1
|
Relationship between Depression with Physical Activity and Obesity in Older Diabetes Patients: Inflammation as a Mediator. Nutrients 2022; 14:nu14194200. [PMID: 36235852 PMCID: PMC9572195 DOI: 10.3390/nu14194200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
Obesity and physical activity (PA) may affect inflammation and are also related to depression. This study aimed to explore the association between depression, obesity, and PA in older diabetes patients mediated by inflammation. We conducted a cross-sectional study with 197 elderly diabetes patients (≥65 y/o). Participants were interviewed to gather demographic and lifestyle data. Assessment of depression was based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. High-sensitivity C-reactive protein was used as a marker of inflammation. Participants with a body mass index (kg/m2) ≥ 27 were considered to be obese. Our data indicated that among all participants with (n = 57) and without (n = 140) depression, older diabetes patients with depression had a lower intake of energy and protein and a lower prevalence of smoking and alcohol consumption than those without depression (p < 0.05). We also found that inflammation may be a partial mediator in the relationship between obesity and depression, and a significant mediator between PA and depression. Additionally, a regression model of obesity and PA showed that PA was a significant predictor of inflammation. However, the association between obesity and inflammation was not significant. When obesity, PA, and inflammation were included in a regression model together, inflammation significantly predicted depression (OR = 4.18, p = 0.004). The association between obesity and depression was also significant (OR = 2.45, p = 0.038). However, the association between PA and depression was not significant, and the mediating effect of inflammation was significant according to the Sobel test (z = −2.01, p = 0.045). In conclusion, the beneficial effects of PA may lower levels of inflammation produced by obesity, thus reducing inflammatory effects that may be related to depression. Overall, inflammation may mediate the relationship between depression and PA in older diabetes patients.
Collapse
|
2
|
Carreira M, Ruiz de Adana MS, Pinzón JL, Anarte-Ortiz MT. Internet-based Cognitive-behavioral therapy (CBT) for depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study): A randomized controlled trial protocol. PLoS One 2022; 17:e0274551. [PMID: 36126050 PMCID: PMC9488778 DOI: 10.1371/journal.pone.0274551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/19/2022] [Indexed: 11/19/2022] Open
Abstract
Background Professionals need adequate tools to help patients with diabetes and depression. Although web programs integrating cognitive-behavioral therapy with diabetes education have shown good results, no similar approach has been performed as yet in Spain. The objective is to develop an Internet-based program for the treatment of mild-moderate depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study) based on Cognitive-behavioral therapy (CBT) and assess its results. Methods A 2-arm randomized controlled trial will be conducted. Adults with type 1 diabetes and mild-moderate depressive symptoms will be screened to participate in the study and randomly assigned to either the treatment group (TG) that will use a Web-based application for a specific 9-week intervention in depression and type 1 diabetes or the control group (CG) that will be on the waiting list during that time. Results Data on the primary variable (depressive symptoms) and secondary variables (treatment-related distress, anxiety, fear of hypoglycemia, quality of life, treatment adherence, coping strategies and glycemic control) will be collected from the TG at the beginning/baseline, at the end of treatment and at 3, 6 and 12 months after treatment. The CG will be assessed at the beginning and at the end of the TG intervention. On completion of the program by the TG, the treatment will then be carried out in the CG. Conclusions The new web application developed is expected to be effective for the treatment of mild-moderate depressive symptoms in adults with type 1 diabetes, reducing depressive symptoms and improving the rest of the analyzed variables. Trial registration Registry: NCT03473704 (March 21, 2018); ClinicalTrials.gov.
Collapse
Affiliation(s)
- Mónica Carreira
- Department of Personality, Assessment and Psychological Treatment, Biomedical Research Institute of Malaga (IBIMA), University of Malaga, Málaga, Spain
| | - María Soledad Ruiz de Adana
- Clinical Management Unit of Endocrinology and Nutrition, Biomedical Research Institute of Malaga (IBIMA), Regional University Hospital, University of Malaga, Málaga, Spain
| | - José Luis Pinzón
- Clinical Management Unit of Endocrinology and Nutrition, Biomedical Research Institute of Malaga (IBIMA), Virgen de la Victoria University Hospital, University of Malaga, Málaga, Spain
| | - María Teresa Anarte-Ortiz
- Department of Personality, Assessment and Psychological Treatment, Biomedical Research Institute of Malaga (IBIMA), University of Malaga, Málaga, Spain
- * E-mail:
| |
Collapse
|
3
|
Keating P, O'Connor R, O'Doherty J, Hannigan A, Cullen W, Hickey L, Harnett A, Meagher D, O'Regan A. Prescription of psychotropic medication in patients with type two diabetes mellitus: A multi-practice study from Ireland. Eur J Gen Pract 2019; 25:157-163. [PMID: 31335225 PMCID: PMC6713112 DOI: 10.1080/13814788.2019.1640208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: Comorbid anxiety and depression and type two diabetes mellitus (T2DM) are commonly managed by General Practitioners (GPs). Objectives: To investigate the proportion of people with T2DM who are prescribed either antidepressant or benzodiazepine medications in general practice; to compare people with T2DM that have a prescription with those that do not in terms of patient characteristics, glycaemic control and healthcare utilization. Methods: Anonymized data was collected by GPs and senior medical students from electronic medical records of patients with T2DM in 34 Irish general practices affiliated with the University of Limerick Graduate Entry Medical School during the 2013/14 academic year. Data included demographics, healthcare utilization, prescriptions and most recent glycosylated haemoglobin (HbA1c) measurement. Results: The sample included 2696 patients with T2DM, of which 733 (36.7%) were female, and with a median age of 66 years. The percentage with a current prescription for an antidepressant or benzodiazepine was 22% (95%CI: 18.9–24.9). Those with a current prescription for either drug were more likely to have attended the emergency department (28.3% vs 15.7%, P <0.001), to have been admitted to hospital (35.4% vs 21.3%, P <0.001) in the past year and attend their GP more frequently (median of 9 vs 7, P <0.001) than those without a prescription. Rates of poor glycaemic control were similar in those with and without a current prescription. Conclusion: Over one-fifth of people with T2DM in Irish general practice are prescribed an antidepressant or benzodiazepine medication. Prescription of these is associated with increased healthcare utilization but not poorer glycaemic control.
Collapse
Affiliation(s)
- Paul Keating
- a Department of General Practice, Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| | - Ray O'Connor
- a Department of General Practice, Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| | - Jane O'Doherty
- a Department of General Practice, Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| | - Ailish Hannigan
- b Biostatistics at Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| | - Walter Cullen
- c School of Medicine, Health Sciences, UCD , Dublin , Ireland
| | | | - Anne Harnett
- e Pharmacology at Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| | - David Meagher
- f Psychiatry at Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| | - Andrew O'Regan
- g General Practice at Graduate Entry Medical School, University of Limerick , Limerick , Ireland
| |
Collapse
|
4
|
Sarfo-Kantanka O, Sarfo FS, Kyei I, Agyemang C, Mbanya JC. Incidence and determinants of diabetes-related lower limb amputations in Ghana, 2010-2015- a retrospective cohort study. BMC Endocr Disord 2019; 19:27. [PMID: 30823912 PMCID: PMC6397489 DOI: 10.1186/s12902-019-0353-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 02/21/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Diabetes-related lower limb amputations (LLA) are associated with significant morbidity and mortality. Although the incidence has decreased over the past two decades in most High-Income Countries, the situation in Low-Middle Income Countries (LMIC), especially those in sub-Saharan Africa (SSA) is not clear. We have determined the incidence and determinants of diabetes-related LLA in Ghana. METHODS This was a tertiary-care-based retrospective cohort study involving patients enrolled in the diabetes clinic of Komfo Anokye Teaching Hospital, Ghana from 1st January 2010 to 31st December 2015 after a median follow-up of 4.2 years. Demographic characteristics and clinical variables at baseline were recorded. The primary outcome was new diabetes-related LLA in each year under study. Cox proportional hazard regression models were used to describe the associations of diabetes-related LLA. RESULTS The mean age at enrolment for the cohort was 55.9 ± 14.6 years, with a female preponderance (62.1%). The average incidence rate of diabetes-related LLA was 2.4 (95% CI:1.84-5.61) per 1000 follow-up years: increasing from 0.6% (95% CI:0.21-2.21) per 1000 follow up years in 2010 to 10.9% (95% CI:6.22-12.44) per 1000 follow-up years in 2015. Diabetes-related LLA was associated with increased age at enrollment (for every 10 year increase in age: HR: 1.11, CI: 1.06-1.22, p < 0.001), male gender (HR: 3.50, CI:2.88-5.23, p < 0.01), type 2 diabetes (HR 3.21, CI: 2.58-10.6, p < 0.001), high Body Mass Index (HR: 3.2, CI: 2.51-7.25 p < 0.001), poor glycemic control (for a percent increase in HbA1c, HR:1.11, CI:1.05-1.25, p = 0.03), hypertension (HR:1.14, CI:1.12-3.21 p < 0.001), peripheral sensory neuropathy (HR:6.56 CI:6.21-8.52 p < 0.001) and peripheral vascular disease (HR: 7.73 CI: 4.39-9.53, p < 0.001). CONCLUSION The study confirms a high incidence of diabetes related-LLA in Ghana. Interventions aimed at addressing systemic and patient-level barriers to good vascular risk factor control and proper foot care for diabetics should be introduced in LMICs to stem the tide of the increasing incidence of LLA.
Collapse
Affiliation(s)
- Osei Sarfo-Kantanka
- Komfo Anokye Teaching Hospital, Endocrine and Diabetes Unit, P.O Box 1934, Kumasi, Ghana
| | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Endocrine and Diabetes Unit, P.O Box 1934, Kumasi, Ghana
- Department of Medicine, Komfo Anokye Teaching Hospital/ School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ishmael Kyei
- Komfo Anokye Teaching Hospital, Endocrine and Diabetes Unit, P.O Box 1934, Kumasi, Ghana
| | - Charles Agyemang
- Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jean Claude Mbanya
- Faculty of Medicine and Department of Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| |
Collapse
|
5
|
Lower quality of life, lower limb pain with neuropathic characteristics, female sex, and ineffective metabolic control are predictors of depressive symptoms in patients with type 2 diabetes mellitus treated in primary care. Int J Diabetes Dev Ctries 2018. [DOI: 10.1007/s13410-018-0667-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
|
6
|
Khalaila R. Depression statuses and related predictors in later life: A 10-year follow-up study in Israel. Eur J Ageing 2016; 13:311-321. [PMID: 28804385 DOI: 10.1007/s10433-016-0384-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The aim of the current study was to investigate the factors associated with depression statuses in a 10-year follow-up of community-dwelling older adults in Israel. Longitudinal data were used from the Israeli sample of the Survey of Health, Aging and Retirement in Europe, assessing the depressive symptoms in 1042 respondents, aged 50 or above, at three time points: 2004/2005 (Wave I); 2009/2010 (Wave II); and 2014/2015 (Wave III). Multinomial logistic regression was used to determine the relationships among explanatory variables and depression statuses (no-depression, intermittent depression, or persistent depression). Some 46.5 % of the participants suffered from intermittent or persistent depression. Five factors were associated with increasing the probability of both intermittent and persistent depression: being female, unemployed, less educated, physically disabled, and in poor health. Five other explanatory variables were associated only with a higher risk for persistent depression: low family income, widowhood, physical inactivity, more than two chronic diseases, and cognitive dysfunction. According to these findings, depression is common among older people in Israel. Low socio-economic status and poor subjective and physical health are significant determinants of depression statuses over time, underlining the importance of taking measures to improve these conditions in order to reduce the risk of depression in old age.
Collapse
Affiliation(s)
- Rabia Khalaila
- Nursing Department, Zefat Academic College, 11 Jerusalem St., P.O.B. 160, Zefat, 13206 Israel
| |
Collapse
|
7
|
Kim GM, Woo JM, Jung SY, Shin S, Song HJ, Park J, Ahn J. Positive association between serious psychiatric outcomes and complications of diabetes mellitus in patients with depressive disorders. Int J Psychiatry Med 2015; 50:131-46. [PMID: 26353830 DOI: 10.1177/0091217415605024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Depression and diabetes are closely biologically and behaviorally intertwined. We examined the impact of comorbid diabetes mellitus on the incidence of serious psychiatric outcomes among patients with depression. METHODS We used claims data from the Korean Health Insurance Review & Assessment Service database of patients who were diagnosed with depression within one year of an index prescription for antidepressants between January 2007 and June 2008. We investigated the association between the comorbidity of diabetes mellitus and serious psychiatric outcomes of depression, such as psychiatric hospitalization, psychiatric emergency room visits, and suicide attempts. RESULTS Among 200,936 patients with depression, 74,160 (36.9%) had diabetes mellitus, including 57,418 (28.6%) with complications. The incidence of serious psychiatric outcomes was 3.3% in patients with depression without diabetes and 6.7% in patients with depression and diabetes mellitus. Patients with depression and diabetes mellitus complications showed higher rates of serious outcomes than that did those without diabetes mellitus complications (odds ratio, 1.19; 95% confidence interval, 1.11-1.13). Similarly, depressed patients with micro and macrovascular diabetic complications were more likely to experience serious outcomes than those without diabetes mellitus complications (odds ratio, 2.2; 95% confidence interval, 2.07-2.34). CONCLUSIONS Our results showed that comorbid diabetes mellitus can increase the risk of serious outcomes of depression, such as suicide and hospitalization, and thus may alter the antidepressants prescription patterns and healthcare service use among patients with depressive disorders.
Collapse
Affiliation(s)
- Gyung-Mee Kim
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea Department of Psychiatry, Haeundae Paik Hospital, Inje University School of Medicine, Busan, Korea
| | - Jong-Min Woo
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea Department of Psychiatry, Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea Stress Research Institute, Inje University, Seoul, Korea
| | - Sun-Young Jung
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea Korea Institute of Drug Safety and Risk Management (KIDS), Seoul, Korea
| | - Sangjin Shin
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea
| | - Hyun Jin Song
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea School of Pharmacy, Sungkyunkwan University, Suwon, Korea
| | - Jooyeon Park
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea
| | - Jeonghoon Ahn
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea
| |
Collapse
|
8
|
Starkstein SE, Davis WA, Dragovic M, Cetrullo V, Davis TME, Bruce DG. Diagnostic criteria for depression in type 2 diabetes: a data-driven approach. PLoS One 2014; 9:e112049. [PMID: 25390370 PMCID: PMC4229133 DOI: 10.1371/journal.pone.0112049] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 10/11/2014] [Indexed: 01/22/2023] Open
Abstract
Background While depression is a frequent psychiatric comorbid condition in diabetes and has significant clinical impact, the syndromal profile of depression and anxiety symptoms has not been examined in detail. Aims To determine the syndromal pattern of the depression and anxiety spectrum in a large series of patients with type 2 diabetes, as determined using a data-driven approach based on latent class analysis (LCA). Method Type 2 diabetes participants from the observational community-based Fremantle Diabetes Study Phase II underwent assessment of lifetime depression using the Brief Lifetime Depression Scale, the Patient Health Questionnaire 9-item version (PHQ-9) for current depression symptoms, and the Generalized Anxiety Disorder Scale that was specifically developed and validated for this study. The main outcome measure was classes of patients with a specific syndromal profile of depression and anxiety symptoms based on LCA. Results LCA identified four classes that were interpreted as “major anxious depression”, “minor anxious depression”, “subclinical anxiety”, and “no anxious depression”. All nine DSM-IV/5 diagnostic criteria for major depression identified a class with a high frequency of major depression. All symptoms of anxiety had similar high probabilities as symptoms of depression for the “major depression-anxiety” class. There were significant differences between classes in terms of history of depression and anxiety, use of psychoactive medication, and diabetes-related variables. Conclusions Patients with type 2 diabetes show specific profiles of depression and anxiety. Anxiety symptoms are an integral part of major depression in type 2 diabetes. The different classes identified here provide empirically validated phenotypes for future research.
Collapse
Affiliation(s)
- Sergio E. Starkstein
- School of Psychiatry & Clinical Neuroscience, University of Western Australia, Crawley, Western Australia, Australia
- * E-mail:
| | - Wendy A. Davis
- School of Medicine & Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Milan Dragovic
- School of Psychiatry & Clinical Neuroscience, University of Western Australia, Crawley, Western Australia, Australia
| | - Violetta Cetrullo
- School of Medicine & Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Timothy M. E. Davis
- School of Medicine & Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - David G. Bruce
- School of Medicine & Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| |
Collapse
|
9
|
Mendenhall E, Norris SA, Shidhaye R, Prabhakaran D. Depression and type 2 diabetes in low- and middle-income countries: a systematic review. Diabetes Res Clin Pract 2014; 103:276-85. [PMID: 24485858 PMCID: PMC3982306 DOI: 10.1016/j.diabres.2014.01.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/16/2013] [Accepted: 01/01/2014] [Indexed: 01/28/2023]
Abstract
Eighty percent of people with type 2 diabetes reside in low- and middle-income countries (LMICs). Yet much of the research around depression among people with diabetes has been conducted in high-income countries (HICs). In this systematic review we searched Ovid Medline, PubMed, and PsychINFO for studies that assessed depression among people with type 2 diabetes in LMICs. Our focus on quantitative studies provided a prevalence of comorbid depression among those with diabetes. We reviewed 48 studies from 1,091 references. We found that this research has been conducted primarily in middle-income countries, including India (n = 8), Mexico (n = 8), Brazil (n = 5), and China (n = 5). There was variation in prevalence of comorbid depression across studies, but these differences did not reveal regional differences and seemed to result from study sample (e.g., urban vs rural and clinical vs population-based samples). Fifteen depression inventories were administered across the studies. We concluded that despite substantial diabetes burden in LMICs, few studies have reviewed comorbid depression and diabetes. Our review suggests depression among people with diabetes in LMICs may be higher than in HICs. Evidence from these 48 studies underscores the need for comprehensive mental health care that can be integrated into diabetes care within LMIC health systems.
Collapse
Affiliation(s)
- Emily Mendenhall
- Science, Technology, and International Affairs Program, Walsh School of Foreign Service, 301 Intercultural Center, Georgetown University, Washington D.C. 20057, United States.
| | - Shane A Norris
- MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Rahul Shidhaye
- Indian Institute of Public Health and Public Health Foundation of India, Hyderabad, India
| | - Dorairaj Prabhakaran
- Centre of Excellence for Cardiometabolic Risk Reduction in South Asia (CARRS), and Centre for Chronic Disease Control, New Delhi, India
| |
Collapse
|
10
|
|
11
|
Lloyd CE, Roy T, Nouwen A, Chauhan AM. Epidemiology of depression in diabetes: international and cross-cultural issues. J Affect Disord 2012; 142 Suppl:S22-9. [PMID: 23062853 DOI: 10.1016/s0165-0327(12)70005-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This paper reviews the most up-to-date epidemiological evidence of the relationship between depression and diabetes, and considers the risk factors for the development of depression and the consequences of depression in diabetes with an emphasis on international and cross-cultural data. The difficulties that researchers face when epidemiological studies require assessment of psychological phenomena, such as depression, across different cultural settings are explored. METHODS Relevant papers were sought on the epidemiology of diabetes and depression in people with diabetes by undertaking a literature search of electronic databases including MEDLINE, Psych-INFO, CINAHL and EMBASE. These papers were assessed by the authors and a narrative review of the relevant literature was composed. RESULTS Systematic reviews of the prevalence of depression in people with diabetes have focused on studies conducted in English speaking countries and emerging data suggest that there may be international variations in prevalence and also in how symptoms of depression are reported. There appears to be a bi-directional relationship between depression and diabetes, with one influencing the other; however, research in this area is further complicated by the fact that potential risk factors for depression in people with diabetes often interact with each other and with other factors. Further research is needed to elucidate the causal mechanisms underlying these associations. LIMITATIONS Data from non-English speaking countries remain scarce and so it is difficult to come to any firm conclusions as to the international variation in prevalence rates of co-morbid diabetes and depression in these countries until further research has been conducted. CONCLUSION It is important to take a culture-centered approach to our understanding of mental health and illness and consider the key issues related to the development of culturally sensitive depression screening tools. In order to come to any firm conclusions about the international variation in prevalence of co-morbid diabetes and depression, issues of culture and diversity must be taken into account prior to conducting international epidemiological studies.
Collapse
|