether the associations between DR and diagnosed depression are bidirectional.

METHODS

We performed a national register-based cohort study of individuals with type 2 diabetes, who attended diabetic eye screening between January 2013 and June 2022. Level of DR was extracted from the Danish Registry of Diabetic Retinopathy. The severity of DR was assessed according to the International Clinical Diabetic Retinopathy severity scale. Diagnosed depression was ascertained by physician diagnostic codes of unipolar depression (F32), recurrent depression (F33) or dysthymia (F34.1) from the Danish National Patient Register. We estimated presence of diagnosed depression according to DR level at index date and risk of diagnosed depression during follow-up using multivariable logistic and Cox regression, respectively. Secondly, we assessed whether diagnosed depression at index date could predict incident DR.

RESULTS

We included 240,893 individuals with type 2 diabetes with baseline rates of diagnosed depression ranging from 5.2 to 6.0 % for DR level 1-4. At index date, individuals with type 2 diabetes and DR were less likely to have a history of diagnosed depression (multivariable adjusted OR, 0.77 [95 % CI 0.73-0.82]). In 226,523 individuals with type 2 diabetes followed for 1,159,755 person-years, 1.7 % developed at least one episode of diagnosed depression. In a model adjusted for age and sex, individuals with DR at index date had an increased risk of incident diagnosed depression compared to those without DR (HR 1.25 [95 % CI 1.16-1.36]). Adjusting for marital status, use of glucose-, lipid- and blood pressure lowering medication, HbA1c, diabetic neuropathy and Charlson comorbidity index waived the above risk (multivariable adjusted HR 1.02 [95 % CI 0.93-1.12]). Furthermore a previous history of diagnosed depression was not associated with increased risk of incident DR (multivariable adjusted HR 0.89 [95 % CI 0.77-1.03]).

CONCLUSION

In this nationwide cohort study, individuals with DR at first screening were 23 % less likely to have a history of depression, but our data did not support a bidirectional association between DR and depression. Selection bias may have occurred as diagnosed depression is a known barrier for attending DR-screening.

Associations of concomitant retinopathy and depression with mortality in a nationally representative population

OBJECTIVE

To evaluate the interaction effects between retinopathy and depression on mortality risks in genral population and subpopulation with diabetes.

METHODS

Prospective analyses were conducted on data from the National Health and Nutrition Examination Surveys study. Associations of retinopathy, depression and their interaction with all-cause, cardiovascular disease (CVD)-specific, cancer-specific and other-specific mortality risk were estimated using Kaplan-Meier curves and multivariate Cox proportional hazards models.

RESULTS

Among 5367 participants, the weighted prevalence of retinopathy and depression was 9.6 % and 7.1 %, respectively. After a follow-up period of 12.1 years, 1295 deaths (17.3 %) occurred. Retinopathy was associated with an increased risk of all-cause (hazard ratio [HR]; 95 % confidence interval [CI]) (1.47; 1.27-1.71), CVD-specific (1.87; 1.45-2.41), and other-specific (1.43; 1.14-1.79) mortality. Similar relationship was observed between depression and all-cause mortality (1.24; 1.02-1.52). Retinopathy and depression had a positive multiplicative and additive interaction effect on all-cause (P_interaction = 0.015; relative excess risk of interaction [RERI] 1.30; 95 % CI 0.15-2.45) and CVD-specific mortality (P_interaction = 0.042; RERI 2.65; 95 % CI -0.12-5.42). Concomitant retinopathy and depression was more markedly associated with all-cause (2.86; 1.91-4.28), CVD-specific (4.70; 2.57-8.62), and other-specific mortality risks (2.18; 1.14-4.15) compared to those without retinopathy and depression. These associations were more pronounced in the diabetic participants.

CONCLUSIONS

The co-occurrence of retinopathy and depression increases the risk of all-cause and CVD-specific mortality among middle-aged and older adults in the United States, especially in population with diabetes. Focus on diabetic patients and active evaluation and intervention of retinopathy with depression may improve their quality of life and mortality outcomes.

Associations between psycho-behavioral risk factors and diabetic retinopathy: NHANES (2005-2018)

Introduction

Diabetes mellitus (DM) and diabetic retinopathy (DR) increase the global burden. Since their pathogenesis is complex, it is necessary to use the biopsychosocial model to discover the most effective strategies. The study is aimed to investigate the psycho-behavioral factors of DR and confirm the discrepancies from previous studies.

Research design and methods

The study comprised seven cycles of cross-sectional data of the National Health and Nutrition Examination Survey (NHANES) from 2005-2006 to 2017-2018. Samples of DM were selected from this complex multi-stage probability sample and divided into the non-DR and DR groups, where 4,426 samples represented 18,990,825 individuals after weighting. This study comprehensively explored the biological, social, and psychological risk factors of DR, among which the biological factors included blood pressure, blood routine, HbA1c%, blood glucose, the duration of DM, family history, comorbidities, and treatment methods. Social aspects include gender, education, income, insurance, smoking, drinking, sleep habits, and recreational activities. The Patient Health Questionnaire-9 (PHQ-9) was used to assess the psychological state. Taylor series regression was used to examine the connection between factors and DR.

Results

Men accounted for 55.5% of the DR group (P = 0.0174). Lymphocyte count, insulin treatment, heart failure, stroke, liver condition, and renal failure showed significant differences in DR (P < 0.05). The incidence of depression in DR was 40.5%. Mild to moderate depression [odds ratio was associated with DR [(OR) = 1.37, 95% confidence interval (CI): 1.06-1.79], but there was no statistical difference in severe depression (OR = 1.34, 95% CI: 0.83-2.17). Although ≤ 6 h of sleep was associated with DR (OR = 1.38, 95% CI: 1.01-1.88), we found no statistical differences in alcohol consumption, recreational activities, or sedentary time between the two groups in our current study (P > 0.05).

Conclusions

The biological risk factors of DR are significant. It showed that stroke is associated with DR, and retinal exams have the potential value as a screening tool for the brain. Besides, psycho-behavioral risk factors of DR should also be paid attention. Our study highlights that mild and moderate depression and ≤6 h of sleep are distinguishably associated with DM complicated with DR. It indicates that psycho-behavioral risk factors confer a vital influence on diabetic health care and DR.

The effect of psychotherapy on anxiety, depression, and quality of life in patients with diabetic retinopathy: A protocol for systematic review and network meta-analysis

BACKGROUND

Diabetic retinopathy (DR) is one of the common microvascular complications in diabetic patients, which is characterized by progressive development and often leads to irreversible visual impairment. More seriously, DR patients suffer great psychological stress due to impaired visual function and reduced self-care ability such as anxiety and depression, which seriously affect the quality of life of patients. In recent years, various psychological therapies have been applied to alleviate anxiety, depression, and quality of life in DR patients, which have achieved positive results. However, the effectiveness and safety of different psychological therapies are unclear. This study aims to assess the effects of psychotherapy on anxiety, depression, and quality of life in DR patients through a network meta-analysis.

METHODS

All randomized controlled trials (RCTs) on the effects of psychotherapy on anxiety, depression, and quality of life in patients with DR published before 30 November 30, 2021, will be searched in the PubMed, EMBASE, Cochrane Register of Controlled Trials, Web of Science, Chinese Scientific Journal Database, China National Knowledge Infrastructure Database, Wanfang, and China Biomedical Literature Database. There will have no restrictions on publication status and language. Two researchers will be independently responsible for RCT screening, data extraction, and quality evaluation. All statistical analyses will be performed using Stata 14.0 and R 4.1.2.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide comprehensive and reliable evidence-based references for elucidating the efficacy of psychotherapy on anxiety, depression, and quality of life in DR patients.

ETHICS AND DISSEMINATION

Ethical approval was not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/K8T27.

The functional burden of diabetic retinopathy in the United States

OBJECTIVE

To study the association between diabetic retinopathy (DR) and physical functional difficulty using contemporary psychometric validation techniques, and to explore the predictors of physical difficulty among those with diabetes, non-proliferative DR (NPDR), or proliferative DR (PDR).

METHODS

Cross-sectional study using the National Health and Nutrition Examination Survey (NHANES) database from 2005-2008. Participants were classified as either (i) no diabetes no DR, (ii) diabetes without DR, (iii) mild/moderate NPDR, or (iv) severe NPDR/PDR. The presence of DR was detected by retinal imaging and severity was graded using the Early Treatment Diabetic Retinopathy Study Protocol. The physical difficulty was assessed using a 13-question self-reported questionnaire, validated using factor analysis and item response theory (graded response model) psychometric techniques. Secondary analyses of diabetes and DR populations most at risk of reporting greater physical functional difficulty were undertaken.

RESULTS

A total of 5321 participants over the age of 40 were included in our study. Of the 13 original physical difficulty questions, one latent trait was identified and 9 questions demonstrated good discrimination and were subsequently retained. In univariable analyses, participants with diabetes and any form of DR all reported significantly higher physical functional difficulty vs those with neither diabetes nor DR (p < 0.01 for all). In multivariable analyses, while those with diabetes or any form of DR remained more likely to report higher physical difficulty vs those with neither diabetes nor DR, only those with severe NPDR/PDR reported substantially higher scores (2.1 sum points higher, p = 0.002). Among participants with diabetes or any form of DR, those with 3 or more medical comorbidities and those with depression reported substantially higher sum physical difficulty scores (p < 0.05 for all).

CONCLUSIONS

Those with diabetes or DR experience greater functional physical difficulty than those without, particularly profound among those with severe forms of DR. For those with DR, the presence of concurrent depression or medical comorbidities conferred a significantly higher risk of physical difficulty. Providers and healthcare systems should be aware of particularly vulnerable DR populations at increased risk of experiencing daily functioning deficits.

Depression and Retinopathy in Patients With Type 2 Diabetes Mellitus: A Meta-Analysis

OBJECTIVE

Patients with diabetes mellitus with comorbid depression are at an increased risk of macrovascular and microvascular complications. Studies have suggested a positive association between depression and diabetic retinopathy (DR), but the evidence has not been systematically summarized. Therefore, the aim of the study was to perform a meta-analysis to investigate the correlation of depression with DR in patients with type 2 diabetes mellitus.

METHODS

PubMed and EMBASE were searched for relevant studies through January 7, 2017. Fixed-effects and random-effects models were used to calculate overall odds ratio (OR) and confidence interval (CI). Subgroup analyses were conducted to examine whether the association was affected by adjustment for confounders or by age of study population.

RESULTS

A total of 11 cross-sectional and prospective cohort studies were included in the analyses, with 34,185 individuals involved. Overall, patients with depression were at a significantly elevated risk of development of DR (fixed-effects OR = 1.50, 95% CI = 1.39-1.63; random-effects OR = 1.58, 95% CI = 1.35-1.84). The association did not vary by adjustment for confounders. However, a slightly larger pooled estimate was observed among studies with a mean age of <60 years (OR = 1.78, 95% CI = 1.46-2.07) than those with a mean age of ≥60 years (OR = 1.42, 95% CI = 1.16-1.75).

CONCLUSIONS

Depression was significantly associated with an increased incidence of DR in patients with type 2 diabetes mellitus. However, the existing literature does not yet definitely document that whether depression contributes directly or indirectly to incident DR. Further prospective investigations identifying high-risk subgroups are warranted.

Changes Induced by Mind-Body Intervention Including Epigenetic Marks and Its Effects on Diabetes

Studies have evidenced that epigenetic marks associated with type 2 diabetes (T2D) can be inherited from parents or acquired through fetal and early-life events, as well as through lifelong environments or lifestyles, which can increase the risk of diabetes in adulthood. However, epigenetic modifications are reversible, and can be altered through proper intervention, thus mitigating the risk factors of T2D. Mind-body intervention (MBI) refers to interventions like meditation, yoga, and qigong, which deal with both physical and mental well-being. MBI not only induces psychological changes, such as alleviation of depression, anxiety, and stress, but also physiological changes like parasympathetic activation, lower cortisol secretion, reduced inflammation, and aging rate delay, which are all risk factors for T2D. Notably, MBI has been reported to reduce blood glucose in patients with T2D. Herein, based on recent findings, we review the effects of MBI on diabetes and the mechanisms involved, including epigenetic modifications.

Association of reduced retinal arteriolar tortuosity with depression in older participants from the Northern Ireland Cohort for the Longitudinal Study of Ageing

INTRODUCTION

The retina shares similar anatomical and physiological features with the brain and subtle variations in retinal microvascular parameters (RMPs) may reflect similar vascular variation in the brain. The aim of this study was to assess associations between RMPs and measures of depression in the Northern Ireland Cohort for the Longitudinal Study of Ageing.

METHODS

RMPs (arteriolar and venular caliber, fractal dimension and tortuosity) were measured from optic disc centred fundus images using semi-automated software. Depression was characterised by the Centre for Epidemiologic Studies Depression Scale (CES-D) in the absence of mild cognitive impairment or use of anti-depressive medications. Associations between depression and RMPs were assessed by regression analyses with adjustment for potential confounders.

RESULTS

Data were available for 1376 participants of which 113 (8.2%) and 1263 (91.8%) were classified with and without depression. Participants had a mean age of 62.0 ± 8.4 yrs., 52% were female, and 8% were smokers. Individuals with depression had a higher CES-D score than those without (22.0 ± 6.2 versus 4.4 ± 3.9). Lower values of arteriolar tortuosity were significantly associated with depression, before and after adjustment for potential confounders (odds ratio = 0.79; 95% confidence intervals: 0.65, 0.96; P = 0.02).

CONCLUSION

Decreased retinal arteriolar tortuosity, a measure of the complexity of the retinal microvasculature was associated with depression in older adults independent of potential confounding factors. Retinal measures may offer opportunistic assessment of microvascular health associated with outcomes of depression.

Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis

To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi-directional association between depression and diabetes macrovascular and microvascular complications. Embase, Medline and PsycINFO databases were searched from inception through 27 November 2017. A total of 4592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Twenty-two studies were included in the systematic review. Sixteen studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over one million participants were suitable for meta-analysis. Depression was associated with an increased risk of incident macrovascular (HR = 1.38; 95% CI: 1.30-1.47) and microvascular disease (HR = 1.33; 95% CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two studies involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR = 1.14; 95% CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research.

The relationship between diabetic retinopathy and psychosocial functioning: a systematic review

IMPORTANCE

Previous work has reported a link between diabetic retinopathy/diabetic macular edema (DR/DME) and psychosocial functioning, although the extent and direction of the association remains uncertain.

OBJECTIVE

To determine the relationship between DR/DME and psychosocial functioning, the latter an umbrella term used to capture the emotional and social aspects of functioning which may include, for example, depression; depressive disorder; anxiety; vision-specific distress; diabetes-specific distress and emotional and social well-being.

EVIDENCE REVIEW

PubMed, Embase, Medline and the Cochrane Central register were systematically searched for relevant interventional and observational quantitative studies using standardised criteria. Studies with DR/DME and psychosocial functioning as exposures or outcomes were accepted. Study quality was evaluated using the modified Newcastle-Ottawa scale for observational studies, and the modified Down's and Black checklist for interventional studies.

FINDINGS

Of 1827 titles initially identified, 42 were included in the systematic review. They comprised of four interventions (one RCT, three non-RCTs) and 38 observational studies (33 cross sectional, five prospective). In studies with DR/DME as the exposure (n = 28), its severity and related vision impairment were consistently associated with poor psychosocial outcomes, mostly higher incidence of depression and depressive symptoms. Baseline depression and depressive symptoms were also associated with greater DR incidence and progression of DR. Medical intervention strategies showed significant improvement in psychosocial outcomes in patients with DR, such as significant improvements in mental health domain scores of the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ 25).

CONCLUSION AND RELEVANCE

Severity of DR, DME and associated vision loss are significantly associated with poor psychosocial outcomes. Aspects of depression and its symptoms show a bi-directional association, with increased incidence and progression of DR significant in those with baseline depression or depressive symptoms. Based on these findings, we propose two areas that may benefit from targeted interventions: (1) Prevention of development of poor psychological outcomes by preventing and delaying progression of DR/DME; and (2) Improved detection and management of poor psychological functioning by improving screening tools and multidisciplinary care for patients. Subsequent longitudinal studies can further help establish the underlying relationship between the two measures.

The predictive potential of altered spontaneous brain activity patterns in diabetic retinopathy and nephropathy

Objective

The amplitude of low-frequency fluctuation (ALFF) fMRI technique was used to study the changes of spontaneous brain activity in patients with diabetic retinopathy and nephropathy (DRN), and to explore the application of ALFF technique in the potential prediction and the targeted prevention of diabetic microangiopathy.

Methods

Nineteen patients with diabetic retinopathy and nephropathy and 19 healthy controls (HCs) were matched for age and gender. Spontaneous cerebral activity variations were investigated using the ALFF technique. The average ALFF values of the DRN patients and the HCs were classified utilizing receiver operating characteristic (ROC) curves.

Results

In contrast to the results in the HCs, the patients with DRN had significantly higher ALFF values in the cerebellum (bilaterally in the posterior and anterior lobes) and the left inferior temporal gyrus, but the ALFF values of the bilateral medial frontal gyrus, right superior temporal gyrus, right middle frontal gyrus, left middle/inferior frontal gyrus, bilateral precuneus, and left inferior parietal lobule were lower. ROC curve analysis of each brain region showed the accuracy of AUC was excellent. However, the mean ALFF values in the different regions did not correlate with clinical performance. The subjects showed abnormal neuronal synchronization in many areas of the brain, which is consistent with cognitive and visual functional deficits.

Conclusion

Abnormal spontaneous activity was detected in many areas of the brain, which may provide useful information for understanding the pathology of DRN. Abnormal ALFF values of these brain regions may be of predictive value in the development of early DRN and be a targeted intervention indicator for individualized treatment of diabetic microvascular diseases.

The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies

AIMS

Depression is a common co-morbidity in patients with type 2 diabetes mellitus (T2DM). Untreated depression in these patients adversely affects self-care activities and other diabetes complications. The aim of this study is to estimate the prevalence of depression among patients with T2DM by conducting a meta-analysis of observational studies.

METHODS

MEDLINE, Web of Science, Science Direct, and Google Scholar databases were searched for all observational studies that assessed depression in T2DM. Relevant articles were searched using the combination of Medical Subject Heading (MeSH) terms of "depression", "depressive disorder", and "diabetes mellitus" published between January 2007 and July 2018. Random effects model was used to estimate the weighted prevalence rates and 95% CI using "metaprop program in STATA 11".

RESULTS

In total, the 248 included studies (with 273 reported prevalence) identified 83,020,812 participants; of them, 23,245,827 (28%; 95% CI 27, 29) suffered from different severity levels of depressive disorders. The prevalence of depression was separately reported in 137,372 males and 134,332 females. Of them, 31,396 males (23%, 95% CI: 20, 26) and 45,673 females (34%, 95% CI: 31, 38) were depressed. Compared with global estimate, depression prevalence was lower in Europe (24%) and Africa (27%), but higher in Australia (29%) and Asia (32%). The prevalence in America was equal to the estimated prevalence in the world (28%). Depression was more common in subjects younger than 65 compared with elderlies (31% vs. 21%).

CONCLUSION

Our findings demonstrated that almost one in four adults with T2DM experienced depression. Given the high prevalence of depressive disorders in diabetic patients, screening these patients for co-morbid depression and its relevant risk factors is highly recommended.

Soluble CD163 was linked to galectin-3, diabetic retinopathy and antidepressants in type 1 diabetes

OBJECTIVE

Depression has been associated with diabetic retinopathy and increased plasma levels of galectin-3, a lectin expressed in activated macrophages. Increased levels of sCD163, the soluble form of a macrophage expressed scavenger receptor involved in several inflammatory processes, have been demonstrated in the vitreous of the eye in type 1 diabetes (T1D) patients with severe diabetic retinopathy. The aim was to explore whether circulating sCD163 was associated with diabetic retinopathy, depression and/or galectin-3 in T1D patients, controlling for gender, metabolic factors, other diabetes complications, life style and medication.

DESIGN

Cross sectional.

METHODS

Two hundred eighty-seven T1D patients, men 56%, age 18-59 years, diabetes duration ≥1 year, were consecutively recruited from one specialist diabetes clinic. Depression was assessed by Hospital Anxiety and Depression Scale-Depression subscale. Blood samples, anthropometrics and blood pressure values were collected, supplemented with data from electronic medical records and the Swedish National Diabetes Registry. High plasma sCD163 was defined as ≥0.575 mg/L (corresponding to the 80th percentile) and high plasma galectin-3 as ≥4.659 µg/L (corresponding to the 95th percentile).

RESULTS

The prevalence of depression was 10%, antidepressant medication 8%, diabetic retinopathy 72%, high sCD163 20% and high galectin 3 5%. High galectin-3 (AOR 9.7), antidepressants (AOR 3.8), diabetic retinopathy (AOR 2.4) and systolic blood pressure (per mmHg) (AOR 1.03) were associated with high sCD163.

CONCLUSIONS

This is the first study to show that circulating sCD163 was independently associated with galectin-3, the use of antidepressants and diabetic retinopathy, in patients with T1D. Depression was not associated with sCD163.

Interaction Between Depression, Obesity, and Type 2 Diabetes: A Complex Picture

Depression plays an important role in the pathogenesis and treatment of obesity and type 2 diabetes (T2D). However, its relevance is frequently unrecognized by clinicians and researchers. The purpose of this review is to present a critical analysis of the evidence linking depression and metabolic disorders and to highlight the practical implications of this complex relationship. Evidence obtained from epidemiological, basic, clinical and controlled studies demonstrate that the association goes beyond a random phenomenon. Epidemiological studies have rendered controversial results due to the lack of control of the confounding variables and the bidirectional relationship that exists between the outcomes and the conditions that modulate the association (i.e. socioeconomic status). Animal and human studies have been useful to define the anatomic substrates and physiologic processes that participate in the association, but, the evidence is preliminary in many areas (i.e gene × environmental interactions). Controlled studies have shown the strong impact that treatment of depression has on body weight and the large effect that has the correction of excess body weight on the depression-related symptoms. Practical implications of the depression-obesity duet include the training of the health providers to assess and treat these conditions in a concomitant manner, the need for translational medicine projects and the application the systems biology approach to fill the existing gaps of knowledge.

The burden of suicidal ideation among persons with type II diabetes: A scoping review

OBJECTIVE

Diabetes is a major global health concern. People with diabetes have worse mental health outcomes than those without diabetes. Researchers have recently sought to examine the relationship between diabetes and suicidal ideation. The aim of this study is to determine the burden of suicidal ideation among adults with type II diabetes from existing literature.

METHODS

We conducted a scoping review of published literature in PubMed, PsycINFO, CINAHL, Web of Science, and Google Scholar published before March 2017. To identify relevant literature, search terms included suicidal ideation and type II diabetes. The search was limited to English language peer-reviewed journal articles. The main outcome of interest was suicidal ideation captured on a validated scale in a population with type II diabetes.

RESULTS

This review resulted in 10 relevant studies, which reported the prevalence of suicidal ideation ranging from 2.5-51.4% with a median prevalence of 18.6% among adults with diabetes. Across the five studies reporting the associated risks, all but one study found a significant risk for persons with diabetes to endorse suicidal ideation and only three studies adjusted for depression.

CONCLUSIONS

This review demonstrates the need for future studies to investigate potential mechanistic pathways of suicidality among persons with diabetes.

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.

Female sex, young age, northern German residence, hypoglycemia and disabling diabetes complications are associated with depressed mood in the WHO-5 questionnaire - A multicenter DPV study among 17,563 adult patients with type 2 diabetes

BACKGROUND

Like other mental illnesses, depression is a culturally sensitive topic. Hence, findings cannot be transferred between countries. We investigated the frequency of depressed mood and its association with diabetes-related factors in a large type 2 diabetes (T2D) cohort from real-life care in Germany.

METHODS

17,563 adults (median [IQR]: 64.5[55.9-71.1] years) from the multicenter diabetes follow-up registry, DPV (diabetes prospective follow-up), were investigated. All had completed the WHO-5 questionnaire, a screening tool for depression. Logistic regression was applied to study the association of demographic and diabetes-related factors with depressed mood (SAS 9.4). P<0.05 was considered significant.

RESULTS

Using a WHO-5 cut-off of <13, 27.4% of patients were at risk for depressed mood. A clinical depression diagnosis was recognized in 8.4%. Female sex (OR: 1.5[95%-CI: 1.4-1.6]), young age (1.2[1.1-1.4]), longer diabetes duration (1.2[1.1-1.3]), and living in Northern Germany (1.3[1.2-1.4]) were each associated with increased odds for depressed mood. After adjusting for these confounders, worse glycemic control (1.4[1.3-1.5]), insulin use (1.3[1.2-1.4]), myocardial infarction (1.3[1.2-1.5]), stroke (1.8[1.5-2.0]), retinopathy (1.4[1.3-1.6]), renal failure (1.4[1.2-1.8]), diabetic foot syndrome (1.3[1.2-1.4]), severe hypoglycemia (1.5[1.2-1.9]), two or more inpatient admissions (2.1[1.8-2.4]), and longer duration of hospital stay (1-<14 days: 1.3[1.2-2.3]; >14 days: 2.1[1.9-2.3]) were related to depressed mood.

LIMITATION

Due to the cross-sectional design, no causality can be drawn.

CONCLUSIONS

In T2D, depressed mood is not uncommon. However, in routine care a clinical depression might be missed and regular screening is advisable. Besides the well-known associations with depressed mood, northern German residence and mainly life-compromising diabetes comorbidities were identified as related factors.

Increased Risk of Incident Chronic Kidney Disease, Cardiovascular Disease, and Mortality in Patients With Diabetes With Comorbid Depression

OBJECTIVE

It is not known if patients with diabetes with depression have an increased risk of chronic kidney disease (CKD). We examined the association between depression and incident CKD, mortality, and incident cardiovascular events in U.S. veterans with diabetes.

RESEARCH DESIGN AND METHODS

Among a nationally representative prospective cohort of >3 million U.S. veterans with baseline estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2, we identified 933,211 patients with diabetes. Diabetes was ascertained by an ICD-9-CM code for diabetes, an HbA1c >6.4%, or receiving antidiabetes medication during the inclusion period. Depression was defined by an ICD-9-CM code for depression or by antidepressant use during the inclusion period. Incident CKD was defined as two eGFR levels <60 mL/min/1.73 m2 separated by ≥90 days and a >25% decline in baseline eGFR. The associations between depression and outcomes were assessed using Cox proportional regression.

RESULTS

Depression was present in 340,806 patients at enrollment. Depressed patients were younger (61 ± 11 vs. 65 ± 11 years), had higher eGFR (84 ± 15 vs. 81 ± 14 mL/min/1.73 m2), but had more comorbidities. Incident CKD developed in 180,343 patients. Depression was associated with 20% higher risk of incident CKD (adjusted hazard ratio [aHR] and 95% CI: 1.20 [1.19-1.21]). Similarly, depression was associated with increased all-cause mortality (aHR and 95% CI: 1.25 [1.24-1.26]).

CONCLUSIONS

The presence of depression in patients with diabetes is associated with higher risk of developing CKD compared with nondepressed patients. Intervention studies should determine if effective treatment of depression in patients with diabetes would prevent major renal and cardiovascular complications.

Divergent Perceptions of Barriers to Diabetic Retinopathy Screening Among Patients and Care Providers, Los Angeles, California, 2014-2015

Introduction

Despite availability of screening for diabetic retinopathy, testing is underused by many low-income and racial/ethnic minority patients with diabetes. We examined perceived barriers to diabetic retinopathy screening among low-income patients and their health care providers and provider staffers.

Methods

We collected survey data from 101 patients with diabetes and 44 providers and staffers at a safety-net clinic where annual diabetic retinopathy screening rates were low. Barriers specified in the survey were derived from the literature.

Results

Patients surveyed (mean [standard deviation] age, 54.0 [7.7] y; 41% were male) were primarily Hispanics (70%) and African Americans (27%) of low socioeconomic status. Overall, 55% of patients received diabetic retinopathy screening in the previous year. Patients who could not explain why this screening is needed reported more barriers than patients who could (2.5 vs 1.4 barriers, P = .02). Fewer patients reported that they experienced barriers such as transportation (15%), language issues (15%), cultural beliefs or myths (4%), denial (8%), and fear (5%), which providers and staffers considered very or extremely important (all P < .001). Financial burdens (26%) and depression (22%) were most commonly reported by patients as barriers, yet providers and staffers did not rate these barriers as important, P < .001.

Conclusion

Patients and health care providers had markedly divergent perceptions of barriers to diabetic retinopathy screening. Patients with poor understanding of the need for screening were more likely to report such barriers. These results suggest a need for active community engagement to find key elements for education programs and other interventions to increase rates of diabetic retinopathy screening, particularly among low-income, minority populations.

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.

Depression in Diabetic Retinopathy: A Review and Recommendation for Psychiatric Management

BACKGROUND

Diabetic retinopathy (DR) is the most common microvascular complication of diabetes and one of the main causes of irreversible vision impairment in the working-age population. Multiple studies have demonstrated the significantly high prevalence of depression in patients with DR in recent years. The progression of DR could lead to depression, whereas depressive symptoms often worsen the condition of DR. Therefore, DR is one of the causes of psychosomatic diseases, the treatment for which should combine traditional DR therapy with depression interventions.

METHODS

We reviewed existing articles that investigated the association between DR and depression in the context of prevalence, risk factors, biological mechanisms, and treatment indications.

RESULTS

The literature review in this article includes a brief introduction to current studies of depression and DR, followed by a focus on the epidemiology of depression in DR that help doctors better identify potential or existing depression patients upon first diagnosis. The underlying biologic mechanisms between the 2 diseases are briefly reviewed, and potential treatments are addressed.

CONCLUSIONS

Depression in patients with DR is not uncommon and has a negative effect on the condition of DR. To achieve optimal prognosis in patients with DR and depression, more attention to combined psychiatric therapies for depression is recommended.

Depression in type 2 diabetes mellitus: prevalence, impact, and treatment

Clinically significant depression is present in one of every four people with type 2 diabetes mellitus (T2DM). Depression increases the risk of the development of T2DM and the subsequent risks of hyperglycemia, insulin resistance, and micro- and macrovascular complications. Conversely, a diagnosis of T2DM increases the risk of incident depression and can contribute to a more severe course of depression. This linkage reflects a shared etiology consisting of complex bidirectional interactions among multiple variables, a process that may include autonomic and neurohormonal dysregulation, weight gain, inflammation, and hippocampal structural alterations. Two recent meta-analyses of randomized controlled depression treatment trials in patients with T2DM concluded that psychotherapy and antidepressant medication (ADM) were each moderately effective for depression and that cognitive behavior therapy (CBT) had beneficial effects on glycemic control. However, the number of studies (and patients exposed to randomized treatment) included in these analyses is extremely small and limits the certainty of conclusions that can be drawn from the data. Ultimately, there is no escaping the paucity of the evidence base and the need for additional controlled trials that specifically address depression management in T2DM. Future trials should determine both the effects of treatment and the change in depression during treatment on measures of mood, glycemic control, and medical outcome.

The association of antidepressant medications and diabetic retinopathy among people with diabetes

OBJECTIVE

To determine if the use of antidepressants was associated with lower odds of diabetic retinopathy and if so, to determine if this association was mediated by decreased inflammation as measured by C-reactive protein (CRP).

DESIGN

This was a cross sectional study of 1,041 participants with type 2 diabetes 40-85years old from the 2005-2008 National Health and Nutrition Examination Survey (NHANES). Multiple logistic regression was used to examine the association between the outcome of diabetic retinopathy and the primary exposure of antidepressant medication usage. We also determined whether CRP meets standard criteria as a mediator between antidepressant use and diabetic retinopathy.

RESULTS

Participants using antidepressants were less likely to have diabetic retinopathy (OR 0.50, 95% CI: 0.31-0.82). CRP did not meet one of the criteria for mediation. However, CRP was an effect modifier such that the association of antidepressant use and diabetic retinopathy was only present among participants with CRP ≥0.3mg/dl. Among the antidepressant drug classes, selective serotonin reuptake inhibitor (SSRI) users had significantly lower odds of developing diabetic retinopathy compared to non-users of antidepressants.

CONCLUSIONS

Using representative survey data of US adults with type-2 diabetes, this study found that antidepressant use was associated with lower odds of diabetic retinopathy. Further longitudinal and experimental studies are necessary to confirm this finding and to determine if there is a role for antidepressants in preventing diabetic retinopathy in select patient populations.

Light therapy for better mood and insulin sensitivity in patients with major depression and type 2 diabetes: a randomised, double-blind, parallel-arm trial

BACKGROUND

Major depression and type 2 diabetes often co-occur. Novel treatment strategies for depression in type 2 diabetes patients are warranted, as depression in type 2 diabetes patients is associated with poor prognosis and treatment results. Major depression and concurrent sleep disorders have been related to disturbances of the biological clock. The biological clock is also involved in regulation of glucose metabolism by modulating peripheral insulin sensitivity. Light therapy has been shown to be an effective antidepressant that 'resets' the biological clock. We here describe the protocol of a study that evaluates the hypothesis that light therapy improves mood as well as insulin sensitivity in patients with a major depressive episode and type 2 diabetes.

METHODS/DESIGN

This study is a randomised, double-blind, parallel-arm trial in 98 participants with type 2 diabetes and a major depressive episode, according to DSM-IV criteria. We will assess whether light therapy improves depressive symptoms and insulin sensitivity, our primary outcome measures, and additionally investigate whether these effects are mediated by restoration of the circadian rhythmicity, as measured by sleep and hypothalamic-pituitary-adrenal axis activity. Participants will be randomly allocated to a bright white-yellowish light condition or dim green light condition. Participants will undergo light therapy for half an hour every morning for 4 weeks at home. At several time points, namely before the start of light therapy, during light therapy, after completion of 4 weeks of light therapy and after 4 weeks follow-up, several psychometrical, psychophysiological and glucometabolic measures will be performed.

DISCUSSION

If light therapy effectively improves mood and insulin sensitivity in type 2 diabetes patients with a major depressive episode, light therapy may be a valuable patient friendly addition to the currently available treatment strategies. Additionally, if our data support the role of restoration of circadian rhythmicity, such an observation may guide further development of chronobiological treatment strategies in this patient population.

TRIAL REGISTRATION

The Netherlands Trial Register (NTR) NTR4942 . Registered 13 January 2015.

Adverse effects of depression on glycemic control and health outcomes in people with diabetes: a review

In the past decades, important advances have been achieved in the psychological aspects of diabetes. This article reviews the associations between diabetes, depression, and adverse health outcomes. The article provides an update on the literature regarding the prevalence of depression in diabetes, discusses the impact of depression on diabetes self-care and glycemic control in people with diabetes, and summarizes the results of longitudinal studies that have investigated depression as a risk factor for adverse health outcomes.

The relationship between bipolar disorder and type 2 diabetes: more than just co-morbid disorders

Type 2 diabetes mellitus (T2DM) rates are three times higher in patients with bipolar disorder (BD), compared to the general population. This is a major contributing factor to the elevated risk of cardiovascular mortality, the leading cause of death in bipolar patients. There may be shared pathophysiology linking the two disorders, including hypothalamic-pituitary-adrenal and mitochondrial dysfunction, common genetic links, and epigenetic interactions. Life-style, phenomenology of bipolar symptoms, and adverse effects of pharmacotherapy may be contributing factors. Patients with BD and T2DM have a more severe course of illness and are more refractory to treatment. Control of their diabetes is poorer when compared to diabetics without BD, and an existing disparity in medical care may be partly responsible. Glucose abnormalities in bipolar patients need to be screened for and treated. Metformin appears to have the best benefit/risk ratio, and the dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists and analogues also appear promising, although these agents have not been specifically studied in populations with mood disorders. Physicians need to be aware of the increased risk for T2DM and cardiovascular disease in bipolar patients, and appropriate prevention, screening, case finding, and treatment is recommended.

Plasma plasminogen activator inhibitor-1 is associated with end-stage proliferative diabetic retinopathy in the Northern Chinese Han population

Objective. To identify predictors of end-stage proliferative diabetic retinopathy (PDR) in a cohort of individuals with type 2 diabetes mellitus (T2DM) from the Northern Chinese Han population. Methods. We investigated characteristics of 153 consecutive diabetic patients with end-stage PDR (62 males, 91 females), 123 consecutive PDR patients without end-stage PDR (48 males, 75 females), and 151 normal subjects (63 males, 88 females). Only one eye of each patient or healthy subject was included in this study. Univariate logistic regression models and multivariate logistic regression models were constructed to evaluate the predictors of end-stage PDR. Results. In univariate analysis, systolic blood pressure, diastolic blood pressure, duration of diabetes, family history of T2DM, and plasminogen activator inhibitor-1 (PAI-1) were significently associated with end-stage PDR. After multivariate analysis, family history of T2DM, plasma PAI-1 levels, smoking, and duration of diabetes were four positive predictors associated with end-stage PDR. Conclusions. Higher plasma levels of PAI-1 were associated with end-stage PDR in the Northern Chinese Han population with T2DM.

Key concepts in screening for depression in people with diabetes

BACKGROUND

The prevalence of depression is increased in people with diabetes and there are both national and international recommendations for screening of depression in people with diabetes. The aim of this review is to assess the justification for screening for depression in people with diabetes.

METHODS

The viability, effectiveness and appropriateness of screening for depression in people with diabetes were assessed based on the UK National Screening Committee criteria for appraising screening programs. For this purpose, a review of relevant publications from the literature listed in MEDLINE, Psych-INFO and EMBASE was performed.

RESULTS

Most criteria for screening of depression in diabetes are fully or partially fulfilled. Further research is needed to provide fully scientifically substantiated recommendations for screening for depression in diabetes, especially in the areas of effectiveness and cost-effectiveness of such screening programs.

LIMITATIONS

As most screening is currently sporadic and there are no formal screening programs, some criteria are not satisfied.

CONCLUSIONS

There is a rationale to introduce screening for depression in patients with diabetes in a clinical setting but further research is needed to evaluate the most clinically effective and cost effective way of doing so in structured screening programs.