Treatment of depression in diabetes: an update

The Interrelationship between Diabetes Mellitus and Emotional Well-Being: Current Concepts and Future Prospects

Diabetes mellitus is a lifelong metabolic disorder that impacts people's well-being and biopsychosocial status. Psychiatric problems and diabetes mellitus have a complex, reciprocal interaction in which one condition affects the other. In this narrative review, we provide an overview of the literature on the psychological effects of diabetes, expound on the evaluation of emotional disorders in the setting of diabetes, and suggest interventions aimed at enhancing both mental and physical health. Diabetes can make daily life complicated and stressful. Frequent blood glucose testing, taking medications on a regular basis, adhering to a tight diet plan, and exercising are some examples of the suggested daily routine of subjects with diabetes. Furthermore, comorbid diseases and typical diabetic complications can have a detrimental impact on quality of life. When mental health conditions coexist with diabetes mellitus, there is a greater likelihood of medication noncompliance, a decreased commitment to diabetes-related self-care, increased functional impairment, inadequate glycemic control, a higher risk of complications, and overall higher healthcare expenses. Thus, evaluation of the mental health status of patients with diabetes is crucial. When treating psychological issues and psychiatric disorders, a comprehensive biopsychosocial approach should be taken, and where appropriate, psychopharmacological therapies or psychotherapy should be applied. The goal of continuous education and assistance for self-care is to give individuals with the disease the information and abilities they need to control their condition over time.

Economic Evaluation of a Web Application Implemented in Primary Care for the Treatment of Depression in Patients With Type 2 Diabetes Mellitus: Multicenter Randomized Controlled Trial

BACKGROUND

Depressive disorder and type 2 diabetes mellitus (T2DM) are prevalent in primary care (PC). Pharmacological treatment, despite controversy, is commonly chosen due to resource limitations and difficulties in accessing face-to-face interventions. Depression significantly impacts various aspects of a person's life, affecting adherence to medical prescriptions and glycemic control and leading to future complications and increased health care costs. To address these challenges, information and communication technologies (eg, eHealth) have been introduced, showing promise in improving treatment continuity and accessibility. However, while eHealth programs have demonstrated effectiveness in alleviating depressive symptoms, evidence regarding glycemic control remains inconclusive. This randomized controlled trial aimed to test the efficacy of a low-intensity psychological intervention via a web app for mild-moderate depressive symptoms in individuals with T2DM compared with treatment as usual (TAU) in PC.

OBJECTIVE

This study aimed to analyze the cost-effectiveness and cost-utility of a web-based psychological intervention to treat depressive symptomatology in people with T2DM compared with TAU in a PC setting.

METHODS

A multicenter randomized controlled trial was conducted with 49 patients with T2DM, depressive symptoms of moderate severity, and glycosylated hemoglobin (HbA1c) of 7.47% in PC settings. Patients were randomized to TAU (n=27) or a web-based psychological treatment group (n=22). This web-based treatment consisted of cognitive behavioral therapy, improvement of diabetes self-care behaviors, and mindfulness. Cost-effectiveness analysis for the improvement of depressive symptomatology was conducted based on reductions in 3, 5, or 50 points on the Patient Health Questionnaire-9 (PHQ-9). The efficacy of diabetes control was estimated based on a 0.5% reduction in HbA1c levels. Follow-up was performed at 3 and 6 months. The cost-utility analysis was performed based on quality-adjusted life years.

RESULTS

Efficacy analysis showed that the web-based treatment program was more effective in improving depressive symptoms than TAU but showed only a slight improvement in HbA1c. Incremental cost-effectiveness ratios of 186.76 for a 3-point reduction in PHQ-9 and 206.31 for reductions of 5 and 50 percentage points were obtained. In contrast, the incremental cost-effectiveness ratio for improving HbA1c levels amounted to €1510.90 (€1=US $1.18 in 2018) per participant. The incremental cost-utility ratio resulted in €4119.33 per quality-adjusted life year gained.

CONCLUSIONS

The intervention, using web-based modules incorporating cognitive behavioral therapy tools, diabetes self-care promotion, and mindfulness, effectively reduced depressive symptoms and enhanced glycemic control in patients with T2DM. Notably, it demonstrated clinical efficacy and economic efficiency. This supports the idea that eHealth interventions not only benefit patients clinically but also offer cost-effectiveness for health care systems. The study emphasizes the importance of including specific modules to enhance diabetes self-care behaviors in future web-based psychological interventions, emphasizing personalization and adaptation for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/S12888-019-2037-3.

The Effectiveness of Cognitive Behavioral Therapy for Depression Among Individuals with Diabetes: a Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Depression is prevalent and common among individuals living with diabetes. The aim of this review is to systematically assess and meta-analyze the treatment effect of cognitive-behavioral therapy for depression (and other affective outcomes) among patients with diabetes.

RECENT FINDINGS

Earlier investigations found both psychosocial and pharmacological interventions, including cognitive-behavioral therapy, were promising in managing depression in patients with diabetes, though these findings remain inclusive due to poor study designs and a small number of trials included, which calls for a comprehensive systematic review and meta-analysis. A total of 33 studies (89 effect sizes) reported a moderate and statistically significant treatment effect of cognitive-behavioral therapy for depressive symptoms among individuals with diabetes (d = 0.301, 95% CI 0.115-0.487, p < 0.001). On average, cognitive-behavioral therapy was effective for psychological stress/distress outcomes but not for anxiety or physiological outcomes. The findings of the study confirmed CBT as an effective treatment option for depression among diabetes patients and identified important areas for future research.

Effectiveness of physical activity in managing co-morbid depression in adults with type 2 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Physical activity may be effective in alleviating depressive symptoms and improving glycaemic control; however, evidence to guide practice is limited. The current review was conducted to assess the effects of physical activity on depression and glycaemic control in people with type 2 diabetes mellitus.

METHODS

Randomized controlled clinical trials, from the earliest record to October 2021, which recruited adults with the diagnosis of type 2 diabetes mellitus and compared physical activity with no interventions or usual care for the management of depression were included. The outcomes were change in depression severity and glycaemic control.

RESULTS

In 17 trials, including 1362 participants, physical activity was effective in reducing the severity of depressive symptoms (SMD = -057; 95%CI = -0.80, -0.34). However, physical activity did not have a significant effect in improving markers of glycaemic control (SMD = -0.18; 95%CI = -0.46, 0.10).

LIMITATIONS

There was substantial heterogeneity in the included studies. Furthermore, risk of bias assessment showed that most of the included studies were of low quality.

CONCLUSIONS

Physical activity can effectively reduce the severity of depressive symptoms, nonetheless, it appears that physical activity is not significantly effective in improving glycaemic control in adults who have both type 2 diabetes mellitus and depressive symptoms. The latter finding is surprising, however, given the limited evidence on which this is based, future research on the effectiveness of physical activity for depression in this population should include high quality trials with glycaemic control as an outcome.

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.

Effectiveness of eHealth-Based Psychological Interventions for Depression Treatment in Patients With Type 1 or Type 2 Diabetes Mellitus: A Systematic Review

BACKGROUND

Comorbidity between diabetes mellitus and depression is highly prevalent. The risk of depression in a person with diabetes is approximately twice that of a person without this disease. Depression has a major impact on patient well-being and control of diabetes. However, despite the availability of effective and specific therapeutic interventions for the treatment of depression in people with diabetes, 50% of patients do not receive psychological treatment due to insufficient and difficult accessibility to psychological therapies in health systems. The use of information and communication technologies (ICTs) has therefore been proposed as a useful tool for the delivery of psychological interventions, but it continues to be a field in which scientific evidence is recent and controversial. This systematic review aims to update the available information on the efficacy of psychological interventions delivered through ICTs to improve depressive symptomatology in patients with diabetes.

METHODS

A systematic review of the literature was performed following the PRISMA guidelines and using MEDLINE, Embase, PubMed, Web of Science, PsycINFO, Scopus, and Cochrane Library databases to search for randomized clinical trials of eHealth treatments for patients with diabetes and comorbid depression from 1995 through 2020. In addition, studies related to follow-up appointments were identified. Inclusion criteria were as follows: (a) randomized clinical trials (RCTs); (b) patients with type 1 and type 2 diabetes; (c) adult population over 18 years of age; (d) presence of depressive symptomatology assessed with standardized instruments; (e) treatments for depression based on established psychotherapeutic techniques and principles; (f) delivered through eHealth technologies. We did not limit severity of depressive symptomatology, delivery setting or comparison group (treatment as usual or other treatment). Two coauthors independently reviewed the publications identified for inclusion and extracted data from the included studies. A third reviewer was involved to discuss discrepancies found. The PEDro scale was used to assess the quality of the RCTs. No meta-analysis of the results was performed. The protocol used for this review is available in PROSPERO (Reg; CRD42020180405).

RESULTS

The initial search identified 427 relevant scientific publications. After removing duplicates and ineligible citations, a total of 201 articles were analyzed in full text. Ten articles met the criteria of this review and were included, obtaining very good scientific quality after evaluation with the PEDro scale. The main results show that the eHealth psychological intervention for depression in patients with diabetes showed beneficial effects both at the end of treatment and in the short (3 months) and long term (6 and 12 months) for the improvement of depressive symptomatology. The methodology used (type of diabetes, eHealth technology used, recruitment context, implementation and follow-up) was very heterogeneous. However, all studies were based on cognitive-behavioral tools and used standardized assessment instruments to evaluate depressive symptomatology or diagnosis of MDD. Glycemic control was assessed by glycosylated hemoglobin, but no benefits were found in improving glycemic control. Only four studies included psychoeducational content on diabetes and depression, but none used tools to improve or enhance adherence to medical prescriptions or diabetes self-care.

CONCLUSIONS

ICT-based psychological interventions for the treatment of depression in people with diabetes appear to be effective in reducing depressive symptomatology but do not appear to provide significant results with regard to glycemic control. Nonetheless, the scientific evidence reported to date is still very limited and the methodology very diverse. In addition, no studies have implemented these systems in routine clinical practice, and no studies are available on the economic analysis of these interventions. Future research should focus on studying and including new tools to ensure improvements in diabetes outcomes and not only on psychological well-being in order to advance knowledge about these treatments. Economic evaluations should also be undertaken to analyze whether these treatment programs implemented using eHealth technologies are cost-effective.

Depression among patients with type 2 diabetes mellitus: Evidence from the Northeast region of Vietnam

BACKGROUND AND AIMS

Herein, we aim to examine the prevalence of depression in type 2 diabetic patients at a provincial general hospital located in the Northeast region of Vietnam and to explore its relationship with some sociodemographic, lifestyle and medical history characteristics.

MATERIALS AND METHODS

This was a single-centre cross-sectional descriptive study. The patients of both sexes who were at the age of 18 years or above, were treated at our institution and were diagnosed with type 2 diabetes mellitus, previously or during the study period. A total of 220 patients were included in the study.

RESULTS

Depression prevalence was 32.27% according to ICD-10. The severity of depression was categorized as mild in 77.46% patients, moderate in 19.72% patients and severe in 2.82% patients. The odds of depression was 0.18 (95%CI 0.05-0.69, p = 0.012) less for those known as the upper social class compared with those in lower social class. Those who were not on insulin treatment had significantly higher odds of depression than those on treatment with insulin (OR 2.06, 95%CI: 1.01-4.21). Individuals on treatment without oral diabetes drugs had higher odd of depression compared to those being treated with oral diabetes drugs (OR 2.77, 95%CI: 1.14-6.73). Also, hypertension was an increasing contributor to the depression prevalence (OR 2.32, 95%CI: 1.10-4.90).

CONCLUSIONS

A high prevalence of depression among type 2 diabetic patients was documented. Only significant factors for depression were lower social class, co-morbid hypertension and none of the insulin treatment or oral diabetes drugs.

Agomelatine might be more appropriate for elderly, depressed, type 2 diabetes mellitus patients than paroxetine/fluoxetine

Agomelatine was a novel and melatonergic antidepressant. The present study was conducted to find out whether age was an important factor for agomelatine in treating depressed type 2 diabetes mellitus (T2DM) patients. In total, 193 depressed T2DM patients were included. There were 84 patients ranged from 27 years old to 49 years old (age phase I) (n = 44 receiving agomelatine, n = 40 receiving paroxetine or fluoxetine), and 109 patients ranged from 50 years old to 70 years old (age phase II) (n = 56 receiving agomelatine, n = 53 receiving paroxetine or fluoxetine). The Hamilton Depression Rating Scale (HDRS) score, Hamilton Anxiety Rating Scale (HARS) score, fasting plasma glucose (FPG), hemoglobin A1c (HbA1c) level and body mass index (BMI) were assessed after 12 weeks treatment. After treatment, we found that among patients in age phase I, there were no significant differences in final average HDRS score, HARS score, FPG, HbA1c level, BMI, response rate and remission rate between the two groups. However, among patients in age phase II, compared to patients receiving paroxetine or fluoxetine, patients receiving agomelatine had the significantly lower average HDRS score, HARS score, HbA1c level and BMI, and significantly higher response rate and remission rate. The incidence of treatment-related adverse events was similar between the two groups in both age phases. These results suggested that age was an important factor for agomelatine in treating depressed T2DM patients. Compared to paroxetine/fluoxetine, agomelatine might be more appropriate for elderly depressed T2DM patients.

Assessing prevalence and predictors of depression in Type 2 Diabetes Mellitus (DM) patients - The DEPDIAB study

OBJECTIVES

Depression is common in diabetes and has significant impact on health outcomes. Suicidal ideation also forms a part of the spectrum of diabetes and coexistent depression. To assess the predictors of depression as well as its prevalence in Type 2 Diabetes Mellitus (T2DM) patients, we conducted a cross sectional study entitled "DEPression in DIABetes" (DEPDIAB).

MATERIAL AND METHODS

A cohort of consecutive 1371 T2DM patients from Eastern India suffering from diabetes greater than 1 year was assessed in a cross- sectional survey in 9 different hospitals and medical polyclinics in Kolkata, India for depression by administering the 9-item PHQ - 9 and Beck depression scales. Socioeconomic status was assessed by the "Revised Kuppuswamy and B G Prasad socio-economic scales for 2016", a validated scoring system for assessing the socioeconomic status of Indian patients.

RESULTS

In our study 836 patients (60.9%) were male and 535 (39.02%) were female. 56 patients (4.1%) met the criteria for major depression and 494 patients (36.16%) for minor depression. No sign of depression was found in 816 patients (59.74%). Depression was strongly associated with younger age (18-40 years vs. >60 years) [OR-2.09; 95% CI 1.11-3.96], female sex [OR-1.31; 95% CI 1.11-2.01], low socioeconomic status [OR-2.69; 95% CI 1.34-3.79], poor compliance [OR- 5.05; 95% CI 2.79-8.13], hypoglycemia [OR 1.466; 95% CI 1.076-1.999] and difficulty in managing day-to-day activities [OR- 4.648; 95% CI 3.450-6.262] Suicidal ideation was detected in 201 patients (14.8%). Among patients who had repeated attacks of hypoglycemia (>1 episode per month), 22% experienced suicidal ideation. This was significantly higher than in patients who had not suffered from hypoglycemia (12%) (p < 0.0001). Patients with HbA1C of 7% or lower experienced statistically significantly lesser suicidal ideation than patients with a higher HbA1C (12% vs. 16.8% {p = 0.016}). Suicidal ideation did not correlate withbody mass index (BMI), fasting plasma glucose (FPG) or insulin usage.

CONCLUSIONS

We found a high prevalence of depression in T2DM patients in Eastern India. Younger age, female sex, lower socio-economic status, poor compliance, hypoglycemia, and difficulty in managing day to day activities emerged as significant predictors of depression in this study. Recurrent episodes of hypoglycemia were an independent risk factor for suicidal ideation in patients with depression. Depression was not significantly associated with co morbidities associated with T2D and surprisingly insulin usage was not associated with increased depression.

Web-Based Interventions for Depression in Individuals with Diabetes: Review and Discussion

Background

Depression is twice as common in people with diabetes, and this comorbidity worsens the course of both pathologies. In clinical practice guidelines, screening and treatment of depression in patients with diabetes are highly recommended. However, depression is still both underrecognized and undertreated. To find ways to enhance their reach, psychological treatments have taken advantage of benefits of internet and technological devices as delivery formats, providing interventions that require considerably less (or even no) interaction time with therapists. Web-based treatments hold promise for effective interventions at low cost with positive results.

Objective

The objectives of this review were to describe Web-based interventions for depression in individuals with diabetes and to discuss these studies’ procedures and findings in light of evidence from a wider range of interventions for depression and diabetes.

Methods

A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included when they met the following selection criteria: the study was available in a peer-reviewed journal mainly publishing studies written in either English or Spanish; the studied sample comprised individuals with diabetes; the intervention targeted depression symptomatology; the intervention was accessible via the internet; and the intervention was accessible via the internet with little or no clinician support.

Results

Overall, 5 research studies were identified in the review. All studies were randomized controlled trials, and most used a wait list as a control; 4 studies reported treatment dropout, rates of which varied from 13% to 42%. Studies supported the notion that the Web-based format is a suitable psychology service delivery option for diabetic individuals with depression (effect size range for completers 0.7-0.89). Interventions varied in their characteristics but most were clinical-assisted, had a cognitive behavioral therapy approach, used diabetes-specific topics, had a weekly modular display, used homework assignments, and had some adherence management strategy. These characteristics are consistent with the intervention features associated with positive results in the literature.

Conclusions

The analyzed studies’ findings and procedures are discussed in light of evidence drawn from a wider range of reviews on Web-based interventions for depression and diabetes. Consistent with previous research on depression treatment, Web-based interventions for depression among individuals with diabetes have shown positive results. Future research should contribute new evidence as to why these interventions are effective, for whom, and which particular aspects can increase patients’ adherence.

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.

Reduction of depressive symptoms predicts improved glycaemic control: Secondary results from the DIAMOS study

AIMS

Evidence from randomised trials analysing effects of depression treatment on glycaemic control in group comparisons is inconsistent. The aim of this study was to test if the reduction of depressive symptoms would explain improved glycaemic control irrespective of treatment groups.

METHODS

The DIAMOS study tested effects of cognitive-behavioural therapy (CBT) versus usual care on depressive symptoms in a 12-month prospective trial; HbA_1c was a secondary outcome. Since the results suggested superiority of CBT for improving depressive symptoms, but not HbA_1c, we conducted this secondary analysis to test if reduction of depressive symptoms could explain improved glycaemic control when assessed irrespective of treatment group affiliation. Reduction of depressive symptoms was assessed using baseline-to-follow-up changes in the Center for Epidemiologic Studies Depression Scale (CES-D). We used multiple regression analyses, adjusting for baseline HbA_1c and depression, group affiliation and covariates, to assess associations between reduction of depressive symptoms and follow-up HbA_1c.

RESULTS

181 participants provided eligible data. Depressive symptoms decreased between baseline and follow-up by averagely -5.1±11.8 CES-D points. Greater reduction of depressive symptoms predicted greater improvement of HbA_1c at follow-up, while adjusting for baseline HbA_1c and covariates (Beta=-0.24, P=0.004). Additionally, patients with greater reduction of depressive symptoms were more likely to reach in-target HbA_1c (<7.5%) at follow-up (adjusted OR=1.04, 95% CI 1.01-1.08, P=0.023).

CONCLUSIONS

The findings suggest that reduction of depressive symptoms can explain improved glycaemic control. Behavioural treatments might aim to improve both affective and glycaemic outcomes.

Use of antidepressants in patients with depression and comorbid diabetes mellitus: a systematic review

OBJECTIVE

Depression may be difficult to treat and with comorbid diabetes mellitus (DM) it is an even bigger challenge. This article aims to evaluate antidepressants most suitable for patients with depression and comorbid DM. Design and methods Initially we searched for randomised, controlled double-blind trials of treatment with antidepressants in depressed with DM but there were only a few studies and many of them were small trials. Thus, we decided to include studies that were not only randomised-controlled trials. In total, we ended up with 18 articles for our purposes.

RESULTS

The combination of depression and DM may be harmful as depression has a strong impact on psychosocial and medical outcomes in patients with DM. Almost all of the trials in this review showed a reduction in depressive symptoms after treatment with an antidepressant in the acute as well as during maintenance phase. It showed that depression improvement had a favourable effect on glycaemic control that was weight independent. Some studies included only subjects with minor depression or with suboptimal-controlled diabetes making it difficult to show an effect.

CONCLUSION

From these data, we will recommend choosing an selective serotonin reuptake inhibitor (SSRI) if possible to treat a depression among patients with diabetes. If treatment with a tricyclic antidepressant is needed, closer glycaemic monitoring is recommended. Bear in mind that there is a possible risk of hypoglycemia when using SSRIs. Agomelatine and bupropion have shown promising results, but need to be investigated in more trials.

Diabetes, adult neurogenesis and brain remodeling: New insights from rodent and zebrafish models

The prevalence of diabetes rapidly increased during the last decades in association with important changes in lifestyle. Diabetes and hyperglycemia are well-known for inducing deleterious effects on physiologic processes, increasing for instance cardiovascular diseases, nephropathy, retinopathy and foot ulceration. Interestingly, diabetes also impairs brain morphology and functions such as (1) decreased neurogenesis (proliferation, differentiation and cell survival), (2) decreased brain volumes, (3) increased blood-brain barrier leakage, (4) increased cognitive impairments, as well as (5) increased stroke incidence and worse neurologic outcomes following stroke. Importantly, diabetes is positively associated with a higher risk to develop Alzheimer disease. In this context, we aim at reviewing the impact of diabetes on neural stem cell proliferation, newborn cell differentiation and survival in a homeostatic context or following stroke. We also report the effects of hyper- and hypoglycemia on the blood-brain barrier physiology through modifications of tight junctions and transporters. Finally, we discuss the implication of diabetes on cognition and behavior.

Psychiatric referral and glycemic control of Egyptian type 2 diabetes mellitus patients with depression

OBJECTIVE

To evaluate the relationship between psychiatric referral acceptance for fluoxetine treatment and glycemic control in type 2 diabetes mellitus (T2DM) Egyptian patients with depression.

METHODS

Patients with T2DM who attended the diabetes outpatients clinic at Zagazig University Hospital, Egypt, between May 2013 and April 2015 and who scored ≥20 on screening with the Major Depression Inventory (MDI) (n=196) were offered a psychiatric referral for fluoxetine treatment and monitoring. Decliners (56.1%) received time/attention matched care via diabetologist visits (attentional controls). Fluoxetine patients and controls were compared at the time of the offer (T1) and 8weeks later (T2). Factors that significantly correlated with glycemic control were used in a linear regression analysis as the independent variables.

RESULTS

Eighty-six patients (43.9%) accepted psychiatric referral. Most of them (97.7%) remained throughout the study adherent to fluoxetine (mean daily dose=31.9mg). At T2, these patients, in comparison to controls, showed a reduction from baseline in MDI, fasting plasma glucose and glycosylated hemoglobin (HbA1c) levels (P for all comparisons <.001). In the final model of a regression analysis, 65.9% of the variation in percentage change in HbA1c was explained by adherence to antidiabetics, psychiatric referral acceptance and Internalized Stigma of Mental Illness (ISMI) and MDI scores.

CONCLUSION

In T2DM patients with depression, psychiatric referral acceptance for fluoxetine treatment is a significant predictor of both depression and glycemic control improvements.

Does low well-being modify the effects of PRISMA (Dutch DESMOND), a structured self-management-education program for people with type 2 diabetes?

AIMS

Diabetes self-management education improves behavioural and clinical outcomes in type 2 diabetes patients, however little is known about the modifying effects of well-being. This is relevant given high prevalence of depression and distress among diabetes patients. We aimed to test whether low well-being modifies the effects of the PRISMA self-management education program (Dutch DESMOND).

METHODS

297 primary care type 2 diabetes patients participated in the PRISMA observational study with a pre-post measurement design. Patients were grouped in low (n=63) and normal well-being (n=234). Low well-being was defined as either low mood (WHO-5<50) and/or high diabetes-distress (PAID-5>8). Outcome measures were: diabetes self-efficacy (CIDS), illness perception (IPQ) and diabetes self-care activities (SDSCA).

RESULTS

Improvements were found in illness perception (b=1.586, p<0.001), general diet (b=1.508, p=0.001), foot care (b=0.678, p=0.037), weekly average diet (b=1.140, p=0.001), creating action plan (b=0.405, p=0.007). Well-being interaction effects were found for general diet (p=0.009), weekly average diet (p=0.022), and creating an action plan (p=0.002).

CONCLUSIONS

PRISMA self-management education seems as effective for people with normal well-being as for people with low well-being. Further research should examine whether addressing mood and diabetes-distress as part of self-management education could reduce attrition and maintain or improve well-being among participants.

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

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

Antidepressant medication use and glycaemic control in co-morbid type 2 diabetes and depression

OBJECTIVE

Depression is prevalent in diabetes and is associated with increased risks of hyperglycaemia, morbidity and mortality. The effect of antidepressant medication (ADM) on glycaemic control is uncertain owing to a paucity of relevant data. We sought to determine whether the use of ADM is associated with glycaemic control in depressed patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A retrospective cohort study (n = 1399) was conducted using electronic medical record registry data of ambulatory primary care visits from 2008 to 2013. Depression and type 2 diabetes were identified from ICD-9-CM codes; ADM use was determined from prescription orders; and glycaemic control was determined from measures of glycated haemoglobin (A1c). Good glycaemic control was defined as A1c < 7.0% (53 mmol/mol). Generalized estimating equations were used to determine the effect of depression and ADM use on glycaemic control.

RESULTS

Good glycaemic control was achieved by 50.9% of depressed subjects receiving ADM versus 34.6% of depressed subjects without ADM. After adjusting for covariates, depressed patients receiving ADM were twice as likely as those not receiving ADM to achieve good glycaemic control (odds ratio = 1.95; 95% confidence interval: 1.02-3.71).

CONCLUSIONS

In this retrospective cohort study of a large sample of primary care patients with type 2 diabetes, ADM use was associated with improved glycaemic control.

Association between self-stigma and self-care behaviors in patients with type 2 diabetes: a cross-sectional study

OBJECTIVE

Growing qualitative evidence reveals that many patients with chronic illnesses struggle to rebuild a positive self-image after diagnosis while attempting to find a balance between their current physical status and their ongoing social duties. One factor destabilizing patients' identities is self-stigma, which seems to affect their behavioral goals through decreased self-efficacy. We hypothesized that self-stigma would be an independent factor, distinct from self-efficacy, for developing self-care behaviors in patients with type 2 diabetes.

METHODS

We used a consecutive sample of 209 outpatients with type 2 diabetes treated by endocrinologists at two university hospitals, one general hospital and one clinic. We performed multiple linear regression analyses to test the relationship between the patients' activation levels for self-care behaviors (dependent variable) and self-stigma, self-efficacy, and depression symptoms (independent variables), adjusting for covariates involving sociodemographic and clinical characteristics.

RESULTS

In a multiple linear regression model adjusted for prior covariates, there was significant association between self-stigma and activation levels for self-care behaviors in patients with type 2 diabetes (adjusted R(2)=0.26, F (12,196)=7.20, p<0.001). The standardized partial regression coefficient of self-stigma was -0.23 (p=0.001), whereas that of self-efficacy was 0.19 (p=0.007).

CONCLUSIONS

Self-stigma is a negative independent factor, separate from self-efficacy, affecting the self-care behaviors of patients with type 2 diabetes. Self-stigma also has, at least, a similar impact on self-care behaviors to that of self-efficacy. To optimize treatment outcomes, patients' self-stigma should be minimized, whereas their self-efficacy should be enhanced.

Depression and diabetes: treatment and health-care delivery

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

The effect of problem solving and decision making skills on tendency to depression and anxiety in patients with type 2 diabetes

BACKGROUND

Diabetes is the most prevalent disease that has involved 177 million people all over the world and, due to this, these patients suffer from depression and anxiety and they should use special methods for controlling the same. The aim of this research is the study of the effect of problem solving and decision making skill on the rate of the tendency to depression and anxiety.

MATERIALS AND METHODS

This research is a quasi-experimental (case-control) study. Statistically, the population of the present study was all diabetic patients of Qaemshahr who were controlled by physicians in 2011-2012. Thirty files were selected randomly from them and divided into two 15 patients' groups (control and subject group) randomly. The measurement tools were Back depression inventory (21 items) and Zank anxiety questionnaire that were distributed among two groups. Then, the subject group participated in eight sessions of teaching problem solving and decision making courses separately, and the second group (control group) did not receive any instruction.

RESULTS

Finally, both groups had passed post-test and the data obtained from the questionnaires were studied by variance analysis statistical methods.

CONCLUSION

The results showed that teaching problem solving and decision making skills was very effective in reducing diabetic patients' depression and anxiety and resulted in reducing their depression and anxiety.

Cognitive Behavioral Therapy Versus Sertraline in Patients With Depression and Poorly Controlled Diabetes: The Diabetes and Depression (DAD) Study: A Randomized Controlled Multicenter Trial

OBJECTIVE

This study compared the long-term efficacy of a diabetes-specific cognitive behavioral group therapy (CBT) with sertraline in patients with diabetes and depression who initially responded to short-term depression treatment.

RESEARCH DESIGN AND METHODS

A randomized controlled single-blind trial was conducted in 70 secondary care centers across Germany comparing 12 weeks of CBT with sertraline in 251 patients with type 1 or 2 diabetes (mean HbA1c 9.3%, 78 mmol/mol) and major depression (Structured Clinical Interview for DSM-IV [SCID]). After 12 weeks, treatment responders (≥50% reduction Hamilton Depression Rating Scale [HAMD-17]) were included in the 1-year study phase where CBT patients were encouraged to use bibliotherapy and sertraline patients received continuous treatment. We analyzed differences for HbA1c (primary outcome) and reduction (HAMD-17) or remission (SCID) of depression from baseline to the 1-year follow-up using ANCOVA or logistic regression analysis.

RESULTS

After 12 weeks, 45.8% of patients responded to antidepressant treatment and were included in the 1-year study phase. Adjusted HbA1c mean score changes from baseline to the end of the long-term phase (-0.27, 95% CI -0.62 to 0.08) revealed no significant difference between interventions. Depression improved in both groups, with a significant advantage for sertraline (HAMD-17 change: -2.59, 95% CI 1.15-4.04, P < 0.05).

CONCLUSIONS

Depression improved under CBT and sertraline in patients with diabetes and depression, with a significant advantage for sertraline, but glycemic control remained unchanged. CBT and sertraline as single treatment are insufficient to treat secondary care diabetes patients with depression and poor glycemic control.

Variations of depression treatment among women with hypertension

The objective was to examine depression treatment among non-pregnant women, aged 22 and older, with hypertension, utilizing cross-sectional data from the 2006 and 2007 Medical Expenditure Panel Survey. Depression treatment patterns by demographic, socioeconomic, health care access, and health characteristics were analyzed utilizing chi-square tests and logistic and multinomial logistic regressions. Overall, 23.9% had no depression treatment, 56.8% had antidepressant use only, and 19.3% had psychotherapy with or without antidepressants. African Americans (adjusted odds ratio [AOR] = 0.47), Latinas (AOR = 0.46), and uninsured women (AOR = 0.39) were significantly less likely to report any treatment for depression compared with Whites and those with private insurance.

Comparison of paroxetine and agomelatine in depressed type 2 diabetes mellitus patients: a double-blind, randomized, clinical trial

BACKGROUND

Comorbid depression/anxiety in type 2 diabetes mellitus (DM) patients is highly prevalent, affecting both diabetes control and quality of life. However, the best treating method for depression/anxiety in type 2 DM patients is still unclear. This study was conducted to compare the efficacy of paroxetine and agomelatine on depression/anxiety and metabolic control of type 2 DM patients.

METHODS

A total of 116 depressed, type 2 DM patients were recruited for 12 weeks treatment. Patients were randomly assigned to receive either paroxetine or agomelatine. Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale were used to assess depression and anxiety, respectively. Hemoglobin A1c, fasting plasma glucose, and body mass index were assessed at baseline and at the end of the trial.

RESULTS

At the end of the trial, there were 34 (60.7%) responders and 22 (39.3%) remissions in paroxetine group; and 38 (63.3%) responders and 26 (43.3%) remissions in agomelatine group. Compared to paroxetine group, lower depression scores were observed in agomelatine group. Fasting plasma glucose and body mass index were not significantly different after 12 weeks treatment between the two groups, but agomelatine group had a significantly lower final hemoglobin A1c level compared to paroxetine group. The two antidepressants had comparable acceptability.

CONCLUSION

These results showed that compared to paroxetine, agomelatine might have some advantages in treating symptoms of depression/anxiety and glycemic control in depressed type 2 DM patients. The clinical applicability of agomelatine shows greater promise and should be explored further. Limited by the relatively small samples, future studies are needed to verify and support our findings.

Is depression a risk factor for diabetic foot ulcers? 11-years follow-up of the Nord-Trøndelag Health Study (HUNT)

AIM

To prospectively examine whether depressive symptoms increase the risk of diabetes and a diabetic foot ulcer.

METHODS

The Nord-Trøndelag Health Study (HUNT) is a community-based longitudinal study. The Hospital Anxiety and Depression Scale (HADS-D subscale) assessed depressive symptoms. We followed individuals with complete HADS-D data from HUNT2 (1995-97) and assessed whether they reported diabetes with or without a history of diabetic foot ulcer (DFU) in HUNT3 (2006-08) (n=36,031). Logistic regression was used to investigate the effect of depressive symptoms on subsequent development of diabetes and of DFU.

RESULTS

Unadjusted odds for reporting diabetes at follow-up was higher among individuals who reported a HADS-D score≥8 at baseline (OR 1.30 95% CI, 1.07-1.57) than among those reporting a lower score. After adjusting for age, gender and BMI, this association was no longer significant. The odds of developing a DFU was almost two-fold (OR=1.95 95% CI, 1.02-3.74) for those reporting a HADS-D score of 8-10, and 3-fold (OR=3.06 95% CI, 1.24-7.54) for HADS-D scores≥11, compared to HADS-D scores<8, after adjusting for age, gender and serum glucose.

CONCLUSIONS

Symptoms of depression at baseline are associated with an increased risk of a diabetic foot ulcer in a dose response manner during this 11-year follow-up.

Prevalence of depression in type 2 diabetes mellitus

BACKGROUND

The relationship between depression and diabetes has been widely documented but there have been methodological limitations such as the failure to conduct a diagnostic interview of the depressive condition. We have estimated the prevalence of depression in patients with type 2 diabetes mellitus (DM2) and its relationship with sociodemographic, lifestyle and clinical variables.

PATIENTS AND METHODS

This was a cross-sectional, randomized study (stratified by sex and age) of patients with DM2 treated in a healthcare area with approximately 3000 eligible patients. The depressive symptoms were assessed using the Beck Depression Inventory (depression defined as a BDI score>16) and a psychiatric interview. We used a multivariate logistic regression model to evaluate the association between depression and DM2, after adjusting for known risk factors.

RESULTS

We examined 275 patients with DM2 (mean age, 64.5 years; men, 56.4%). The prevalence of depression was calculated at 32.7% (95% CI 27.4-38.5) and increased with age. A greater prevalence of depression was found in women, widowers, patients with obesity, those with poor compliance with the prescription, those with poor glycemic control and those who developed complications from diabetes. Thirty-five percent (95% CI 26.4-45.8) of the patients who scored>16 on the BDI scale had not been diagnosed with depression.

CONCLUSIONS

Depression is highly prevalent in patients with DM2, especially in women. For approximately one-third of the patients, a diagnosis of depression had not been reached.

Negative association between depression and diabetes control only when accompanied by diabetes-specific distress

Evidence of the negative impact of depression on glycaemic control is equivocal, and diabetes-related distress has been proposed as potential mediator. 466 diabetes patients were cross-sectionally assessed for depression (Center for Epidemiologic Studies Depression Scale), diabetes-related distress (Diabetes Distress Scale), and glycaemic control (HbA1c). We distinguished the associations of depression and diabetes distress with glycaemic control using analysis of variance and multiple regression. Neither patients with depression only nor diabetes distress only differed significantly from controls regarding HbA1c. However, HbA1c was substantially increased when both conditions were present (9.2 vs. 8.6 %, P = 0.01). As in previous studies, we observed a significant association between depression and hyperglycaemia (P < 0.01). However, a mediation analysis revealed that this association in fact depended on the presence of diabetes distress (P < 0.01). Depression seems to be associated with hyperglycaemia particularly when accompanied by diabetes distress, suggesting that adjusting clinical procedures regarding diabetes distress may facilitate the identification and care of high-risk patients.

Ondansetron, a 5HT3 receptor antagonist reverses depression and anxiety-like behavior in streptozotocin-induced diabetic mice: possible implication of serotonergic system

Increased prevalence and high comorbidity of depression-like mood disorders and diabetes have prompted investigation of new targets and potential contributing agents. There is considerable evidence supporting the inconsistent clinical efficacy and persistent undesirable effects of existing antidepressant therapy for depression associated with diabetes. Therefore, the present study was aimed at investigating the effect of ondansetron, a selective 5HT3 receptor antagonist in attenuating depression and anxiety-like behavior comorbid with diabetes. Experimentally, Swiss albino mice were rendered diabetic by a single intraperitoneal (i.p.) injection of streptozotocin (STZ, 200 mg/kg). After 8 weeks, diabetic mice received a single dose of vehicle/ondansetron (0.5 and 1 mg/kg, p.o.)/fluoxetine (the positive control, 10 mg/kg p.o.) for 28 days. Thereafter, behavioral studies were conducted to test depression-like behavior using forced swim test (FST) and anxiety-like deficits using hole-board and light-dark tests, followed by biochemical estimation of serotonin content in discrete brain regions. The results demonstrated that, STZ-induced diabetic mice exhibited increased duration of immobility and decreased swimming behavior in FST, reduced exploratory behavior during hole-board test and increased aversion to brightly illuminated light area in light-dark test as compared to non-diabetic mice, while ondansetron (similar to fluoxetine) treatment significantly reversed the same. Biochemical assay revealed that ondansetron administration attenuated diabetes-induced neurochemical impairment of serotonin function, indicated by elevated serotonin levels in discrete brain regions of diabetic mice. Collectively, the data indicate that ondansetron may reverse depression and anxiety-like behavioral deficits associated with diabetes in mice and modulation of serotonergic activity may be a key mechanism of the compound.

State of the science: depression and type 2 diabetes

Depression is a significant comorbid condition in diabetes. Individuals with type 2 diabetes (T2DM) are 2 times more likely to experience depression or elevated depressive symptoms compared to those without T2DM. The aims of this state of the science review were to summarize the putative links between diabetes and depression and review empirically supported treatments of depression in diabetes. Findings suggest that a bidirectional association between depression and T2DM exists and that several biological and psychosocial mediators underlie these conditions. Available data indicate that conventional treatments (antidepressant medication, cognitive behavioral therapy, and collaborative care) reduce depression and symptoms of depression; however more controlled studies and development of novel therapies are needed. Glycemic outcomes have most frequently been examined, but findings have been mixed. Self-care and adherence outcomes have been less well studied. Emerging evidence suggests that these outcomes may be important targets for future depression research in T2DM.

Efficacy and cost-effectiveness of a web-based intervention with mobile phone support to treat depressive symptoms in adults with diabetes mellitus type 1 and type 2: design of a randomised controlled trial

BACKGROUND

A diagnosis of diabetes mellitus types 1 or 2 doubles the odds of a comorbid depressive disorder. The combined diseases have a wide range of adverse outcomes, such as a lower quality of life, poorer diabetes outcomes and increased healthcare utilisation. Diabetes patients with depression can be treated effectively with psychotherapy, but access to psychological care is limited. In this study we will examine the efficacy and cost-effectiveness of a newly developed web-based intervention (GET.ON Mood Enhancer Diabetes) for people with diabetes and comorbid depressive symptoms.

METHODS/DESIGN

A two-arm randomised controlled trial will be conducted. Adults with diabetes (type 1 or type 2) with increased depression scores (> 22 on the German version of the Center for Epidemiological Studies Depression Scale (CES-D)) will be included. Eligible participants will be recruited through advertisement in diabetes patient journals and via a large-scale German health insurance company. The participants will be randomly assigned to either a 6-week minimally guided web-based self-help program or an online psychoeducation program on depression. The study will include 260 participants, which will enable us to detect a statistically significant difference with a group effect size of d = 0.35 at a power of 80% and a significance level of p = 0.05. The primary outcome measure will be the level of depression as assessed by the CES-D. The secondary outcome measures will be: diabetes-specific emotional distress, glycaemic control, self-management behaviour and the participants' satisfaction with the intervention. Online self-assessments will be collected at baseline and after a 2 months period, with additional follow-up measurements 6 and 12 months after randomisation. The data will be analysed on an intention-to-treat basis and per protocol. In addition, we will conduct an economic evaluation from a societal perspective.

DISCUSSION

If this intervention is shown to be cost-effective, it has considerable potential for implementing psychological care for large numbers of people with diabetes and comorbid depression in routine practice and improve health outcomes.

TRIAL REGISTRATION

German Clinical Trial Register (DRKS): DRKS00004748.

The Treatment of Comorbid Anxiety in a Male With Poorly Controlled Diabetes in a Very Remote Primary Health Care Service

Rural Australians are shown to have poorer health and mental-health outcomes compared with their metropolitan counterparts, particularly for diabetes. Individuals with diabetes often meet criteria for comorbid mental-health conditions, such as anxiety and depression. Psychological treatment, as an adjunct to medical care, for individuals with diabetes is shown to improve overall health and wellbeing. This article describes a 38-year-old male who was referred to a very remote primary health care service by his diabetes educator for strategies to reduce work-related stress and improve his diabetes mismanagement. Mindfulness-based cognitive behavior therapy techniques were used, over six sessions, in the context of a rural and very remote community. Pre- and post-intervention measures showed a reduction in anxiety, distress, and improvement in his perception of his quality of life. Clinical implications for psychological treatment of diabetes and comorbid mental-health issues in rural and remote communities are discussed.

Effects of diabetes on hippocampal neurogenesis: links to cognition and depression

Diabetes often leads to a number of complications involving brain function, including cognitive decline and depression. In addition, depression is a risk factor for developing diabetes. A loss of hippocampal neuroplasticity, which impairs the ability of the brain to adapt and reorganize key behavioral and emotional functions, provides a framework for understanding this reciprocal relationship. The effects of diabetes on brain and behavioral functions in experimental models of type 1 and type 2 diabetes are reviewed, with a focus on the negative impact of impaired hippocampal neurogenesis, dendritic remodeling and increased apoptosis. Mechanisms shown to regulate neuroplasticity and behavior in diabetes models, including stress hormones, neurotransmitters, neurotrophins, inflammation and aging, are integrated within this framework. Pathological changes in hippocampal function can contribute to the brain symptoms of diabetes-associated complications by failing to regulate the hypothalamic-pituitary-axis, maintain learning and memory and govern emotional expression. Further characterization of alterations in neuroplasticity along with glycemic control will facilitate the development and evaluation of pharmacological interventions that could successfully prevent and/or reverse the detrimental effects of diabetes on brain and behavior.

[Diabetes mellitus and depressive disorder, an undesirable association]

Type 2 diabetes and depressive disorder are 2 chronic diseases highly prevalent in developed countries and with a negative impact on quality of life and life expectancy. In recent years, both conditions have been shown to be strongly associated. Thus, diabetics have an increased risk of suffering depressive disorder, as well as impaired glucose homeostasis, if they experience depression. In diabetic patients, concurrent depression is associated to greater difficulties in disease management and metabolic control, increased risk of developing chronic complications, decreased quality of life, and higher healthcare expenses. As a result, the interest of diabetic scientific societies in this association has increased, and they recommend regular mood assessment in diabetic patients. However, the limited clinical experience available and the conflicting results reported to date make it difficult to draw conclusions.

Agomelatine and sertraline for the treatment of depression in type 2 diabetes mellitus

OBJECTIVE

The present study compared the efficacy of agomelatine and sertraline in the treatment of symptoms of depression/anxiety, diabetes self-care and metabolic control in a sample of depressed patients with non-optimally controlled type 2 diabetes mellitus (DM).

METHOD

This was an observational open label study of 40 depressed patients with DM who were randomly assigned to receive either agomelatine or sertraline, and were assessed over a 4-month period for depression, anxiety, self-care, fasting plasma glucose, haemoglobin A1c and body weight.

RESULTS

Lower anxiety and depression scores as well as higher self-care scores were measured in the agomelatine group compared with the sertraline group after 4 months of treatment. Although the main effects of treatment on final body weight and fasting plasma glucose were not significant, significantly lower final haemoglobin A1c levels were measured in the agomelatine group compared with the sertraline group. Both antidepressants were well tolerated and none of the patients dropped-out of the study.

CONCLUSION

The main finding of the present small pilot study was that agomelatine may be a promising agent in the treatment of symptoms of depression and anxiety as well as in the improvement of health-related behaviours, in depressed patients with type 2 DM possibly offering some advantages over sertraline. However, the lack of a placebo control group limits the generalisability of the findings and warrants further studies.

Prevalence of depression in consecutive patients with type 2 diabetes mellitus of 5-year duration and its impact on glycemic control

CONTEXT

Type 2 diabetes mellitus doubles the odds of suffering from depressive illness. Co-morbid depression is associated with poorer outcomes in diabetes mellitus in terms of glycemic control, medication adherence, quality of life, physical activity, and blood pressure control.

AIM

The present study aims to estimate the prevalence of depression among a consecutive group of patients with type 2 diabetes and assess its impact on glycemic and blood pressure control.

SETTING

Outpatient department of the endocrinology department of a university affiliated teaching hospital in north India.

SUBJECTS

Consecutive adult patients (18-65 years) with type 2 diabetes mellitus of over 5-year duration with no prior history of psychiatric illnesses or intake of anti-depressants.

MATERIALS AND METHODS

A semi-structured questionnaire was used for demographic data, HbA1c was obtained to assess glycemic control, and blood pressure was recorded twice during patient interview to assess blood pressure control. Depression was assessed with the Major Depression Inventory and scores obtained were classified as consistent with mild, moderate and severe depression. Data was analyzed with SPSS v16, and multiple logistical regression test was done to compare the effect of depression on glycemic control after adjusting for age and sex.

RESULTS

Of the 80 patients interviewed, 31 (38.8%) had depressive symptoms. Among them 20 (25%) had mild depression, 10 (12.5%) had moderate depression, and 1 (1.3%) had severe depression.

CONCLUSIONS

Over one third of patients with type 2 diabetes mellitus of over 5-year duration had depressive symptoms. The presence of depressive symptoms was associated with a significant worsening of glycemic control.

Diabetes and cognitive dysfunction

Cognitive dysfunction in type 1 and type 2 diabetes share many similarities, but important differences do exist. A primary distinguishing feature of type 2 diabetes is that people with this disorder often (but not invariably) do poorly on measures of learning and memory, whereas deficits in these domains are rarely seen in people with type 1 diabetes. Chronic hyperglycaemia and microvascular disease contribute to cognitive dysfunction in both type 1 and type 2 diabetes, and both disorders are associated with mental and motor slowing and decrements of similar magnitude on measures of attention and executive functioning. Additionally, both types are characterised by neural slowing, increased cortical atrophy, microstructural abnormalities in white matter tracts, and similar, but not identical, changes in concentrations of brain neurometabolites. Disconcertingly, the rapid rise in obesity and type 2 diabetes in all age groups might result in a substantial increase in prevalence of diabetes-related cognitive dysfunction.

[Organic and comorbid causes of depression: a first step]

The primary objective of this review is to obtain a clinical orientation as to evidence-supported common «other» causes of depressive symptomatology, which predominantly are: medical issues; life events; vitamin, mineral and diet-related deficiencies; and hormones. A secondary goal was to reflect those more frequent "other" causes in a checklist for clinical use, comprising also the preferred treatment (medical/dietary, antidepressants, or psychological) resulting from the available evidence. Medline, Cochrane and main related databases were searched from 4(th) October 2010 to 27(th) April 2011, no language limits, with keywords: depression; organic; comorbid; medication; life events; hormones; vitamin; mineral; diet; disease; as well as further searches into each upcoming possibly related issue. Total studies contemplated: 3.211; total studies reviewed: 301, with criteria of relevancy; date of study or review; size and type; journal status. Data were abstracted based upon probable clinical relevancy and use. The main results obtained were evidence-supported indications as to these other causes of depressive symptomatology, that warrant early screening, attention and treatment, possibly before antidepressant or psychological therapy is started. PRELIMINARY CONCLUSION: There appears to be a clinical rationale for early checking of a number of evidence-based causes of depressive symptoms for which first-line testing is readily available. In several cases clinical treatment may be simple, and improvements in depressive symptoms rapidly obtainable. Using a pre-treatment protocol, both patients and health systems could benefit from biological and comorbid causes of depressive symptoms being established early. An enhanced response to low-cost corrective measures can decrease the risk of suicide.

Association of sleep duration with untreated diabetes in Japanese men

OBJECTIVE

We assessed the cross-sectional association between sleep duration and untreated diabetes in Japanese men.

METHODS

Participants included 20,744 men aged 30-64 years who first visited the general hospital in Tokyo for routine health assessments during 2003-2007. Untreated diabetes was defined as not being under diabetes treatment and fasting blood glucose of ≥126 mg/dL or hemoglobin A(1c) of ≥6.5%. Sleep duration (≤5, 6, 7, or ≥8 h) and confounders were assessed using a questionnaire. Logistic regression was used to calculate odds ratios (ORs) for diabetes after adjustment for confounders.

RESULTS

The prevalence of untreated diabetes was 3.4% in all men. The prevalence of untreated diabetes by sleep duration was as follows: ≤5 h: 3.5%; 6 h: 3.3%; 7 h: 3.2%; and ≥8 h: 5.1%. Men who reported sleeping for ≤5 h (OR: 1.52, 95% confidential interval [CI]: 1.22-1.90) and ≥8 h (OR: 1.39, 95% CI: 1.05-1.85) were significantly more likely to have untreated diabetes compared with those who reported sleeping for 7 h. In stratified analyses by obesity (body mass index ≥25.0 kg/m(2)), the association between long sleep duration (≥8 h) and untreated diabetes remained significant only in obese men.

CONCLUSION

Short sleep duration was significantly associated with untreated diabetes in both nonobese and obese men. Regarding long sleep duration, a significant association was observed in obese men only.

Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial

PURPOSE

Depression commonly accompanies diabetes, resulting in reduced adherence to medications and increased risk for morbidity and mortality. The objective of this study was to examine whether a simple, brief integrated approach to depression and type 2 diabetes mellitus (type 2 diabetes) treatment improved adherence to oral hypoglycemic agents and antidepressant medications, glycemic control, and depression among primary care patients.

METHODS

We undertook a randomized controlled trial conducted from April 2010 through April 2011 of 180 patients prescribed pharmacotherapy for type 2 diabetes and depression in primary care. Patients were randomly assigned to an integrated care intervention or usual care. Integrated care managers collaborated with physicians to offer education and guideline-based treatment recommendations and to monitor adherence and clinical status. Adherence was assessed using the Medication Event Monitoring System (MEMS). We used glycated hemoglobin (HbA(1c)) assays to measure glycemic control and the 9-item Patient Health Questionnaire (PHQ-9) to assess depression.

RESULTS

Intervention and usual care groups did not differ statistically on baseline measures. Patients who received the intervention were more likely to achieve HbA(1c) levels of less than 7% (intervention 60.9% vs. usual care 35.7%; P < .001) and remission of depression (PHQ-9 score of less than 5: intervention 58.7% vs. usual care 30.7%; P < .001) in comparison with patients in the usual care group at 12 weeks.

CONCLUSIONS

A randomized controlled trial of a simple, brief intervention integrating treatment of type 2 diabetes and depression was successful in improving outcomes in primary care. An integrated approach to depression and type 2 diabetes treatment may facilitate its deployment in real-world practices with competing demands for limited resources.

Development and reach of a web-based cognitive behavioural therapy programme to reduce symptoms of depression and diabetes-specific distress

OBJECTIVES

There is an urgent need for more effective and efficient depression treatments in diabetes. We developed a diabetes-specific version of the Dutch web-based 'Coping with Depression' (CWD) course. Here, we report on the development, reach, patients' reasons for choosing our intervention and their characteristics.

METHODS

The CWD programme was amended for use in diabetes patients with co-morbid depression. Data were collected using a telephone interview, self-report questionnaires, and medical records.

RESULTS

Adding diabetes-specific topics to an effective web-based depression programme resulted in an 8-lesson intervention ("www.diabetergestemd.nl"), with minimal guidance by coaches. In the framework of a randomised trial, the intervention attracted serious interest of 540 patients. After screening, 255 depressed diabetes patients were enrolled. Less than half had a history of depression treatment; 80% reported the diabetes-specific approach to be an important reason for signing up.

CONCLUSION

We successfully developed a diabetes-specific version of the web-based CWD course, which attracted a large group of patients. Our results affirm the importance of addressing diabetes-specific issues in the context of depression treatment.

PRACTICE IMPLICATIONS

Our intervention could be implemented on a large scale at low costs, and may serve as a model on how to develop other illness-specific online self-help interventions.

[Possibilities and limitations of psychopharmacological treatments in patients with psychological comorbidity]

Comorbid depressive and anxiety disorders are associated with chronic physical illnesses. Treatment with antidepressants and mood stabilizers require knowledge about toxicity, potential side effects, and drug interactions. According to controlled studies in comorbid cardiovascular diseases, diabetes mellitus, and cerebrovascular disorders (post-stroke depression), serotonin-selective reuptake inhibitors (SSRIs), e.g., sertraline and citalopram, are preferred. Pramipexole, reboxetine, mirtazapine, or nortriptyline showed efficacy in treatment of Parkinson depression. Chronic pain syndromes can be improved with low-dose tricyclic antidepressants. Both establishment of compliance and follow-up examinations are essential. Combined treatment with psychotherapeutic interventions, including coping strategies, should be used whenever possible.