Screening for depression and diabetes-related distress in a diabetes outpatient clinic

Patient and healthcare professionals' perceived barriers and facilitators to the implementation of psychosocial screening in cardiac practice: A Delphi study

BACKGROUND

Psychosocial risk factors contribute to the incidence and progression of coronary heart disease (CHD). Psychosocial screening may identify individuals who are at risk and aid them with getting appropriate care. To successfully implement psychosocial screening in the cardiology practice, the current study aims to identify key barriers and facilitators to its implementation and evaluate their perceived importance among health care professionals (HCPs) and patients.

METHODS

We took a modified 3-round Delphi study approach to gain insight into key determinants that could either impede or ease implementation. Round 1 gathered data from HCPs (n = 9; cardiologists, medical psychologists, cardiac nurses) and CHD patients (n = 21), which we transcribed verbatim, coded, and processed into unique determinants. In rounds 2 and 3, participants were asked to select the most relevant determinants and rank them based on importance. Subsequently, determinants were classified by implementation level.

RESULTS

Patients were generally more positive towards screening. HCP barriers included time-constraints, disruption of primary activities, and limited knowledge on psychosocial risk and screening, while patient barriers were commonly related to accessibility and patient characteristics (e.g., health literacy, motivation). Facilitators of both groups mainly pertained to the use of the screener and follow-up care, such as increasing the accessibility and the benefits of the screener.

CONCLUSION

Barriers may be targeted by enhancing the effects of the facilitators. Increasing the accessibility to the screener and interventions, improving information provision, and appointing a contact person to oversee the screening process may ease the screening and care process for both patients and HCPs.

Exploring the Needs of Adults Living With Type 1 or Type 2 Diabetes Distress Using the Problem Areas in Diabetes 5 Tool

OBJECTIVES

This study investigated the feasibility and acceptability of implementing a screening tool as a part of routine care and the subsequent screening experiences of patients and clinicians. Additionally, potential sources of diabetes distress (DD) were identified in this clinical population.

METHODS

Our investigation was a cross-sectional, mixed-methods, convenience sample of 203 patients living with type 1 or type 2 diabetes from 2 Canadian tertiary hospital-based clinics. The Problem Areas in Diabetes 5 (PAID5) scale was used to assess DD. Structured telephone interviews of patients with high DD scores and care provider focus group transcriptions were analyzed using a deductive thematic content analysis.

RESULTS

The prevalence of DD was 45%. Lack of medication coverage (p=0.02) and presence of neuropathy (p=0.04) were approximately 5- and 2-fold more likely to be predictors of high DD, respectively. Patient interviews identified DD screening as an opportunity to share and feel supported but demonstrated their fear of discussing mental health concerns. Patients found discussion about mental health helpful and often did not require a referral to a mental health specialist. Staff focus groups discussed screening as a feasible tool, but also acknowledged barriers and knowledge gaps that preclude DD screening integration in routine clinical practice. Specialized training for clinicians may help increase confidence and improve uptake of DD screening into routine clinical practice.

CONCLUSIONS

The prevalence of DD in outpatient care settings is high. Findings suggest that integrating the PAID5 screening tool into regular clinical practice is feasible by patients and care providers.

Internet-based Cognitive-behavioral therapy (CBT) for depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study): A randomized controlled trial protocol

Background

Professionals need adequate tools to help patients with diabetes and depression. Although web programs integrating cognitive-behavioral therapy with diabetes education have shown good results, no similar approach has been performed as yet in Spain. The objective is to develop an Internet-based program for the treatment of mild-moderate depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study) based on Cognitive-behavioral therapy (CBT) and assess its results.

Methods

A 2-arm randomized controlled trial will be conducted. Adults with type 1 diabetes and mild-moderate depressive symptoms will be screened to participate in the study and randomly assigned to either the treatment group (TG) that will use a Web-based application for a specific 9-week intervention in depression and type 1 diabetes or the control group (CG) that will be on the waiting list during that time.

Results

Data on the primary variable (depressive symptoms) and secondary variables (treatment-related distress, anxiety, fear of hypoglycemia, quality of life, treatment adherence, coping strategies and glycemic control) will be collected from the TG at the beginning/baseline, at the end of treatment and at 3, 6 and 12 months after treatment. The CG will be assessed at the beginning and at the end of the TG intervention. On completion of the program by the TG, the treatment will then be carried out in the CG.

Conclusions

The new web application developed is expected to be effective for the treatment of mild-moderate depressive symptoms in adults with type 1 diabetes, reducing depressive symptoms and improving the rest of the analyzed variables.

Trial registration

Registry: NCT03473704 (March 21, 2018); ClinicalTrials.gov.

Patient and Provider Views on Psychosocial Screening in a Comprehensive Diabetes Center

Guidelines recommend routinely screening adults with diabetes for psychological concerns, but few diabetes clinics have adopted screening procedures. This study assessed patient and provider perspectives regarding the role of mental health in diabetes care, psychosocial screening procedures, and patients’ support needs. Patients with diabetes (n = 15; 73.3% type 2) and their medical providers (n = 11) participated in qualitative interviews. Thematic content analysis was used to categorize results. Participants believed that mental health was important to address within comprehensive diabetes care. Patients expressed positive or neutral opinions about psychosocial screening. Providers had mixed reactions; many thought that screening would be too time-consuming. Both groups emphasized that screening must include referral procedures to direct patients to mental health services. Patients and providers interviewed in this study viewed psychosocial screening as compatible with diabetes care. Including a mental health professional on the treatment team could reduce potential burden on other team members.

Determining Acceptance of e-Mental Health Interventions in Digital Psychodiabetology Using a Quantitative Web-Based Survey: Cross-sectional Study

Background

Diabetes is a very common chronic disease that exerts massive physiological and psychological burdens on patients. The digitalization of mental health care has generated effective e-mental health approaches, which offer an indubitable practical value for patient treatment. However, before implementing and optimizing e-mental health tools, their acceptance and underlying barriers and resources should be first determined for developing and establishing effective patient-oriented interventions.

Objective

This study aims to assess the acceptance of e-mental health interventions among patients with diabetes and explore its underlying barriers and resources.

Methods

A cross-sectional study was conducted in Germany from April 9, 2020, to June 15, 2020, through a web-based survey for which patients were recruited via web-based diabetes channels. The eligibility requirements were adult age (18 years or older), a good command of the German language, internet access, and a diagnosis of diabetes. Acceptance was measured using a modified questionnaire, which was based on the well-established Unified Theory of Acceptance and Use of Technology (UTAUT) and assessed health-related internet use, acceptance of e-mental health interventions, and its barriers and resources. Mental health was measured using validated and established instruments, namely the Generalized Anxiety Disorder Scale-7, Patient Health Questionnaire-2, and Distress Thermometer. In addition, sociodemographic and medical data regarding diabetes were collected.

Results

Of the 340 participants who started the survey, 261 (76.8%) completed it and the final sample comprised 258 participants with complete data sets. The acceptance of e-mental health interventions in patients with diabetes was overall moderate (mean 3.02, SD 1.14). Gender and having a mental disorder had a significant influence on acceptance (P<.001). In an extended UTAUT regression model (UTAUT predictors plus sociodemographics and mental health variables), distress (β=.11; P=.03) as well as the UTAUT predictors performance expectancy (β=.50; P<.001), effort expectancy (β=.15; P=.001), and social influence (β=.28; P<.001) significantly predicted acceptance. The comparison between an extended UTAUT regression model (13 predictors) and the UTAUT-only regression model (performance expectancy, effort expectancy, social influence) revealed no significant difference in explained variance (F_10,244=1.567; P=.12).

Conclusions

This study supports the viability of the UTAUT model and its predictors in assessing the acceptance of e-mental health interventions among patients with diabetes. Three UTAUT predictors reached a notable amount of explained variance of 75% in the acceptance, indicating that it is a very useful and efficient method for measuring e-mental health intervention acceptance in patients with diabetes. Owing to the close link between acceptance and use, acceptance-facilitating interventions focusing on these three UTAUT predictors should be fostered to bring forward the highly needed establishment of effective e-mental health interventions in psychodiabetology.

Nurses' and physicians' experiences with diabetes consultations and the use of dialogue tools in the DiaPROM pilot trial: A qualitative study

AIM

To explore nurses' and physicians' experiences with diabetes consultations in general and the use of dialogue tools in the Diabetes Patient-Related Outcome Measures (DiaPROM) pilot trial.

METHODS

We used a qualitative explorative design by conducting semi-structured in-depth interviews with five nurses and nine physicians engaged in the DiaPROM pilot trial. The pilot trial aimed to test an intervention utilizing the patient-reported Problem Areas In Diabetes (PAID) scale and person-centred communication skills as dialogue tools in clinical consultations with adults with type 1 diabetes. We used thematic analysis to analyse the data.

RESULTS

We generated three themes (each including two subthemes) from the analysis of participants' experiences: (1) 'Conflicting demands and priorities' (subthemes: 'Balancing guideline recommendations with patients' main concerns' and 'Experiencing that patients need more support to disclose their emotional concerns'); (2) 'Insights about using dialogue tools' (subthemes: 'The benefits and challenges of using the PAID as a dialogue tool' and 'Communication techniques are helpful'); and (3) 'Facilitating new interventions is challenging' (subthemes: 'Unclear roles and responsibilities in the multidisciplinary teamwork' and 'The capacity sets the limit, not the willingness').

CONCLUSIONS

Our findings indicate that the physicians and nurses experienced substantial challenges related to time and resources in the use of dialogue tools to support people's emotional concerns in clinical diabetes consultations. Thus, there is a need for healthcare organizations to adjust priorities to focus on the emotional burden of diabetes if the multidisciplinary diabetes teams are to successfully integrate psychosocial support into routine diabetes care.

Psychosocial needs of patients and spouses justify a position of psychosocial health professionals in the multidisciplinary care for Parkinson's disease

Introduction

Living a life with Parkinson's Disease (PD) is a challenge for both patients and spouses. Patients have to cope with an increasing limitation in all domains of their daily life and spouses need to adjust to these changes. The focus of this study is on exploring, both quantitatively and qualitatively, the psychosocial needs of both patients with PD and spouses.

Methods

An online survey with 11 themes, related to dealing with a chronic disease, was sent by an email to patients and spouses and two focus groups were planned, one with patients and one with spouses. Data from the survey were quantitatively analysed and audiotapes from the focus groups were transcribed verbatim and combined with notes.

Results

Percentages of relevance are higher than 50% for all the themes, whereas those of the need for and received support are all lower than 50%. Focus groups revealed a negative image of psychosocial therapy and associations with failure, but also difficulties in signalling problems by professionals, little attention for spouses and limited access to specialized psychosocial care.

Conclusion

Based on this exploration, there appears to be a threshold to ask for psychosocial support on the one hand and to find the right professional on the other hand. A permanent position for psychosocial health professionals in the multidisciplinary Parkinson teams and networks may close the gap between ‘supply and demand’.

•

Living a life with Parkinson's Disease (PD) is a challenge for both patients and spouses

•

Psychosocial therapy has a negative image leading to a high threshold to ask for support.

•

The access to psychosocial professionals with expertise in PD is limited

•

Psychosocial professions should have a permanent position in the multidisciplinary teams and networks to normalize their image and close the gap between needs and support.

A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial

Background

Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression.

Objective

The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined.

Methods

Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes.

Results

myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement.

Conclusions

Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true (Archived by WebCite at http://www.webcitation.org/7850eg8pi)

Psychosocial health care needs of people with type 2 diabetes in primary care: Views of patients and health care providers

Aims

This study examined (a) psychosocial health care needs of people with type 2 diabetes from the perspective of patients and diabetes healthcare providers in primary care, in terms of topics, attention in diabetes care and preferences and (b) factors associated with a positive attitude towards specialized psychosocial health care.

Design

Qualitative focus group study.

Methods

Using purposive sampling, participants were selected from general practices. In 2012–2013, three focus groups were conducted in people with type 2 diabetes (N = 20) and three with healthcare providers (N = 18).

Results

Opinions differed considerably on whether there was a need for psychosocial health care. Topics focused mainly on diabetes‐specific issues ranging from a need for additional diabetes education to attention and support in regular diabetes care. However, not all healthcare providers felt competent enough to address psychosocial problems. Some participants reported a need for specialized psychosocial help. A positive attitude towards specialized psychosocial health care appeared to be influenced by care setting (e.g., in the primary care practice or ‘outside’ mental health care), care accessibility, proactive discussion of psychosocial issues with and referral by healthcare providers and previous experiences with psychosocial health care.

Conclusion

Although only few participants expressed a need for specialized psychosocial care, attention for psychosocial well‐being in regular diabetes care was generally appreciated.

Impact

People with type 2 diabetes generally felt psychosocial care could be provided as part of regular diabetes care. Suggestions for healthcare providers to meet psychosocial health care needs include training and discussion tools.

Reasons for low uptake of a psychological intervention offered to cancer survivors with elevated depressive symptoms

Objective

In line with screening guidelines, cancer survivors were consecutively screened on depressive symptoms (as part of standard care), with those reporting elevated levels of symptoms offered psychological care as part of a trial. Because of the low uptake, no conclusions could be drawn about the interventions' efficacy. Given the trial set‐up (following screening guidelines and strict methodological quality criteria), we believe that this observational study reporting the flow of participation, reasons for and characteristics associated with nonparticipation, adds to the debate about the feasibility and efficiency of screening guidelines.

Methods

Two thousand six hundred eight medium‐ to long‐term cancer survivors were consecutively screened on depressive symptoms using the Patient Health Questionnaire‐9 (PHQ‐9). Those with moderate depressive symptoms (PHQ‐9 ≥ 10) were contacted and informed about the trial. Patient flow and reasons for nonparticipation were carefully monitored.

Results

One thousand thirty seven survivors (74.3%) returned the questionnaire, with 147 (7.6%) reporting moderate depressive symptoms. Of this group, 49 survivors (33.3%) were ineligible, including 26 survivors (17.7%) already receiving treatment and another 44 survivors (30.0%) reporting no need for treatment. Only 25 survivors (1.0%) participated in the trial.

Conclusion

Of the approached survivors for screening, only 1% was eligible and interested in receiving psychological care as part of our trial. Four reasons for nonparticipation were: nonresponse to screening, low levels of depressive symptoms, no need, or already receiving care. Our findings question whether to spend the limited resources in psycho‐oncological care on following screening guidelines and the efficiency of using consecutive screening for trial recruitment in cancer survivors.

Is type of depressive symptoms associated with patient-perceived need for professional psychological care in depressed individuals with diabetes?

Aims

The objective of this study is to investigate whether type of depressive symptoms (i.e. cognitive-affective or somatic) is related to a patient-perceived need for professional psychological care in individuals with diabetes.

Methods

In total 2266 participants were recruited as part of the screening procedure for a multi-center randomized controlled trial on the treatment of depressive symptoms among individuals with diabetes. Individuals were invited to complete Beck Depression Inventory-II (BDI-II). Patients with elevated depressive symptoms (BDI-II ≥14) were interviewed about their psychological care need. Based on their care needs patients were categorized into: unmet need, no need, met need and unclear need. These groups were compared on type of depressive symptoms, as categorized into cognitive-affective symptoms and somatic symptoms.

Results

568 eligible individuals had elevated depressive symptoms, of whom 519 were reached. Among these depressed individuals, 19.7% (102 of 519) had an unmet need for psychological care. Participants with an unmet need were younger (p<0.001) and had higher total depression scores compared to the group with no need (p<0.001). They also scored higher on cognitive-affective symptoms (p<0.001), whereas somatic symptoms did not significantly differ (p = 0.232). Logistic regression revealed that cognitive-affective symptoms predicted an unmet need (p = 0.001). However, overall predictive capacity of type of depressive symptoms on care needs was weak.

Conclusions

Cognitive-affective symptoms of depression—but not somatic symptoms—were associated with an unmet need for psychological care among depressed individuals with diabetes. Future research is needed to reveal better predictors explaining the discrepancy between distress and low care needs in order to optimize screening procedures.

Use of patient-reported outcome measures (PROMs) in clinical diabetes consultations: study protocol for the DiaPROM randomised controlled trial pilot study

INTRODUCTION

Although diabetes distress is found to be associated with decreased glycaemic control among adults with type 1 diabetes, the psychological and emotional impact of living with the condition is often not recognised and often under-reported in diabetes care. Therefore, regular assessment of diabetes distress is recommended. Assessment of diabetes distress using patient-reported outcome measures (PROMs) in clinical practice has the potential to enhance care for people with diabetes by identifying problems and improving patient-clinician communication. In this study protocol, we describe a pilot randomised controlled trial (RCT) aiming to test the feasibility of all components of an empowerment-based intervention using PROMs as dialogue support in clinical diabetes consultations, and to address the uncertainties associated with running a fully powered evaluation study.

METHODS AND ANALYSIS

We will undertake a two-arm pilot RCT of an intervention using the Problem Areas In Diabetes (PAID) scale in clinical diabetes consultations in order to conclude whether a fully powered trial is appropriate and/or feasible. The study will also include qualitative indepth interviews with participants and healthcare providers. Our objectives are to (1) evaluate the recruitment procedures and attrition rates; (2) evaluate the performance of the randomisation procedure; (3) evaluate the participants' mean scores on the outcome measures before and after the intervention; (4) evaluate if the intervention consultations are acceptable and feasible; and (5) explore patients' and healthcare providers' experiences with the use of PAID as dialogue support and empowerment-based communication skills in clinical diabetes consultations. The quantitative data analysis includes descriptive statistics (frequencies, percentages, means, SD and CI). For the qualitative data, we will perform thematic analysis.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Western Norway Regional Committee for Medical and Health Research Ethics (2017/1506/REC west). We will present the findings from the study phases at national and international conferences and submit manuscripts to peer-reviewed journals and popular science journals.

TRIAL REGISTRATION NUMBER

NCT03471104; Pre-results.

WHO-5 and BDI-II are acceptable screening instruments for depression in people with diabetes

AIMS

To investigate the acceptability of two questionnaires, the five item WHO Well-being Index (WHO-5) and the Beck Depression Inventory II (BDI-II), which differ in length and focus, by comparing three screening groups: (1) WHO-5, (2) BDI-II and (3) WHO-5 and BDI-II.

METHODS

A total of 699 individuals with diabetes were approached to participate in the study, of whom 95 completed the WHO-5, 254 completed the BDI-II and 350 completed both the WHO-5 and the BDI-II questionnaires. Five facets of acceptability were compared, including objective aspects (response rate and completion level) and subjective aspects (appreciation, agreeableness and accuracy of the screening questionnaire). Data were analysed using logistic regression analysis and (multivariate) analysis of covariance.

RESULTS

The overall response rate was 65% (453 out of 699). No differences between the three groups were found with respect to the response rate (WHO-5: 66%; BDI-II: 63%; WHO-5 and BDI-II: 66%; P ≥ 0.19) and completion level (WHO-5: 99.5%; BDI-II: 97.8%; WHO-5 and BDI-II: 98.7%; P=0.45). The three groups did differ significantly in their scores on two of the three subjective indicators (P<0.03), i.e. appreciation (P=0.002) and agreeableness (P=0.035), with those completing only the WHO-5 reporting greater appreciation and agreeableness.

CONCLUSIONS

A brief well-being questionnaire, such as the WHO-5, results in greater appreciation of mood screening and appreciation of completing the questionnaire, but this does not result in a better response rate and higher questionnaire completion. Given these results, either or both questionnaires can be used to screen for depressive symptoms in people with diabetes in clinical practice.

Analysis of global research output on diabetes depression and suicide

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Identifying Patients with COPD in Need for Psychosocial Care Through Screening with the HSCL-25 and the CCQ Mental State

High levels of psychological distress are documented in patients with COPD. This study investigates the extent to which patients with a high score on the Hopkins Symptoms Checklist-25 (HSCL-25) or with a high score on the Mental State scale of the Clinical COPD Questionnaire (CCQ) endorse a need for psychosocial care, and investigates several characteristics of patients with a need. Outpatients with COPD of the Department of Pulmonary Diseases of a University Medical Center were assessed with the HSCL-25, CCQ and a question on need for psychosocial care. For patients indicating a need, the percentage of patients with HSCL-25 ≥39 was compared with the percentage of patients with CCQ Mental State >2 and tested with a Chi-square. In total 323 patients participated; 57% of them were distressed according to the HSCL-25 (≥39) and 20% according to the CCQ Mental State (>2); 28% reported a need for psychosocial care. For patients reporting a need for psychosocial care a higher percentage was identified by the HSCL-25 than by the CCQ Mental State (χ² = 9.41, p <. 002) and they were younger than patients without a need (t = 4.48, p <. 001). No differences existed for sex, FEV_1, FEV₁% predicted or medical comorbidities. The HSCL-25 identified more patients in need than the CCQ Mental State scale. However, not all patients with a need were identified. No relationship was found between need for psychosocial care and illness variables or comorbidities. Distress screening is questioned as the most effective way to identity patients with COPD in need for psychosocial care.

A Web-Based Public Health Intervention to Reduce Functional Impairment and Depressive Symptoms in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial Protocol

Background

Depressive symptoms are common in people with type 2 diabetes and contribute to adverse health consequences that substantially impact social and vocational function. Despite the existence of effective depression treatments, the majority of people with type 2 diabetes do not access these when needed. Web-based alternatives to more traditional psychotherapies offer a potential solution to reducing the personal and economic burdens of type 2 diabetes.

Objective

This paper outlines the protocol for a randomized controlled trial (RCT) of myCompass, a Web-based public health psychotherapy intervention, in people with type 2 diabetes. Fully automated, interactive, and delivered via the Internet without clinician support, myCompass teaches cognitive behavioral therapy-based skills and supports symptom monitoring to improve daily functioning and reduce mild-to-moderate mental health symptoms.

Methods

A two-arm RCT will be conducted. People with type 2 diabetes and mild-to-moderately severe depressive symptoms will be recruited from the community and general practice settings. Screening and enrollment is via an open-access website. Participants will be randomized to use either myCompass or an active placebo program for 8 weeks, followed by a 4-week tailing-off period. The placebo program is matched to myCompass on mode of delivery, interactivity, and duration. Outcomes will be assessed at baseline and at 3-month, 6-month, and 12-month follow-up. The primary study outcome is work and social functioning. Secondary study outcomes include depressive and anxious symptoms, diabetes-related distress, self-care behaviors, and glycemic control.

Results

Nationwide recruitment is currently underway with the aim of recruiting 600 people with type 2 diabetes. Recruitment will continue until October 2017.

Conclusions

This is the first known trial of a Web-based psychotherapy program that is not diabetes specific for improving social and vocational function in people with type 2 diabetes and mild-to-moderately severe depressive symptoms. With the increasing prevalence of type 2 diabetes and depression, a potentially scalable public health intervention could play a very large role in reducing unmet mental health need and ameliorating the personal and societal impact of illness comorbidity.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) Number: ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109 (Archived by WebCite at http://www.webcitation.org/ 6rh3imVMh)

Screening for and subsequent participation in a trial for depression and anxiety in people with type 2 diabetes treated in primary care: Who do we reach?

AIMS

This study investigated (factors related to) (a) the response to a screening procedure for depression and anxiety in people with type 2 diabetes in primary care, and (b) participation in a subsequent randomised controlled trial targeting depressive or anxiety symptoms.

METHODS

People with type 2 diabetes (n=1837) received a screening questionnaire assessing depressive symptoms (PHQ-9) and anxiety symptoms (GAD-7). Eligible persons who scored above the cut-off score (PHQ-9≥7 or GAD-7≥8) were offered to participate in the trial.

RESULTS

In total, 798 people (43%) returned the screening questionnaire. Non-responders were more often female (53% vs 44%, p<0.001), had higher LDL cholesterol levels (Cohen's d=0.17, p=0.001) and a higher albumin/creatinine ratio (Cohen's d=0.08, p=0.01). In total, 130 people (18%) reported elevated depressive or anxiety symptoms. Twenty-seven persons agreed to participate in the trial. Factors related to participation were a high education level, a higher level of diabetes distress and a history of psychological problems.

CONCLUSIONS

Using screening as recruitment resulted in a small number of participants in a treatment trial for anxiety and depression. Research is needed to investigate whether screening is also followed by a low uptake of treatment in primary care outside a RCT setting.

Diabetes Distress, Depression and Glycemic Control in a Canadian-Based Specialty Care Setting

OBJECTIVES

The objectives of this study were to determine rates of diabetes distress and depression in patients with type 2 diabetes in a tertiary care setting, to examine the relationship among glycemic control, diabetes distress and depression, and to identify predictors of diabetes distress and depression on the basis of demographic and clinical characteristics.

METHODS

We recruited 148 adults with type 2 diabetes who were presenting to a specialty diabetes clinic in Vancouver, British Columbia, Canada. Participants completed a questionnaire measuring diabetes distress, depressive symptoms and demographic backgrounds. The Diabetes Distress Scale was used to assess overall distress as well as 4 distinct distress dimensions, including emotional burden, physician-related, regimen-related and interpersonal distress. The Personal Health Questionnaire-9 was used to assess depressive symptoms. Glycated hemoglobin (A1C) data were also collected.

RESULTS

The prevalence of diabetes distress and depression was 39% and 12% in our population, respectively. A1C levels emerged as a significant predictor of emotional burden (p=0.03) and regimen-related distress (p=0.01); higher A1C levels were associated with increased distress regarding emotional functioning and regimen adherence. A1C levels (p=0.02) and education levels (p=0.03) emerged as predictors of physician-related distress, with higher A1C levels associated with decreased distress regarding confidence in physicians.

CONCLUSIONS

Our findings reveal that the rate of diabetes distress for patients in a tertiary care setting is high. Furthermore, diabetes distress, particularly emotion- and self-care-related distress, plays a significant role in glycemic control, whereas depression does not. Routine screening for diabetes distress as part of an initial specialty clinic evaluation should be explored.

Characterising the latent structure and organisation of self-reported thoughts, feelings and behaviours in adolescents and young adults

Little is known about the underlying relationships between self-reported mental health items measuring both positive and negative emotional and behavioural symptoms at the population level in young people. Improved measurement of the full range of mental well-being and mental illness may aid in understanding the aetiological substrates underlying the development of both mental wellness as well as specific psychiatric diagnoses. A general population sample aged 14 to 24 years completed self-report questionnaires on anxiety, depression, psychotic-like symptoms, obsessionality and well-being. Exploratory and confirmatory factor models for categorical data and latent profile analyses were used to evaluate the structure of both mental wellness and illness items. First order, second order and bifactor structures were evaluated on 118 self-reported items obtained from 2228 participants. A bifactor solution was the best fitting latent variable model with one general latent factor termed 'distress' and five 'distress independent' specific factors defined as self-confidence, antisocial behaviour, worry, aberrant thinking, and mood. Next, six distinct subgroups were derived from a person-centred latent profile analysis of the factor scores. Finally, concurrent validity was assessed using information on hazardous behaviours (alcohol use, substance misuse, self-harm) and treatment for mental ill health: both discriminated between the latent traits and latent profile subgroups. The findings suggest a complex, multidimensional mental health structure in the youth population rather than the previously assumed first or second order factor structure. Additionally, the analysis revealed a low hazardous behaviour/low mental illness risk subgroup not previously described. Population sub-groups show greater validity over single variable factors in revealing mental illness risks. In conclusion, our findings indicate that the structure of self reported mental health is multidimensional in nature and uniquely finds improved prediction to mental illness risk within person-centred subgroups derived from the multidimensional latent traits.

Mobile Phone and Web-based Cognitive Behavior Therapy for Depressive Symptoms and Mental Health Comorbidities in People Living With Diabetes: Results of a Feasibility Study

BACKGROUND

Depression is often comorbid with diabetes; however, undertreatment of depressive symptoms in people affected is common.

OBJECTIVE

We studied preliminary acceptability and effectiveness of a fully automated, mobile phone, and web-based public health intervention, myCompass, for reducing depressive symptoms and improving mental health comorbidities in people with diabetes.

METHODS

In this single-group feasibility study, 89 volunteers with type 1 (n=34) or type 2 (n=55) diabetes and at least mild depressive symptoms used myCompass for 7 weeks. Web-based measures of depressive and anxious symptoms, functional impairment, diabetes-specific variables, and user satisfaction were completed at baseline, postintervention, and 3-month follow-up.

RESULTS

Retention rates were 54% (n=48) at postintervention and 36% (n=32) at follow-up. Depressive symptoms were significantly improved at postintervention (P<.001; within-group effect size d=1.05), with gains persisting at follow-up. Mental health comorbidities, including anxiety (P<.001), functioning (P<.001), and diabetes-specific distress (P<.001), also showed significant and sustained improvement. Satisfaction with myCompass was high, with convenience and ease of program use, and relevance of program content rated positively by participants.

CONCLUSIONS

The myCompass program shows promise as an acceptable and effective treatment for depression and comorbid mental health problems in people with diabetes. The program is broadly available, free to use, and may benefit patients with diabetes who do not access services and/or wish to manage their mental health themselves. Replication of these findings in a controlled study is warranted.

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.

Diabetes-Related Distress, Depression and Distress-Depression among Adults with Type 2 Diabetes Mellitus in Malaysia

Type 2 diabetes mellitus (T2DM) brings about an increasing psychosocial problem in adult patients. Prevalence data on and associated factors of diabetes related distress (DRD) and depression have been lacking in Asia. This study aimed to examine the prevalence of DRD and depression, and their associated factors in Asian adult T2DM patients. This study was conducted in three public health clinics measuring DRD (Diabetes Distress Scale, DDS), and depression (Patient Health Questionnaire, PHQ). Patients who were at least 30 years of age, had T2DM for more than one year, with regular follow-up and recent laboratory results (< 3 months) were consecutively recruited. Associations between DRD, depression and the combination DRD-depression with demographic and clinical characteristics were analysed using generalized linear models. From 752 invited people, 700 participated (mean age 56.9 years, 52.8% female, 52.9% Malay, 79.1% married). Prevalence of DRD and depression were 49.2% and 41.7%, respectively. Distress and depression were correlated, spearman's r = 0.50. Patients with higher DRD were younger (OR 0.995, 95% CI 0.996 to 0.991), Chinese (OR 1.2, 95% CI 1.04 to 1.29), attending Dengkil health clinic (OR 1.1, 95% CI 1.00 to 1.22) and had higher scores on the PHQ (OR 1.1, 95% CI 1.04 to 1.06). Depression was less likely in the unmarried compared to divorced/separately living and those attending Dengkil health clinic, but more likely in patients with microvascular complications (OR 1.4, 95% CI 1.06 to 1.73) and higher DDS (OR 1.03, 95% CI 1.02 to 1.03). For the combination of DRD and depression, unemployment (OR 4.7, 95% CI 1.02 to 21.20) had positive association, whereas those under medical care at the Salak health clinics (OR 0.28, 95% CI 0.12 to 0.63), and those with a blood pressure > 130/80 mmHg (OR 0.53, 95% CI 0.32 to 0.89) were less likely to experience both DRD and depression. DRD and depression were common and correlated in Asian adults with T2DM at primary care level. Socio-demographic more than clinical characteristics were related to DRD and depression.

The detection and management of diabetes distress in people with type 1 diabetes

Diabetes distress (DD) represents a significant clinical burden in which levels of DD are related to both glycated haemoglobin (HbA1c) and some self-management behaviours. DD is related to, but different from, depression. Differences in DD experienced in people with type 1 and type 2 diabetes have been observed. Commonly measured using the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), rates of elevated DD in research study participants range from 20 to 30 %. Risk factors for elevated DD in type 1 diabetes are longer duration of diabetes, severe hypoglycaemia, younger age and being female. A systematic review of intervention studies assessing DD identified eight randomised controlled trials (RCTs) and nine pre-post design studies. Only three studies targeted DD with the intervention. Intervention types were diabetes self-management education (DSME), psychologically informed self-management and devices. DSME pre-post studies, namely the Dose Adjustment For Normal Eating (DAFNE) programme, produced more consistent improvements in DD and HbA1c at follow-up. Psychologically informed self-management was more heterogeneous, but several RCTs were effective in reducing DD. Group interventions offered the greatest benefits across intervention designs.

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.

Annual Psychological Screening in Youth and Young Adults with Type 1 Diabetes

Aim

Youth and young adults with type 1 diabetes are at a great risk for developing depression and diabetes specific distress, therefore, systematic psychological screening is recommended. Routine psychological screening was implemented in Slovene diabetes clinic for children, adolescents and young adults in 2012. One-year results are presented.

Methods

Adolescents and young adults (N = 159, aged 11 – 25 years), attending the obligatory yearly educational outpatient visit at University Children’s Hospital, Ljubljana, Slovenia, were examined using questionnaires measuring depression (depression scale from Slovene version of Trauma Symptom Checklist for Children) and diabetes distress (Diabetes Distress Screening Scale). Six additional items were included to assess the fear of hypoglycemia and family support. Socio-demographic and diabetes-related data were collected. Questionnaires were analyzed by a psychologist, and the patients that scored above cut-off point were invited to an individual psychological assessment.

Results

Of the sample, 1.3 % reached the threshold for elevated depressive symptoms, and 32.7 % reported significant diabetes distress. The need for psychological support from a specialist was expressed by 5.0 %. There were statistically significant associations between all psychological variables; moreover, better glycemic control was associated with lower diabetes distress and better family support. Nine patients (5.7 %) started with psychological treatment according to the referrals after screening.

Conclusions

The results after one year of psychological screening in Slovene type 1 diabetes population displayed small rates of depression and a large proportion of diabetes distress. Only a small percentage of patients attended the offered individual psychological assessment.

Prevalence and influencing factors of co-morbid depression in patients with type 2 diabetes mellitus: a General Hospital based study

BACKGROUND

Depression and diabetes have been recognized as major public health issues in China, however, no studies to date examined the factors associated with the development of depression in patients with diabetes in China. This study aimed to estimate the prevalence of co-morbid depression among adults with type 2 diabetes mellitus (DM) and to examine the influence factors of co-morbid depression in a group of patients with type 2 DM.

METHODS

The study was conducted from March l to May 31, 2012, in the Department of Endocrinology of the First Affiliated Hospital of the General Hospital of the People's Liberation Army (PLA). A systematic random sample of 412 type 2 DM patients aged over 18 years was selected. A structured questionnaire was used for collecting the information about socio-demographic data, lifestyle factors and clinical characteristics. Depression and social support was evaluated by using the Chinese version of Beck Depression Inventory (BDI) and Social Support Rate Scale (SSRS), respectively. Weights and heights were measured. Hemoglobin A1c (HbA1c) was abstracted from each patient directly after the interview.

RESULTS

Of the total sample, 142 patients had depression according to the BDI scores (BDI scores ≥14), the prevalence of co-morbid depression in this study population was 5.7 % (142/2500). Of which, 56 had major depression (BDI ≥ 21), and 86 had moderate depression (BDI ≥ 14&BDI < 21). Logistic regression analysis indicated that a high HbA1c level, a high BMI, low quality health insurance, and being single, were significantly associated with the development of depression. However, a family history of diabetes and a high social support level are likely protective factors.

CONCLUSIONS

The prevalence of co-morbid depression was 5.7 % among Chinese subjects with type 2 DM in this study. High HbA1c level, high BMI score, being single, low social support level, and low quality health insurance were associated with the presence of depression. These findings support a recommendation for routine screening and management in China for depression in patients with diabetes, especially for those in primary care, to reduce the number of the depressed or the misrecognized depressed diabetic patients.

Depression symptoms in people with diabetes attending outpatient podiatry clinics for the treatment of foot ulcers

Background

The purpose of this study was to examine the prevalence of depressive symptoms, diabetes self-management, and quality of life in people with diabetes and foot ulcers. Ulcer status, mortality and amputations were also assessed at six months follow-up.

Methods

This was a cross-sectional survey of people attending outpatient podiatry clinics at a major tertiary referral hospital. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ). Diabetes self-care was assessed using the Summary of Diabetes Self Care Activities (SDSCA) measure. Health-related quality of life was measured using the physical component summary score (PCS) and the mental component summary score (MCS) of the SF-12.

Results

Of the 60 participants in the study 14 (23.3%) reported mild symptoms of depression (PHQ score 5–9) and 17 (28.3%) moderate to severe depressive symptoms (PHQ score > 9). Twenty-one (35%) met the criteria for previously recognized depression (on antidepressants and/or a diagnosis of depression in the last 12 months) and 17 (28.3%) for depression not previously recognized (PHQ > 4). Seventeen (28%) participants had been receiving antidepressant treatment for a median duration of 104 weeks (IQR 20, 494 weeks). Despite antidepressant treatment 12 participants (70.6% of those taking antidepressants) still reported moderate to severe depressive symptoms at the time of the study. Patients with PHQ scores > 4 reported poorer adherence to diabetes self-care activities including general diet, exercise, blood sugar monitoring and foot care when compared to those participants with PHQ scores < 5. No association was found between physical functioning (PCS) and depressive symptoms. Decreasing mental wellbeing (MCS) was associated with increasing depressive symptoms. At six months follow-up, there were three deaths and three amputations in participants with PHQ scores > 4 compared with no deaths and 2 amputations in participants with PHQ scores < 5. There was no association between depressive symptoms and ulcer healing or ulcer recurrence at the six-month follow-up.

Conclusions

This study found a high prevalence of depressive symptoms both recognized and unrecognized in people with diabetes and foot ulcers. Depressive symptoms were associated with overall poorer diabetes self-management and health-related quality of life (HRQoL). There was no association between depressive symptoms and ulcer outcomes at six-months follow-up.

Diabetes-specific emotional distress in people with Type 2 diabetes: a comparison between primary and secondary care

AIMS

To compare levels of diabetes distress in people with Type 2 diabetes treated in primary and secondary care and to examine demographic and clinical correlates that may explain potential differences in levels of distress between care settings.

METHODS

People with Type 2 diabetes from 24 primary care practices (n = 774) and three secondary care clinics (n = 526) completed the Problem Areas In Diabetes questionnaire. Data on HbA1c levels and diabetes complications were derived from medical charts. Hierarchical ordinal regression analysis was used to investigate which correlates could explain the potential differences in level of diabetes distress between care settings.

RESULTS

Diabetes distress levels and the prevalence of elevated diabetes distress were considerably lower in the participants treated in primary care (mean (SD) total diabetes distress score 8 (11); 4% of participants with a Problem Areas In Diabetes score ≥ 40) than in secondary care (mean (SD) total diabetes distress score 23 (21); 19% of participants with a Problem Areas In Diabetes score ≥ 40, P < 0.001). In addition to care setting, the following variables were also independently related to diabetes distress: younger age, ethnic minority status, using insulin, having a higher HbA1c level, having a higher BMI and the presence of neuropathy. Other diabetes complications were not independently associated with diabetes distress.

CONCLUSIONS

In primary care, lower levels of diabetes distress were reported than in secondary care. The difference in diabetes distress between care settings can be largely, but not fully, explained by specific demographic and clinical characteristics. These results need to be interpreted with caution as they are based on two separate studies, but do call into question the need to screen for diabetes distress in people with Type 2 diabetes in primary care.

Embedding integrated mental health assessment and management in general hospital settings: feasibility, acceptability and the prevalence of common mental disorder

OBJECTIVE

To assess the feasibility and acceptability of routine web-based screening in general hospital settings, and describe the level of common mental disorder.

METHOD

A service development platform to integrate mental and physical healthcare was implemented in six specialties (rheumatology, limb reconstruction, hepatitis C, psoriasis, adult congenital heart disease (ACHD), chronic pain) across three general hospitals in London, UK. Under service conditions, patients completed a web-based questionnaire comprising mental and physical patient-reported outcome measures, whilst waiting for their appointment. Feasibility was quantified as the proportion of patients who completed the questionnaire. Acceptability was quantified as the proportion of patients declining screening, and the proportion requiring assistance completing the questionnaire. The prevalence of probable depression and anxiety was expressed as the percentage of cases determined by the Patient Health Questionnaire-9 and Generalised Anxiety Disorder Questionnaire-7.

RESULTS

The proportion of patients screened varied widely across specialties (40.1-98.2%). The decline rate was low (0.6-9.7%) and the minority required assistance (11.7-40.4%). The prevalence of probable depression ranged from 60.9% in chronic pain to 6.6% in ACHD. The prevalence of probable anxiety ranged from 25.1% in rheumatology to 11.4% in ACHD.

CONCLUSION

Web-based screening is acceptable to patients and can be effectively embedded in routine practice. General hospital patients are at increased risk of common mental disorder, and routine screening may help identify need, inform care and monitor outcomes.