The association of lifetime psychiatric illness and increased retinopathy in patients with type I diabetes mellitus

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.

50 Years of Behavioral Science in Diabetes: A 2020 Vision of the Future

This article is adapted from a speech Dr. de Groot delivered in June 2020 as President, Health Care & Education, of the American Diabetes Association at the Association's 80th Scientific Sessions, which was held online as a result of coronavirus disease 2019. Dr. de Groot is an Associate Professor of Medicine in the Division of Endocrinology, Diabetes and Metabolism at Indiana University (IU) School of Medicine. She serves as the Acting Director of the IU Diabetes Translational Research Center. Dr. de Groot is the 2020 recipient of the Rachmiel Levine Medal for Leadership from the American Diabetes Association.In the year 2020, we marked the 50th anniversary of the field of behavioral science in diabetes in the modern era. Over this relatively short period of time, this field has charted the psychosocial landscape of prediabetes and diabetes by establishing the prevalence and impact of emotional and behavioral aspects of diabetes. Interventions to address these conditions have been developed that span the T2 to T4 translational research spectrum ranging from the intrapsychic to population-based interventions. Policies ranging from standards of care to Medicare benefits have been implemented. A review of research in the area of diabetes and depression is provided as an example of innovations in this field. Behavior is the foundation of all interventions we make in diabetes and prediabetes. As a mature science, it is critical to stemming the tide of diabetes and its outcomes. To make additional strides, we must rebalance our focus and augment funding for behavioral interventions for individuals, communities, and health care systems in conjunction with other forms of treatment.

50 Years of Behavioral Science in Diabetes: A 2020 Vision of the Future

Editor's Note: This article is adapted from a speech Dr. de Groot delivered in June 2020 as President, Health Care & Education, of the American Diabetes Association. She delivered her address at the Association's 80th Scientific Sessions, which was held online as a result of the coronavirus disease 2019.

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.

Examining Knowledge, Attitudes, and Beliefs About Depression Among Latino Adults With Type 2 Diabetes

PURPOSE

The purpose of this study was to explore knowledge, attitudes, and beliefs about depression among Latinos with type 2 diabetes.

METHODS

Eight 90-minute focus groups were conducted, each moderated by a bilingual, bicultural woman. Participants included 45 self-identified Latino adults with diabetes. Discussion topics included diabetes management, perceived control, emotional barriers, conceptualization of depression, and help-seeking behavior. Themes pertinent to depression and emotional health were identified using a combined deductive/inductive approach and an iterative process of consensus coding.

RESULTS

Participants' mean age was 40 years, 44% were male, and most were born in Mexico. The mean time with diabetes was 6.5 years. The primary theme identified was the bidirectional relationship between emotional health and diabetes. Diagnosis of diabetes led to feelings of hopelessness and upset, while difficulty with diabetes management led to feelings of anxiety and depression. Participants felt that being "stressed out" or sad directly affected their blood sugar. Participants described factors that influence the relationship between emotions and diabetes, including family and societal stressors, and they reported little discussion of depression with providers. Depression and emotional health are closely associated with diabetes in the minds of these Latino adults. It is important to ask patients with diabetes about their emotional health, to screen for depression, and to elicit preferences about treatment when indicated.

Depression Increases Diabetes Symptoms by Complicating Patients’ Self-Care Adherence

PURPOSE

This study evaluated whether diabetes patients with depressive symptoms are more likely than other diabetes patients to report symptoms of glucose dysregulation, and whether this relationship is mediated by the impact of depressive symptoms on patients' adherence to their diabetes self-care regimen.

METHODS

Participants were English- and Spanish-speaking adults with type 2 diabetes. Interviewers assessed participants' depressive symptoms and diabetes-related symptoms at baseline. Self-care behaviors and diabetes symptoms were measured at a 1-year follow-up. Structural equation models were used to determine whether depression affected diabetes symptoms by limiting patients' ability to adhere to self-care recommendations.

RESULTS

An initial model identified direct effects of baseline depressive symptoms on self-care and diabetes symptoms at follow-up. The relationship between self-care behaviors and physical symptoms of poor glycemic control were assessed using a second model. Results explained the relationship between depressive symptoms at baseline and diabetes symptoms at 1 year.

CONCLUSIONS

Depressive symptoms impact subsequent physical symptoms of poor glucose control by influencing patients' ability to adhere to their self-care regimen. More aggressive management of depression among patients with diabetes may improve their physical health as well as their mental health.

Angiographic evidence of proliferative retinopathy predicts neuropsychiatric morbidity in diabetic patients

INTRODUCTION

Diabetic retinopathy (DR) is a common vasculopathy categorized as either non-proliferative (NPDR) or proliferative (PDR),characterized by dysfunctional blood-retinal barrier (BRB) and diagnosed using fluorescein angiography (FA). Since the BRB is similar in structure and function to the blood-brain barrier (BBB) and BBB dysfunction plays a key role in the pathogenesis of brain disorders, we hypothesized that PDR, the severe form of DR, is likely to mirror BBB damage and to predict a worse neuropsychiatric outcome.

METHODS

A retrospective cohort study was conducted among subjects with diabetes (N=2982) with FA-confirmed NPDR (N=2606) or PDR (N=376). Incidence and probability to develop brain pathologies and mortality were investigated in a 10-year follow-up study. We used Kaplan-Meier, Cox and logistic regression analyses to examine association between DR severity and neuropsychiatric morbidity adjusting for confounders.

RESULTS

Patients with PDR had significantly higher rates of all-cause brain pathologies (P<0.001), specifically stroke (P=0.005), epilepsy (P=0.006) and psychosis (P=0.024), and a shorter time to develop any neuropsychiatric event (P<0.001) or death (P=0.014) compared to NPDR. Cox adjusted hazard ratio for developing all-cause brain impairments was higher for PDR (HR=1.37, 95% CI 1.16-1.61, P<0.001) which was an independent predictor for all-cause brain impairments (OR 1.30, 95% CI 1.04-1.64, P=0.022), epilepsy (OR 2.16, 95% CI 1.05-4.41, P=0.035) and mortality (HR=1.35, 95% CI 1.06-1.70, P=0.014).

CONCLUSIONS

This is the first study to confirm that angiography-proven microvasculopathy identifies patients at high risk for neuropsychiatric morbidity and mortality.

The association between diabetes and depression: a very disabling condition

Rates of depression are significantly increased in diabetic patients, and even more in the elderly. About 20-30% of patients with diabetes suffer from clinically relevant depressive disorders, 10% of which being affected by the major depression disorder. Moreover, people with depression seem to be more prone to develop an associated diabetes mellitus, and depression can worsen glycemic control in diabetes, with higher risk to develop complications and adverse outcomes, whereas improving depressive symptoms is generally associated with a better glycemic control. Thus, the coexistence of depression and diabetes has a negative impact on both lifestyle and quality of life, with a reduction of physical activity and an increase in the request for medical care and prescriptions, possibly increasing the healthcare costs and the susceptibility to further diseases. These negative aspects are particularly evident in the elderly, with further decrease in the mobility, worsening of disability, frailty, geriatric syndromes and increased mortality. Healthcare providers should be aware of the possible coexistence of depression and diabetes and of the related consequences, to better manage the patients affected by these two pathological conditions.

The Prevalence and Correlates of Mental and Emotional Health Among American Indian Adults With Type 2 Diabetes

AIMS

The purpose of this study was to examine the prevalence and correlates of mental and emotional health factors among a sample of American Indian (Indigenous) adults diagnosed with type 2 diabetes.

METHODS

Data are from a community-based participatory research project involving 2 Indigenous reservation communities. Data were collected from 218 Indigenous adults diagnosed with type 2 diabetes via in-person paper-and-pencil survey interviews.

RESULTS

Reports of greater numbers of mental/emotional health problems were associated with increases in self-reported hyperglycemia, comorbid health problems, and health-impaired physical activities.

CONCLUSIONS

This study addresses a gap in the literature by demonstrating the associations between various mental/emotional health factors and diabetes-related health problems for Indigenous Americans. Findings underscore the importance of holistic, integrated primary care models for more effective diabetes care.

Mental health issues in adolescents and young adults with type 1 diabetes: prevalence and impact on glycemic control

Mental health comorbidities can negatively affect disease management in adolescents with chronic illnesses. This study sought to determine the prevalence and impact of mental health issues in a population of adolescents and young adults with type 1 diabetes. A cross-sectional study of 150 patients aged 11 to 25 years with type 1 diabetes from an urban, academic diabetes center was conducted. Participants completed 3 validated mental health disorder screening instruments: Beck's Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders-41 anxiety screen, and the Eating Disorder Screen for Primary Care. More than a third screened positive: 11.3% for depression, 21.3% for anxiety, and 20.7% for disordered eating (14.7% had ≥2 positive screens). Patients with a positive screen had twice the odds of having poor glycemic control as those without, as measured by HgbA1c. This study supports screening for mental health issues in adolescents and young adults with type 1 diabetes.

Increased risk of affective disorders in type 2 diabetes is minimized by sulfonylurea and metformin combination: a population-based cohort study

BACKGROUND

To confirm whether type 2 diabetes (T2DM) is an affective disorder (AD) precursor, and to establish possible effects of oral anti-hyperglycemic agents (OAAs).

METHODS

A representative cohort of 800,000 subjects was obtained from the Taiwanese National Health Insurance database on 1 January 2000. Those with consistent data (n = 762,753) were followed up between 1 January 1996 and 31 December 2007. Over this period, we assessed the presence (n = 62,988) or absence (n = 699,795) of T2DM, and whether any OAA was used (n = 40,232) or not (n = 22,756). To compare the risk of AD by diabetic status, those with T2DM were matched for birth date and gender with those without T2DM. To assess the effect of OAAs, we considered those 50 years and over. Matched AD-free patients with T2DM on OAAs were compared with those without OAAs, for age, gender, locality, health service, Charlson Comorbidity Index. and diabetes diagnosis date to avoid immortal time bias. AD incidence densities, hazard ratios (HR) and 95% confidence intervals (CIs) were calculated.

RESULTS

Compared with diabetes-free subjects, the HR (95% CI) for AD was 2.62 (2.31 to 2.98) for patients with T2DM who were not on OAAs, and 1.08 (0.99 to 1.18) for those who were on OAAs. The AD incidence density decreased from 91.1 to 39.4 per 10,000 person-years for patients on the combination of metformin and sulfonylurea. The HR (95% CI) for AD was 0.92 (0.59 to 1.45) for those on metformin alone, 1.08 (0.84 to 1.38) for those on sulfonylurea alone, and 0.40 (0.32 to 0.50) for the combined treatment, and the decrease was not related to sequence or insulin usage. Similar patterns were seen for incident AD exclusion for up to 3 years, although more so for bipolar than unipolar.

CONCLUSIONS

The incident AD risk is increased by 2.6-fold in T2DM, and the combination of sulfonylurea and metformin minimizes this risk.

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.

Social and emotional impact of diabetic retinopathy: a review

People with vision-threatening diabetic retinopathy are likely to experience enhanced social and emotional strain. Critically, those with both vision-threatening diabetic retinopathy and psychosocial problems may have significantly reduced levels of functioning compared with psychologically healthy counterparts. This can cause inadequate compliance, increased strain on family functioning, worse diabetes control, increased progression of diabetic retinopathy and, consequently, further psychosocial stress resulting in a number of concerning implications for disease management, clinical outcomes and healthcare costs. However, the emotional and social health consequences of diabetic retinopathy have not yet been systematically explored. This information is crucial as it allows for a targeted approach to treatment and prevention and avoidance of the potentially detrimental implications described above. Therefore, this paper reviews the current qualitative and quantitative evidence regarding the social and emotional impact of diabetic retinopathy and identifies directions for future research. Key search terms were applied to the electronic databases Pubmed, ISI Web of Science and Embase and the bibliographies of relevant papers were systematically reviewed for additional references. Overall, the evidence suggests that diabetic retinopathy and associated vision loss have several debilitating effects, including disruption of family functioning, relationships and roles; increased social isolation and dependence; and deterioration of work prospects resulting in increased financial strain. Adverse emotional responses include fear, anxiety, vulnerability, guilt, loss of confidence, anger, stress and self-perception issues. However, the research to date is largely qualitative in nature, with most quantitative studies being small, cross-sectional and somewhat outdated. Similarly, the outcome measures used in many studies to date are suboptimal in terms of content and validity. Therefore, this review identifies the need for improved outcome measures to provide valid, meaningful measurement of the social and emotional impact of diabetic retinopathy and discusses potential directions for future research such as item banking and computer adaptive testing.

Depression among adults with diabetes in Jordan: risk factors and relationship to blood sugar control

OBJECTIVES

The aims of this study were to estimate the prevalence of undiagnosed depression among adults with diabetes mellitus in Jordan and to determine the factors that may indicate the presence of depression and to examine the relationship between depression and blood sugar control among Jordanian subjects with diabetes.

METHODS

A systemic random sample of 649 type 1 and type 2 diabetic patients aged 18-75 years was selected during the period from July 2009 to January 2010. A prestructured questionnaire was used for collecting the information about sociodemographic data and clinical characteristics. Depression was evaluated using the Patients' Health Questionnaire-8 (PHQ-8). A PHQ-8 score ≥10 has been recommended as a cutoff point for depression. Self-care management behaviors and barrier to adherence were collected. Weights and heights were measured. Glycated hemoglobin was abstracted from each patient directly after the interview.

RESULT

Of the 649, 128 (19.7) have depression according to the PHQ-8 scores. According to the multivariate analysis, females are more likely to develop depression than males with [odds ratio (OR), 1.91; P=001] and low-educated people versus educated people (OR, 3.09; P≤.002). Being on insulin treatment also has a significant association with depression (OR, 3.31; P=.001). Not following eating plans as recommended by dietitians, lacking self-monitoring blood glucose and increased barriers to adherence scale scores were also associated with depression among the subjects with diabetes.

CONCLUSION

The prevalence of depression among Jordanian subjects with type 1 and type 2 diabetes is high compared with some developed countries. This was associated with gender, educational level, insulin treatment, low self-management behaviors and increased barriers to adherence. This result shows the urgent need to include the routine screening of depression during outpatient visit, which might help prevention, early detection and management of depression.

Lifetime prevalence of comorbid mood disorders in a representative sample of Canadians with type 1 diabetes

AIMS

To compare the lifetime prevalence of mood disorders among those with and without type 1 diabetes.

METHODS

Data from a nationally representative sample were obtained. Individuals were classified as having type 1 diabetes if a health professional diagnosed them with diabetes before age 30 and they began insulin within 1 month of their diagnosis (N=314).

RESULTS

The prevalence of mood disorders in persons with type 1 diabetes was 7.9% (95% CI 3.1-12.7) compared to 5.6% (95% CI 5.4-5.8) for those without type 1 diabetes (age- and sex-adjusted OR=1.56, 95% CI 1.04-2.34).

CONCLUSIONS

Future research would benefit from the use of community-based representative samples.

Glycemic control, coping, and internalizing and externalizing symptoms in adolescents with type 1 diabetes: a cross-lagged longitudinal approach

OBJECTIVE

This study examines how active coping and withdrawal, psychological (internalizing and externalizing) symptoms, and glycemic control (A1C values) influence each other across time in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

One hundred and nine adolescents participated in a four-wave longitudinal study spanning four years (mean age at Time 1 was 13.77). Patients were visited at home and completed questionnaires measuring coping and psychological symptoms. The treating physicians were contacted to obtain A1C values. Cross-lagged path analysis from a structural equation modeling approach was used for data analysis.

RESULTS

Clinically meaningful pathways between coping and glycemic control were found across time. Active coping prospectively predicted lower A1C levels, which, in turn, predicted active coping. Higher A1C levels and higher psychological symptoms consistently predicted avoidance coping across time. Finally, psychological symptomatology constituted an important link in the observed longitudinal chain of effects. More specifically, higher A1C values and symptomatology at Time 1 positively predicted withdrawal at Time 2, which, in turn, positively predicted symptomatology at Time 3. Next, symptomatology at Time 3 positively predicted higher A1C values at Time 4, thus coming full circle.

CONCLUSIONS

Coping with everyday stress, psychological symptoms, and glycemic control were interrelated across time. Evidence was obtained for reciprocal pathways and mutually reinforcing mechanisms, indicating the need to monitor coping strategies and psychological symptoms along with glycemic control in optimizing clinical care in adolescents with type 1 diabetes.

Exploring the relationship between diabetes self-efficacy, depressive symptoms, and glycemic control among men and women with type 2 diabetes

Depression and low self-efficacy are both associated with worse glycemic control in adults with diabetes, but the relationship between these variables is poorly understood. We conducted a cross-sectional study examining associations between depressive symptoms, self-efficacy, and glycemic control among men (n = 64) and women (n = 98) with type 2 diabetes to see if self-efficacy mediates the relationship between depression and glycemic control. Correlational and mediational analyses examined the relationship between these three variables for the sample as a whole and separately by sex. A significant association between depressive symptoms and glycemic control was found for men (0.34, P < 0.01) but not for women (0.05, P = 0.59). Path analysis suggested that, among men, self-efficacy mediates the relationship between depressive symptoms and glycemic control. We conclude that men with depressive symptoms and type 2 diabetes may need tailored interventions that improve their self-efficacy in order to achieve glycemic control.

Examining a bidirectional association between depressive symptoms and diabetes

CONTEXT

Depressive symptoms are associated with development of type 2 diabetes, but it is unclear whether type 2 diabetes is a risk factor for elevated depressive symptoms.

OBJECTIVE

To examine the bidirectional association between depressive symptoms and type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 years enrolled in 2000-2002 and followed up until 2004-2005.

MAIN OUTCOME MEASURES

Elevated depressive symptoms defined by Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or higher, use of antidepressant medications, or both. The CES-D score was also modeled continuously. Participants were categorized as normal fasting glucose (< 100 mg/dL), impaired fasting glucose (100-125 mg/dL), or type 2 diabetes (> or = 126 mg/dL or receiving treatment). Analysis 1 included 5201 participants without type 2 diabetes at baseline and estimated the relative hazard of incident type 2 diabetes over 3.2 years for those with and without depressive symptoms. Analysis 2 included 4847 participants without depressive symptoms at baseline and calculated the relative odds of developing depressive symptoms over 3.1 years for those with and without type 2 diabetes.

RESULTS

In analysis 1, the incidence rate of type 2 diabetes was 22.0 and 16.6 per 1000 person-years for those with and without elevated depressive symptoms, respectively. The risk of incident type 2 diabetes was 1.10 times higher for each 5-unit increment in CES-D score (95% confidence interval [CI], 1.02-1.19) after adjustment for demographic factors and body mass index. This association persisted following adjustment for metabolic, inflammatory, socioeconomic, or lifestyle factors, although it was no longer statistically significant following adjustment for the latter (relative hazard, 1.08; 95% CI, 0.99-1.19). In analysis 2, the incidence rates of elevated depressive symptoms per 1000-person years were 36.8 for participants with normal fasting glucose; 27.9 for impaired fasting glucose; 31.2 for untreated type 2 diabetes, and 61.9 for treated type 2 diabetes. Compared with normal fasting glucose, the demographic-adjusted odds ratios of developing elevated depressive symptoms were 0.79 (95% CI, 0.63-0.99) for impaired fasting glucose, 0.75 (95% CI, 0.44-1.27) for untreated type 2 diabetes, and 1.54 (95% CI, 1.13-2.09) for treated type 2 diabetes. None of these associations with incident depressive symptoms were materially altered with adjustment for body mass index, socioeconomic and lifestyle factors, and comorbidities. Findings in both analyses were comparable across ethnic groups.

CONCLUSIONS

A modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors. Impaired fasting glucose and untreated type 2 diabetes were inversely associated with incident depressive symptoms, whereas treated type 2 diabetes showed a positive association with depressive symptoms. These associations were not substantively affected by adjustment for potential confounding or mediating factors.

Depression and type 2 diabetes mellitus: the multiethnic study of atherosclerosis

OBJECTIVE

To assess the cross-sectional association between depression and glucose tolerance status.

METHODS

We conducted a study of 6754 White, Black, Hispanic, and Chinese men and women aged 45 to 84 years in the Multiethnic Study of Atherosclerosis (MESA). Depression was defined as Center for Epidemiologic Studies Depression scale score of > or =16 and/or antidepressant use. Glucose tolerance status was defined as normal, impaired fasting glucose (IFG) or Type 2 diabetes mellitus (untreated and treated).

RESULTS

In the minimally adjusted model, although depression was not associated with a greater odds of IFG (odds ratio (OR) = 1.01; 95% confidence interval (CI): 0.87-1.18) or untreated diabetes (OR = 1.03; 95% CI: 0.74-1.45), it was associated with a greater odds of treated diabetes (OR = 1.57; 95% CI: 1.27-1.96). This persisted following adjustment for body mass index (OR = 1.52; 95% CI: 1.22-1.90), metabolic (OR = 1.54; 95% CI: 1.23-1.93), and inflammatory (OR=1.53; 95% CI: 1.21-1.92) factors, daily caloric intake and smoking (OR = 1.48; 95% CI: 1.16-1.88), and socioeconomic markers (OR = 1.47; 95% CI: 1.17-1.85). Among individuals with treated diabetes, median depression scores were higher in those with microalbuminuria compared with those without microalbuminuria (median = 7; interquartile range: 3-13 versus median = 6; interquartile range: 2-11; p = .046). Depression scores were not associated with homeostatic model assessment of insulin resistance among individuals without diabetes.

CONCLUSIONS

In MESA, depression was significantly associated with treated diabetes. Further studies are needed to determine the temporality of this association.

Changes in depressive symptoms and glycemic control in diabetes mellitus

OBJECTIVE

To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes.

METHODS

Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels.

RESULTS

Mean and standard deviation baseline BDI and HbA1c levels were 17.9 +/- 5.8 and 7.6 +/- 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group.

CONCLUSION

Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The evaluation of the Turkish version of the Well-being Questionnaire (WBQ-22) in patients with Type 2 diabetes: the effects of diabetic complications

OBJECTIVE

Psychopathological conditions including depression and anxiety are important in patients with diabetes due to their negative effects on the quality of life, treatment and glycemic control. The specially designed questionnaire for diabetics, the Well-being Questionnaire (WBQ-22), was used to determine the psychological well-being in Turkish diabetic patients.

METHOD

A total of 100 patients, 45 males and 55 females, were included in the study. Patients completed WBQ-22 questionnaire.

RESULTS

Sex, in-patient follow-up, age, duration of diabetes, form of treatment, diabetic microvascular complications, diabetic foot, and increased number of complications were the factors detected to have an effect on the scores of general well-being or its subscales. Scores of depression and general well-being were 7.10 +/- 3.82 and 39.74 +/- 12.27 in females, and 4.20 +/- 3.48 and 48.84 +/- 11.45 in males (p<0.05). Anxiety score was found to be 5.70 +/- 3.71 in the outpatient clinic, and 7.28 +/- 4.38 in the inpatient clinics (p<0.05). General well-being score was 49.40 +/- 8.83 in patients having a diabetes duration of 1 yr or less and 33.70 +/- 8.83 in patients with 20 yr or more (p<0.05). Patients treated with insulin had depression score of 7.02 +/- 4.07 whereas patients treated with diet had 4.50 +/- 3.27 (p<0.05). The increasing total chronic complication points were also found to have a negative effect on WBQ-22 scores. General well-being score was 51.08 +/- 9.84 in patients with no complications and 34.50 +/- 14.14 in patients with 4 complications (p<0.05).

CONCLUSIONS

Psychosocial support should be provided to Type 2 diabetic patients by studying the psychological well-being with WBQ-22 questionnaire.

Psychological aspects of diabetes mellitus

Diabetes mellitus (DM) presents itself in two forms: insulin-dependent (type 1 DM) and non-insulin-dependent (type 2 DM). Although type 2 DM usually has an adult onset, in recent years there has been a significant rise in the number of children diagnosed with type 2 DM in the United States. Reasons for this increased frequency are believed to be a larger percentage of children who are overweight, a family history of diabetes, and a considerable increase in the use of psychotropic medication in children. The diagnosis of DM is a significant stressor not only for patients but also for their environment. Children with DM are sometimes stigmatized by their peers and relatives who do not understand the illness or are frightened by it. Some children also may need to alter several of their customary routines and are often scared to participate in activities in which they were previously engaged. The family's response to the diagnosis of DM may have a negative effect on glycemic control. Differences have been found in the way patients with type 1 DM and type 2 DM cope with and adapt to their diagnosis.

Eating disorders and type 1 diabetes mellitus in adolescence

One of the main difficulties in managing type 1 diabetes mellitus (T1DM) in the young is nutritional treatment. Studies have shown that adolescents (particularly adolescent girls and young women) have an increased risk for clinical and sub-clinical eating disorders. Adjustment to the nutritional regimen and, consequently, to the management of the disease in adolescence seems to involve a complex interplay of various psychosocial and biological aspects. The aim of this review is to consider the relationship between T1DM and eating disorders in adolescence in the light of some important biological psychological and familial factors. Further research is required in order to detect the degree of the interactions between these factors in adolescents with T1DM.

Psychosocial factors and diabetes-related outcomes following diagnosis of Type 1 diabetes in adults: the Edinburgh Prospective Diabetes Study

AIMS

To examine prospectively the relationships between psychosocial variables and diabetes-related outcomes in adults with newly diagnosed Type 1 diabetes.

METHODS

A total of 84 adults (48 male) with a median (range) age of 30.8 (17-51) years with newly diagnosed Type 1 diabetes were recruited for the study. Shortly after initial diagnosis each participant's personality, cognitive ability, and recent psychiatric distress were assessed. At 4 months (n = 69) and at 12 months (n = 66) after diagnosis diabetes-related outcomes were measured, including each respondent's knowledge of diabetes, satisfaction with diabetes treatment and diabetes-related quality of life. Glycated haemoglobin (HbA1c) was recorded at each clinic attendance.

RESULTS

Social class (Spearman's correlation r = -0.30 and -0.28, respectively, P < 0.05) and scores on the National Adult Reading Test (r = 0.38 and 0.36, respectively, P < 0.01) were consistently associated with knowledge of diabetes at 4 months and at 12 months after diagnosis. Hierarchical regression revealed that alcohol consumption recorded at diagnosis and knowledge of diabetes at 4 months were independent predictors of glycaemic control at 12 months (adjusted r2 = 0.16). Total scores on the Diabetes Treatment Satisfaction Questionnaire (DTSQ) at 12 months were significantly predicted by age at diagnosis (adjusted r2 = 0.08). High neuroticism at diagnosis was consistently associated with poorer self-reported diabetes quality of life at 4 months and at 12 months after diagnosis (rs between -0.30 and -0.39, P < 0.05).

CONCLUSIONS

Long-standing psychosocial factors have a significant influence on self-reported outcomes during the 12 months following diagnosis of Type 1 diabetes but may not be reliable predictors of glycaemic control. Further follow-up is necessary to determine the longer-term predictors of objective (e.g. glycaemic control) and subjective (e.g. quality of life) indicators of coping in people with diabetes.

Depression in adolescents with diabetes

TOPIC

Prevalence and interventions for depression in youth with type 1 diabetes.

PURPOSE

To explore the co-morbidity of youth with diabetes and psychiatric conditions, and evaluate the relationship of youth with co-morbid depression and diabetes on glycemic control, quality of life, family support, behavioral problems, attributional style, and self-esteem.

SOURCES

Relevant literature in both child and adolescent populations of psychiatry, psychology, and nursing.

CONCLUSIONS

Youth with type 1 diabetes have significantly higher rates of depression over the general population. Seratonin reuptake inhibitors, cognitive behavioral treatment, interpersonal therapy, improving family communication and problem-solving skills, and diabetes education hold promise as treatment that can decrease depression in youth with diabetes. Advanced practice nurses are positioned to provide these interventions and treatments.

Depressed mood is a factor in glycemic control in type 1 diabetes

OBJECTIVE

The diabetes literature contains conflicting evidence on the relationship between depression and glycemic control. This may be due, in part, to the fact that past studies failed to distinguish between patients with type 1 and type 2 diabetes. Because these are actually completely different diseases that are often treated differently and consequently make different demands on patients, the relationship between glycemic control and depressed mood in type 1 and type 2 diabetes was examined separately.

METHODS

The relationship between Beck Depression Inventory (BDI) scores and HbA1c, as an index of long-term glycemic control, was measured in samples of 30 patients with type 1 and 34 patients with type 2 diabetes.

RESULTS

Groups of patients with type 1 and type 2 diabetes did not differ in mean BDI score or HbA1c level. Correlation analysis revealed a significant positive relationship between BDI scores and HbA1c in the type 1 group (r = .44, p < .02) but not in the type 2 group (r = -0.06, p > .05). This relationship was evident throughout the entire range of BDI scores and was not restricted to scores indicative of clinical depression. Patients with type 1 diabetes who had higher HbA1c and BDI scores reported a lower frequency of home blood glucose monitoring.

CONCLUSIONS

Variations in depressive mood, below the level of clinical depression, are associated with meaningful differences in glycemic control in type 1 but not type 2 diabetes. Preliminary data analysis suggests that this effect may be mediated, at least in part, by decreased self-care behaviors in patients with more depressed mood.

Meaning of illness and health outcomes in type 1 diabetes

OBJECTIVE

To determine whether a relationship exists between the meaning attributed to type 1 diabetes and mental and physical health outcomes.

METHODS

The study sample consisted of 49 adults with type 1 diabetes. Each participant voluntarily agreed to complete the Meaning of Illness Questionnaire (MIQ), the Short Form-36 Health Survey (SF-36), and the Diabetes Health Survey. Multivariant analysis of covariance was used to determine the relationships among the MIQ and SF-36, a history of depression, hemoglobin A1c, and other demographic variables.

RESULTS

The meaning attributed to illness predicted health outcomes. Specifically, the impact of illness (MIQ subscale 1; P = 0.030) predicted SF-36 physical functioning, bodily pain, and general mental health; the degree of stress (MIQ subscale 3; P = 0.008) predicted SF-36 general physical health, vitality, and general mental health. Conversely, a history of depression (P = 0.014) and high hemoglobin A1c (P = 0.039) predicted a more negative meaning attributed to illness.

CONCLUSION

The meaning attributed to illness varies with physical and mental health. In addition, physical and mental health outcomes and hemoglobin A1c, a measure of mean blood glucose, affect the meaning attributed to diabetes. The findings in this study support a bidirectional relationship between the meaning attributed to illness and health outcomes in patients with type 1 diabetes.

Association of depression and diabetes complications: a meta-analysis

OBJECTIVE

The objective of this study was to examine the strength and consistency of the relationship between depression and diabetes complications in studies of type 1 and type 2 adult patients with diabetes.

METHOD

MEDLINE and PsycINFO databases were searched for articles examining depression and diabetes complications in type 1 and type 2 diabetes samples published between 1975 and 1999. Meta-analytic procedures were used. Studies were reviewed for diabetes type, sample size, statistical tests, and measures of diabetes complications and depression. Significance values, weighted effect sizes r, 95% confidence intervals (CI), and tests of homogeneity of variance were calculated for the overall sample (k = 27) and for subsets of interest.

RESULTS

A total of 27 studies (total combined N = 5374) met the inclusion criteria. A significant association was found between depression and complications of diabetes (p < .00001, z = 5.94). A moderate and significant weighted effect size (r = 0.25; 95% CI: 0.22-0.28) was calculated for all studies reporting sufficient data (k = 22). Depression was significantly associated with a variety of diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction). Effect sizes were in the small to moderate range (r = 0.17 to 0.32).

CONCLUSIONS

These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.

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

OBJECTIVE

To estimate the odds and prevalence of clinically relevant depression in adults with type 1 or type 2 diabetes. Depression is associated with hyperglycemia and an increased risk for diabetic complications; relief of depression is associated with improved glycemic control. A more accurate estimate of depression prevalence than what is currently available is needed to gauge the potential impact of depression management in diabetes.

RESEARCH DESIGN AND METHODS

MEDLINE and PsycINFO databases and published references were used to identify studies that reported the prevalence of depression in diabetes. Prevalence was calculated as an aggregate mean weighted by the combined number of subjects in the included studies. We used chi(2) statistics and odds ratios (ORs) to assess the rate and likelihood of depression as a function of type of diabetes, sex, subject source, depression assessment method, and study design.

RESULTS

A total of 42 eligible studies were identified; 20 (48%) included a nondiabetic comparison group. In the controlled studies, the odds of depression in the diabetic group were twice that of the nondiabetic comparison group (OR = 2.0, 95% CI 1.8-2.2) and did not differ by sex, type of diabetes, subject source, or assessment method. The prevalence of comorbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%).

CONCLUSIONS

The presence of diabetes doubles the odds of comorbid depression. Prevalence estimates are affected by several clinical and methodological variables that do not affect the stability of the ORs.

Glycemic control and major depression in patients with type 1 and type 2 diabetes mellitus

The current study evaluated the association of glycemic control and major depression in 33 type 1 and 39 type 2 diabetes mellitus patients. Type 1 patients with a lifetime history of major depression showed significantly worse glycemic control than patients without a history of psychiatric illness (t = 2.09; df = 31, p < 0.05). Type 2 diabetes patients with a lifetime history of major depression did not have significantly worse control than those with no history of psychiatric illness. Findings from this study indicate different relationships between lifetime major depression and glycemic control for patients with type 1 and type 2 diabetes. Treatment implications for glycemic control in type 1 and type 2 diabetes patients are discussed.

Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: a controlled study

OBJECTIVE

To compare compliance, psychiatric disorders, and family support in children with insulin-dependent diabetes mellitus (IDDM) hospitalized with diabetic ketoacidosis (DKA) and clinic controls.

METHOD

Twenty-five youths hospitalized with DKA and 25 matched outpatient subjects with IDDM with no history of DKA during the preceding year were assessed cross-sectionally, using the Diagnostic Interview Schedule for Children, measures of general and diabetes-specific family functioning, and measures of self-esteem and social competence. Levels of glycosylated hemoglobin and information about compliance with the treatment regimen were obtained.

RESULTS

A significantly higher number of psychiatric disorders was observed in the hospitalized children, with 88% meeting criteria for at least one disorder (versus 28% of controls). Self-esteem and social competence were lower in the hospitalized group, and their families scored lower on problem-solving and diabetes-specific "warmth-caring."

CONCLUSIONS

Children with recurrent DKA may be at greater risk of associated psychopathology than diabetic controls with no such history. DKA children's reports of noncompliance may be more sensitive than their parents' reports, and their families may lack warm, caring parent-child relationships.

Eating disorders and insulin-dependent diabetes mellitus

The eating disorders anorexia nervosa and bulimia nervosa have been reported to occur in Type I diabetes mellitus. Although prevalence estimates vary, the most rigorous studies yield rates similar to the population at large. Intentional insulin omission is more common, especially in young diabetic women, and at times may indicate an eating disorder in Type I diabetic patients. Both diagnosable eating disorders and intentional insulin omission are associated with worse glycemic control and higher rates of secondary diabetic complications. Recognition of these conditions, followed by carefully coordinated treatment involving both diabetes care providers and mental health providers, is necessary to improve treatment outcome.

Consequences of irregular versus continuous medical follow-up in children and adolescents with insulin-dependent diabetes mellitus

OBJECTIVES

To study the social and family characteristics of patients with insulin-dependent diabetes mellitus with irregular versus continuous clinical follow-up and to study the medical outcomes of patients with these follow-up patterns.

METHODS

An onset cohort of 61 children and adolescents with insulin-dependent diabetes mellitus and their parents were studied. Aspects of their social and family environment were assessed at study inception and examined in relation to frequency of follow-up early in the course of the illness. Follow-up was dichotomized so that patients with continuous follow-up were compared with patients with irregular follow-up, who were defined as those missing 1 full year of planned medical appointments during the second through fourth years after diagnosis. Patients with irregular and continuous follow-up were compared in terms of acute metabolic complications, glycemic control, and retinopathy status during a 10-year period.

RESULTS

Compared with individuals with continuous follow-up, patients with irregular clinical visits were more likely to be from families of lower socioeconomic class levels, have a parental history of separation and divorce, and were members of families that reported being least openly expressive of positive emotions. Poor glycemic control in year 1 was associated with irregular follow-up in years 2 through 4. Patients with irregular follow-up continued to have worse glycemic control in years 2 through 4 than patients with continuous follow-up. However, in years 7 and 10 their glycemic control no longer differed from patients with continuous follow-up. More episodes of diabetic ketoacidosis occurred in the irregular follow-up group. Finally, retinopathy occurred more frequently among those in the irregular follow-up group.

CONCLUSION

Early irregular clinical follow-up should be considered a risk factor for complications of insulin-dependent diabetes mellitus.