Diabetes and poor disease control: is comorbid depression associated with poor medication adherence or lack of treatment intensification?

Clinical Health Psychology Perspectives in Diabetes Care: A Retrospective Cohort Study Examining the Role of Depression in Adherence to Visits and Examinations in Type 2 Diabetes Management

BACKGROUND

Depression in type 2 diabetes mellitus (T2DM) impacts glycemic control and complications. This study examines the influence of depression on compliance with recommended annual diabetes assessments in patients within the Local Healthcare Authority of Romagna. From a clinical health psychology perspective, understanding how depression influences patients' engagement in managing their conditions is crucial. This insight can help improve healthcare services by ensuring they address mental health needs and thereby enhance treatment effectiveness and overall patient outcomes.

METHODS

This retrospective cohort study included residents of Romagna with incident T2DM from 2015 to 2017, followed from 1 January 2018 to 31 December 2022. Depression was identified via hospital discharge records or antidepressant prescriptions. Adherence to diabetes care guidelines was measured using the Guideline Composite Indicator (GCI).

RESULTS

The study included 13,285 patients, with a mean age of 61.1 years. Prevalence of post-diabetes depression increased from 3.0% in 2018 to 8.9% in 2022. Initial analyses showed higher GCI rates among patients with depression. However, propensity-score adjustment revealed that by 2021-2022, patients with pre-diabetes depression had 5% lower compliance rates (p-value ≤ 0.05). Older adults with depression had reduced adherence, while younger adults with post-diabetes depression had higher adherence rates.

CONCLUSIONS

Depression significantly affects adherence to diabetes care guidelines in T2DM patients, particularly among older adults. Integrated care models addressing both diabetes and depression are crucial for improving health outcomes.

Food Insecurity and Diabetes Insulin Adherence Among Older Adults

Older adults in the United States continue to be impacted by food insecurity. Diabetes is on the rise in older adults and insulin therapy is often recommended as treatment. However, less is known about the relationship between food insecurity and insulin adherence among older adults. The current study utilized secondary data analysis methods to examine the 2021 National Health Interview Survey to explore the relationship between food insecurity and insulin adherence among adults aged 55 and older who are living with diabetes. Results of multivariable logistic regression suggest that participants experiencing food insecurity were more likely to take less insulin than needed and delay buying insulin in the past 12 months compared to participants who were food secure. Homeownership was inversely associated with taking less insulin than needed. Higher income-to-poverty ratio was also inversely associated with skipping insulin doses, taking less insulin than needed, and delaying the purchase of insulin. Our results showed that other racialized/ethnic groups (i.e., American Indian, Alaskan Native, Asian, biracial, and multiracial persons) compared to White were less likely to skip an insulin dose and take less insulin than needed. Suggesting food insecurity should be considered when insulin therapy is recommended for older adults with diabetes.

The Diabetes Remission in India (DiRemI) study: Protocol for a prospective matched-control trial

BACKGROUND

The global rise in diabetes, particularly in India, poses a significant public health challenge, with factors such as limited awareness, financial strain, and cultural considerations hindering its effective management. Although lifestyle changes have shown promising results, their consistent implementation and maintenance continue to pose challenges. Most studies have focused primarily on dietary modifications, overlooking other essential aspects of lifestyle intervention. The DiRemI study aims to address these gaps by evaluating the efficacy of a comprehensive one-year program that combines diet, exercise, psychological support, and medical management to achieve weight loss, diabetes remission, and improved glycemic control among patients with type 2 diabetes (T2D) in India, while also considering the unique needs of the Indian population.

METHODS

The DiRemI study is a prospective, open-label, matched-group trial aimed at assessing the impact of a one-year online integrated intensive lifestyle intervention (ILI) comprising dietary modifications, physical activity, psychological support, and medical management on weight loss and remission in adult T2D patients (aged 30-70 years), with a body mass index (BMI) between 25 and 35 kg/m2, and disease duration of <15 years. ILI will be compared with routine medical care (RMC). Participants will be recruited from three clinics: one providing ILI and two others providing RMC. The co-primary outcome will be weight loss and remission at 12 months, with a follow-up at 18 months. The proposed sample size is 360 participants (180 each in intervention and control group).

DISCUSSION

The DiRemI study represents the first large-scale remission study in India to show the effectiveness of an integrated approach in the remission and management of T2D and its complications. The findings of this study hold the potential to report evidence-based strategies for managing T2D both in India and globally, thus alleviating the substantial burden of diabetes on public health systems.

TRIAL REGISTRATION

Clinical Trials Registry, India (Registered Number: CTRI/2023/06/053885).

Study of cognitive functions and their association with depression in type II diabetes mellitus

Introduction

Individuals with diabetes have higher risk of developing depression, cognitive impairment, and dementia compared to those who do not have diabetes. The present study aims to assess the level of cognitive functions and the presence of depression in diabetes patients and healthy controls. The study also explores the level of cognition among the normal control, diabetes without depression, and diabetes with depression.

Methods

In the present study, the presence of depression and the level of cognitive functions of 59 cases of diabetes mellitus type-2 were compared with an age- and gender-matched control group of 40 individuals. Clinical and demographic details were recorded on a semi-structured performa. Montreal Cognitive Assessment (MoCA) and Patient Health Questionnaire-9 (PHQ-9) were applied to both diabetes patients and healthy controls to assess the level of cognitive functions and the presence of depression, respectively.

Results

On applying odds ratio (OR), it was observed in the present study that there were 93.50% more chances [OR 1.935 with 95% confidence interval (CI) being 0.481-7.789] of depression among diabetic cases as compared to the control group. Similarly, the chance of MoCA score being less than 26 was twice among the diabetic group as compared to the control group (OR 2.208 with 95% CI being 0.702-6.946). On application of the Chi-square test, the association of depression was significant with HBA1C level, level of education, and presence of complications.

Conclusions

Patients with diabetes had almost double the risk of developing depression and poor cognitive functions as compared to the healthy control. High HbA1C level, level of education, and presence of complication in diabetes had a positive statistical association with depression. Thus, it is advisable to investigate patients with diabetes for the presence of depression and cognitive dysfunction by applying simple tools.

Impact of depression on self-efficacy, illness perceptions and self-management among people with type 2 diabetes: A systematic review of longitudinal studies

BACKGROUND

Treating comorbid depression does not always improve outcomes for people with type 2 diabetes. Evidence is lacking on potential psychological and behavioural intermediaries of the impact of depression on diabetes outcomes.

OBJECTIVE

To synthesise evidence on the impact of comorbid depression on self-efficacy, illness perceptions, and self-management in people with type 2 diabetes.

DATA SOURCES

We searched PubMed, Embase, PsycINFO, and Global Health databases from inception up to 29th March 2023.

STUDY ELIGIBILITY CRITERIA

Only prospective studies (cohort or intervention studies) were included, with no restrictions on language. The outcomes were self-efficacy, illness perceptions, and self-management.

PARTICIPANTS

People with type 2 diabetes in community or health settings.

EXPOSURE

Comorbid depression or depressive symptoms in people with type 2 diabetes.

SYNTHESIS OF RESULTS

A narrative review of heterogeneous studies.

RISK OF BIAS

The risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies.

RESULTS

Twenty-five studies were included, all from high-income countries. Depression was associated with lower self-efficacy (2 studies), poor illness perception (1 study), and poor self-management practices (17 studies) in people with type 2 diabetes. In 6/7 studies, depressive symptoms predicted less adherence to dietary recommendations, 8/10 studies found depressive symptoms were associated with poor medication adherence, 1/3 study found that depressive symptoms were associated with poor weight control, 3/4 with less physical exercise, and 2/3 with general self-care practices.

LIMITATIONS

There were no studies from low- and middle-income countries and non-Western settings, and we cannot assume the mechanisms linking comorbid depression with diabetes outcomes are similar.

CONCLUSIONS

Comorbid depression was associated with lower self-efficacy, poorer self-management, and less adaptive illness perceptions among people with diabetes.

Medication Adherence among Primary Care Patients with Common Mental Disorders and Chronic Medical Conditions in Rural India

Background

Only a few studies have explored the relationship between psychosocial factors and medication adherence in Indian patients with noncommunicable diseases (NCDs). We aimed to examine the association of psychosocial variables with medication adherence in people with NCDs and comorbid common mental disorders (CMDs) from primary care in rural southern India.

Methods

We performed a secondary analysis using baseline data from a randomized controlled trial in 49 primary care health centers in rural southern India (HOPE study). Participants were adults (≥30 years) with NCDs that included hypertension, diabetes, and/or ischemic heart disease, and comorbid depression or anxiety disorders. Medication adherence was assessed by asking participants if they had missed any prescribed NCD medication in the past month. Data were collected between May 2015 and November 2018. The association between psychosocial and demographic variables and medication nonadherence were assessed via logistic regression analyses.

Results

Of the 2486 participants enrolled, almost one-fifth (18.06%) reported missing medication. Male sex (OR = 1.74, 95% CI 1.37-2.22) and higher internalized mental illness stigma (OR = 1.46, 95% CI 1.07-2.00) were associated with higher odds of missing medication. Older age (OR = 0.40, 95% CI 0.26-0.60, for participants aged 64-75 years vs 30-44 years), reporting more social support (OR = 0.65, 95% CI 0.49-0.86), and higher satisfaction with health (OR = 0.74, 95% CI 0.61-0.89) were associated with lower odds of missing medication.

Conclusions

Greater internalized mental illness stigma and less social support are significantly associated with lower rates of medication adherence in patients with NCDs and comorbid CMDs in rural India.

Sex differences in the association between diabetes and depressive symptoms: findings from Mexican National Health and Nutrition Survey 2018-2019

AIMS

We set out to investigate the potential sex differences in the association between diabetes and depressive symptoms by conducting an interaction analysis, and to investigate whether sex mediates the effect of diabetes on depressive symptoms.

METHODS

We conducted analyses on cross-sectional data of adults aged 20 years or older in the Mexican National Health and Nutrition Survey 2018-2019 (ENSANUT 2018-2019). Diabetes was defined by self-reported medical diagnosis, and depressive symptoms were measured using the seven-item Centre for Epidemiologic Studies Depression scale. First, an unadjusted interaction analysis was conducted. Second, the inverse probability of treatment weighting was applied to account for imbalances and biases. Third, the four-way decomposition method was used to estimate the potential mediating effect of sex.

RESULTS

In the study population (N=43 074), the prevalence of diabetes was 9.3% for men and 11.7% for women. Depressive symptoms were more prevalent in women (19.0%) than in men (9.5%). Women with diabetes had the greatest odds of having depressive symptoms, compared with men without diabetes (ORwomen-diabetes3.49 (95% CI: 3.16 to 3.86)). The interaction analysis indicated that diabetes and sex interact on both, multiplicative and additive scales (ratio of ORs (95% CI) 1.22 (1.02 to 1.45), and relative excess risk due to interaction (95% CI) 0.99 (0.63 to 1.36)). The four-way decomposition analysis showed that the interaction effect between diabetes and sex is larger than the mediation effect.

CONCLUSIONS

We found a positive interaction between diabetes and sex in the odds of having depressive symptoms. Mental health and diabetes care services planning would benefit from adopting a sex-informed approach.

Does awareness of diabetic status increase risk of depressive or anxious symptoms? Findings from the China Multi-Ethnic cohort (CMEC) study

INTRODUCTION

People with diabetes mellitus (DM) have increased risk of depressive symptoms (DS) or anxious symptoms (AS). This study explores whether awareness of DM will contribute to prevalence of DS or AS.

METHODS

The baseline data including 81,717 adults from Southwest China was analyzed. DS and AS were assessed using PHQ-2 and GAD-2. Exposures were defined as 1) having self-reported physician diagnosis of diabetes (self-reported DM), 2) no prior diagnosis of diabetes but meeting diagnostic criteria (newly diagnosed DM), 3) having self-reported physician diagnosis or meeting criteria of non-diabetic diseases (non-diabetic patients), 4) healthy participants. Generalized linear mixed models were used to assess impact of presence and awareness of DM on DS or AS, adjusting for regional and individual related factors.

RESULTS

The prevalence of DS in self-reported DM, newly diagnosed DM, non-diabetic patient and healthy participants was 7.08 %, 4.30 %, 5.37 % and 3.17 %. The prevalence of AS was 7.80 %, 5.77 %, 6.37 % and 3.91 %. After adjusting for related factors, compared with healthy participants, self-reported DM and non-diabetic patients were associated with DS [AOR_{DS, self-reported} = 1.443(1.218,1.710), AOR_{DS, nondiabetic patients} = 1.265(1.143,1.400)], while the association between newly diagnosed DM and DS was not statistically significant. The associations between self-reported DM, newly diagnosed DM, non-diabetic patients and AS were all statistically significant.

LIMITATIONS

DS and AS were assessed through self-report and may suffer recall or information bias.

CONCLUSIONS

The association between awareness of diabetes and DS/AS suggests to pay attention to distinguish between self-reported and newly diagnosed DM and screening for DS and AS in diabetic population.

A Cross-Sectional Study on the Associations between Physical Activity Level, Depression, and Anxiety in Smokers and Ex-Smokers

Introduction: depression and anxiety is one of the most relevant public health problems. The link between smoking and depression has been demonstrated. Regular physical activity (PA) could act as a protector against mental health diseases. Objectives: (1) to explore the prevalence of depression and anxiety in relation to sex and to the condition of smoker and ex-smoker, (2) to study the differences in prevalence proportions according to the frequency and level of PA, and (3) to calculate the probability of presenting depression or anxiety according to the frequency and level of PA. Methods: a cross-sectional study was conducted, based on data extracted from the 2014 and 2020 Spanish European Health Survey and the 2017 Spanish National Health Survey. The sample included 9524, 7813, and 9079 participants, respectively. Descriptive analysis was performed (comparisons using a Chi-square test and z-test for independent proportions). Probability odds ratios of anxiety and depression were calculated according to PA. Results: women had a higher prevalence of depression and anxiety than men (p < 0.001−0.003). Higher levels of prevalence were observed in inactive people versus very active or active people (p < 0.001). Inactive people had a higher risk of depression and anxiety compared to very active people. Conclusion: inactive smokers and ex-smokers had higher levels of prevalence of depression and anxiety than active and very active people. Physical inactivity could increase the risk of suffering these mental disorders in this population. This could affect women more than men.

Effectiveness of Line application and telephone-based counseling to improve medication adherence: A randomized control trial study among uncontrolled type 2 diabetes patients

Background: More than 4.2 million cases of diabetes mellitus (DM) were reported in Thailand during 2019. Medication adherence is necessary to delay disease progression and prevent complications among uncontrolled type 2 DM patients. The objective of this research was to study how education via the Line application and telephone-based counseling impacted medication adherence knowledge by analyzing the behavior of uncontrolled type 2 diabetic patients. Methods: Uncontrolled type 2 DM patients in Doi Saket Hospital, Doi Saket district, Chiang Mai province, Thailand. were included in the study. The sample was divided into an experimental (n=30) and control group (n=30). Patients who met the inclusion criteria of having uncontrolled type 2 diabetes diagnosed by a physician for at least one year, capable of communicating in Thai, possessing a mobile phone with the Line application and able to partake in activities for eight weeks were recruited in the parallel-group randomized trial. The experimental group participated in the developed education program, while the control group received standard routine health education activities provided by their health care providers. The intervention was based on the 5Rs principle as right medicine, right dose, right route, right patient and right time and included activities via the Line application and telephone-based counseling. Participants were evaluated for their medication adherence knowledge and behavior. Results: After eight weeks of education through the Line application and telephone-based counseling, posttest mean scores of medication adherence knowledge of the experimental and control groups were 18.03 (SD=0.28) and 12.37 (SD=0.62), while posttest mean scores of medication adherence behavior of the experimental and control groups were 49.28 (SD=3.77) and 33.84 (SD=3.81), respectively. Results revealed that the experimental group had statistically significant (P <0.01) higher medication adherence knowledge and behavior mean scores. Conclusion: Education using the Line application and telephone-based counseling program improved medication adherence knowledge and behavior among uncontrolled type 2 DM patients. Other outcomes of social media interactions such as patient engagement, patient behavior and attitudes, and the efficacy of patient-health care provider communication levels are possible areas for future study.

Glycemic Control and Awareness of Insulin Therapy

Introduction

Glycemic control is associated with better health outcomes among patients with diabetes. No previous research has examined the relationship between knowledge of one’s insulin dose and glycemic control. This study sought to determine if patients who accurately recalled their insulin dose achieved better glycemic control than patients who could not remember their dose.

Methods

Interviews were conducted with 106 patients. Data were collected during patients’ appointments at two endocrinology clinics in Wichita, Kansas from May 29, 2018 to February 15, 2019. Adequate glycemic control was defined as an HbA1c of less than 7.5%. A multiple logistic regression model was developed to identify factors associated with glycemic control.

Results

Of the 109 patients asked to participate, 105 agreed to participate in the study. About half (45%, n = 48) were male. Patients’ mean age was 50 years (SD = 17). Seventy-seven percent (n = 81) were overweight (body mass index (BMI) of 25 to 29.9) or obese (BMI >30). Patients who correctly stated their insulin dose had a mean Hemoglobin A1c (HbA1c) of 6.9% (SD = 0.98), whereas those who incorrectly stated their dose had a mean HbA1c of 9.5% (SD = 1.9; p <0.0001).

Conclusions

There was a significant relationship between knowledge of one’s insulin dose and adequate glycemic control.

Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised.

RESULTS

The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I²=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs.

CONCLUSIONS

The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management.

PROSPERO REGISTRATION NUMBER

CRD42019133849.

La Clinica In LaK’ech: Establishing a Practicum Site Integrating Practice, Advocacy, and Research With Latinx Clients

This article concerns the establishment and development of La Clinica In LaK’ech, a bilingual mental health clinic collectively founded and staffed by a counseling psychologist and doctoral students in a counseling psychology doctoral program in the Southeast United States. During over 5 years of existence, the clinic has blended bilingual counseling psychology services, advocacy, interdisciplinary collaboration, and research with the Latinx population. The authors describe the development of the clinic and resultant clinical, training, and ethical issues that confronted the clinic in terms of providing services to a marginalized community in a state where anti-immigrant rhetoric, detention, and deportations were escalating. Also discussed are implications for training in practice, advocacy, service, and research for counseling psychologists working with Latinx communities.

Self-Management to Improve Function After Amputation: A Randomized Controlled Trial of the VETPALS Intervention

OBJECTIVE

To (1) evaluate the effects of a group-based self-management treatment intervention (VETPALS) on physical and psychosocial functioning (primary outcomes) and quality of life (secondary outcome) in individuals with amputation and (2) examine the feasibility and acceptability of the intervention in a large national health care system.

DESIGN

Randomized controlled trial with masked outcome assessment.

SETTING

Five Veterans Affairs medical centers geographically dispersed across the United States.

PARTICIPANTS

147 individuals with amputation during the past 2 years due to chronic limb threatening ischemia (N=147).

INTERVENTIONS

Participants were randomized into VETPALS (N =71) or education control (N=76). VETPALS consisted of a 4-hour workshop and 4 additional 2-hour sessions addressing self-management skills, health and activity, managing emotions, communication and social support, and maintaining goals and gains. Education control consisted of the provision of amputation-related educational materials and provider follow-up if requested.

MAIN OUTCOME MEASURES

Primary outcomes were physical functioning (Short Musculoskeletal Functional Assessment) and psychosocial functioning (Patient Health Questionnaire-9). Secondary outcomes were quality of life (global) and quality of life (satisfaction with health) from the World Health Organization Quality of Life Scale (brief). Assessment was conducted at baseline, 6 weeks (treatment completion), and 6 months (follow-up).

RESULTS

Participants randomized to VETPALS reported significantly improved psychosocial functioning and quality of life (satisfaction with health) relative to controls at 6 months (B=1.84; 95% confidence interval, 0.37,3.31 and B=-0.61; 95% confidence interval, -1.11,-0.12, respectively). There were no differences in physical functioning over time between VETPALS and education control at either time point. Follow-up multiple imputation sensitivity analyses produced an identical pattern of results. Among VETPALS participants, treatment initiation was low (56%), but treatment retention (93% attended 4 of 5 classes) and overall satisfaction (100% reported very helpful or better and would recommend to a friend) were high.

CONCLUSIONS

Group-based self-management improves psychosocial functioning for individuals with amputation due to chronic limb threatening ischemia. In-person participation is challenging for this population, but individuals who successfully initiate treatment typically persist and are highly satisfied.

Evaluation of the effectiveness of Persian diabetes self-management education in older adults with type 2 diabetes at a diabetes outpatient clinic in Tehran: a pilot randomized control trial

Purpose

The effectiveness of diabetes self-management interventions has been more generally demonstrated in adults, but there is little evidence of diabetes self-management specific to older adults situated in Iran. The purpose of this study was to evaluate the effectiveness of Persian Diabetes Self-Management Education on self-efficacy, quality of life, self-care activity, depression and loneliness in older adults with type 2 diabetes.

Methods

In pilot randomized controlled trial, a total of 34 participants ≥60 years with type 2 diabetes were randomly assigned into intervention (n = 17) and control (n = 17) group in an outpatient diabetes clinic in Tehran. To assess the primary outcome of participant experiences, the Diabetes Management Self-efficacy Scale (DMSES) was the method of measurement. The Diabetes Quality of Life-Basic Clinical Inventory (DQoL-BCI), Patient Health Questionnaire-9 (PHQ-9), Diabetes Self-Management Education Scale (DSMES), and adult Social-Emotional Loneliness Scale Short form (SELSA-S) were used as secondary outcomes. Participants' evaluations were completed at baseline, while measurements were conducted two and four weeks after allocation, using repeated measurements of Univariate and multivariate ANOVA (adjusted for baseline values) to analyze the data.

Results

In the multivariate model, there was a significant difference between the control and intervention groups regarding reported quality of life (p = 0.04) and the medical-domain's reported self-efficacy (p = 0.02). However, there were no significant differences in the reported self-management, depression, loneliness, as well as the other domain of self-efficacy; as compared between the two groups before and after intervention.

Conclusion

The study depicts a promising impact on older adults, imparted by the pertinent program. The finding showed PDSME has a positive effect on quality of life and medical control domain of self-efficacy. This pilot study showed that the program is feasible and duly beneficial if delivered to older adults. This pilot proves appealing to begin further testing within a larger sample population.

The impact of hospital-diagnosed depression or use of antidepressants on treatment initiation, adherence and HbA1c/LDL target achievement in newly diagnosed type 2 diabetes

AIMS/HYPOTHESIS

We aimed to assess whether current antidepressant therapy or a history of hospital-diagnosed depression affects diabetes treatment initiation, adherence, and HbA_1c and LDL-cholesterol target achievement.

METHODS

In this register-based study, we included all individuals from Central and Northern Denmark with newly diagnosed type 2 diabetes, defined as a first-ever HbA_1c measurement of ≥48 mmol/mol (6.5%), between 2000 and 2016. Individuals either diagnosed with depression at a psychiatric hospital in the 2 years prior to their diabetes diagnosis or currently receiving treatment with an antidepressant were compared with individuals with type 2 diabetes, but without depression treatment or previous history of depression. Outcome measures included initiation of glucose-lowering drugs and lipid-modifying agents, adherence to these medications (medication possession ratio >80%), and HbA_1c (<53 mmol/mol [7%]) and LDL-cholesterol (<2.6 mmol/l) target achievement. The assessment of association between depression or antidepressant treatment and these outcomes was conducted using regression analyses with adjustment for potential confounders.

RESULTS

We included a total of 87,650 individuals with first-ever HbA_1c-diagnosed type 2 diabetes, of whom 0.9% (n = 784) had hospital-diagnosed depression and 11.4% (n = 9963) currently received antidepressant treatment. Compared with those without depression treatment, treatment with an antidepressant was associated with increased likelihood of glucose-lowering drug initiation (HR 1.39 [95% CI 1.34, 1.44]) and adherence (OR 1.27 [95% CI 1.18, 1.36]), lipid-modifying agent initiation (HR 1.17 [95% CI 1.11, 1.23]) and adherence (OR 1.25 [95% CI 1.09, 1.43]), and achievement of LDL (OR 1.08 [95% CI 1.03, 1.14]) but not HbA_1c target (OR 0.99 [95% CI 0.93, 1.06]). The findings were similar for individuals who had hospital-diagnosed depression.

CONCLUSIONS/INTERPRETATION

In individuals with newly diagnosed type 2 diabetes, antidepressant treatment and depression were associated with improved diabetes treatment quality. Graphical abstract.

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.

Factors Affecting Health-Promoting Behaviors in Patients with Cardiovascular Disease

Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.

Depressive symptoms and non-adherence to treatable cardiovascular risk factors' medications in the CONSTANCES cohort

AIMS

Depression is associated with increased risk of cardiovascular disease (CVD) and the role of poor medical adherence is mostly unknown. We studied the association between depressive symptoms and non-adherence to medications targeting treatable cardiovascular risk factors in the CONSTANCES population-based French cohort.

METHODS AND RESULTS

We used CONSTANCES data linked to the French national healthcare database to study the prospective association between depressive symptoms (assessed at inclusion with the Center for Epidemiological Studies Depression scale) and non-adherence to medications (less than 80% of trimesters with at least one drug dispensed) treating type 2 diabetes, hypertension, and dyslipidaemia over 36 months of follow-up. Binary logistic regression models were adjusted for socio-demographics, body mass index, and personal history of CVD at inclusion. Among 4998 individuals with hypertension, 793 with diabetes, and 3692 with dyslipidaemia at baseline, respectively 13.1% vs. 11.5%, 10.5% vs. 5.8%, and 29.0% vs. 27.1% of those depressed vs. those non-depressed were non-adherent over the first 18 months of follow-up (15.9% vs. 13.6%, 11.1% vs. 7.4%, and 34.8% vs. 36.6% between 19 and 36 months). Adjusting for all covariates, depressive symptoms were neither associated with non-adherence to medications for hypertension, diabetes, and dyslipidaemia over the first 18 months of follow-up, nor afterwards. Depressive symptoms were only associated with non-adherence to anti-diabetic medications between the first 3-6 months of follow-up.

CONCLUSION

Non-adherence to medications targeting treatable cardiovascular risk factors is unlikely to explain much of the association between depressive symptoms and CVD at a population level. Clinicians are urged to search for and treat depression in individuals with diabetes to foster medications adherence.

Biopsychosocial factors associated with a current depressive episode in diabetes: the ELSA-Brasil study

AIMS

Depression is more prevalent in people with diabetes, and is associated with worse diabetes outcomes. Depression in diabetes is more treatment resistant, and as underlying mechanisms are unknown, development of more effective treatment strategies is complicated. A biopsychosocial model may improve our understanding of the pathophysiology, and therewith help improving treatment options.

METHODS

Diabetes was diagnosed according to American Diabetes Association (ADA) criteria and a current depressive episode according to the International Classification of Diseases (ICD-10), based on the Clinical Interview Schedule Revised (CIS-R). From the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), we included 455 participants without diabetes with a current depressive episode and 10 900 without either diabetes or a current depressive episode. Furthermore, 2183 participants had diabetes alone and 106 had both diabetes and a current depressive episode. Variable selection was based on their relationship with depression and/or diabetes. Multinomial multivariate logistic regression was used to determine how the models differed between participants with and without diabetes.

RESULTS

A current depressive episode in diabetes was related to being older and female, having poorer education, financial problems, experiencing discrimination at work, home and school, higher waist circumference, albumin to creatinine ratio and insulin resistance, and the presence of hypertension and cardiovascular disease. In non-diabetes, a current depressive disorder was related to being female, not being black, low income, psychological and social factors, non-current alcohol use, lower HDL cholesterol, higher insulin resistance and the presence of cardiovascular disease.

CONCLUSIONS

A current depressive episode in the presence compared with the absence of diabetes was related more to biological than to psychosocial factors.

Depression prevalence, its psychosocial and clinical predictors, in diabetes mellitus patients attending two health institutions of north India catering rural population

BACKGROUND

Diabetes mellitus (DM) poses a greater risk of depression and a poor quality of life (QoL). There is a limited data regarding relationship of depression to QoL in patients from rural health care settings of North India.

AIM

To know the prevalence and predictors of depression in patients of DM among various sociodemographic, clinical and QoL variables.

SETTINGS AND DESIGN

This cross-sectional study was conducted in two hospitals of North India mostly catering rural population from 2014 to 2018.

MATERIALS AND METHODS

Sociodemographic and clinical data of DM patients was collected. They were applied Hindi translation of QoL Instrument for Indian Diabetes Patients and Patient Health Questionnaire-9. Analyses were done by Statistical Package for Social Sciences (Version 17.0, USA).

RESULTS

Among 300 patients, 25.6% had clinical depression. Illiteracy, the affect on general, emotional/mental health and role limitation by diabetes predicted risk of depression.

CONCLUSION

Education of patients regarding self-management in DM to assure good health should be emphasised.

The Importance of Addressing Depression and Diabetes Distress in Adults with Type 2 Diabetes

People with type 2 diabetes often experience two common mental health conditions: depression and diabetes distress. Both increase a patient's risk for mortality, poor disease management, diabetes-related complications, and poor quality of life. The American Diabetes Association and the U.S. Preventive Services Task Force recommend routine evaluations for these conditions in adults for optimal disease management and prevention of life-threatening complications. However, barriers exist within primary care and specialty settings that make screening for depression and diabetes distress challenging. Depression and diabetes distress influence diabetes self-care and diabetes control and barriers in clinical care practice that can hinder detection and management of psychosocial issues in diabetes care. This paper highlights opportunities to increase mental health screenings and provides strategies to help providers address depression and diabetes distress in patients with type 2 diabetes.

The Impact of Depressive Symptoms on the Quality of Life of Patients with Type 2 Diabetes in Jazan Region, KSA

BACKGROUND

The purpose of this study is to determine the impact of depressive symptoms on the quality of life of type 2 diabetic patients (T2DM).

METHODS

A cross-sectional study of 332 T2DM patients aged ≥18 years living in Jazan region of Saudi Arabia was conducted. Validated questionnaire was used for demographic and disease characteristics. Depressive symptoms of the participants were assessed using the Patient Health Questionnaire (PHQ-9). The Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF) was utilized to assess the degree of life enjoyment and satisfaction.

RESULTS

Depressive symptoms were observed in 34.7% (112) of the total participants. The overall sense of wellbeing (mean 3.23, P. value 0.000), physical (mean 3.37, P. value 0.003), psychosocial (mean 2.99 P. value 0.000) and social domains (mean 3.53, P. value 0.000) of quality of life were significantly reduced in T2DM patients with depressive symptoms.

CONCLUSION

The impact of depressive symptoms on quality of life of T2DM patients was more significant than the impact of diabetes alone. Symptoms of depression reduce the individual coping and hence reduce functioning. This study emphasizes the vital importance of an integrated holistic approach that addresses both the practical and emotional issues in diabetes care.

Depression and related risk factors among patients with type 2 diabetes mellitus, Jazan area, KSA: A cross-sectional study

PURPOSE

To determine the prevalence of depression and related risk factors among type 2 diabetes mellitus patients (T2DM) in Jazan area, Saudi Arabia.

METHOD

A cross sectional, self-administered questionnaire study was conducted among T2DM patients in Jazan area, Saudi Arabia. A total of 385 patients were selected at randomly. The Patient Health Questionnaire (PHQ-9) was utilized to measure symptoms and signs of depression.

RESULTS

The overall prevalence of depression among T2DM patients was 37.6%. Of them, 24.2% were mildly depressed, 9.6% were moderately severely depressed, and 4.2% were severely depression. Significant predictors of depression include the presence of diabetic foot (P=0.000), cardio-vascular diseases (P=0.000), eye complication (P=0.073), and erectile dysfunction (P=0.090). The prevalence of depression was not significantly associated with the age (P=0.375) and gender (P=0.374). Similarly no association was found with duration of diabetes (P=0.475) and HbA1c (P=0.555).

CONCLUSION

The study revealed that diabetes complications are strong predictors of the rate of depression among T2DM patients. Therefore, early depression screening is needed to improve the quality of life of diabetic patients.

Comorbidity of depressive symptoms among primary care patients with diabetes in a federally qualified health center

Depression is frequently comorbid with diabetes; however, less is known about this comorbidity in socially disadvantaged populations. This cross-sectional study examined depressive symptomatology among 424 patients with prediabetes or type 2 diabetes mellitus at a federally qualified health center. Prevalence of clinically significant depressive symptoms was assessed using the World Health Organization Five-Item Well-Being Index. The majority (67.7%) endorsed depressive symptoms, with greater prevalence among middle-aged adults (45–64 years) than younger or older counterparts. More women than men endorsed depressive symptoms. Findings suggest the need for routine depression screening in both prediabetes and type 2 diabetes mellitus, particularly among middle-aged and low-income individuals.

Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review

AIMS

Therapeutic inertia, defined as the failure to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines, is a key reason for uncontrolled hyperglycaemia in patients with type 2 diabetes. The aims of this systematic review were to identify how therapeutic inertia in the management of hyperglycaemia was measured and to assess its extent over the past decade.

MATERIALS AND METHODS

Systematic searches for articles published from January 1, 2004 to August 1, 2016 were conducted in MEDLINE and Embase. Two researchers independently screened all of the titles and abstracts, and the full texts of publications deemed relevant. Data were extracted by a single researcher using a standardized data extraction form.

RESULTS

The final selection for the review included 53 articles. Measurements used to assess therapeutic inertia varied across studies, making comparisons difficult. Data from low- to middle-income countries were scarce. In most studies, the median time to treatment intensification after a glycated haemoglobin (HbA1c) measurement above target was more than 1 year (range 0.3 to >7.2 years). Therapeutic inertia increased as the number of antidiabetic drugs rose and decreased with increasing HbA1c levels. Data were mainly available from Western countries. Diversity of inertia measures precluded meta-analysis.

CONCLUSIONS

Therapeutic inertia in the management of hyperglycaemia in patients with type 2 diabetes is a major concern. This is well documented in Western countries, but corresponding data are urgently needed in low- and middle-income countries, in view of their high prevalence of type 2 diabetes.

"Down in the Sewers": Perceptions of Depression and Depression Care Among African American Men

Depression is one of the most common, costly, and debilitating psychiatric disorders in the United States. One of the most persistent mental health disparities is the underutilization of treatment services among African American men with depression. Little is known about appropriateness or acceptability of depression care among African American men. The purpose of this study was to examine perceptions of depression and determine barriers to depression treatment among African American men. A series of four focus groups were conducted with 26 African American men. The average age of the sample was 41 years and most participants reported that they had completed high school. Nearly half of the participants reported that they are currently unemployed and most had never been married. The most common descriptions of depression in this study were defining depression as feeling down, stressed, and isolated. A small group of participants expressed disbelief of depression. The majority of participants recognized the need to identify depression and were supportive of depression treatment. Nonetheless, most men in this sample had never sought treatment for depression and discussed a number of barriers to depression care including norms of masculinity, mistrust of the health care system, and affordability of treatment. Men also voiced their desire to discuss stress in nonjudgmental support groups. Research findings highlight the need to increase the awareness of symptoms some African American men display and the need to provide appropriate depression treatment options to African American men.

Factors Associated With Medication Engagement Among Older Adults With Diabetes: Systematic Review and Meta-Analysis

Purpose

The purpose of this systematic review and meta-analysis is to explore the factors associated with medication engagement among older adults (≥60 years) with diabetes.

Methods

Five databases (PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Scopus) were systematically searched to identify studies examining the association between factors and medication engagement among older diabetes patients. A study met inclusion for meta-analysis if the prevalence of medication engagement or factor was reported in ≥2 studies and the frequency or strength of association was either reported or able to be computed. Quality appraisal was performed with the Downs and Black tool.

Results

Of 538 retrieved studies, 33 (20 cohort and 13 cross-sectional) were included for systematic review; of these, 22 met criteria for meta-analysis. Findings from meta-analysis show that women (odds ratio [OR], 0.92; 95% CI, 0.86-0.97), those with depression (OR, 0.73; 95% CI, 0.62-0.87), and those with higher out-of-pocket spending for prescription drugs (OR, 0.87; 95% CI, 0.80-0.94) were less likely to take diabetes medication when compared with men, those without depression, and those with lower out-of-pocket costs, respectively. Older age (OR, 1.13; 95% CI, 1.00-1.27) was associated with better engagement to diabetes medication.

Conclusions

Of 4 identified factors, 2 are modifiable. Recent policy efforts to decrease the cost burden of prescribed medication for older adults, such as Medicare Part D, may remove this barrier to medication engagement. Routine screening for depression among older adults with diabetes should be included as part of usual care to facilitate an integrated treatment approach.

Predictors of Depression Among Adult Women With Diabetes in the United States: An Analysis Using National Health and Nutrition Examination Survey Data From 2007 to 2012

PURPOSE

The purpose of the study was to identify the sex-specific characteristics that predict depression among adult women with diabetes.

METHODS

Data from the 2007-2012 National Health and Nutrition Examination Survey in the United States were used to identify the predictors of depression in a large sample of women ages 20 years and older with diabetes (n = 946).

RESULTS

When extrapolated to almost 9 million women in the United States ≥ 20 years of age with diabetes, 19.0% had depression. Female-specific significant predictors of depression included younger age (< 65 years old), less than high school graduation, self-rated fair or poor health, inactivity due to poor health, and pain that interferes with usual activities. Marital status and diabetes-related factors (years living with diabetes, use of insulin, parent or sibling with diabetes) were not significant predictors of depression in adult women with diabetes.

CONCLUSION

When educating and counseling women with diabetes, diabetes educators should be aware that some of the predictors of depression in women with diabetes differ from those of populations that include both sexes. Depression screening, although important for all women with diabetes, should especially be performed among women with female-specific depression predictors.

Barriers to Self-Management in Depressed Women With Type 2 Diabetes

Purpose To describe the impact of family functioning on the self-management of type 2 diabetes (T2DM) and depression in a subsample of women who completed a randomized clinical trial using vitamin D3 (5000 or 50,000 IUs weekly) for depression treatment. Background Women are at higher risk for increased severity of T2DM when experiencing depression. Methods Narrative inquiry was used. A semi-structured interview was conducted to understand helpful strategies and barriers in managing T2DM and depression. In addition, women were asked their meaning of family quality of life (FQOL). Results Twenty-one women participated after completion of the six-month final visit in the randomized clinical trial. The mean age was 55.2 years. Participants were 24% Hispanic, 48% African-American, and 52% Caucasian. The major themes generated related to family issues that impacted their self-management, yet participants did not want to "bring fault" to their families. Three themes emerged: (a) experience of family hardships-"it's been hard for me," (b) lack of disclosure to family about being depressed-"no point in talking to them," and (c) the need for connectedness with family and others-"the way it used to be… close as a family." Conclusion Family-centered approaches could address barriers to self-management. A "family lens" for practice and research may improve health outcomes.

Erectile Dysfunction: An Underestimated Presentation in Patients with Diabetes Mellitus

INTRODUCTION

Erectile dysfunction (ED) is a common complication of diabetes mellitus. ED, like other sexual disorders, is often under-reported and under-diagnosed, as talking about sex is considered a taboo in our society.

METHODOLOGY

All the male patients with diabetes mellitus (with or without active complaints of ED) attending Medicine or Psychiatry OPD of the institute during the study period were enrolled in the study. They were investigated for their body-mass index (BMI), blood sugar and lipid profile; and were assessed on HAM-D, General Health Questionnaire-30, IIEF, sex myth checklist and QOL Instrument for Indian Diabetes Patients (QOLID).

RESULT AND DISCUSSION

In the present study, a total of 138 diabetic patients were assessed, and those with severe ED were found to have poor glycemic control, worse lipid profile, higher body mass index, later age of onset, and longer duration of untreated diabetes as compared to non-ED patients. ED patients also scored higher on depression rating scale, had poorer general health and quality of life (QOL). Early attention to ED in diabetic patients can improve general health and QOL of the sufferers.

CONCLUSION

DM patients with poor glycemic control and advanced age have a higher propensity of developing severe ED, which further deteriorates the already compromised health & QOL.

The impact of incident depression on medication adherence in patients with type 2 diabetes

BACKGROUND

Depression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes.

METHODS

We performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e.,<90% of days covered by≥1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence.

RESULTS

Between 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13-1.37).

CONCLUSIONS

The results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.

Association between all-cause mortality and severity of depressive symptoms in patients with type 2 diabetes: Analysis from the Japan Diabetes Complications Study (JDCS)

OBJECTIVE

The aims of this study are to confirm whether the excess mortality caused by depressive symptoms is independent of severe hypoglycemia in patients with type 2 diabetes mellitus (T2DM) and to evaluate the association between all-cause mortality and degrees of severity of depressive symptoms in Japanese patients with T2DM.

METHODS

A total of 1160 Japanese patients with T2DM were eligible for this analysis. Participants were followed prospectively for 3years and their depressive states were evaluated at baseline by the Center for Epidemiologic Studies Depression Scale (CES-D). Cox proportional hazards model was used to evaluate the relative risk of all-cause mortality and was adjusted by possible confounding factors, including severe hypoglycemia, all of which are known as risk factors for both depression and mortality.

RESULTS

After adjustment for severe hypoglycemia, each 5-point increase in the CES-D score was significantly associated with excess all-cause mortality (hazard ratio 1.69 [95% CI 1.26-2.17]). The spline curve of HRs for mortality according to total CES-D scores showed that mortality risk was slightly increased at lower scores but was sharply elevated at higher scores.

CONCLUSION

A high score on the CES-D at baseline was significantly associated with all-cause mortality in patients with T2DM after adjusting for confounders including severe hypoglycemia. However, only a small effect on mortality risk was found at relatively lower levels of depressive symptoms in this population. Further research is needed to confirm this relationship between the severity of depressive symptoms and mortality in patients with T2DM.

Resilience-based Diabetes Self-management Education: Perspectives From African American Participants, Community Leaders, and Healthcare Providers

Purpose The purpose of this qualitative, focus group study was to further refine the Resilience-based Diabetes Self-management Education (RB-DSME) recruitment process and intervention, build greater trust in the community, and identify strategies to enhance its sustainability as a community-based intervention in African American church settings. Methods Six 2-hour focus groups (N = 55; 10 men and 45 women) were led by a trained moderator with a written guide to facilitate discussion. Two sessions were conducted with individuals diagnosed with type 2 diabetes mellitus (T2DM) who participated in previous RB-DSME pilot interventions and their family members, two sessions with local church leaders, and two sessions with community healthcare providers who care for patients with T2DM. Two independent reviewers performed content analysis to identify major themes using a grounded theory approach. The validity of core themes was enhanced by external review and subsequent discussions with two qualitative methods consultants. Results There was expressed interest and acceptability of the RB-DSME program. Church connection and pastor support were noted as key factors in building trust and enhancing recruitment, retention, and sustainability of the program. Core themes across all groups included the value of incentives, the need for foundational knowledge shared with genuine concern, teaching with visuals, dealing with denial, balancing the reality of adverse consequences with hope, the importance of social support, and addressing healthcare delivery barriers. Conclusion Focus groups documented the feasibility and potential effectiveness of RB-DSME interventions to enhance diabetes care in the African American community. In clinical practice, inclusion of these core themes may enhance T2DM self-care and treatment outcomes.

Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes.

DATA SOURCES/SETTING

Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012.

STUDY DESIGN

Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence.

DATA COLLECTION

Adherence and OOP costs were based on pharmacy dispensing records and benefits.

PRINCIPAL FINDINGS

Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months).

CONCLUSIONS

Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.

Glucose-lowering therapies, adequacy of metabolic control, and their relationship with comorbid depression in outpatients with type 2 diabetes in a tertiary hospital in Kenya

BACKGROUND

Depression and diabetes mellitus are important comorbid conditions with serious health consequences. When depression and diabetes are comorbid, depression negatively affects self-management activities of diabetes with serious consequences. Relationship between treatment regimens of diabetes, the adequacy of glycemic control, and occurrence of comorbid depression is not known among our patients.

PATIENTS AND METHODS

This was a cross-sectional descriptive study at the outpatient diabetes clinic of the Kenyatta National Hospital where 220 ambulatory patients with type 2 diabetes on follow-up were systematically sampled. Sociodemographic data and clinical information were documented. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression. Ethylenediaminetetraacetic acid-anticoagulated blood was used for glycated hemoglobin (HbA1C) assay on automated system, COBAS INTEGRA machine.

RESULTS

Two hundred twenty patients with type 2 diabetes were enrolled. The prevalence of comorbid depression by PHQ-9 was 32.3% (95% confidence interval: 26.4%-38.6%). The majority, 69.5%, had poor glycemic control, HbA1C >7.0%, mean HbA1C was 8.9%±2.4%. Half, 50.4%, of the study subjects were on insulin-containing regimens. Over 8% (84.5%) of the participants with comorbid depression had poor glycemic control, which worsened with increasing severity of depression. There was significant correlation between comorbid depression and poor glycemic control, which is more consistent in the insulin-treated patients. However, patients on oral agents only, both with and without comorbid depression, were similar in their glycemic control.

CONCLUSION

Among our type 2 diabetic population with comorbid depression, a large proportion had poor glycemic control, which worsened with increasing severity of depression. The insulin treatment increased the odds of comorbid depression and poor glycemic control in patients. It is justifiable to screen for comorbid depression in patients with type 2 diabetes who are in poor glycemic control, especially the insulin-treated, and then provide specific and appropriate interventions that are necessary to optimize their metabolic outcomes.

Cognitive behavioural therapy on improving the depression symptoms in patients with diabetes: a meta-analysis of randomized control trials

This meta-analysis was performed to evaluate the effect of cognitive behavioural therapy (CBT) in improving the depression symptoms of patients with diabetes. Literature search was conducted in PubMed and Embase up to October 2016 without the initial date. The pooled SMD (standard mean difference) and its 95% confidence interval (CI) were calculated by Revman 5.3. Subgroup analyses were performed by type of diabetes and evaluation criteria of depression. A total of five randomized control trials involving 834 patients with diabetes mellitus (including 417 patients in CBT group and 417 patients in control group) were included in this meta-analysis. The pooled estimates indicated significant improvement of depression by CBT compared with routine approaches in overall outcomes (SMD =–0.33, 95% CI =–0.46 to –0.21, P<0.00001), post-intervention outcomes (SMD =–0.43, 95% CI =–0.73 to –0.12, P=0.006) and outcomes after 12 months intervention (SMD =–0.38, 95% CI = –0.54 to –0.23, P<0.0001). Subgroup analyses showed that the results were not influenced by the type of diabetes. However, the effect of CBT on improving the depression symptoms disappeared when only using CES-D (Centre for Epidemiological Studies scale for Depression) to evaluate depression.

Depressive symptoms and adherence to cardiometabolic therapies across phases of treatment among adults with diabetes: the Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

Among adults with diabetes, depression is associated with poorer adherence to cardiometabolic medications in ongoing users; however, it is unknown whether this extends to early adherence among patients newly prescribed these medications. This study examined whether depressive symptoms among adults with diabetes newly prescribed cardiometabolic medications are associated with early and long-term nonadherence.

PATIENTS AND METHODS

An observational follow-up of 4,018 adults with type 2 diabetes who completed a survey in 2006 and were newly prescribed oral antihyperglycemic, antihypertensive, or lipid-lowering agents within the following year at Kaiser Permanente Northern California was conducted. Depressive symptoms were examined based on Patient Health Questionnaire-8 scores. Pharmacy utilization data were used to identify nonadherence by using validated methods: early nonadherence (medication never dispensed or dispensed once and never refilled) and long-term nonadherence (new prescription medication gap [NPMG]: percentage of time without medication supply). These analyses were conducted in 2016.

RESULTS

Patients with moderate-to-severe depressive symptoms had poorer adherence than nondepressed patients (8.3% more patients with early nonadherence, P=0.01; 4.9% patients with longer NPMG, P=0.002; 7.8% more patients with overall nonadherence [medication gap >20%], P=0.03). After adjustment for confounders, the models remained statistically significant for new NPMG (3.7% difference, P=0.02). There was a graded association between greater depression severity and nonadherence for all the models (test of trend, P<0.05).

CONCLUSION

Depressive symptoms were associated with modest differences in early and long-term adherence to newly prescribed cardiometabolic medications in diabetes patients. Interventions targeting adherence among adults with diabetes and depression need to address both initiation and maintenance of medication use.

Redesigning Diabetes Care: Defining the Role of Endocrinologists Among Alternative Providers

The current diabetes epidemic threatens to overwhelm the healthcare system unless we redesign how diabetes care is delivered. The number of endocrinologists is grossly inadequate to provide care for all individuals with diabetes, but with the appropriate utilization of the primary care workforce and alternative healthcare providers working together in teams, effective diabetes care can be provided to all. We propose a patient-centered, goal-based approach with resources devoted to care coordination, measurement of outcomes, appropriate use of technology, and measurement of patient satisfaction. Financial incentives to healthcare systems and providers need to be based on defined outcome measures and reducing long-term total medical expenditures, rather than reimbursement based on number of visits and lengthy documentation. Endocrinologists have a responsibility in setting up effective diabetes care delivery systems within their organizations, in addition to delivering diabetes care and serving as a resource for the educational needs for other medical professionals in the community. There are major challenges to implementing such systems, both at the financial and organizational levels. We suggest a stepwise implementation of discrete components based on the local priorities and resources and provide some examples of steps we have taken at our institution.

Telepsychiatrists' Medication Treatment Strategies in the Children's Attention-Deficit/Hyperactivity Disorder Telemental Health Treatment Study

OBJECTIVE

The purpose of this study was to examine the prescribing strategies that telepsychiatrists used to provide pharmacologic treatment in the Children's Attention-Deficit/Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS).

METHODS

CATTS was a randomized controlled trial that demonstrated the superiority of a telehealth service delivery model for the treatment of ADHD with combined pharmacotherapy and behavior training (n=111), compared with management in primary care augmented with a telepsychiatry consultation (n=112). A diagnosis of ADHD was established with the Computerized Diagnostic Interview Schedule for Children (CDISC), and comorbidity for oppositional defiant disorder (ODD) and anxiety disorders (AD) was established using the CDISC and the Child Behavior Checklist. Telepsychiatrists used the Texas Children's Medication Algorithm Project (TCMAP) for ADHD to guide pharmacotherapy and the treat-to-target model to encourage their assertive medication management to a predetermined goal of 50% reduction in ADHD-related symptoms. We assessed whether telepsychiatrists' decision making about making medication changes was associated with baseline ADHD symptom severity, comorbidity, and attainment of the treat-to-target goal.

RESULTS

Telepsychiatrists showed high fidelity (91%) to their chosen algorithms in medication management. At the end of the trial, the CATTS intervention showed 46.0% attainment of the treat-to-target goal compared with 13.6% for the augmented primary care condition, and significantly greater attainment of the goal by comorbidity status for the ADHD with one and ADHD with two comorbidities groups. Telepsychiatrists' were more likely to decide to make medication adjustments for youth with higher baseline ADHD severity and the presence of disorders comorbid with ADHD. Multiple mixed methods regression analyses controlling for baseline ADHD severity and comorbidity status indicated that the telepsychiatrists also based their decision making session to session on attainment of the treat-to-target goal.

CONCLUSIONS

Telepsychiatry is an effective service delivery model for providing pharmacotherapy for ADHD, and the CATTS telepsychiatrists showed high fidelity to evidence-based protocols.

A Double-Blind, Randomized Pilot Trial of Chromium Picolinate for Overweight Individuals with Binge-Eating Disorder: Effects on Glucose Regulation

PURPOSE

Chromium treatment has been shown to improve glucose regulation in some populations. The purpose of this study was to evaluate whether chromium picolinate (CrPic) supplementation improves glucose regulation in overweight individuals with binge-eating disorder (BED).

METHODS

In this double-blinded randomized pilot trial, participants (N = 24) were randomized to high (HIGH, 1000 mcg/day, n = 8) or moderate (MOD, 600 mcg/day, n = 9) dose of CrPic or placebo (PL, n = 7) for 6 months. Participants completed an oral glucose tolerance test (OGTT) at baseline, 3 months, and 6 months. Fixed effects models were used to estimate mean change in glucose area under the curve (AUC), insulin_AUC, and insulin sensitivity index (ISI).

RESULTS

Results revealed a significant group and time interaction (p < 0.04) for glucose_AUC, with glucose_AUC increasing significantly in the PL group (p < 0.02) but decreasing significantly in the MOD group (p < 0.03) at 6 months. Insulin_AUC increased significantly over time (main effect, p < 0.02), whereas ISI decreased significantly over time (main effect, p < 0.03).

CONCLUSION

As anticipated, a moderate dose of CrPic was associated with improved glycemic control, whereas PL was associated with decreased glycemic control. It was unexpected that the improved glycemic control seen in the MOD dose group was not seen in the HIGH dose group. However, although participants randomized to the HIGH dose group did not have improved glycemic control, they had better glycemic control than participants randomized to the PL group. These findings support the need for larger trials.

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.

Quality Over Quantity: Integrating Mental Health Assessment Tools into Primary Care Practice

Depression is one of the most common, costly, and debilitating psychiatric disorders in the US. There are also strong associations between depression and physical health outcomes, particularly chronic diseases such as diabetes mellitus. Yet, mental health services are underutilized throughout the US. Recent policy changes have encouraged depression screening in primary care settings. However, there is not much guidance about how depression screeners are administered. There are people suffering from depression who are not getting the treatment they need. It is important to consider whether enough care is being taken when administering depression screeners in primary care settings.

Prevalence of Depression among Rural Residents with Diabetes Mellitus: A Cross-Sectional Study from Northeast China

Recent economic development in China has resulted in large increases in psychogenic and metabolic diseases. However, few studies have focused on the mental status of rural residents with diabetes. We aimed to investigate the prevalence of depressive symptoms among patients with diabetes to establish the association between depressive symptoms and socio-demographic and clinical factors. We conducted a cross-sectional analysis of 1187 patients with diabetes aged ≥35 years from rural Northeast China. Metabolic and anthropometric indicators were measured according to standard methods. Depressive symptoms were defined using the Patient Health Questionnaire-9 (PHQ-9). Five hundred and twenty-six residents (44.3%) of the total sample were male and 931 (78.4%) were <65 years old. One hundred and eight residents (8.76%) score ≥10 on the PHQ-9 scale. A statistically significant relationship was found between depressive symptoms and female gender, older age (≥65 years), high school or above education level, moderate physical activity, high family income, multiple additional illnesses, current alcohol consumption, and 7-8 h/d sleep duration. Multivariate analysis showed that female gender [odds ratio (OR) = 1.984, p = 0.028], high family income (OR = 0.483 for 5000-20,000 CNY/year, p = 0.011; OR = 0.356 for >2000 CNY/year, p = 0.003), 7-8 h/d sleep duration (OR = 0.453, p = 0.020), and having multiple additional illness (OR = 3.080, p < 0.001) were significantly associated with depressive symptoms. Prevalence of depressive symptoms in our study was high. Female gender and multiple illnesses were risk factors for depression, while long sleep duration and high family income seem to protect against depression among rural residents with diabetes in China.

Feasibility and Acceptability of a Positive Psychological Intervention for Patients With Type 2 Diabetes

OBJECTIVE

Positive psychological attributes (eg, optimism) have been associated with a healthier lifestyle and superior medical outcomes in patients with type 2 diabetes; however, there has been minimal study of behavioral interventions that target positive psychological constructs in this population. Accordingly, we developed a novel, telephone-based, 12-week positive psychology intervention and assessed its feasibility and short-term impact in adults with type 2 diabetes and suboptimal health behavior adherence.

METHOD

This was a pilot and feasibility study in adult inpatients and outpatients at an urban academic medical center recruited between December 2013 and December 2014. Adult patients with (1) type 2 diabetes (meeting American Diabetes Association criteria, eg, glycated hemoglobin A1c [HbA1c] > 6.5% or fasting glucose > 126 mg/dL) and (2) suboptimal adherence (score < 15/18 on the Medical Outcomes Study Specific Adherence Scale items for medication, diet, and exercise) were eligible. Participants received a positive psychology manual, completed exercises (eg, writing a gratitude letter, performing acts of kindness), and reviewed these activities by phone with a study trainer over the 12-week study period. Feasibility and acceptability were assessed via exercise completion rates and postexercise ratings of ease/utility on 0-10 Likert scales. Longer-term efficacy was explored by examining changes in psychological states and health behaviors from baseline to 12 weeks using random-effects regression models and estimates of effect size.

RESULTS

A total of 15 participants enrolled; 12 participants provided complete baseline and follow-up data and were included in the analyses. Over 90% of these participants completed at least 2 exercises, and 75% completed a majority of the exercises. Participants rated the exercises as helpful (mean = 7.8/10) and easy to complete (mean = 7.1/10), and they reported improvements in optimism, gratitude, depression, anxiety, physical function, self-care, and health behaviors (Cohen d = 0.28-1.00).

CONCLUSION

A positive psychology intervention for suboptimally adherent patients with type 2 diabetes was feasible, acceptable, and associated with broad pre-post psychological and health behavior improvement in a small initial study. Further testing of this promising intervention is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02736084.

The Comorbid Influence of High Depressive Symptoms and Diabetes on Mortality and Disability in Mexican Americans Aged 75 and Above

OBJECTIVE

To examine the individual and combined effects of depression and diabetes on mortality and disability over 6 years among Mexican Americans aged ≥75.

METHOD

The final sample included 1,785 participants from the Hispanic Established Population for the Epidemiological Study of the Elderly. Cox proportional hazards regression models were used to estimate the hazard ratios for incidence for mortality and disability according to diabetes and depressive symptoms.

RESULTS

Diabetics were more likely to become activities of daily living (ADL) disabled Hazard Ratio (HR) = 1.44, 95% confidence interval [CI] = [1.18, 1.77]) and deceased (HR = 1.47, 95% CI = [1.24, 1.74]) compared with non-diabetics. Diabetics reporting high depressive symptomatology were more than two times as likely to become ADL disabled and deceased compared with diabetics not reporting high depressive symptoms. Participants with high depressive symptoms and taking insulin alone or both oral medications and insulin were at the greatest risk of disability (HR = 3.83, 95% CI = [1.66, 8.81]).

CONCLUSION

Diabetes increases the risk of disability and mortality, especially among Mexican Americans with high depressive symptoms or who are taking insulin alone or both oral medications and insulin. Interventions that are able to reduce the prevalence of depression and diabetes are needed to limit the future burden of disability and mortality in this population.

Understanding adherence to medications in type 2 diabetes care and clinical trials to overcome barriers: a narrative review

AIM

To identify factors affecting adherence to medications in type 2 diabetes (T2D) care and clinical trials.

BACKGROUND

Adherence to medication is associated with better patient outcomes, lower healthcare costs, and improved quality and robustness of trial data. In T2D, non-adherence to regimens may compromise glycemic, blood pressure and lipid control, which can, in turn, increase morbidity and mortality rates.

DESIGN

A literature search was performed to identify studies reporting adherence to medications and highlighting specific adherence challenges/approaches in T2D. The search was limited to clinical trials, comparative studies or meta-analyses, reported in English with a freely available abstract.

DATA SOURCE

MEDLINE (31 December 2008 to 31 December 2013).

REVIEW METHODS

Studies not reporting adherence to medications or highlighting adherence challenges/approaches in T2D, presenting only self-reported adherence or including fewer than 100 patients were excluded. Eligible reports are discussed narratively.

RESULTS

Factors identified as having a detrimental impact on adherence were smoking, depression and polypharmacy. Conversely, increased convenience (e.g. pen compared with vial and syringe; medication supplied by mail order vs. retail pharmacy) was associated with better patient adherence, as were interventions that increased patient motivation (e.g. individualized, nurse-led consultation) and education.

CONCLUSIONS

Medication adherence is influenced by complex and multifactorial issues, which can include smoking, depression, polypharmacy, convenience of obtaining and administering the medication, patient motivation and education. We recommend simplifying treatment regimens, where possible, improving provider-patient communication, and providing support and education to increase medication adherence, with a view to improving patient outcomes and clinical trial data quality.

The Australasian Hepatology Association consensus guidelines for the provision of adherence support to patients with hepatitis C on direct acting antivirals

BACKGROUND

Hepatitis C is a blood-borne virus primarily spread through sharing of drug-injecting equipment. Approximately 150 million people worldwide and 230,000 Australians are living with chronic hepatitis C infection. In March 2016, the Australian government began subsidizing direct acting antivirals (DAAs) for the treatment of hepatitis C, which are highly effective (95% cure rate) and have few side effects. However, there is limited evidence to inform the provision of adherence support to people with hepatitis C on DAAs including the level of medication adherence required to achieve a cure.

METHODOLOGY

In February 2016, a steering committee comprising four authors convened an expert panel consisting of six hepatology nurses, a hepatologist, a pharmacist, a consumer with hepatitis C and treatment experience, and a consumer advocate. The expert panel focused on the following criteria: barriers and enablers to DAA adherence; assessment and monitoring of DAA adherence; components of a patient-centered approach to DAA adherence; patients that may require additional adherence support; and interventions to support DAA adherence. The resultant guidelines underwent three rounds of consultation with the expert panel, Australasian Hepatology Association (AHA) members (n=12), and key stakeholders (n=7) in June 2016. Feedback was considered by the steering committee and incorporated if consensus was achieved.

RESULTS

Twenty-four guidelines emerged from the evidence synthesis and expert panel discussion. The guidelines focus on the pretreatment assessment and education, assessment of treatment readiness, and monitoring of medication adherence. The guidelines are embedded in a patient-centered approach which highlights that all patients are at risk of nonadherence. The guidelines recommend implementing interventions focused on identifying patients' memory triggers and hooks; use of nonconfrontational and nonjudgmental language by health professionals; and objectively monitoring adherence.

CONCLUSION

These are the first guidelines to support patients and health professionals in the delivery of clinical care by identifying practical adherence support interventions for patients taking DAAs.

Depression remission, receipt of problem-solving therapy, and self-care behavior frequency among low-income, predominantly Hispanic diabetes patients

OBJECTIVE

This study explored whether depression remission and problem-solving therapy (PST) receipt are associated with more frequent self-care behaviors via cross-sectional and prospective analyses.

METHOD

We analyzed data from a randomized clinical trial (N=387) that tested collaborative depression care among predominantly Hispanic patients with diabetes in safety-net clinics. Data at 12-month follow-up, measured with the Patient Health Questionnaire-9 and Hopkins Symptom Checklist-20, were used to define depression remission. PST was provided by a bilingual social worker. Multivariate regression analysis was used to examine associations between predictors and frequency change of each self-care behavior (healthy diet, exercise, self-blood glucose monitoring, and foot care between baseline and 12-month (N=281), 18-month (N=249), and 24-month (N=235) follow-up surveys.

RESULTS

Inconsistent relationships were observed depending on the instrument to identify depression remission, type of self-care behaviors, and time when self-care behavior was measured. Significant associations were more likely to be observed in cross-sectional analyses. PST receipt was not associated with self-care behaviors.

CONCLUSIONS

Depression remission or the receipt of PST may not be a reliable antecedent for more frequent self-care behaviors among this group. A few recommendations for studies were offered to enhance existing depression care for diabetes patients.