Interaction of depressive symptoms and diabetes-related distress with glycaemic control in Type 2 diabetic patients

Are depressive symptoms associated with quality of care in diabetes? Findings from a nationwide population-based study

INTRODUCTION

We investigated whether the presence of depressive symptoms among adults with diagnosed diabetes is associated with adverse quality of diabetes care.

RESEARCH DESIGN AND METHODS

The study population was drawn from the German national health survey 'German Health Update' 2014/2015-European Health Interview Survey and included 1712 participants aged ≥18 years with self-reported diabetes during the past 12 months. Depressive symptoms in the past 2 weeks were assessed by the eight-item depression module of the Patient Health Questionnaire (PHQ-8), with PHQ-8 sum score values ≥10 indicating current depressive symptoms. We selected 12 care indicators in diabetes based on self-reported information on care processes and outcomes. Associations of depressive symptoms with those indicators were examined in multivariable logistic regression models with stepwise adjustments.

RESULTS

Overall, 15.6% of adults with diagnosed diabetes reported depressive symptoms, which were higher in women than in men (18.7% vs 12.9%). Adjusted for age, sex, education, social support, health-related behaviors, and diabetes duration, adults with depressive symptoms were more likely to report acute hypoglycemia (OR 1.81, 95% CI 1.13 to 2.88) or hyperglycemia (OR 2.10, 95% CI 1.30 to 3.37) in the past 12 months, long-term diabetes complications (OR 2.30, 95% CI 1.55 to 3.39) as well as currently having a diet plan (OR 2.14, 95% CI 1.39 to 3.29) than adults without depressive symptoms. Significant associations between depressive symptoms and other care indicators were not observed.

CONCLUSIONS

The present population-based study of adults with diagnosed diabetes indicates an association between depressive symptoms and adverse diabetes-specific care with respect to outcome but largely not to process indicators. Our findings underline the need for intensified care for persons with diabetes and depressive symptoms. Future research needs to identify underlying mechanisms with a focus on the inter-relationship between diabetes, depression and diabetes-related distress.

Depression is linked to hyperglycaemia via suboptimal diabetes self-management: A cross-sectional mediation analysis

OBJECTIVE

To analyse if the association between depressive symptoms and hyperglycaemia is mediated by diabetes self-management.

METHODS

430 people with diabetes (57.7% type 1, 42.3% type 2) were cross-sectionally assessed using validated self-report scales for depressive symptoms (Center for Epidemiologic Studies Depression Scale (CES-D)) and diabetes self-management (Diabetes Self-Management Questionnaire (DSMQ)); HbA_1c was analysed simultaneously in a central laboratory. Structural equation modelling was used to test if the association between depressive symptoms and hyperglycaemia (HbA_1c) was mediated by suboptimal self-management in people with type 1 and type 2 diabetes.

RESULTS

The hypothesised model of depressive symptoms, diabetes self-management and hyperglycaemia fit the data well for both diabetes types (SRMR≤0.04, TLI≥0.99, CFI>0.99, RMSEA≤0.02 for both models). In both the type 1 and type 2 diabetes group, higher depressive symptoms were associated with lower self-management (P<0.001) and lower self-management was associated with higher HbA_1c (P<0.001). Results indicated that the association between depressive symptoms and hyperglycaemia was significantly mediated by suboptimal diabetes self-management in both type 1 and type 2 diabetes patients (P<0.001). Significant direct associations between depressive symptoms and hyperglycaemia, not mediated by self-management, could not be observed.

CONCLUSIONS

This study provides good evidence supporting that depression is linked to hyperglycaemia via suboptimal diabetes self-management in both major diabetes types.

How to assess diabetes distress: comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS)

AIMS

To compare the properties of the two most commonly used assessment tools for diabetes distress, the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), in order to discriminate their psychometric capabilities and functions.

METHODS

Six hundred and twenty-eight people with diabetes (67% Type 1, 33% Type 2) were cross-sectionally assessed with the PAID, the DDS and further self-report scales regarding coping, quality of life, depressive symptoms and self-care, and medical data were gained. We analysed the PAID and DDS for areas of contentual/psychometric divergence in assessing diabetes distress and compared their associations with criteria of interest.

RESULTS

Content analysis: The PAID covers a greater variety of emotional concerns and shows a stronger focus on food-related problems and complications. The DDS is more reflective of physician-related distress and problems concerning diabetes self-management. Psychometric analysis: Exploratory factor analyses revealed four-factor structures of both scales, explaining 60% (PAID) and 67% (DDS) of variance. Confirmatory factor analyses confirmed that single-factor and four-factor models fit the data. Total scales proved high and subscales mostly satisfactory reliability. Associations with criteria of interest: The PAID was significantly more strongly associated with dysfunctional coping styles, quality of life and depressive symptoms. The DDS showed significantly stronger associations with diabetes self-care and metabolic outcomes.

CONCLUSION

Our results support both PAID and DDS as good self-report measures of diabetes distress. The observed contentual/psychometric differences suggest that a justified choice with regard to the intended clinical or scientific purpose can improve the acquisition of the required data.

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.

Impact of neuropathy on the adherence to diabetes-related self-care activities: a cross-sectional study

PURPOSE

The purpose of this study was to evaluate the impact of the presence and severity of neuropathy and depression on the patient's adherence to diabetes-related self-care activities (DRSCA) in a cohort of patients with type 2 diabetes mellitus (T2DM).

PATIENTS AND METHODS

In this cross-sectional, noninterventional study, 198 patients with T2DM were enrolled according to a population-based, consecutive-case enrollment principle. In all patients, the adherence to DRSCA was evaluated using the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire; a higher SDSCA score is associated with a better adherence. The presence and severity of neuropathy was assessed using the Michigan Neuropathy Screening Instrument (MNSI) and the severity of depression using the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

The presence of neuropathy was associated with a decreased SDSCA score (26 points vs 37 points; P<0.001), an increased severe depression prevalence (24.7% vs 4.3%; P<0.001), and an increased PHQ-9 score (12 points vs 7 points; P<0.001). The MNSI score was reverse correlated with SDSCA score (r=-0.527; P<0.001) and positively correlated with PHQ-9 score (r=0.495; P<0.001). The reverse correlation between MNSI score and SDSCA score was present for all the subcomponents of SDSCA questionnaire (diet, exercise, glycemic monitoring, and foot care).

CONCLUSION

The presence of neuropathy is associated with decreases in the quality of adherence to DRSCA in patients with T2DM and with increases in the symptomatology of depression. The significant, negative association between the severity of T2DM and the quality of disease self-management points to a possible loop-type relationship between these two components, being possible a reciprocal augmentation with negative consequences on the global management of the disease.

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.

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.

The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control

Background

Though several questionnaires on self-care and regimen adherence have been introduced, the evaluations do not always report consistent and substantial correlations with measures of glycaemic control. Small ability to explain variance in HbA_1c constitutes a significant limitation of an instrument’s use for scientific purposes as well as clinical practice. In order to assess self-care activities which can predict glycaemic control, the Diabetes Self-Management Questionnaire (DSMQ) was designed.

Methods

A 16 item questionnaire to assess self-care activities associated with glycaemic control was developed, based on theoretical considerations and a process of empirical improvements. Four subscales, ‘Glucose Management’ (GM), ‘Dietary Control’ (DC), ‘Physical Activity’ (PA), and ‘Health-Care Use’ (HU), as well as a ‘Sum Scale’ (SS) as a global measure of self-care were derived. To evaluate its psychometric quality, 261 patients with type 1 or 2 diabetes were assessed with the DSMQ and an established analogous scale, the Summary of Diabetes Self-Care Activities Measure (SDSCA). The DSMQ’s item and scale characteristics as well as factorial and convergent validity were analysed, and its convergence with HbA_1c was compared to the SDSCA.

Results

The items showed appropriate characteristics (mean item-total-correlation: 0.46 ± 0.12; mean correlation with HbA_1c: -0.23 ± 0.09). Overall internal consistency (Cronbach’s alpha) was good (0.84), consistencies of the subscales were acceptable (GM: 0.77; DC: 0.77; PA: 0.76; HU: 0.60). Principal component analysis indicated a four factor structure and confirmed the designed scale structure. Confirmatory factor analysis indicated appropriate fit of the four factor model. The DSMQ scales showed significant convergent correlations with their parallel SDSCA scales (GM: 0.57; DC: 0.52; PA: 0.58; HU: n/a; SS: 0.57) and HbA_1c (GM: -0.39; DC: -0.30; PA: -0.15; HU: -0.22; SS: -0.40). All correlations with HbA_1c were significantly stronger than those obtained with the SDSCA.

Conclusions

This study provides preliminary evidence that the DSMQ is a reliable and valid instrument and enables an efficient assessment of self-care behaviours associated with glycaemic control. The questionnaire should be valuable for scientific analyses as well as clinical use in both type 1 and type 2 diabetes patients.

Aspects of culturally competent care are associated with less emotional burden among patients with diabetes

BACKGROUND

Diabetes distress is associated with poor diabetes self-management and worse clinical outcomes. Whether there is an association between patient experience of health care and degree of emotional burden (EB) of diabetes distress is not known.

OBJECTIVE

To investigate whether aspects of culturally competent care are associated with the EB of diabetes distress.

DESIGN

Cross-sectional survey consisting of face-to-face interviews.

SUBJECTS

A total of 502 ethnically diverse patients with diabetes receiving care in safety-net clinics in 2 cities.

MEASURES

The main outcome measure was high EB on the Diabetes Distress Scale (mean score ≥ 3). The predictors were 3 domains (Doctor Communication--Positive Behaviors, Trust, and Doctor Communication-Health Promotion) of the Consumer Assessment of Healthcare Providers and Systems--Cultural Competence (Consumer Assessments of Healthcare Providers and Systems' Cultural Competence Item Set) instrument.

RESULTS

Of 502 patients, 263 (52%) reported high EB. In adjusted logistic regressions controlling for sociodemographic and clinical factors, patient report of optimal Doctor Communication-Positive Behaviors (adjusted odds ratio, 0.46; 95% confidence interval, 0.39-0.54), and optimal Trust (adjusted odds ratio, 0.65; 95% confidence interval, 0.54-0.78) were associated with lower EB. Doctor Communication-Health Promotion Communication was not associated with EB.

DISCUSSION

Patient report of better doctor communication behavior and higher trust in physician are inversely associated with high EB among patients with diabetes. Further research should determine whether interventions improving patient physician communication and trust can lower the EB of diabetes.

Diabetes-specific emotional distress mediates the association between depressive symptoms and glycaemic control in Type 1 and Type 2 diabetes

OBJECTIVES

To investigate whether diabetes-specific emotional distress mediates the relationship between depression and glycaemic control in patients with Type 1 and Type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were derived from the baseline assessment of a depression in diabetes screening study carried out in three tertiary diabetes clinics in the Netherlands. Most recent glycated haemoglobin (HbA(1c)) measurement was obtained from medical records. The Centre for Epidemiologic Studies Depression Scale (CES-D) and Problem Areas in Diabetes scale (PAID) were used to measure depression and diabetes-specific emotional distress respectively. Linear regression was performed to examine the mediating effect of diabetes-distress.

RESULTS

Complete data were available for 627 outpatients with Type 1 (n = 280) and Type 2 (n = 347) diabetes. Analyses showed that diabetes-distress mediated the relation between depression and glycaemic control and not differently for both disease types. Post-hoc analyses revealed that patients depressed and distressed by their diabetes were in significantly poorer glycaemic control relative to those not depressed nor distressed (HbA(1c) 8.7 +/- 1.7 vs. 7.6 +/- 1.2% in those without depressive symptoms, 7.6 +/- 1.1% in depressed only and 7.7 +/- 1.1% in the distressed only, P < 0.001). Depressed patients without elevated diabetes-distress did not show a significantly increased risk of elevated HbA(1c).

CONCLUSIONS

In explaining the association between depression and glycaemic control, diabetes-specific emotional distress appears to be an important mediator. Addressing diabetes-specific emotional problems as part of depression treatment in diabetes patients may help improve glycaemic outcomes.