Key concepts in screening for depression in people with diabetes

A randomised controlled feasibility trial of Behavioural activation as a treatment for people with diabetes and depression: (DiaDeM feasibility trial)

BACKGROUND

There is a lack of evidence on effective treatments for depression in people with T2DM, particularly in Low and Middle-Income Countries (LMICs). This study aims to test the feasibility and acceptability of a culturally adapted Behavioural Activation (BA) intervention (DiaDeM) for people with depression and T2DM in two South Asian LMICs.

METHODS

A multicountry, individually randomised-controlled feasibility trial was conducted from March 2022 to November 2022. We recruited adults from diabetes healthcare facilities in Bangladesh and Pakistan with a diagnosis of depression and T2DM. Consenting individuals were randomised to either optimised usual care or the DiaDeM intervention, which comprised six BA sessions delivered by non-mental health facilitators over six to twelve weeks. Participants were followed up at three and six months post-randomisation. The feasibility and acceptability of recruitment and retention, intervention delivery, and data collection were assessed. A mixed-methods process evaluation was also performed to inform the main trial.

RESULTS

The DiaDeM feasibility trial successfully recruited 128 participants, with 85 % retention at six months follow-up. The majority of participants engaged with the intervention, demonstrating good adherence to the Behavioural Activation (BA) sessions. Data completeness for key outcomes, including depression severity and HbA1c levels, was high across all time points (>90 %). The process evaluation showed high acceptability of the intervention, with participants reporting increased motivation and improved management of both T2DM and depression.

DISCUSSION

Good recruitment and retention rates, completeness of data collection, and high acceptability of the intervention showed that it would be feasible to undertake a full-scale trial.

The prevalence of depression and its associated factors among patients with diabetes mellitus attending a tertiary clinic in Gaborone, Botswana

Background

Depression is one of the commonest co-existing medical conditions among patients with diabetes mellitus (DM). A bidirectional relationship between depression and DM exists, complicating glycaemic control leading to an increase in diabetic complications. There is a dearth of information regarding the prevalence of depression and associated factors among patients with DM in Botswana.

Aim

This study aimed to determine the prevalence of depression and associated factors among patients with DM. The study also assessed the association between depression and glycaemic control.

Setting

A tertiary diabetic referral clinic in Gaborone, Botswana.

Method

A sample of 260 randomly selected patients with DM was recruited in this cross-sectional study. Socio-demographic and clinical characteristics of the patients were collected using a case report form. Depression was evaluated using the Patient Health Questionnaire (PHQ)-9 scale. Multivariate regression analysis was used to determine factors significantly associated with depression.

Results

The mean age (standard deviation [s.d.]) of study participants was 58.4 (11.8) years, and the majority, 160/260 (61.5%), were females. The prevalence of depression was 30.4% and significantly associated with female sex (adjusted odds ratio [AOR] = 5.529, p-value = 0.004), three or more diabetes-related hospitalisations (AOR = 3.886, p-value = 0.049) and inversely associated with systolic blood pressure (SBP) ≥ 140 mmHg (AOR = 0.11, p-value = 0.001).

Conclusion

Depression is a common problem among patients with DM in our setting. Routine screening of depression in diabetic patients to enable early detection and treatment is recommended.

Development and Validation of the Depression Inventory for Type 1 Diabetes (DID-1)

People with type 1 diabetes (T1D) are more likely to have depression than the general population and their prognosis is worse. Unfortunately, the characteristics of persons with T1D lead to inadequate screening for depression in this population. To aid in the detection of depression in this population, this study was undertaken to develop a depressive symptoms assessment instrument specific to patients with T1D and to examine its psychometric properties. A total of 207 people with T1D participated in this study. The reliability of the new scale was assessed using Cronbach’s alpha and the Spearman-Brown split-half coefficient. The Depression Inventory for type 1 Diabetes (DID-1), composed of 45 items on a Likert scale (1–7), shows high internal and temporal consistency, as well as adequate concurrent, convergent and discriminant validity. Factor analysis identified 7 factors (Symptoms of depression, Diminished interest, Hopelessness and dissatisfaction, Guilt, Fear, frustration and irritability, Defenselessness, and Interference in daily life) that explained 61.612% of the total variability. The cut-off score for diagnosis was set at 155 points. It was concluded that the DID-1 scale is a reliable, valid and useful tool for the assessment of depressive symptoms, eliminating the bias of other nonspecific diabetes scales.

Intervention Strategies for Prevention of Comorbid Depression Among Individuals With Type 2 Diabetes: A Scoping Review

Background: Type 2 diabetes (T2D)-related depression has a significant impact on quality of life and leads to greater morbidity and mortality. Current educational and treatment programs for T2D rarely include a specific depression-prevention component, focusing largely on remediating depressive symptoms that have reached clinical levels. Objective: Given the vast field of research on the association between T2D and depression, and the unknown status of prevention efforts for the latter, the goal of this scoping review was to conduct a synopsis of intervention strategies specifically targeting the prevention of depression among adults with T2D. Eligibility Criteria: (1) participants aged 18 and over with T2D; (2) experimental and quasi-experimental designs (3) intervention strategies seeking to prevent the onset or worsening of (non-clinical) depressive symptoms; (4) a valid measure of depressive symptoms; (5) full-text articles available in English or French. Sources of Evidence: Databases including Medline, PubMed, and SCOPUS were searched between 2000 and 2018 resulting in 4,219 potential articles. Charting Methods: This review was conducted in-line with the current methodological framework for scoping reviews. Titles, abstract and full text articles were screened independently and in duplicate. A narrative analysis was conducted to synthesize study characteristics and the nature of intervention strategies and components. Results: Twelve studies were identified with the primary aim of preventing the incidence of depressive symptoms or improving non-clinical depression levels. Individual and group-based approaches included educational interventions incorporating diabetes self-management, problem-solving, and resilience-focused approaches, emotion-targeted techniques as well as alternative interventions. Self-monitoring, home practices, and motivational interviewing were common elements. Conclusions: This review lays the groundwork for future studies seeking to develop, validate, and improve prevention strategies targeting the diabetes-depression comorbidity. More studies over longer periods and with larger samples are needed to capture the effects of prevention efforts.

Analysis of global research output on diabetes depression and suicide

BACKGROUND

Diabetic patients, during the course of the disease, are most likely to experience depressive symptoms that might ultimately lead to suicidal ideation or suicide. The size of literature in diabetes depression/suicide is a good indicator of national and international efforts to address psychological co-morbidities associated with diabetes mellitus (DM). Therefore, the objective of this study was to give a comprehensive analysis, both quantitative and qualitative, of scientific literature in diabetes depression/suicide.

METHODS

SciVerse Scopus was used to retrieve relevant literature up to 2016.

RESULTS

In total, 1664 journal documents were retrieved with an average of 26.9 citations per article and an h-index of 98. Publications started in 1949 but showed a steep and noticeable increase after 2001. Retrieved articles were published in 641 different journals with Diabetes Care journal being the top productive one with a total of 130 (7.8%) articles. Researchers from 83 different countries participated in retrieved publications. Researchers from the United States of America participated in publishing 685 articles. There was a strong and positive correlation between research output and Gross Domestic Product (r = 0.083; p < 0.001) but not with prevalence or mortality caused by DM. Researchers from 4870 different institutions/organizations participated in publishing retrieved articles. Publications from the University of Washington, Seattle, USA had the highest h-index (38), while "VA medical centers" had the highest number of publications (75; 4.5%). In total, 5715 authors appeared in retrieved articles giving an average of 3.4 authors per article. Top cited articles focused on prevalence, impact of depression on glycemic control, and potential risk of diabetic complications. The total number of publications in depression/suicide in diabetic patients was lesser than that in cardiac (1938) or in cancer (1828) patients. However, publications in diabetes depression/suicide exceeded those in cardiac and cancer in the last 2 years of the study period.

CONCLUSION

The current study showed a noticeable growth of publications indicative of the importance of this topic. Research focusing on the psychiatric component of diabetes mellitus needs to be strengthened and encouraged. At the practical level, screening for depression/suicide among patients attending primary healthcare clinics is needed to optimize health and quality of life of diabetic patients.

Attitude toward Prenatal Testing and Termination of Pregnancy among Health Professionals and Medical Students in Saudi Arabia

This study was aimed at assessing the attitude of health care professionals in Jeddah city toward prenatal diagnosis (PND) and termination of pregnancy (TOP). A cross-sectional study was conducted, and the participants completed a self-administered questionnaire. Approximately 82% of participants showed a consistent trend of accepting PND when appropriate, and 47.5% of the respondents were in favor of TOP if the fetus had a severe disease. Compared with men (69.3%), a significantly greater number of women (88%) accepted to have PND. The most acceptable prenatal diagnostic tests in the study were invasive techniques as most of the participants thought that noninvasive tests were nonspecific.

Psychological conditions in adults with diabetes

Type 1 (T1D) and Type 2 diabetes (T2D) represent a demanding set of biopsychosocial challenges for patients and their families, whether the age of disease onset occurs in childhood, adolescence, or adulthood. Psychological conditions, defined as syndromes, disorders, and diabetes-specific psychological issues affect a larger proportion of individuals with T1D and T2D compared to the general population. In this review, we summarize the prevalence, impact and psychological treatments associated with the primary categories of psychological conditions that affect adults with T1D and T2D: depressive symptoms and syndromes, anxiety disorders, eating behaviors and disorders and serious mental illness. The implications of the literature for psychologists are discussed, and priorities for future research to advance the science of psychological conditions for adults with T1D and T2D are identified. (PsycINFO Database Record

Deconstructing Diabetes and Depression: Clinical Context, Treatment Strategies, and New Directions

Depression and diabetes are common, chronic, and frequently comorbid diseases that contribute substantially to global disability and mortality. Their relationship is bidirectional: depression increases the risk of developing type 2 diabetes mellitus (T2DM), and diabetes increases the risk of depression. Unhealthy lifestyles and poor self-care by patients with depression contribute to the increased T2DM risk. The psychosocial burden of a diabetes diagnosis and its eventual complications predispose diabetic patients to depressive symptoms. Neuroendocrine alterations and inflammation may underlie the increased risk of T2DM in depression but are also proposed as common causative factors for both illnesses. Screening for depression is essential in T2DM, and vice versa. Selective serotonin reuptake inhibitors effectively treat depression of patients with diabetes and positively influence glycemic control. Psychological interventions are effective for depressive symptoms, but their effect on glycemic control varies. Novel depression interventions targeting inflammation or insulin resistance underscore the common biological underpinnings of mood and metabolism.

Depression and diabetes: treatment and health-care delivery

Despite research efforts in the past 20 years, scientific evidence about screening and treatment for depression in diabetes remains incomplete and is mostly focused on North American and European health-care systems. Validated instruments to detect depression in diabetes, although widely available, only become effective and thus recommended if subsequent treatment pathways are accessible, which is often not the case. Because of the well known adverse effects of the interaction between depression and diabetes, treatment goals should focus on the remission or improvement of depression as well as improvement in glycaemic control as a marker for subsequent diabetes outcome. Scientific evidence evaluating treatment for depression in type 1 and type 2 diabetes shows that depression can be treated with moderate success by various psychological and pharmacological interventions, which are often implemented through collaborative care and stepped-care approaches. The evidence for improved glycaemic control in the treatment of depression by use of selective serotonin reuptake inhibitors or psychological approaches is conflicting; only some analyses show small to moderate improvements in glycaemic control. More research is needed to evaluate treatment of different depression subtypes in people with diabetes, the cost-effectiveness of treatments, the use of health-care resources, the need to account for cultural differences and different health-care systems, and new treatment and prevention approaches.

Diabetes and depression

Diabetes and depression occur together approximately twice as frequently as would be predicted by chance alone. Comorbid diabetes and depression are a major clinical challenge as the outcomes of both conditions are worsened by the other. Although the psychological burden of diabetes may contribute to depression, this explanation does not fully explain the relationship between these 2 conditions. Both conditions may be driven by shared underlying biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors. Depression is frequently missed in people with diabetes despite effective screening tools being available. Both psychological interventions and antidepressants are effective in treating depressive symptoms in people with diabetes but have mixed effects on glycemic control. Clear care pathways involving a multidisciplinary team are needed to obtain optimal medical and psychiatric outcomes for people with comorbid diabetes and depression.

Probing for depression and finding diabetes: a mixed-methods analysis of depression interviews with adults treated for type 2 diabetes

BACKGROUND

Depression has increased prevalence and consistently predicts poor health outcomes among patients with diabetes. The impact of stressors related to diabetes and its treatment on depression assessment is infrequently considered.

METHODS

We used mixed methods to evaluate depressive symptoms in adults with type 2 diabetes. We categorized responses related to diabetes and its treatment during interviews (n=70) using the Montgomery-Åsberg Depression Rating Scale (MADRS) and administered questionnaires to measure diabetes-related distress and depressive symptoms.

RESULTS

Participants (M age=56, SD=7; 67% female; 64% Black; 21% Latino) had mild depression on average (MADRS M=10, SD=9). Half of those with symptoms spontaneously mentioned diabetes context; 61% said diabetes contributed to their symptoms when questioned directly. Qualitative themes included: overlapping symptoms of diabetes and depression; burden of diabetes treatment; emotional impact of diabetes; and the bidirectional influence of depression and diabetes. Diabetes was mentioned more often at higher levels of depression severity (r=.38, p=.001). Higher HbA1c was associated with mentioning diabetes as a context for depressive symptoms (r=.32, p=.007). Insulin-users mentioned diabetes more often than those on oral medications only (p=.005).

LIMITATIONS

MADRS is not a traditional qualitative interview so themes may not provide an exhaustive view of the role of diabetes context in depression assessment.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The burden of type 2 diabetes and its treatment often provide an explanatory context for depressive symptoms assessed by structured clinical interviews, the gold standard of depression assessment. Diabetes context may influence accuracy of assessment and should inform intervention planning for those needing treatment.