Is ignorance bliss? Depression, antidepressants, and the diagnosis of prediabetes and type 2 diabetes

Association between depression and the prevalence and prognosis of prediabetes: Data from National Health and Nutrition Examination Survey (NHANES) 2013-2018

BACKGROUND

Diagnosis and intervention of prediabetes is an emerging approach to preventing the progression and complications of diabetes. Inflammatory factors and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis have been suggested as potential mechanisms underlying the pathogenesis of both diabetes and depression. However, the relationship between depression levels and the prevalence of prediabetes and its prognosis remains elusive. This study aimed to explore the relationship between depression and the prevalence of prediabetes and to further explore the all-cause mortality of different levels of depression in patients with prediabetes.

METHODS

Our study used a data set from the National Health and Nutrition Examination Survey (NHANES). Participants were initially divided into two groups (depression vs. non-depression) and further stratified by different depression severity levels. We used a weighted multiple logistic regression model to analyze the association between depression and prediabetes prevalence and a Cox regression model to assess all-cause mortality in prediabetic patients.

RESULTS

A total of 4384 participants were included, divided into depression group (n = 1379) and non-depression group (n = 3005). Results showed that people with depression were at higher risk of developing prediabetes. After adjusting for covariates, moderate to severe depression was positively associated with prediabetes (moderate to severe depression vs no depression: OR = 1.834, 95%CI: 0.713-4.721; severe depression vs no depression: OR = 1.004, 95% CI 0.429-2.351). In addition, we explored the relationship between all-cause mortality and depressive status in patients diagnosed with prediabetes (n = 2240) and found that moderate to severe depression (HR = 2.109, 95%CI 0.952-4.670) was associated with higher mortality in patients with prediabetes.

CONCLUSIONS

Overall, the findings consistently suggest that depression is positively associated with both the prevalence and mortality risk among individuals with prediabetes. This suggests that depression may be a new and valuable indicator of prediabetes risk. Early treatment of depression improves outcomes in prediabetes.

Which self-reported measures are useful to explore diabetes support needs among adults with diabetes and severe mental illness?

OBJECTIVES

To construct and test patient-reported outcome measures (PROMs) for identifying diabetes support needs of adults with co-existing diabetes and severe mental illness (SMI) provided by mental health professionals at psychiatric outpatient clinics.

METHODS

Design thinking was used to identify, select, and modify PROMs in collaboration with 18 adults with type 1 or type 2 diabetes and SMI and 10 healthcare experts. The PROMs were then tested with 86 adults with diabetes and SMI recruited from eight psychiatric outpatient clinics in Denmark. Data were analysed using systematic text condensation (questionnaire construction) and descriptive statistics (testing).

RESULTS

Four principles for PROMs were identified: (a) be modified to be relevant for the target group, (b) be concise and simple to complete, (c) have a clear and unambiguous wording, and (d) be designed to measure topics that are perceived as meaningful. Test of the questionnaire contained 49 items in four domains. Missing response rates in the test were 1.2-4.7% in three domains and 4.7-11.6% in a domain addressing potential sources of diabetes support.

DISCUSSION

PROMs can successfully be constructed in collaboration with this vulnerable population that yield low rates of missing responses.

Roles of physical functioning and comorbid mental illness of chronically ill parents and their spouses' health status in adolescent functioning

INTRODUCTION

Emerging research suggests that physically ill parents' psychological adjustment to illness and emotional well-being may affect adolescents' psychosocial functioning. As people with chronic medical conditions often develop mental disorders, it is important to examine the influence of comorbidity of parental physical and mental health conditions on adolescents' functioning. In addition, the physical and mental health status of the spouses/partners of chronically ill parents needs to be explored to further understand the potential impact of parental chronic illness on adolescents' psychological distress and academic performance.

METHODS

Cross-sectional data from 164 parent-adolescent pairs were collected through online surveys in the United States between 2018 and 2019. Parent participants (Mage  = 42.69, SD = 5.96) included parents who had been diagnosed with a chronic physical illness (e.g., multiple sclerosis, diabetes, chronic pain, cancer). Adolescent participants were middle- and high-school-aged children who lived with their physically ill parents (Mage  = 14.34, SD = 2.07).

RESULTS

Hierarchical regression analyses indicated that comorbid mental illness of parental chronic illness and spousal mental health status were associated with adolescents' distress. The level of physical functioning of chronically ill parents was related to adolescents' academic performance.

CONCLUSION

Parental chronic illness appears to affect adolescents' psychological and academic outcomes through distinct pathways. It is important to examine the comorbid mental health status of chronically ill parents and their spouses'/partners' mental health conditions to better understand the impact of parental chronic illness on adolescents' psychological adjustment.

Depressive Symptom Subgroups and Their Association with Prevalent and Incident Cardiovascular Risk Factors in the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

We sought to identify depressive symptom subgroups in a community sample of young adults, investigate their stability over time, and determine their association with prevalent and incident cardiovascular disease (CVD) risk factors.

METHOD

Participants were 3377 adults from the Coronary Artery Risk Development in Young Adults study. Using latent class and latent transition analysis, we derived subgroups based on items of the 20-item version of the Center for Epidemiologic Studies Depression Scale in 1990, and examined patterns of change over a 10-year period (1990-2000). Cox regression models were used to examine associations between subgroup membership and prevalent (2000) and incident (2000 to 2016) obesity, hypertension, and diabetes.

RESULTS

Three baseline subgroups were identified and labeled: "No Symptoms" (63.5%), "Lack of Positive Affect" (PA, 25.6%), and "Depressed Mood" (10.9%). At 10-year follow-up, individuals in "No Symptoms" subgroup had the highest probability (0.84) of being classified within the same subgroup. Participants classified as "Lack of PA" were likely (0.46) to remain in the same subgroup or be classified as "No Symptoms." Participants in the "Depressed Mood" were most likely to transition to the "Lack of PA" subgroup (0.38). Overall, 30.5% of participants transitioned between subgroups, with 11.4% classified as "Worsening" and 19.1% as "Improving." Relative to the "No Symptoms Stable," other subgroups ("Depressed Stable," "Worsening," and "Improving") were associated with prevalent obesity and hypertension.

CONCLUSION

We identified distinct depressive symptom subgroups that are variably stable over time, and their change patterns were differentially associated with CVD risk factor prevalence.

Sick and depressed? The causal impact of a diabetes diagnosis on depression

BACKGROUND

There is sparse evidence on the impact of health information on mental health as well as on the mechanisms governing this relationship. We estimate the causal impact of health information on mental health via the effect of a diabetes diagnosis on depression.

METHODS

We employ a fuzzy regression discontinuity design (RDD) exploiting the exogenous cut-off value of a biomarker used to diagnose type-2 diabetes (glycated haemoglobin, HbA1c) and information on psycometrically validated measures of diagnosed clinical depression drawn from rich administrative longitudinal individual-level data from a large municipality in Spain. This approach allows estimating the causal impact of a type-2 diabetes diagnosis on clinica ldepression.

RESULTS

We find that overall a type-2 diabetes diagnosis increases the probability of becoming depressed, however this effect appears to be driven mostly by women, and in particular those who are relatively younger and obese. Results also appear to differ by changes in lifestyle induced by the diabetes diagnosis: while women who did not lose weight are more likely to develop depression, men who did lose weight present a reduced probability of being depressed. Results are robust to alternative parametric and non-parametric specifications and placebo tests.

CONCLUSIONS

The study provides novel empirical evidence on the causal impact of health information on mental health, shedding light on gender-based differences in such effects and potential mechanisms through changes in lifestyle behaviours.

Prevalence and clinical correlates of abnormal glucose metabolism in young, first- episode and medication-naïve outpatients with major depressive disorder

BACKGROUNDS

The high co-morbidity of abnormal glucose metabolism in depressed patients has been extensively studied, but few studies have explored abnormal glucose metabolism in young patients with major depressive disorder (MDD). This study aimed to examine the prevalence and clinical correlates of abnormal glucose metabolism in young patients with first-episode medication-naïve (FEMN) MDD.

METHODS

A cross-sectional study was conducted on 1289 young Chinese outpatients with FEMN MDD. All subjects were assessed on the Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale (HAMA), Positive and Negative Syndrome Scale, and their sociodemographic information was collected, and blood pressure, blood glucose, lipid and thyroid hormone levels were measured.

RESULTS

The prevalence of abnormal glucose metabolism was 12.57% in young FEMN MDD outpatients. Thyroid stimulating hormone (TSH) levels and HAMA scale scores were associated with fasting blood glucose levels in patients with FEMN MDD (P<0.05), and TSH could differentiate patients with abnormal normal glucose metabolism from those without abnormal glucose metabolism (Area Under Curve of 0.774).

CONCLUSIONS

Our study showed a high prevalence of comorbid glucose metabolism abnormalities in young FEMN MDD outpatients. TSH may be a promising biomarker of abnormal glucose metabolism in young patients with FEMN MDD.

Dynamic relationships between depressive symptoms and insulin resistance over 20 years of adulthood

BACKGROUND

Bidirectional longitudinal relationships between depression and diabetes have been observed, but the dominant direction of their temporal relationships remains controversial.

METHODS

The random-intercept cross-lagged panel model decomposes observed variables into a latent intercept representing the traits, and occasion-specific latent 'state' variables. This permits correlations to be assessed between the traits, while longitudinal 'cross-lagged' associations and cross-sectional correlations can be assessed between occasion-specific latent variables. We examined dynamic relationships between depressive symptoms and insulin resistance across five visits over 20 years of adulthood in the population-based Coronary Artery Risk Development in Young Adults (CARDIA) study. Possible differences based on population group (Black v. White participants), sex and years of education were tested. Depressive symptoms and insulin resistance were quantified using the Center for Epidemiologic Studies Depression (CES-D) scale and the homeostatic model assessment for insulin resistance (HOMA-IR), respectively.

RESULTS

Among 4044 participants (baseline mean age 34.9 ± 3.7 years, 53% women, 51% Black participants), HOMA-IR and CES-D traits were weakly correlated (r = 0.081, p = 0.002). Some occasion-specific correlations, but no cross-lagged associations were observed overall. Longitudinal dynamics of these relationships differed by population groups such that HOMA-IR at age 50 was associated with CES-D score at age 55 (β = 0.076, p = 0.038) in White participants only. Longitudinal dynamics were consistent between sexes and based on education.

CONCLUSIONS

The relationship between depressive symptoms and insulin resistance was best characterized by weak correlations between occasion-specific states and enduring traits, with weak evidence that insulin resistance might be temporally associated with subsequent depressive symptoms among White participants later in adulthood.

Psychopathology and eating behaviour in people with type 2 diabetes referred for bariatric surgery

PURPOSE

Psychopathology and disordered eating behaviours are putative pre-operative risk factors for suboptimal outcomes post-bariatric surgery. Documented psychopathology prevalence rates vary in bariatric candidate samples. Further, less attention has been paid to vulnerable subgroups such as people with diabetes who might be at an elevated risk. For these reasons, this study aimed to investigate the rates of psychopathology and disordered eating in pre-surgical candidates with type 2 diabetes mellitus (T2DM).

METHODS

Participants were 401 consecutive patients from a state-wide bariatric surgery service for people with T2DM. Psychopathology was measured using multi-modal assessment including diagnostic interview and battery of validated questionnaires. The mean age of the sample was 51 years with a mean BMI of 46 kg/m2. The majority of the sample was female (60.6%), born in Australia (87%) and 18.2% identified as Aboriginal and/or Torres Strait Islander.

RESULTS

Rates of current psychopathology in this sample included: major depressive disorder (MDD; 16.75%), generalised anxiety disorder (GAD; 20.25%), insomnia (17.75%) and binge eating disorder (BED; 10.75%). There were no significant differences on measures between people who endorsed Aboriginal and/or Torres Strait Islander status compared to those who did not endorse. The mean total score on the BES was 21.82 ± 10.40 (range 0-39), with 8.2% of participants meeting criteria for severe binge eating. Presence of an eating disorder was not significantly associated with degree of glycemic compensation. Average emotional eating scores were significantly higher in this study, compared to reference samples. Significantly increased binge eating severity and emotional eating severity was revealed for people with T2DM and comorbid MDD, social anxiety and eating disorders. Binge eating severity was associated with GAD, food addiction, substance use disorders, and history of suicide attempt but not emotional eating severity.

CONCLUSION

Amongst people with T2DM seeking bariatric surgery, MDD, GAD and emotional eating were common. Psychopathology in a sample of people with T2DM seeking bariatric surgery was significantly associated with severity of disordered eating. These findings suggest people with T2DM seeking bariatric surgery may be vulnerable to psychopathology and disordered eating with implications for early identification and intervention.

LEVEL OF EVIDENCE

Evidence obtained from cohort or case-control analytic studies.

Depressive symptoms mediate the relationship between diabetes and cognitive performance in a community-based sample of older adults

AIMS

To evaluate whether diabetes and prediabetes are associated with impaired cognitive performance among older adults and examine depressive symptoms as a mediator.

METHODS

We used cross-sectional data from the Einstein Aging Study, a systematically recruited, community-based cohort study of diverse older adults (N = 794; Age Mean (SD) = 78.9 (5.3); 64.4% Non-Hispanic White, 28.7% Non-Hispanic Black, 5.7% Hispanic). Diabetes status was established via self-reported diagnosis, prescribed medications, and fasting blood glucose. Depressive symptoms were assessed using the Geriatric Depression Scale. Cognitive tests included Digit Symbol, Trails-B, Free Recall, Category Fluency, Boston Naming, and Block Design. Linear regression and mediation analyses were applied.

RESULTS

Compared to those without diabetes, diabetes was associated with worse performance on all cognitive tests (ps < 0.05), except Trails-B (p = 0.53), and increased depressive symptoms (p < 0.01). For diabetes, mediation via increased depressive symptoms was observed for Free Recall (p = 0.044), Category Fluency (p = 0.033), and Boston Naming (p = 0.048).

CONCLUSIONS

Diabetes was consistently associated with worse cognitive performance and increased depressive symptoms among this older cohort, while prediabetes was not. Mediation findings suggest depressive symptoms may be a biobehavioral pathway linking diabetes and cognition, though the temporal sequence is unclear. If causal, addressing both diabetes and depressive symptoms among older adults may protect cognitive function.

A systematic review and meta-analysis to compare the prevalence of depression between people with and without Type 1 and Type 2 diabetes

AIMS

Diabetes can significantly impact quality of life and mental health. However, inconsistencies have been reported in the prevalence of depression in those with Type 1 and Type 2 diabetes, and those without. Systematic reviews also included studies without adequate control subjects. We update existing literature, by comparing depression prevalence between individuals with and without Type 1 and Type 2 diabetes.

METHODS

A systematic review and meta-analysis. We searched MEDLINE, EMBASE and PSYCHINFO, from January 1985 to August 2021. Studies were excluded if they failed to have an adequate control group, specified type of diabetes, or reported depression prevalence by type of diabetes.

RESULTS

44 studies were selected for inclusion. The prevalence of depression was significantly higher in people with Type 1 (22% vs 13%, OR = 2.10 (95% CI: 1.23, 3.52)), or Type 2 diabetes (19% vs 11%, OR = 1.76 (1.55, 2.01)) compared to those without diabetes. There was no association between study effect size and mean age or gender. Findings did not significantly differ between methods of depression assessment. Prevalence of depression in people with diabetes was higher in studies carried out in specialist care (36%, OR = 3.14 (2.12, 4.63)) compared to those in community or primary care (12%, OR = 1.51 (1.35, 1.70) and in low- and middle-income countries (OR = 2.58 (1.91, 3.50) compared to countries with high income economies (OR = 1.59 (1.39, 1.82)).

CONCLUSIONS

Depression prevalence remains significant in those with type 1 and type 2 diabetes. Effective chronic disease management in people with diabetes is important, particularly screening and managing depression and diabetes distress in specialist care settings.

Investigating the association between diabetes and mental health: A train-and-test approach

Diabetes is a chronic health condition that affects how the body turns food into energy. Research has demonstrated a relationship between diabetes and various mental health issues, which include psychiatric disorders and other problems that are specific for people living with diabetes. Although previous studies have shed light on the associations between diabetes and various types of mental health issues with a focus on depression and anxiety, much less is known about how diabetes is associated with other dimensions of mental health such as social dysfunction and anhedonia and loss of confidence in a large nationally representative survey from the United Kingdom. The aim of the current study is to replicate the factor structure of the GHQ-12 and investigate how diabetes is related to general mental health and dimensions of mental health. By adopting a train-and-test approach to data from the UKHLS including 2,255 diabetes patients and 14,585 age and sex-matched participants who indicated that they were not clinically diagnosed with diabetes, the current study found that hypotheses are well-supported by the results.

Is There Limited Utility for Lifestyle Recommendations for Diabetes Prevention Among Overweight or Obese Depressed Patients?

Background: Lifestyle interventions like diet and exercise are commonly recommended for diabetes prevention, but it is unclear if depression modifies the likelihood of adherence. We evaluated the relationship between high depressive symptomatology and adherence to lifestyle interventions among patients with pre-diabetes. Methods: We conducted an analysis of the nationally representative National Health and Nutrition Examination Survey (NHANES) 2017-2018. Adults, aged ≥18 years old who were overweight or obese (BMI ≥25) and had diagnosed or undiagnosed pre-diabetes (HbA1c 5.7-6.4) were included. Depressive symptomatology was classified by the Patient Health Questionniare-9 (PHQ-9). We used self-reported adherence to physician suggested lifestyle changes of diet and exercise. Results: In this nationally representative survey of overweight or obese adults with pre-diabetes, 14.8% also have high depressive symptomatology. In unadjusted analyses, an interaction was observed with high depressive symptomatology acting as an effect modifier for adherence to exercise oriented interventions among patients with diagnosed pre-diabetes (p = 0.027). In logistic regressions, adjusting for age, sex, race, outpatient medical care in the past 12 months, and obesity, among patients with diagnosed pre-diabetes, depressed patients were less likely to attempt to exercise more (OR = 0.31; 95% CI: 0.10, 0.94) and no association between high depressive symptomatology and attempting to lose weight was observed (OR = 0.45; 95% CI: 0.14, 1.42). Conclusions: The findings of this nationally representative study of US adults, high depressive symptomatology decreases the likelihood of adherence to exercise based lifestyle recommendations among patients with diagnosed pre-diabetes.

Depressive symptoms in Chinese adults with risk factors for diabetes: the Shanghai High-Risk Diabetic Screen (SHiDS) study

AIMS

To evaluate the relationship between newly diagnosed diabetes or prediabetes and depressive symptoms among individuals with risk factors for diabetes in China. We also investigated the associations of depressive symptoms with pancreatic β-cell function and insulin resistance.

METHODS

We used cross-sectional data from the Shanghai High-Risk Diabetic Screen (SHiDS) project. Between 2014 and 2017, a total of 1728 participants were enrolled in this study and underwent an oral glucose tolerance test to screen for diabetes and prediabetes. Insulin resistance was evaluated using the homeostatic model assessment of insulin resistance and the modified Matsuda index. Pancreatic β-cell function was calculated using the homeostatic model assessment of β-cell function, Stumvoll first- and second-phase indexes. Elevated depressive symptoms were determined using the Patient Health Questionnaire-9 (PHQ-9 score ≥ 10).

RESULTS

The prevalence of elevated depressive symptoms in the total study population was 4.8% (83 of 1728). Compared with the normal glucose tolerance group, individuals with newly diagnosed diabetes were less likely to have elevated depressive symptoms even after controlling for potential confounders [adjusted odds ratio (OR) 0.35, 95% confidence interval (CI) 0.18-0.68; P = 0.002]. However, prediabetes was not associated with depressive symptoms. The odds for elevated depressive symptoms were increased in individuals with higher levels of the Stumvoll first-phase index. No association was observed between depressive symptoms and insulin resistance.

CONCLUSION

Elevated depressive symptoms were less prevalent in Chinese individuals with newly diagnosed diabetes among a high-risk population for diabetes.

Understanding the relationship between type 2 diabetes and depression: lessons from genetically informative study designs

AIMS

To conduct a systematic review in order to comprehensively synthesize the findings from a diverse range of genetically informative studies on comorbid depression and type 2 diabetes.

METHODS

Database searches (1 January 2008 to 1 June 2020) in PubMed and EMBASE were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible reports employed any type of genetically informed design, including twin modelling, Mendelian randomization, genome-wide association studies, polygenetic risk scores, or linkage disequilibrium score regression. Searches generated 451 unique citations, and 16 manuscripts met the inclusion criteria.

RESULTS

The included studies addressed three aetiological models of the depression-diabetes relationship: uni- or bi-directional phenotypic causation; shared genetic liability; or gene-environment interaction. From these studies, there is modest evidence that type 2 diabetes is causally related to risk of developing depression, but much more limited evidence that depression is causally related to risk of diabetes. There is little evidence of shared genetic liability between depression and diabetes or of gene-environment interaction.

CONCLUSIONS

Findings from genetically informed studies are mixed but provide some support for the uni- or bi-directional phenotypic model of depression and type 2 diabetes. Future studies should also explore the hypothesis that this relationship may be influenced by shared environmental risk factors. Findings can inform multifaceted approaches to diabetes prevention and care that reflect how psychosocial factors contribute to type 2 diabetes risk and outcomes.

Depression and antecedent medication adherence in a cohort of new metformin users

AIMS

The association between depression and poor medication adherence is based on cross-sectional studies and cohort studies that measure adherence rates after depression status is determined. However, depressive symptoms occur well before diagnosis. This study examined adherence patterns in the year before a depressive episode.

METHODS

This retrospective cohort study followed new metformin users identified in Alberta Health's administrative data between 2008 and 2018. Depressive episodes starting ≥1 year after metformin initiation were identified using a validated case definition. Controls were randomly assigned a pseudo depression date. Adherence to oral antihyperglycemic medications was estimated using proportion of days covered (PDC) and group-based trajectory models to explore the association between depression and poor adherence (PDC<0.8).

RESULTS

A depressive episode occurred in 17,418 (10.6%) of 165,056 new metformin users. Individuals with depression were more likely to have poor adherence compared to controls (adjusted odds ratio 1.21; 95% CI 1.17, 1.26). Five trajectories were identified: nearly perfect adherence (PDC >0.95 [34.8% of cohort]), discontinued (PDC=0 [18.3% of cohort], poor initial adherence (PDC 0.75) that declined either rapidly (9.2% of cohort) or gradually (30.1% of cohort), and poor initial adherence (PDC 0.26) that increased gradually (7.6% of cohort). Individuals with depression were more likely to be in one of the four trajectories of poor adherence compared to controls (adjusted odds ratio 1.24; 95% CI 1.19-1.29).

CONCLUSIONS

Poor medication adherence occurs in the year before a depressive episode; therefore, poor medication use patterns could be used as an early warning sign for depression.

Association of Selective Serotonin Reuptake Inhibitors With the Risk of Type 2 Diabetes in Children and Adolescents

IMPORTANCE

Concerns exist that use of selective serotonin reuptake inhibitors (SSRIs) increases the risk of developing type 2 diabetes (T2D) in adults, but evidence in children and adolescents is limited. In the absence of a randomized clinical trial, evidence must be generated using real-world data.

OBJECTIVE

To evaluate the safety of SSRI use in children and adolescents with respect to the associated risk of T2D.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of patients aged 10 to 19 years with a diagnosis for an SSRI treatment indication was conducted within the nationwide Medicaid Analytic eXtract (MAX; January 1, 2000, to December 31, 2014) and the IBM MarketScan (January 1, 2003, to September 30, 2015) databases. Data were analyzed from November 1, 2018, to December 6, 2019.

EXPOSURES

New users of an SSRI medication and comparator groups with no known metabolic adverse effects (no antidepressant exposure, bupropion hydrochloride exposure, or psychotherapy exposure). Within-class individual SSRI medications were compared with fluoxetine hydrochloride.

MAIN OUTCOMES AND MEASURES

Incident T2D during follow-up. Intention-to-treat effects were estimated using Cox proportional hazards regression models, adjusting for confounding through propensity score stratification. As-treated effects to account for continuous treatment were estimated using inverse probability weighting and marginal structural models.

RESULTS

A total of 1 582 914 patients were included in the analysis (58.3% female; mean [SD] age, 15.1 [2.3] years). The SSRI-treated group included 316 178 patients in the MAX database (publicly insured; mean [SD] age, 14.7 [2.1] years; 62.2% female) and 211 460 in the MarketScan database (privately insured; mean [SD] age, 15.8 [2.3] years; 63.9% female) with at least 2 SSRI prescriptions filled, followed up for a mean (SD) of 2.3 (2.0) and 2.2 (1.9) years, respectively. In publicly insured patients, initiation of SSRI treatment was associated with a 13% increased hazard of T2DM (intention-to-treat adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.22) compared with untreated patients. The association strengthened for continuous SSRI treatment (as-treated aHR, 1.33; 95% CI, 1.21-1.47), corresponding to 6.6 (95% CI, 4.2-10.4) additional cases of T2D per 10 000 patients treated for at least 2 years. Adjusted HRs were lower in privately insured patients (intention-to-treat aHR, 1.01 [95% CI, 0.84-1.23]; as-treated aHR, 1.10 [95% CI, 0.88-1.36]). Findings were similar when comparing SSRI treatment with psychotherapy (publicly insured as-treated aHR, 1.44 [95% CI, 1.25-1.65]; privately insured as-treated aHR, 1.21 [95% CI, 0.93-1.57]), whereas no increased risk was observed compared with bupropion treatment publicly insured as-treated aHR, 1.01 [95% CI, 0.79-1.29]; privately insured as-treated aHR, 0.87 [95% CI, 0.44-1.70]). For the within-class analysis, no medication had an increased hazard of T2D compared with fluoxetine.

CONCLUSIONS AND RELEVANCE

These findings suggest that children and adolescents initiating SSRI treatment may be at a small increased risk of developing T2D, particularly publicly insured patients. The magnitude of association was more modest than previously reported, and the absolute risk was small. The potential small risk should be viewed in relation to the efficacy of SSRIs for its major indications in young patients.

Measures of depression and incident type 2 diabetes in a community sample

PURPOSE

The purpose of this study was to estimate associations between distinct measures of depression and incident type 2 diabetes.

METHODS

Our sample consisted of 30,360 community-dwelling adults aged 40 to 69 in Canada. Depression was defined as elevated depressive symptoms using the Patient Health Questionnaire 9, diagnoses of depression in administrative data, or antidepressant use from a medication inventory. Type 2 diabetes was ascertained in administrative data over up to 7 years of follow-up. Cox proportional hazards models were used to estimate associations between different measures of depression and incident diabetes.

RESULTS

In separate models, elevated depressive symptoms were associated with a 17% increased risk of type 2 diabetes (hazard ratio (HR) 1.17, 95% confidence interval (CI) 1.02-1.34), diagnoses of depression were associated with a 20% increased risk (HR 1.20, 95% CI 0.94-1.52), and antidepressant use was associated with a 19% increased risk (HR 1.19, 95% CI 1.01-1.41). When examining combinations of measures in the same model, depressive symptoms paired with antidepressant use and depressive symptoms paired with diagnoses of depression were associated with the highest risk of type 2 diabetes.

CONCLUSIONS

Various measures of depression and combinations of measures can be used to identify older adults at higher risk of type 2 diabetes in research and public health.

Elevated depressive symptoms and risk of all-cause and cardiovascular mortality among adults with and without diabetes: The REasons for Geographic And Racial Differences in Stroke (REGARDS) study

AIMS

To examine the association of elevated depressive symptoms with all-cause and cardiovascular disease (CVD) mortality and determine whether these associations differ for those with and without diabetes.

METHODS

We included 22,807 black and white men and women aged 45-98 years at baseline (2003-2007) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study. Elevated depressive symptoms were defined as a score ≥ 4 on the 4-item Centers for Epidemiologic Studies of Depression Scale. Participants were classified as having diabetes, prediabetes, or no prediabetes/diabetes based on glucose levels and diabetes medication use. All-cause mortality events were available through 2018 and adjudicated CVD mortality events were available through 2015.

RESULTS

During follow-up, there were 5383 all-cause deaths, of which 1585 were adjudicated CVD deaths. The mean survival time was lower for participants with elevated depressive symptoms than those without elevated depressive symptoms for those with diabetes, prediabetes, and no prediabetes/diabetes. In multivariable adjusted models, elevated depressive symptoms increased the risk of all-cause mortality for those with diabetes (HR = 1.15; 95% CI = 1.00-1.32), prediabetes (HR = 1.56; 95% CI = 1.28-1.91), and neither prediabetes/diabetes (HR = 1.34; 95% CI = 1.19-1.50) (p for interaction = 0.0342). Findings were similar for CVD mortality.

CONCLUSION

Elevated depressive symptoms increased the risk of all-cause and CVD mortality among individuals with and without diabetes, with a stronger magnitude of association observed among those with prediabetes. This underscores the need for assessing depressive symptoms across the glycemic spectrum, including those with prediabetes.

Subjective wellbeing as a determinant of glycated hemoglobin in older adults: longitudinal findings from the English Longitudinal Study of Ageing

BACKGROUND

Previous research has shown an association between subjective wellbeing and incident diabetes. Less is known about the role of wellbeing for subclinical disease trajectories as captured via glycated hemoglobin (HbA1c). We aimed to explore the association between subjective wellbeing and future HbA1c levels, and the role of sociodemographic, behavioral and clinical factors in this association.

METHODS

We used data from the English Longitudinal Study of Ageing for this study (N = 2161). Subjective wellbeing (CASP-19) was measured at wave 2 and HbA1c was measured 8 years later at wave 6. Participants were free from diabetes at baseline. We conducted a series of analyses to examine the extent to which the association was accounted for by a range of sociodemographic, behavioral and clinical factors in linear regression models.

RESULTS

Models showed that subjective wellbeing (CASP-19 total score) was inversely associated with HbA1c 8 years later after controlling for depressive symptoms, age, sex, and baseline HbA1c (B = -0.035, 95% CI -0.060 to -0.011, p = 0.005). Inclusion of sociodemographic variables and behavioral factors in models accounted for a large proportion (17.0% and 24.5%, respectively) of the relationship between wellbeing and later HbA1c; clinical risk factors explained a smaller proportion of the relationship (3.4%).

CONCLUSIONS

Poorer subjective wellbeing is associated with greater HbA1c over 8 years of follow-up and this relationship can in part be explained by sociodemographic, behavioral and clinical factors among older adults.

How patients make sense of a diabetes diagnosis: An application of Weick's model of organizing

AIMS

To identify communication cycles patients use to make sense of a diabetes diagnosis and barriers patients encounter in their sensemaking process.

METHODS

Researchers conducted interviews with 33 participants with type 2 diabetes mellitus or prediabetes at medical centers in Georgia and Nevada. A thematic analysis using the constant comparative method identified communication cycles.

RESULTS

Patients reported engaging three communication cycles to make sense of the diagnosis: (1) interacting with healthcare clinicians; (2) seeking information online; and (3) taking a nutrition/diabetes management class. Patients reported system-level barriers that impact sensemaking: (1) lack of consistent or routine care; and (2) lack of access to resources.

CONCLUSION

Results here reinforce the theoretical proposition that receiving a diagnosis is an equivocal process that requires patients to make sense of new information through communication cycles. Patients in this sample repeatedly described communication cycles to interpret this new information rather than relying on assembly rules. Clinicians can promote patient understanding of diabetes and self-management by taking time to explain the diagnosis, maintaining consistent care, providing guidance to online sources, and ensuring patients have access to diabetes education.

Glucose homeostasis in major depression and schizophrenia: a comparison among drug-naïve first-episode patients

There is evidence for insulin resistance in drug-naïve first-episode schizophrenia (Sz) patients. We have tested whether impaired insulin homeostasis is also present in first-episode patients with major depression (MD) and if this can be discerned from stress-related and medication effects. Homeostatic model assessment of insulin resistance (HOMA-IR) was determined in a cross-sectional cohort study of acute first-episode drug-naïve patients with MD (n = 18) or Sz (n = 24), and healthy controls (C, n = 43). Morning cortisol and catecholamine metabolites were assessed to control for hormonal stress axis activation. Subjects were matched for sex, age, body mass index and waist-hip ratio to exclude the possibility that overweight and visceral adiposity were potential confounding factors. HOMA-IR did not differ between MD and controls, but was increased in Sz compared to MD (p = 0.002) and controls (p = 0.012). Catecholamine metabolites were elevated in both patient groups, indicating presence of hormonal stress axis activation. However, diagnosis-related changes of HOMA-IR were independent from this. Impaired insulin sensitivity was absent in MD, but specifically related to the early disease course of Sz. Thus, considering previous studies in this field, MD may be related to impaired glucose/insulin homeostasis in the long-term but not in early disease stages.

Cumulative effect of depressed mood and obesity on type II diabetes incidence: Findings from the MONICA/KORA cohort study

BACKGROUND

Obesity and depression both individually contribute to the risk of Type II Diabetes (T2DM). The extent to which obesity can be set-off by depression is unknown.

METHODS

In a sample of 9340 participants followed for 15.4 years (79,372 person-years) from the prospective MONICA/KORA population-based cohort conducted in Southern Germany, we investigated the impact of obesity, defined as Body Mass Index (BMI) ≥ 30, and depression on the incidence of T2DM using Cox Proportional Hazards Regression.

RESULTS

The relative risk of T2DM was over 6 fold higher among obese participants in comparison to normal weight participants (HR 6.05; 95% CI 4.82 to 7.59; p < .0001). Nonetheless, among participants with obesity, comorbidity of depression was associated with an additional 2 fold risk T2DM (HR 8.05, 95% CI 5.90-10.98; p < .0001). This finding corresponded to an increase in the 15.4-year absolute risk of T2DM from 15.9 cases per 1000 person-years (py) in participants with obesity but not depression, to 21.4 cases per 1000 py for participants with obesity and depression. Further analysis of joint effects and Relative Excess Risk due to Interaction disclosed that depressed mood is associated with significantly higher risk of T2DM in participants with obesity, and to a lesser extent in overweight participants, however an association was not found in normal weight participants.

CONCLUSIONS

The present investigation discloses that despite the overreaching importance of obesity as a risk factor for T2DM, there is room for depressed mood to add measurable risk prediction.

Incidence of filled antidepressant prescriptions among people with newly diagnosed diabetes and its interaction with occupational status within the working population of Denmark 1996-2010

AIMS

People with diabetes have heightened levels of depressive symptoms, but less is known about the development of these symptoms in relation to diabetes duration. In this study, we examined the use of prescribed antidepressants in the first five years after diagnosis of diabetes among the working-age population in Denmark.

METHODS

All Danish adults aged 18-54 years, diagnosed with diabetes in the study period were included. Diabetes status and purchase of prescription antidepressants were obtained from validated population registers. Data analysis focused on filled antidepressant prescriptions at ≤1 and ≤5years from diagnosis with diabetes.

RESULTS

35,677 people diagnosed with diabetes were included in the study. At ≤1 year post-diagnosis, 2.6% had filled antidepressant prescriptions. At ≤5years, this figure rose to 10.4%. Overall, both female gender and lower socioeconomic status were associated with higher incidence of filled antidepressant prescriptions. Diabetes duration modified the degree of differences between men and women and socioeconomic strata.

CONCLUSION

Diagnosis with diabetes immediately impacts mental wellbeing, with higher rates of filled antidepressant prescriptions in the first year after diagnosis. People of working age diagnosed with diabetes face specific challenges and addressing such challenges would enhance patient experiences. Focus on mental health in the clinical encounter with people newly diagnosed with diabetes is warranted and important.

Anaerobic muscle strengthening physical activity and depression severity among USA adults

We investigated the association between depression and anaerobic physical activity (while controlling aerobic physical activity), using a nationally representative sample of USA adults (n = 7354) who participated in the cross sectional National Health and Nutrition Examination Survey (NHANES, 1999-2006). We defined depression using the validated "Patient Health Questionnaire" (PHQ₉) scale of 0-27 as PHQ₉ ≥ 10. Severity of depression was classified by clinically established PHQ₉ levels: mild (5-9), dysthymic (10-14), moderate (15-19), and major depression (≥20). We used logistic regression to estimate adjusted odds ratios of depression associated with distinct types of activity (only aerobic, only anaerobic, combined regime). We used multinomial logistic regression to examine associations of anaerobic activity with various severity levels of depression (mild, dysthymic, moderate, and major depression) with adjustment for aerobic activity. Women had higher prevalence of depression than men (8.4% versus 5.7%), whereas anaerobic muscle strengthening activity was more common in men than women (35% versus 24%). Adjusting for aerobic activity, anaerobic activity was inversely associated with depression (PHQ₉ ≥ 10) in women under 50 (OR = 0.57; 95%CI = 0.41-0.81), all women (OR = 0.59; 0.43-0.80), men under 50 (OR = 0.85; 0.58-1.2), and all men (OR = 0.72; 0.51-1.01). Anaerobic activity was inversely associated with severity level of depressive symptoms in women and men. The combined regimen of anaerobic muscle strengthening activity and meeting the Physical Activity Guideline for America (PAGA) was related to the lowest odds ratio of depression in women (OR = 0.50; 95%CI = 0.33-0.75) and men (OR = 0.39; 95%CI = 0.23-0.62). Independent of aerobic physical activity, anaerobic muscle strengthening activity is significantly and inversely associated with depression among USA adults.

Discrimination and Depressive Symptoms Among African American Men Across the Adult Lifecourse

Objectives

A lifecourse framework was used to examine the association between major and everyday measures of perceived discrimination and depressive symptoms among African American men and to evaluate whether these relationships differed for young, middle-aged, and older men.

Method

The association between both major and everyday discrimination and depressive symptoms, as measured by the Center for Epidemiologic Studies Depression (CES-D) scale, was assessed among 296 African American men in the 2011-2014 Nashville Stress and Health Study (NSAHS) using ordinary least squares regression. Interactive associations between major and everyday discrimination and age patterns in the discrimination-depressive symptoms relationship were also investigated.

Results

Everyday, but not major discrimination was associated with depressive symptoms among African American men. This relationship was stronger among middle-aged men and diminished among older men. However, major discrimination, but not everyday discrimination, was associated with depressive symptoms of older men (age 55+), with greatest depressive symptomatology among those reporting both forms of discrimination.

Discussion

Everyday discrimination is a more consistent predictor, relative to major discrimination, of depressive symptoms among African American men across the lifecourse, although there were age and/or cohort differences. Findings also demonstrate the synergistic, or additive, impact of multiple forms of discrimination on mental health.

The association of depression and diabetes across methods, measures, and study contexts

Background

Empirical research has revealed a positive relationship between type 2 diabetes mellitus and depression, but questions remain regarding timing of depression measurement, types of instruments used to measure depression, and whether “depression” is defined as clinical depression or depressive symptoms. The present study sought to establish the robustness of the depression-diabetes relationship across depression definition, severity of depressive symptoms, recent depression, and lifetime depression in a nationally representative dataset and a large rural dataset.

Methods

The present examination, conducted between 2014 and 2015, used two large secondary datasets: the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2008 (n = 3072) and the Arthritis, Coping, and Emotion Study (ACES) from 2002 to 2006 (n = 2300). Depressive symptoms in NHANES were measured using the Patient Health Questionnaire 9-item survey (PHQ-9). ACES used the Center for Epidemiologic Studies—Depression Scale (CES-D) to measure depressive symptoms and the Composite International Diagnostic Interview (CIDI) to measure diagnosable depression. Diabetes was modelled as the dichotomous outcome variable (presence vs. absence of diabetes). Logistic regression was used for all analyses, most of which were cross-sectional. Analyses controlled for age, ethnicity, sex, education, and body mass index, and NHANES analyses used sample weights to account for the complex survey design. Additional analyses using NHANES data focused on the addition of health behavior variables and inflammation to the model.

Results

NHANES. Every one-point increase in depressive symptoms was associated with a 5% increase in odds of having diabetes [OR: 1.05 (CI: 1.03, 1.07)]. These findings persisted after controlling for health behaviors and inflammation. ACES. For every one-point increase in depressive symptom score, odds of having diabetes increased by 2% [OR: 1.02 (CI: 1.01, 1.03)]. Recent (past 12 months) depression [OR: 1.49, (CI: 1.03, 2.13)] and lifetime depression [OR: 1.40 (CI: 1.09, 1.81)] were also significantly associated with having diabetes.

Conclusions

This study provides evidence for the robustness of the relationship between depression or depressive symptoms and diabetes and demonstrates that depression occurring over the lifetime can be associated with diabetes just as robustly as that which occurs more proximal to the time of study measurement.

Parental History of Diabetes, Positive Affect, and Diabetes Risk in Adults: Findings from MIDUS

BACKGROUND

Family history of diabetes is one of the major risk factors for diabetes, but significant variability in this association remains unexplained, suggesting the presence of important effect modifiers.

PURPOSE

To our knowledge, no previous work has examined whether psychological factors moderate the degree to which family history of diabetes increases diabetes risk.

METHODS

We investigated the relationships among parental history of diabetes, affective states (positive affect, negative affect, and depressed affect), and diabetes in 978 adults from the MIDUS 2 national sample.

RESULTS

As expected, parental history of diabetes was associated with an almost threefold increase in diabetes risk. We found a significant interaction between positive affect and parental history of diabetes on diabetes (p = .009): higher positive affect was associated with a statistically significant lower relative risk for diabetes in participants who reported having a parental history of diabetes (RR = .66 per unit increase in positive affect; 95 % CI = .47; .93), but it did not influence diabetes risk for participants who reported no parental history of diabetes (p = .34). This pattern persisted after adjusting for an extensive set of health and sociodemographic covariates and was independent of negative and depressed affect.

CONCLUSIONS

These results suggest that psychological well-being may protect individuals at increased risk from developing diabetes. Understanding such interactions between non-modifiable risk factors and modifiable psychological resources is important for delineating biopsychosocial pathways to diabetes and informing theory-based, patient-centered interventions to prevent the development of diabetes.

Neuropsychiatric safety with liraglutide 3.0 mg for weight management: Results from randomized controlled phase 2 and 3a trials

AIMS

Liraglutide, a GLP-1 receptor agonist, regulates appetite via receptors in the brain. Because of concerns regarding the potential of centrally-acting anti-obesity medications to affect mental health, pooled neuropsychiatric safety data from all phase 2 and 3a randomized, double-blind trials with liraglutide 3.0 mg were evaluated post hoc.

METHODS

Data from the liraglutide weight-management programme were pooled. Across trials, individuals with a body mass index ≥30 or ≥27 kg/m2 with weight-related comorbidities were randomized to once-daily subcutaneous liraglutide 3.0 mg (n = 3384) or placebo (n = 1941), both with a 500 kcal/d deficit diet, plus exercise. Adverse events related to neuropsychiatric safety were collected in all trials. Additionally, in the phase 3a trials, validated mental-health questionnaires were prospectively and systematically administered.

RESULTS

In the pooled analysis of 5325 randomized and exposed individuals, rates of depression (2.1 vs 2.1 events/100 person-years) and anxiety (1.9 vs 1.7 events/100 person-years) through adverse event reporting were similarly low in liraglutide and placebo groups. Nine (0.3%) individuals receiving liraglutide and 2 (0.1%) receiving placebo reported adverse events of suicidal ideation or behaviour. In phase 3a trials, mean baseline Patient Health Questionnaire-9 scores of 2.8 ± 3.0 vs 2.9 ± 3.1 for liraglutide vs placebo improved to 1.8 ± 2.7 vs 1.9 ± 2.7, respectively, at treatment end; 34/3291 individuals (1.0%) receiving liraglutide 3.0 mg vs 19/1843 (1.0%) receiving placebo reported suicidal ideation on the Columbia-Suicide Severity Rating Scale.

CONCLUSIONS

Results of this exploratory pooled analysis provide no cause for concern regarding the neuropsychiatric safety of treatment with liraglutide 3.0 mg in patients similar to those included in the examined trials. Although there was a small numerical imbalance in suicidal ideation with liraglutide through adverse event reporting, no between-treatment imbalances in suicidal ideation/behaviour or depression were noted through prospective questionnaire assessments.

Opportunity for interprofessional collaborative care-findings from a sample of federally qualified health center patients in the Midwest

OBJECTIVES

Federally qualified health centers (FQHCs) frequently serve more socio-economically disadvantaged populations; existing literature suggests that underserved groups are more likely to experience various chronic physical and mental health conditions. FQHC patients may have significant needs for various specialty services that are beyond common FQHC providers. This study examines chronic condition prevalence, healthcare satisfaction, and use of multiprovider services in a Midwest FQHC patient population. We also evaluated the potential of interprofessional collaborative practices in FQHC settings.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 232 participants were recruited prior to or immediately after their scheduled clinic visit within an FQHC located on the fringes of an urban area. Respondents were invited to complete a brief questionnaire and grant access to their electronic medical records.

RESULTS

Nearly half of participants were covered by Medicaid, private insurance carriers (19.4%), or Medicare (17.7%). The most prevalent chronic conditions included diabetes, depression, anxiety, and chronic pain. Almost half (46.6%) of participants were seen by two or three providers; 20% had 7+ office visits in the last year. While 35.3% reported health dissatisfaction, 30.6% reported health satisfaction. When asked if they were satisfied with their health care, nearly 70% reported satisfaction with health care, while only 4.7% reported healthcare dissatisfaction.

CONCLUSIONS

The authors of this study recommend an interprofessional collaborate healthcare model be explored to address the complex and multifaceted healthcare needs of this population. Future research in this area should prospectively examine the utility of monitoring patient satisfaction in a collaborative practice setting.

Fasting Glucose and the Risk of Depressive Symptoms: Instrumental-Variable Regression in the Cardiovascular Risk in Young Finns Study

PURPOSE

Type 2 diabetes (T2D) has been associated with depressive symptoms, but the causal direction of this association and the underlying mechanisms, such as increased glucose levels, remain unclear. We used instrumental-variable regression with a genetic instrument (Mendelian randomization) to examine a causal role of increased glucose concentrations in the development of depressive symptoms.

METHOD

Data were from the population-based Cardiovascular Risk in Young Finns Study (n = 1217). Depressive symptoms were assessed in 2012 using a modified Beck Depression Inventory (BDI-I). Fasting glucose was measured concurrently with depressive symptoms. A genetic risk score for fasting glucose (with 35 single nucleotide polymorphisms) was used as an instrumental variable for glucose.

RESULTS

Glucose was not associated with depressive symptoms in the standard linear regression (B = -0.04, 95% CI [-0.12, 0.04], p = .34), but the instrumental-variable regression showed an inverse association between glucose and depressive symptoms (B = -0.43, 95% CI [-0.79, -0.07], p = .020). The difference between the estimates of standard linear regression and instrumental-variable regression was significant (p = .026) CONCLUSION: Our results suggest that the association between T2D and depressive symptoms is unlikely to be caused by increased glucose concentrations. It seems possible that T2D might be linked to depressive symptoms due to low glucose levels.

Impact on psychosocial outcomes of a nationally available weight management program tailored for individuals with type 2 diabetes: Results of a randomized controlled trial

AIMS

Type 2 diabetes mellitus (T2DM) can substantially decrease quality of life (QOL). This study examined the effects on QOL-relevant psychosocial measures of a widely available commercial weight loss program enhanced for individuals with T2DM.

METHODS

A year-long multi-site randomized clinical trial compared the Weight Watchers (WW) approach, supplemented with phone and email counseling with a certified diabetes educator (CDE), to brief standard diabetes nutrition counseling and education (Standard Care; SC). Participants were 400 women and 163 men (N=279 WW; 284 SC) with T2DM [mean (±SD) HbA_1c 8.32±1%; BMI=37.1±5.7kg/m²; age=55.1 ± 9.1years]. Psychosocial outcomes were assessed at baseline, month 6, and month 12 using a diabetes specific psychosocial measure (Diabetes Distress Scale [DDS]), Impact of Weight on Quality of Life-Lite scale (IWQOL), a generic QOL measure (SF-36), and a depression screen (PHQ-9).

RESULTS

WW participants showed significantly greater improvements than did SC participants on all DDS subscales and total score and on IWQOL total score and physical function, sex life and work domains (all ps<.05). There was no significant treatment effect on SF-36 scores or PHQ-9.

CONCLUSIONS

WW enhanced for individuals with T2DM was superior to SC in improving psychosocial outcomes most specific to T2DM and obesity. Available commercial WL programs, combined with scalable complementary program-specific diabetes counseling, may have benefits that extend to diabetes-related distress and weight-relevant QOL.

ForgIng New paths in DIabetes PrevenTion (FINDIT): Study Protocol for a Randomized Controlled Trial

BACKGROUND

Prediabetes is an asymptomatic condition in which patients' blood glucose levels are higher than normal but do not meet diagnostic criteria for type 2 diabetes mellitus (T2DM). A key window of opportunity to increase engagement of patients with prediabetes in strategies to prevent T2DM is when they are screened for T2DM and found to have prediabetes, yet the effects of this screening and brief counseling are unknown.

METHODS

In this parallel-design randomized controlled trial we will recruit 315 non-diabetic patients from the Ann Arbor VA Medical Center (AAVA) who have one or major risk factors for T2DM and an upcoming primary care appointment at the AAVA, but have not had a hemoglobin A1c (HbA1c) test to screen for T2DM in the previous 12 months. After informed consent, participants will complete a baseline survey and be randomly assigned to, at the time of their next primary care appointment, one of two arms: (1) to have a hemoglobin A1c (HbA1c) test to screen for T2DM and receive brief, standardized counseling about these results or (2) to review a brochure about clinical preventive services. Participants will complete surveys 2 weeks, 3 months, and 12 months after their primary care appointment, and a weight measurement 12 months after their primary care appointment. The primary outcome is weight change after 12 months. The secondary outcomes are changes in perception of risk for T2DM; knowledge of T2DM prevention; self-efficacy and motivation to prevent T2DM; use of pharmacotherapy for T2DM prevention; physical activity; participation in weight management programs; and mental health. Quantitative analyses will compare outcomes among participants in the HbA1c test arm found to have prediabetes with participants in the brochure arm. Among participants in the HbA1c test arm found to have prediabetes we will conduct semi-structured interviews about their understanding of and reactions to receiving a prediabetes diagnosis.

DISCUSSION

This trial will generate foundational data on the effects of a prediabetes diagnosis and brief counseling on patients' preventive behaviors and mediators of these behaviors that will enable the development of novel strategies to improve patient engagement in T2DM prevention.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02747108 . Registered on 18 April 2016.

Relationship between depression and diabetes in pregnancy: A systematic review

AIM

To systematically review the literature on women with both diabetes in pregnancy (DIP) and depression during or after pregnancy.

METHODS

In this systematic literature review, PubMed/MEDLINE and EMBASE were searched (13 November 2015) using terms for diabetes (type 1, type 2, or gestational), depression, and pregnancy (no language or date restrictions). Publications that reported on women who had both DIP (any type) and depression or depressive symptoms before, during, or within one year after pregnancy were considered for inclusion. All study types were eligible for inclusion; conference abstracts, narrative reviews, nonclinical letters, editorials, and commentaries were excluded, unless they provided treatment guidance.

RESULTS

Of 1189 articles identified, 48 articles describing women with both DIP and depression were included (sample sizes 36 to > 32 million). Overall study quality was poor; most studies were observational, and only 12 studies (mostly retrospective database studies) required clinical depression diagnosis. The prevalence of concurrent DIP (any type) and depression in general populations of pregnant women ranged from 0% to 1.6% (median 0.61%; 12 studies). The prevalence of depression among women with gestational diabetes ranged from 4.1% to 80% (median 14.7%; 16 studies). Many studies examined whether DIP was a risk factor for depression or depression was a risk factor for DIP. However, there was no clear consensus for either relationship. Importantly, we found limited guidance on the management of women with both DIP and depression.

CONCLUSION

Given the increasing prevalence of diabetes and depression, high-quality research and specific guidance for management of pregnant women with both conditions are warranted.

Differences in depression between unknown diabetes and known diabetes: results from China health and retirement longitudinal study

BACKGROUND

Both diabetes and depression have become serious public health problems and are major contributors to the global burden of disease. People with diabetes have been shown to have higher risk of depression. The purpose of this study was to observe the differences in depression between older Chinese adults with known or unknown diabetes.

METHODS

Data came from the national baseline survey of China Health and Retirement Longitudinal Study (CHARLS). The Center for Epidemiologic Studies Depression Scale was used to assess depression. Participants with a history of diabetes diagnosis were considered to have known diabetes, and those with newly-diagnosed diabetes were considered to have unknown diabetes. Multiple logistic regression analysis was applied to estimate odds ratio (OR) for depression in predictor variables.

RESULTS

Overall, 39.1% of the 2,399 participants with diabetes suffered from depression. The prevalence of depression was significantly higher (p < 0.001) in people with known diabetes (43.5%) than those with unknown diabetes (35.1%). The biggest differences between the two groups were found in the middle aged, in women, in the less educated and in married people. In known diabetes, people treated with traditional Chinese medicine (TCM) coupled with oral western medicine (WM) and/or insulin had two-fold odds of depression compared to those without treatment.

CONCLUSION

The knowledge of having diabetes, treatments and suffering from other chronic diseases were associated with the higher prevalence of depression in people with known diabetes compared to those with unknown diabetes. Prevention of depression in diabetics should receive more attention in the middle aged, women and the less education.

Association of depression with pre-diabetes, undiagnosed diabetes, and previously diagnosed diabetes: a meta-analysis

We performed a meta-analysis to analyze the associations of depression with pre-diabetes (PreDM), undiagnosed diabetes (UDM), and previously diagnosed diabetes (PDM), and whether the association was affected by important study characteristics. We searched relevant articles published in PubMed and EMBASE up to August, 2015. Studies reporting cross-sectional associations of depression with PreDM, UDM, or PDM compared with normal glucose metabolism (NGM) were included. Odds ratios (ORs) were pooled with random-effect and fixed-effect models. Subgroup analyses by sex, study mean age, different degrees of adjustment, publication year, quality score, and depression assessment scales were also performed. Twenty studies were eligible and included in current analysis. Summary estimates showed that compared with NGM individuals, prevalence of depression was moderately increased in PreDM (random-effect odds ratio (OR) 1.11, 95 % confidence interval (CI) 1.03-1.19) and UDM (OR 1.27, 95 % CI 1.02-1.59), and markedly increased in PDM (OR 1.80, 95 % CI 1.40-2.31). Subgroup analyses showed that the positive association remained only among studies with mean age <60 years old but not among those with mean age ≥60 years old. Summary estimates of ORs with cardiovascular disease adjustment substantially attenuated the association. Our findings suggested that risk of prevalent depression was gradually increased with the deterioration of glucose metabolism among younger age groups but not among older age groups. Comorbid cardiovascular diseases might be an important intermediate factor underlying the association between depression and diabetes.

Depression among people with type 2 diabetes mellitus, US National Health and Nutrition Examination Survey (NHANES), 2005-2012

BACKGROUND

Depression in people with diabetes can result in increased risk for diabetes-related complications. The prevalence of depression has been estimated to be 17.6 % in people with type 2 diabetes mellitus (T2DM), based on studies published between 1980 and 2005. There is a lack of more recent estimates of depression prevalence among the US general T2DM population.

METHODS

The present study used the US National Health and Nutrition Examination Survey (NHANES) 2005-2012 data to provide an updated, population-based estimate for the prevalence of depression in people with T2DM. NHANES is a cross-sectional survey of a nationally representative sample of the civilian, non-institutionalized US population. Starting from 2005, the Patient Health Questionnaire (PHQ-9) was included to measure signs and symptoms of depression. We defined PHQ-9 total scores ≥ 10 as clinically relevant depression (CRD), and ≥ 15 as clinically significant depression (CSD). Self-reported current antidepressant use was also combined to estimate overall burden of depression. Predictors of CRD and CSD were investigated using survey logistic regression models.

RESULTS

A total of 2182 participants with T2DM were identified. The overall prevalence of CRD and CSD among people with T2DM is 10.6 % (95 % confidence interval (CI) 8.9-12.2 %), and 4.2 % (95 % CI 3.4-5.1 %), respectively. The combined burden of depressive symptoms and antidepressants may be as high as 25.4 % (95 % CI 23.0-27.9 %). Significant predictors of CRD include age (younger than 65), sex (women), income (lower than 130 % of poverty level), education (below college), smoking (current or former smoker), body mass index (≥30 kg/m(2)), sleep problems, hospitalization in the past year, and total cholesterol (≥200 mg/dl). Significant predictors of CSD also include physical activity (below guideline) and cardiovascular diseases.

CONCLUSIONS

The prevalence of CRD and CSD among people with T2DM in the US may be lower than in earlier studies, however, the burden of depression remains high. Further research with longitudinal follow-up for depression in people with T2DM is needed to understand real world effectiveness of depression management.

Depressive symptoms and glycated hemoglobin A1c: a reciprocal relationship in a prospective cohort study

BACKGROUND

The aim of this study was to evaluate the dynamic association between depressive symptoms and glycated hemoglobin A1c (HbA1c) levels using data from the English Longitudinal Study of Ageing (ELSA).

METHOD

The sample was comprised of 2886 participants aged ⩾50 years who participated in three clinical assessments over an 8-year period (21% with prediabetes and 7% with diabetes at baseline). Structural equation models were used to address reciprocal associations between depressive symptoms and HbA1c levels and to evaluate the mediating effects of lifestyle-related behaviors and cardiometabolic factors.

RESULTS

We found a reciprocal association between depressive symptoms and HbA1c levels: depressive symptoms at one assessment point predicted HbA1c levels at the next assessment point (standardized β = 0.052) which in turn predicted depressive symptoms at the following assessment point (standardized β = 0.051). Mediation analysis suggested that both lifestyle-related behaviors and cardiometabolic factors might mediate the association between depressive symptoms and HbA1c levels: depressive symptoms at baseline predicted lifestyle-related behaviors and cardiometabolic factors at the next assessment, which in turn predicted HbA1c levels 4 years later. A similar association was observed for the other direction: HbA1c levels at baseline predicted lifestyle-related behaviors and cardiometabolic factors at the next assessment, which in turn predicted depressive symptoms 4 years later.

CONCLUSIONS

Our results suggest a dynamic relationship between depressive symptoms and HbA1c which might be mediated by both lifestyle and cardiometabolic factors. This has important implications for investigating the pathways which could link depressive symptoms and increased risk of diabetes.

Fusing Data Mining, Machine Learning and Traditional Statistics to Detect Biomarkers Associated with Depression

BACKGROUND

Atheoretical large-scale data mining techniques using machine learning algorithms have promise in the analysis of large epidemiological datasets. This study illustrates the use of a hybrid methodology for variable selection that took account of missing data and complex survey design to identify key biomarkers associated with depression from a large epidemiological study.

METHODS

The study used a three-step methodology amalgamating multiple imputation, a machine learning boosted regression algorithm and logistic regression, to identify key biomarkers associated with depression in the National Health and Nutrition Examination Study (2009-2010). Depression was measured using the Patient Health Questionnaire-9 and 67 biomarkers were analysed. Covariates in this study included gender, age, race, smoking, food security, Poverty Income Ratio, Body Mass Index, physical activity, alcohol use, medical conditions and medications. The final imputed weighted multiple logistic regression model included possible confounders and moderators.

RESULTS

After the creation of 20 imputation data sets from multiple chained regression sequences, machine learning boosted regression initially identified 21 biomarkers associated with depression. Using traditional logistic regression methods, including controlling for possible confounders and moderators, a final set of three biomarkers were selected. The final three biomarkers from the novel hybrid variable selection methodology were red cell distribution width (OR 1.15; 95% CI 1.01, 1.30), serum glucose (OR 1.01; 95% CI 1.00, 1.01) and total bilirubin (OR 0.12; 95% CI 0.05, 0.28). Significant interactions were found between total bilirubin with Mexican American/Hispanic group (p = 0.016), and current smokers (p<0.001).

CONCLUSION

The systematic use of a hybrid methodology for variable selection, fusing data mining techniques using a machine learning algorithm with traditional statistical modelling, accounted for missing data and complex survey sampling methodology and was demonstrated to be a useful tool for detecting three biomarkers associated with depression for future hypothesis generation: red cell distribution width, serum glucose and total bilirubin.

Depression in Mexican Americans with diagnosed and undiagnosed diabetes

BACKGROUND

Depression and diabetes commonly co-occur; however, the strength of the physiological effects of diabetes as mediating factors towards depression is uncertain.

METHOD

We analyzed extensive clinical, epidemiological and laboratory data from n = 2081 Mexican Americans aged 35-64 years, recruited from the community as part of the Cameron County Hispanic Cohort (CCHC) divided into three groups: Diagnosed (self-reported) diabetes (DD, n = 335), Undiagnosed diabetes (UD, n = 227) and No diabetes (ND, n = 1519). UD participants denied being diagnosed with diabetes, but on testing met the 2010 American Diabetes Association and World Health Organization definitions of diabetes. Depression was measured using the Center for Epidemiological Studies - Depression (CES-D) scale. Weighted data were analyzed using dimensional and categorical outcomes using univariate and multivariate models.

RESULTS

The DD group had significantly higher CES-D scores than both the ND and UD (p ⩽ 0.001) groups, whereas the ND and UD groups did not significantly differ from each other. The DD subjects were more likely to meet the CES-D cut-off score for depression compared to both the ND and UD groups (p = 0.001), respectively. The UD group was also less likely to meet the cut-off score for depression than the ND group (p = 0.003). Our main findings remained significant in models that controlled for socio-demographic and clinical confounders.

CONCLUSIONS

Meeting clinical criteria for diabetes was not sufficient for increased depressive symptoms. Our findings suggest that the 'knowing that one is ill' is associated with depressive symptoms in diabetic subjects.

Mixed methods study of engagement in behaviors to prevent type 2 diabetes among employees with pre-diabetes

BACKGROUND

Many employers use screenings to identify and recommend modification of employees' risk factors for type 2 diabetes, yet little is known about how often employees then engage in recommended behaviors and what factors influence engagement. We examined the frequency of, facilitators of, and barriers to engagement in recommended behaviors among employees found to have pre-diabetes during a workplace screening.

METHODS

We surveyed 82 University of Michigan employees who were found to have pre-diabetes during a 2014 workplace screening and compared the characteristics of employees who 3 months later were and were not engaged in recommended behaviors. We interviewed 40 of these employees to identify the facilitators of and barriers to engagement in recommended behaviors.

RESULTS

3 months after screening, 54% of employees with pre-diabetes reported attempting to lose weight and getting recommended levels of physical activity, had asked their primary care provider about metformin for diabetes prevention, or had attended a Diabetes Prevention Program. These employees had higher median levels of motivation to prevent type 2 diabetes (9/10 vs 7/10, p<0.001) and lower median estimations of their risk for type 2 diabetes (40% vs 60%, p=0.02). Key facilitators of engagement were high motivation and social and external supports. Key barriers were lack of motivation and resources, and competing demands.

CONCLUSIONS

Most employees found to have pre-diabetes through a workplace screening were engaged in a recommended preventive behavior 3 months after the screening. This engagement could be enhanced by optimizing motivation and risk perception as well as leveraging social networks and external supports.

Diabetes burden and diabetes distress: the buffering effect of social support

BACKGROUND

Few studies have examined protective factors for diabetes distress.

PURPOSE

This study aimed to examine the moderating role of social support in the relationship between the burden of diabetes and diabetes distress.

METHODS

Adults with type 2 diabetes (N = 119; 29 % Latino, 61 % Black, 25 % White) completed validated measures of diabetes distress and social support. Multiple linear regression evaluated the moderating role of social support in the relationship between diabetes burden, indicated by prescription of insulin and presence of complications, and distress.

RESULTS

Greater support satisfaction was significantly associated with lower distress after controlling for burden. Support satisfaction and number of supports significantly moderated the relationship between diabetes burden and distress. Post hoc probing revealed a consistent pattern: Insulin was significantly associated with more diabetes distress at low levels of support but was not at high levels of support.

CONCLUSION

Findings support the stress-buffering hypothesis and suggest that social support may protect against diabetes distress.

Antidepressant medication use and trajectories of fasting plasma glucose, glycated haemoglobin, β-cell function and insulin sensitivity: a 9-year longitudinal study of the D.E.S.I.R. cohort

BACKGROUND

Use of antidepressants is seen to be a risk factor for type 2 diabetes, even though the underlying mechanisms remain unclear. We examined whether antidepressant use was associated with change in fasting plasma glucose, glycated haemoglobin (HbA1c), β-cell function (HOMA2-%B) and insulin sensitivity (HOMA2-%S) over time.

METHODS

Participants in the French D.E.S.I.R. cohort study included over 4700 men (48.1%) and women, free of diabetes, aged 30-65 years at baseline in 1994-96 (D.E.S.I.R. 0), who were followed for 9 years at 3-yearly intervals (D.E.S.I.R. 3, 1997-99; 6, 2000-02; 9, 2003-05). Antidepressant use, fasting plasma glucose, HbA1c, HOMA2-%B and HOMA2-%S were assessed concurrently at four medical examinations. Linear mixed models were used to examine the cross-sectional and longitudinal associations of time-dependent antidepressant use with changes in these four biological parameters.

RESULTS

Mean fasting plasma glucose and HbA1c increased whereas HOMA2-%B and HOMA2-%S decreased over the follow-up. In a fully adjusted model, there were no differences in: mean fasting plasma glucose (β = 0.01 mmol/l, P = 0.702); HbA1c (β = 0.01 %, P = 0.738); HOMA2-%B (β = 0.00, P = 0.812); or HOMA2-%S (β =-0.01, P = 0.791) at baseline (1994-96) between antidepressant users and non-users. The interaction term with time also suggested no differences in the annual change in: fasting plasma glucose (β = 0.00 mmol/l, P = 0.322); HbA1c (β = 0.00 %, P = 0.496); HOMA2-%B (β = 0.00, P = 0.609); or HOMA2-%S (β = 0.00, P = 0.332) between antidepressant users and non-users. Similar associations were observed in analyses of type and cumulative use of antidepressants over follow-up.

CONCLUSION

Our longitudinal data show that use of antidepressants is not associated with altered glucose metabolism, suggesting that the association between antidepressant use and diabetes reported by previous studies may not be causal. Detection bias or clinical ascertainment bias may account for much of this apparent association.

Clinical variables associated with depression in patients with type 2 diabetes

SummaryBackground:the aim of the study was to evaluate the relationship between type 2 diabetes (T2DM), depression and depressive symptoms and their clinical impact on T2DM.Methods:the authors evaluated 214 outpatients, 105 with diabetes (T2DM group) and 109 non-diabetics (control group), with ages ranging between 50 and 75 years (T2DM group 65.1 ± 5.6 years, control group 63.4 ± 5.8 years). Use of antidepressant treatment or score ≥ 16 on the Beck depression inventory (BDI) was considered depression. Complications of diabetes and total symptom score (TSS) for peripheral neuropathy were reported by patients.Results:diabetes group had a higher frequency of depression (35.2%) compared to controls (21.1%) (p=0,021), with 2.4 times increased risk of depression. The presence of depressive symptoms was also higher in T2DM group (mean BDI 9.5 ± 8.8 versus 6.9 ± 6.2; p=0.039). Symptoms of diabetic neuropathy were higher in depressed subjects. The metabolic control and presence of complications in T2DM group were not associated with depression.Conclusion:T2DM led to an increased risk of depression, but this did not influence the metabolic control or the presence of other complications.

Association of ABC (HbA1c, blood pressure, LDL-cholesterol) goal attainment with depression and health-related quality of life among adults with type 2 diabetes

AIMS

To determine the relationship between ABC goal attainment, depression, and health-related quality of life (HRQoL) among a national sample of patients with type 2 diabetes (T2DM).

METHODS

A retrospective, cross-sectional analysis was performed examining 808 non-pregnant patients ≥20 years old with T2DM from the National Health and Nutrition Examination Survey (NHANES) 2007-2012. ABC goals were defined as HbA1c<7%, BP<130/80 mm Hg, and LDL-C<100 mg/dL. Patient characteristics associated with ABC goal attainment were examined.

RESULTS

Overall, 23.7% of participants achieved simultaneous ABC goals. Severe depression was significantly associated with lower rates of ABC goal attainment compared to those with no depression (5.0% vs. 25.4%, p=0.048). ABC goal attainment rates were lower among females, Hispanic and non-Hispanic black minority groups, and patients with a duration of diabetes over five years, while increased visits with health care professionals were significantly associated with meeting all three ABC goals for patients with T2DM.

CONCLUSIONS

The relationship between simultaneous ABC goal attainment, depression and HRQoL is complex. Patients with T2DM unable to meet ABC goals may benefit from increased contact with health care professionals.

Association between major depression and type 2 diabetes in midlife: findings from the Screening Across the Lifespan Twin Study

OBJECTIVE

Cohort studies suggest that the relationship between major depression (MD) and Type 2 diabetes (T2DM) is bidirectional. However, this association may be confounded by shared genetic or environmental factors. The objective of this study was to use a twin design to investigate the association between MD and T2DM.

METHODS

Data come from the Screening Across the Lifespan Twin Study, a sample of monozygotic and dizygotic twins 40 years or older sampled from the Swedish Twin Registry (n = 37,043). MD was assessed by using the Composite International Diagnostic Inventory. Structural equation twin modeling and Cox proportional hazards modeling were used to assess the relationship between MD and T2DM.

RESULTS

Approximately 19% of respondents had a history of MD and 5% had a history of T2DM. MD was associated with 32% increased likelihood of T2DM (95% confidence interval = 1.00-1.80) among twins aged 40 to 55 years, even after accounting for genetic risk, but was not associated with T2DM among twins older than 55 years. T2DM was associated with 33% increased likelihood of MD (95% confidence interval = 1.02-1.72) among younger, but not older twins. Cholesky decomposition twin modeling indicated that common unique environmental factors contribute to the association between MD and T2DM.

CONCLUSIONS

Environmental factors that are unique to individuals (i.e., not shared within families) but common to both MD and T2DM contribute to their co-occurrence in midlife. However, we cannot exclude the possibility of bidirectional causation as an alternate explanation. It is likely that multiple processes are operating to effect the relation between psychiatric and medical conditions in midlife.

The association between dietary patterns, diabetes and depression

BACKGROUND

Type 2 diabetes and depression are commonly comorbid high-prevalence chronic disorders. Diet is a key diabetes risk factor and recent research has highlighted the relevance of diet as a possible risk for factor common mental disorders. This study aimed to investigate the interrelationship among dietary patterns, diabetes and depression.

METHODS

Data were integrated from the National Health and Nutrition Examination Study (2009-2010) for adults aged 18+ (n=4588, Mean age=43yr). Depressive symptoms were measured by the Patient Health Questionnaire-9 and diabetes status determined via self-report, usage of diabetic medication and/or fasting glucose levels ≥126mg/dL and a glycated hemoglobin level ≥6.5% (48mmol/mol). A 24-h dietary recall interview was given to determine intakes. Multiple logistic regression was employed, with depression the outcome, and dietary patterns and diabetes the predictors. Covariates included gender, age, marital status, education, race, adult food insecurity level, ratio of family income to poverty, and serum C-reactive protein.

RESULTS

Exploratory factor analysis revealed five dietary patterns (healthy; unhealthy; sweets; 'Mexican' style; breakfast) explaining 39.8% of the total variance. The healthy dietary pattern was associated with reduced odds of depression for those with diabetes (OR 0.68, 95% CI [0.52, 0.88], p=0.006) and those without diabetes (OR 0.79, 95% CI [0.64, 0.97], p=0.029) (interaction p=0.048). The relationship between the sweets dietary pattern and depression was fully explained by diabetes status.

CONCLUSION

In this study, a healthy dietary pattern was associated with a reduced likelihood of depressive symptoms, especially for those with Type 2 diabetes.