More co-morbid depression in patients with Type 2 diabetes with multiple complications. An observational study at a specialized outpatient clinic

The Hidden Burden-Exploring Depression Risk in Patients with Diabetic Nephropathy: A Systematic Review and Meta-Analysis

INTRODUCTION

Diabetic nephropathy is a common complication among patients with diabetes mellitus, and it has been linked to a higher risk of depression. However, the magnitude of this association remains unclear. This study aimed to systematically review and meta-analyse the risk of depression in patients with diabetic nephropathy compared to diabetes patients without nephropathy.

METHODS

We conducted a systematic literature review, searching multiple databases from January 1964 to March 2023, and included randomized controlled trials, non-randomized controlled trials, and observational studies. We assessed the risk of bias using the Newcastle Ottawa scale for observational studies. The statistical analysis was performed using STATA version 14.2, and pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated. A total of 60 studies were included.

RESULTS

The pooled OR for the risk of depression among patients with diabetic nephropathy was 1.78 (95% CI 1.56-2.04; I² = 83%; n = 56), indicating a significantly higher risk compared to diabetes patients without nephropathy (p < 0.001). Pooling the effect size across these studies showed that the pooled OR was 1.15 (95% CI 1.14-1.16; I² = 88%; n = 32). Subgroup analyses based on the type of diabetes and study region revealed no significant differences in the pooled estimates.

CONCLUSION

This study demonstrates that patients with diabetic nephropathy have a significantly higher risk of depression compared to diabetes patients without nephropathy. These findings highlight the importance of assessing and addressing the mental health of patients with diabetic nephropathy as part of their overall healthcare management.

Factors Associated With Initiation of Antidepressant Medication in Adults With Type 1 and Type 2 Diabetes: A Primary Care Retrospective Cohort Study in Ontario, Canada

OBJECTIVES

Depression in patients with diabetes mellitus is common and associated with poorer outcomes. This study aims to identify demographic, socioeconomic and medical factors associated with the initiation of antidepressant medication after a diagnosis of diabetes in adult patients without a previous prescription for antidepressants. We also examined frequency of primary care visits in the year after antidepressant initiation compared with the year before treatment began.

METHODS

This was a retrospective cohort study using routinely collected electronic medical record data spanning January 2011 to December 2019 from the University of Toronto Practice-based Research Network (UTOPIAN) Data Safe Haven. Our primary outcome was a first prescription for an antidepressant in patients with diabetes. We used a mixed-effects logistic regression model to identify sociodemographic and medical factors associated with this event.

RESULTS

Among 22,750 patients with diabetes mellitus, 3,055 patients (13.4%) began taking an antidepressant medication. Increased odds of antidepressant initiation were observed in younger patients (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.39 to 2.26), females (OR, 1.60; 95% CI, 1.46 to 1.7), those receiving insulin treatment (OR, 1.59; 95% CI, 1.43 to 1.78) and cases of polypharmacy (OR, 3.67; 95% CI, 3.29 to 4.11). There was an increase in the mean number of primary care visits from 4.6 to 5.9 per year after antidepressant initiation.

CONCLUSIONS

In patients with diabetes, age, sex and medical characteristics were associated with the initiation of antidepressants. These patients accessed primary care more frequently. Screening and prevention of depression, particularly in these subgroups, could reduce its personal and systemic burdens.

Bidirectional association between depression and diabetic nephropathy by meta-analysis

BACKGROUND

Studies suggested that the association between depression and diabetic nephropathy may be bi-directional, but this hypothesis remains investigating. In this meta-analysis, the bi-directional relationship between depression and diabetic nephropathy was investigated.

METHODS

A search for the publications on depression and diabetic nephropathy in the databases of PubMed, Web of science, and Embase from the earliest available to August 2022 was conducted. Two sets of pooled risk estimates were calculated using random effects models: diabetic nephropathy predicting depression and depression predicting diabetic nephropathy. Cross-sectional studies were assessed using Agency for Healthcare Research and Quality (AHRQ), cohort and case-control studies were assessed using Newcastle-Ottawa Scale (NOS).

RESULT

Of the 974,121 patients in 30 clinical studies, 24 studies met eligibility for diabetic nephropathy predicting onset of depression, representing 28,438 incident cases. The other 6 studies met criteria for depression predicting onset of diabetic nephropathy, representing 945,683 incident cases. The pooled odds ratio (OR) of diabetic nephropathy predicting depression was 1.46 (95% CI 1.27-1.67). The OR of depression predicting diabetic nephropathy was 1.22 (95% CI 1.13-1.31).

CONCLUSION

This meta-analysis shows that the relationship between depression and diabetic nephropathy may be bidirectional. Diabetic nephropathy may be a predictor of depression, and depression may also be an indicator of diabetic nephropathy. The mechanisms underlying the bidirectional relationship need to be further investigated and interventions of the comorbidity of depression and diabetic nephropathy need be studied in clinical practice.

Treatment for comorbid depressive disorder or subthreshold depression in diabetes mellitus: Systematic review and meta-analysis

OBJECTIVE

To provide an estimate of the effect of interventions on comorbid depressive disorder (MDD) or subthreshold depression in type 1 and type 2 diabetes.

METHODS

Systematic review and meta-analysis. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomized controlled trials evaluating the outcome of depression treatments in diabetes and comorbid MDD or subthreshold symptoms published before August 2019 compared to care as usual (CAU), placebo, waiting list (WL), or active comparator treatment as in a comparative effectiveness trial (CET). Primary outcomes were depressive symptom severity and glycemic control. Cohen's d is reported.

RESULTS

Forty-three randomized controlled trials (RCTs) were selected, and 32 RCTs comprising 3,543 patients were included in the meta-analysis. Our meta-analysis showed that, compared to CAU, placebo or WL, all interventions showed a significant effect on combined outcome 0,485 (95% CI 0.360; 0.609). All interventions showed a significant effect on depression. Pharmacological treatment, group therapy, psychotherapy, and collaborative care had a significant effect on glycemic control. High baseline depression score was associated with a greater reduction in HbA1 c and depressive outcome. High baseline HbA1 c was associated with a greater reduction in HbA1 c.

CONCLUSION

All treatments are effective for comorbid depression in type 1 diabetes and type 2 diabetes. Over the last decade, new interventions with large effect sizes have been introduced, such as group-based therapy, online treatment, and exercise. Although all interventions were effective for depression, not all treatments were effective for glycemic control. Effective interventions in comorbid depressive disorder may not be as effective in comorbid subthreshold depression. Baseline depression and HbA1 c scores modify the treatment effect. Based on the findings, we provide guidance for treatment depending on patient profile and desired outcome, and discuss possible avenues for further research.

Induction of anxiolytic, antidepressant and analgesic effects by Shiff base of (E)-3-(1H-imidazol-4-yl)-2-((2-oxoindolin-3-ylidene)amino)propanoic acid derivatives in diabetic rats

Diabetes mellitus is a metabolic disorder with several psychological problems such as anxiety, depression, and pain sense. This study aimed to evaluate the effect of Schiff base on the modulation of anxiety, depression, and pain behaviors in diabetic rats. Anxiety, depression, and pain behaviors were evaluated by elevated plus maze (EPM), forced swim test (FST), and hot-plate test, respectively. The results indicated that induction of diabetes decreased time spent in open arms (OAT) in the EPM whereas injection of insulin (1 ml/kg), glibenclamide (5 mg/kg), and Schiff base II (100 mg/kg) increased OAT in the EPM. So, induction of diabetes in rats caused an anxiogenic effect that this effect reversed by drug treatment. Interestingly, co-treatment of insulin and glibenclamide along with an ineffective dose of Schiff base II potentiated anxiolytic behavior in diabetic rats. Furthermore, induction of diabetes increased immobility time in the FST but administration of insulin (1 ml/kg), glibenclamide (5 mg/kg), and Schiff base II (25, 50, and 100 mg/kg) decreased immobility time in the FST which indicated depressant effect in diabetic rats without drug-treatment and antidepressant effect in diabetic rats with drug-treatment. Additionally, induction of diabetes decreased latency in the hot-plate test while injection of insulin (1 ml/kg), glibenclamide (5 mg/kg), Schiff base I (50 mg/kg), and Schiff base II (25, 50, and 100 mg/kg) enhanced latency in the hot-plate test which revealed hyperalgesic effect in diabetic rats without drug-treatment and analgesic effect in diabetic rats with drug-treatment. Consequently, induction of diabetes-induced anxiogenic, depressant, and hyperalgesia effects that administration of insulin, glibenclamide, Schiff bases I, and II reversed these effects.

Associations of diabetes severity and risk of depression: a population-based cohort study

OBJECTIVE

Previous literature investigating effects of diabetes complications on subsequent depression have been inconsistent. We aim to investigate associations of diabetes, complication severity, and depression.

DESIGN

This study used a nationwide database to establish an 11-year cohort comprised of people with new onset Type II diabetes mellitus (DM) aged 20 and above.

METHOD

Severity of DM was measured using the adapted Diabetes Complication Severity Index (aDCSI). Status of depression was determined by having one recorded depression diagnosis from the inpatient setting or three recorded depression diagnoses from the outpatient setting. The risk of depression was analyzed by multivariate Cox proportional models.

RESULTS

In 50,590 cases with new onset DM from years 2000 to 2011, the incidence of depression increased with severity and rates of progressions in diabetes complications regardless of demographic status, comorbidities, or medication compliance. Adjusted hazard ratios (aHR) of depression were 1.21, 1.25, 1.48 (p<0.001 for trend) in patients with a total aDCSI score of 1, 2, and > 3, respectively. Risks of depression were the highest in subgroup with the most serious progression (change of aDCSI score >2 per year) (aHR ranged between 11.6~26.0). Elevated risks of depression (aHR: 1.59~4.36) were also observed in the slower progression subgroups throughout the disease course.

CONCLUSIONS

Risks of depression were associated with multiple DM-related complications and rates of progression in severity.

A Systematic Review and Delphi Study to Ascertain Common Risk Factors for Type 2 Diabetes Mellitus and Dementia and Brain-Related Complications of Diabetes in Adults

OBJECTIVES

Both type 2 diabetes (T2DM) and dementia have multifactorial etiologies. Both are associated with aging and have well-recognized lifestyle, cardiovascular and psychosocial risk factors. However, uncertainty exists in the literature with regard to: 1) the potentially modifiable risk factors common to both dementia and T2DM, and 2) the risk of brain-related complications in those with established diabetes. In this study, we address this uncertainty and inform design of a survey questionnaire to assess knowledge about diabetes and brain health among at-risk groups.

METHODS

This investigation consisted of a mixed-methods approach, including a Delphi consensus study preceded by a systematic literature review. The review was conducted using MEDLINE, EMBASE and Cochrane Library databases. A 2-round online Delphi study, informed by the review, invited international experts to rate their agreement with proposed risk factors and complications.

RESULTS

Of 7,337 abstracts retrieved, 13 were included in the final review. Among 46 international experts invited to take part in the Delphi study, 14 (32%) responded. In the Delphi study, hypertension, obesity, physical inactivity and heavy alcohol consumption reached consensus as risk factors common to both T2DM and dementia. Proposed brain-related diabetes complications, depression and dementia were also identified.

CONCLUSIONS

Results revealed expert consensus and literature review agreement on a number of common modifiable risk factors for T2DM and dementia, as well as agreement on brain-related complications of diabetes. A number of other proposed shared risk factors did not reach consensus agreement, suggesting a need for more high-quality studies to add to the evidence base.

Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis

To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi-directional association between depression and diabetes macrovascular and microvascular complications. Embase, Medline and PsycINFO databases were searched from inception through 27 November 2017. A total of 4592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Twenty-two studies were included in the systematic review. Sixteen studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over one million participants were suitable for meta-analysis. Depression was associated with an increased risk of incident macrovascular (HR = 1.38; 95% CI: 1.30-1.47) and microvascular disease (HR = 1.33; 95% CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two studies involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR = 1.14; 95% CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research.

BRAIN FUNCTION ALTERATIONS IN PATIENTS WITH DIABETIC NEPHROPATHY COMPLICATED BY RETINOPATHY UNDER RESTING STATE CONDITIONS ASSESSED BY VOXEL-MIRRORED HOMOTOPIC CONNECTIVITY

Objective: The voxel-mirrored homologous connection (VHMC) technique was applied to detect resting brain function alterations in patients with diabetic nephropathy and retinopathy (DNR), and their relationships with clinical manifestations in the kidneys and eyes are discussed. Methods: Twenty-two patients with DNR and 22 healthy controls (HCs) similarly matched in age, sex, and educational background were recruited. Resting-state functional magnetic resonance imaging scans were performed for all subjects. Retinal fundus photography and renal biopsy were employed to observe the clinical features of the kidney and retina. Pearson correlation analysis was used to analyze the relationship between clinical manifestations and experimental results. Results: Compared with the HCs, patients with DNR showed decreased mean VMHC values in the bilateral middle temporal gyrus, bilateral middle occipital gyrus (BMOG), and bilateral medial frontal gyrus. The receiver operating characteristic curve analysis of each brain region confirmed that the accuracy of the area under the curve was excellent. The results showed that the average VHMC value of BMOG signals was positively correlated with the urinary protein to creatinine ratio in female subjects (r = 0.626; P<.05). Nonetheless, no such correlation was noted among the male subjects. Conclusion: There were significant changes in brain function in DNR patients compared to the control group. Changes in the central nervous system in patients with DNR were mainly due to the dual negative effects of kidney function and diabetes mellitus. Abbreviations: ACR = albumin/creatinine ratio; BMFG = bilateral medial frontal gyrus; BMOG = bilateral middle occipital gyrus; BMTG = bilateral middle temporal gyrus; DN = diabetic nephropathy; DNR = diabetic nephropathy complicated by retinopathy; DR = diabetic retinopathy; fMRI = functional magnetic resonance imaging; HC = healthy control; MRI = magnetic resonance imaging; PCR = protein to creatinine ratio; ROC = receiver operating characteristic; VHMC = voxel-mirrored homologous connection.

A review of the bidirectional relationship between psychiatric disorders and diabetes mellitus

The prevalence of type 2 diabetes is rising worldwide, including Saudi Arabia. Among patients with diabetes, 30% suffer from mental disorders, such as depression, schizophrenia, delirium, and substance misuse (for example, tobacco smoking). Moreover, these disorders appear to share a bidirectional relationship with diabetes. For example, the incidence of diabetes has been shown to be 2-4 times greater in patients with schizophrenia than in normal individuals; also, there is a known association between depression and diabetes. In this review, we focus specifically on the bidirectional relationship between diabetes and psychiatric disorders, including the effects of antipsychotic drugs.

The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies

AIMS

Depression is a common co-morbidity in patients with type 2 diabetes mellitus (T2DM). Untreated depression in these patients adversely affects self-care activities and other diabetes complications. The aim of this study is to estimate the prevalence of depression among patients with T2DM by conducting a meta-analysis of observational studies.

METHODS

MEDLINE, Web of Science, Science Direct, and Google Scholar databases were searched for all observational studies that assessed depression in T2DM. Relevant articles were searched using the combination of Medical Subject Heading (MeSH) terms of "depression", "depressive disorder", and "diabetes mellitus" published between January 2007 and July 2018. Random effects model was used to estimate the weighted prevalence rates and 95% CI using "metaprop program in STATA 11".

RESULTS

In total, the 248 included studies (with 273 reported prevalence) identified 83,020,812 participants; of them, 23,245,827 (28%; 95% CI 27, 29) suffered from different severity levels of depressive disorders. The prevalence of depression was separately reported in 137,372 males and 134,332 females. Of them, 31,396 males (23%, 95% CI: 20, 26) and 45,673 females (34%, 95% CI: 31, 38) were depressed. Compared with global estimate, depression prevalence was lower in Europe (24%) and Africa (27%), but higher in Australia (29%) and Asia (32%). The prevalence in America was equal to the estimated prevalence in the world (28%). Depression was more common in subjects younger than 65 compared with elderlies (31% vs. 21%).

CONCLUSION

Our findings demonstrated that almost one in four adults with T2DM experienced depression. Given the high prevalence of depressive disorders in diabetic patients, screening these patients for co-morbid depression and its relevant risk factors is highly recommended.

Incidence of Anxiety and Depression Among Patients with Type 2 Diabetes and the Predicting Factors

Introduction

Diabetes mellitus (DM) is a chronic, progressive metabolic illness which is commonly complicated by coexistence of depression and anxiety. This study aimed to assess the prevalence of anxiety and depression among diabetic patients and the factors predicting this coexistence.

Methods

It was a cross-sectional, observational study which included patients of type 2 DM admitted in the hospital due to diabetes-related condition - diabetic foot infections/ulcers, hyperosmotic hyperglycaemic state (HHS), and hypoglycaemic coma/seizure. Anxiety and depression were measured by using the Hospital Anxiety and Depression Scale (HADS). Data was entered and analysed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA).

Results

Mean anxiety score of the participants was 10.88 ± 4.075 and mean depression score was 11.82 ± 4.049. There were 72 (50.7%) patients who had anxiety and 70 (49.2%) patients who had depression. Higher scores of anxiety and depression were statistically significant in female gender, older participants, individuals with longer duration of diabetes, those taking non-insulin treatment, and individuals with painful neuropathy, nephropathy, and foot ulcers.

Conclusion

The incidence of depression and anxiety among hospitalized patients of diabetes mellitus is high. The coexistence of these two chronic debilitating illnesses is worsening the overall quality of life. It is very important to diagnose and manage anxiety and depression in patients with type 2 DM to ensure higher quality of life and life expectancy.

Illness burden and physical outcomes associated with collaborative care in patients with comorbid depressive disorder in chronic medical conditions: A systematic review and meta-analysis

OBJECTIVE

Collaborative care (CC) improves depressive symptoms in people with comorbid depressive disorder in chronic medical conditions, but its effect on physical symptoms has not yet systematically been reviewed. This study aims to do so.

METHODS

Systematic review and meta-analysis was conducted using PubMed, the Cochrane Library, and the European and US Clinical Trial Registers. Eligible studies included randomized controlled trials (RCTs) of CC compared to care as usual (CAU), in primary care and general hospital setting, reporting on physical and depressive symptoms as outcomes. Overall treatment effects were estimated for illness burden, physical outcomes and depression, respectively.

RESULTS

Twenty RCTs were included, with N=4774 patients. The overall effect size of CC versus CAU for illness burden was OR 1.64 (95%CI 1.47;1.83), d=0.27 (95%CI 0.21;0.33). Best physical outcomes in CC were found for hypertension with comorbiddepression. Overall, depression outcomes were better for CC than for CAU. Moderator analyses did not yield statistically significant differences.

CONCLUSIONS

CC is more effective than CAU in terms of illness burden, physical outcomes and depression, in patients with comorbid depression in chronic medical conditions. More research covering multiple medical conditions is needed.

PROTOCOL REGISTRATION NUMBER

The protocol for this systematic review and meta-analysis has been registered at the International Prospective Register of Systematic Reviews (PROSPERO) on February 19th 2016: http://www.crd.york.ac.uk/PROSPERO/DisplayPDF.php?ID=CRD42016035553.

Diabetes and brain health: implications for practice

BACKGROUND

It is widely accepted that people with mental illness have increased risk of cardiometabolic complications such as obesity and type 2 diabetes mellitus. What is less well known is that individuals with diabetes have an increased risk of brain health complications including depression, cognitive impairment and dementia. These conditions can adversely influence disease self-management and further increase risk of other diabetes complications. Aim The aim of this paper is to highlight the increased risk of brain health complications in populations with diabetes in order to promote awareness of such complications among healthcare professionals and encourage timely intervention.

METHODS

An overview of the prevalence and potential mechanisms linking depression and cognitive impairment with diabetes as well as implications for detection, management and brain health protection, based on a narrative review of the literature.

CONCLUSIONS

Early detection and effective management of depression and cognitive impairment among individuals with diabetes has the potential to minimise adverse health outcomes. In order to promote screening healthcare professionals caring for individuals with diabetes in all settings must be aware of the increased risk of brain health complications in this vulnerable population.

Prevalence and determinants of depressive and anxiety symptoms in adults with type 2 diabetes in China: a cross-sectional study

OBJECTIVES

To evaluate the prevalence and determinants of anxiety and depression and to assess their impact on glycaemic control in participants with type 2 diabetes mellitus.

DESIGN

A cross-sectional study.

SETTING

Community-based investigation in Xuzhou, China.

PARTICIPANTS

893 Chinese men and women aged 18-84 years who fulfilled the inclusion criteria.

METHODS

People with type 2 diabetes completed the Pittsburgh Sleep Quality Index and the Zung Self-Rating Anxiety and Depression Scales. Demographic and physiological characteristics were recorded. Multiple logistic regression was used to evaluate the combined effect of factors associated with anxiety and depression and to assess the effects of anxiety and depression on glycaemic control.

RESULTS

The prevalence of depressive symptoms and anxiety symptoms was 56.1% and 43.6%, respectively. Multivariate logistic regression analysis indicated that anxiety symptoms were associated with being woman, low income, chronic disease, depressive symptoms and poor sleep quality. Depressive symptoms were associated with being woman, older age, low education level, being single, diabetes complications, anxiety symptoms and poor sleep quality. Glycaemic control was not related to anxiety symptoms (OR=1.31, 95% CIs 0.94 to 1.67) or depressive symptoms (OR=1.23, 95% CI 0.85 to 1.63). A combination of depressive symptoms and anxiety symptoms was associated with poor glycaemic control (relative excess risk due to interaction: 4.93, 95% CI 2.09 to 7.87; attributable proportion due to interaction: 0.27, 95% CI 0.12 to 0.45).

CONCLUSIONS

There was a high prevalence of depressive and anxiety symptoms in this Chinese sample of participants, although depression and anxiety were not singly associated with glycaemic control. However, a combination of depressive and anxiety symptoms was negatively correlated with glycaemic control in participants with type 2 diabetes.

Depression and postoperative complications: an overview

BACKGROUND

The interaction of depression and anesthesia and surgery may result in significant increases in morbidity and mortality of patients. Major depressive disorder is a frequent complication of surgery, which may lead to further morbidity and mortality.

LITERATURE SEARCH

Several electronic data bases, including PubMed, were searched pairing "depression" with surgery, postoperative complications, postoperative cognitive impairment, cognition disorder, intensive care unit, mild cognitive impairment and Alzheimer's disease.

REVIEW OF THE LITERATURE

The suppression of the immune system in depressive disorders may expose the patients to increased rates of postoperative infections and increased mortality from cancer. Depression is commonly associated with cognitive impairment, which may be exacerbated postoperatively. There is evidence that acute postoperative pain causes depression and depression lowers the threshold for pain. Depression is also a strong predictor and correlate of chronic post-surgical pain. Many studies have identified depression as an independent risk factor for development of postoperative delirium, which may be a cause for a long and incomplete recovery after surgery. Depression is also frequent in intensive care unit patients and is associated with a lower health-related quality of life and increased mortality. Depression and anxiety have been widely reported soon after coronary artery bypass surgery and remain evident one year after surgery. They may increase the likelihood for new coronary artery events, further hospitalizations and increased mortality. Morbidly obese patients who undergo bariatric surgery have an increased risk of depression. Postoperative depression may also be associated with less weight loss at one year and longer. The extent of preoperative depression in patients scheduled for lumbar discectomy is a predictor of functional outcome and patient's dissatisfaction, especially after revision surgery. General postoperative mortality is increased.

CONCLUSIONS

Depression is a frequent cause of morbidity in surgery patients suffering from a wide range of conditions. Depression may be identified through the use of Patient Health Questionnaire-9 or similar instruments. Counseling interventions may be useful in ameliorating depression, but should be subject to clinical trials.

Effects of motivational enhancement therapy plus cognitive behaviour therapy on depressive symptoms and health-related quality of life in adults with type II diabetes mellitus: a randomised controlled trial

OBJECTIVE

This paper evaluates the effectiveness of motivational enhancement therapy plus cognitive behavioural therapy on depressive symptoms, glycosylated haemoglobin, fasting glucose, body mass index (BMI), and health-related quality of life in type II diabetes patients.

METHODS

A controlled trial was conducted to compare patients who received the behavioural intervention with untreated controls on measures of health outcomes. A total of 31 intervention group participants and 30 controls were selected from patients that met the inclusion criteria from a hospital-based endocrinology outpatient department. The outcome measures including depressive symptoms, glycosylated haemoglobin, fasting glucose, BMI, and both physical and mental quality of life were collected before (T1), after (T2), and after 90 days (T3) following the intervention.

RESULTS

The experimental group showed a significant reduction in glycosylated haemoglobin, fasting glucose, and depressive symptoms and a significant increase in physical quality of life and mental quality of life at T2 and T3, while patients in the control group with usual care showed no changes over time.

CONCLUSION

The behavioural intervention facilitated a significant improvement in psychological adjustment and glycemic control, thus strengthening diabetes control skills and leading to healthy outcomes. It is feasible that nurses and psychiatrists can deliver the behavioural intervention for diabetes patients to decrease their depressive symptoms. Sharing discussion and problem-solving experiences is particularly helpful method for self-control, and these will be beneficially influential on further research.

Depressive symptoms prior to and following insulin initiation in patients with type 2 diabetes mellitus: Prevalence, risk factors and effect on physician resource utilisation

AIMS

To study the frequency and intensity of depressive symptoms and associations with physician resource utilisation following insulin initiation in patients with type 2 diabetes mellitus.

METHODS

SOLVE was a 24-week observational study. In this sub-analysis of data from Poland, depressive symptoms were evaluated using the Patient Health Questionnaire (PHQ)-9.

RESULTS

PHQ-9 was completed by 942 of 1169 patients (80.6%) at baseline, and 751 (64.2%) at both baseline and final (24-week) visit. PHQ-9 scores indicated depressive symptoms in 45.6% (n=430) at baseline, and 27.2% (n=223) at final visit. Mean PHQ-9 change was -2.38 [95% CI -2.73, -2.02], p<0.001. Depressive symptoms at baseline (OR 6.32, p<0.001), microvascular disease (OR 2.45, p=0.016), number of physician contacts (OR 1.16, p=0.009), and change in HbA1c (OR 0.60, p=0.025) were independently associated with moderate/severe depressive symptoms at final visit. Patients with more severe depressive symptoms spent more time training to self-inject (p=0.0016), self-adjust (p=0.0023) and manage other aspects of insulin delivery (p<0.0001). Patients with persistent depressive symptoms had more telephone contacts and dose changes at final visit than those without (both p<0.05).

CONCLUSIONS

Depressive symptoms are common with type 2 diabetes and associated with increased healthcare utilisation, reinforcing the need for holistic interdisciplinary management approaches.

Gastroesophageal reflux disease in patients with diabetes: preliminary study

BACKGROUND AND AIM

Some studies report that complications of gastroesophageal reflux disease (GERD) occur more frequently in patients with diabetes mellitus (DM) than in non-diabetic patients. This study used transnasal endoscopy to elucidate the current status of concurrent GERD in patients with type 2 diabetes mellitus, and to examine the associations between intraesophageal pressure and GERD, as well as other neuropathic conditions.

METHODS

The study included 57 outpatients with type 2 diabetes mellitus. The mean age was 67 years and the duration of DM was 13 years. The mean hemoglobin A1c was 6.8%. Transnasal endoscopic evaluation items were (i) the presence or absence of esophagitis and its severity; (ii) intraesophageal pressure; and (iii) Helicobacter pylori status, which was evaluated by endoscopic findings, such as the presence or absence of gastritis and peptic ulcer, and by urea breath test.

RESULTS

Of 57 patients, 24 (42.1%) were given a diagnosis of GERD based on endoscopy. Patients with concurrent GERD were younger, had shorter duration of DM, and were taller and heavier. Interestingly, no difference in body mass index was observed. There was no significant association between the presence of concurrent GERD and diabetic complications, including peripheral neuropathy, and infection or non-infection with H. pylori. Although there was no significant association between the presence of concurrent GERD and intraesophageal pressure values, we found aging, reduced estimated glomerular filtration rate, and the presence of autonomic nerve symptoms to correlate with reduced intraesophageal pressure.

CONCLUSION

The results of this study could be used to answer the question of whether or not endoscopic GERD is a diabetic complication; however, further study is required.

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.

Diabetes and depression

Diabetes and depression occur together approximately twice as frequently as would be predicted by chance alone. Comorbid diabetes and depression are a major clinical challenge as the outcomes of both conditions are worsened by the other. Although the psychological burden of diabetes may contribute to depression, this explanation does not fully explain the relationship between these 2 conditions. Both conditions may be driven by shared underlying biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors. Depression is frequently missed in people with diabetes despite effective screening tools being available. Both psychological interventions and antidepressants are effective in treating depressive symptoms in people with diabetes but have mixed effects on glycemic control. Clear care pathways involving a multidisciplinary team are needed to obtain optimal medical and psychiatric outcomes for people with comorbid diabetes and depression.

Validation of the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Diabetes Mellitus in patients with diabetic nephropathy

BACKGROUND

Diabetic nephropathy (DMN) is the most common cause of end-stage renal disease. Progression of DMN leads to impairment of physical activity, restriction of daily activities, and diminished social participation. Therefore, the precise assessment of the physical and psychosocial problems of DMN patients is important. The objective of this study was to validate the Comprehensive International Classification of Functioning, Disability and Health Core Set for Diabetes Mellitus (ICF-CS for DM) from the perspective of DMN patients.

METHODS

A total of 176 DMN outpatients were interviewed using the ICF-CS for DM. Content and construct validity were evaluated. Patients were divided into 2 groups: DMN patients without hemodialysis (HD) (non-HD group) and DMN patients undergoing HD (HD group). Content validity was evaluated based on the frequency of patients who had a problem in each category. For construct validity, the patients were divided into two groups based on DM duration and hemoglobin A1C levels.

RESULTS

Content validity evaluation revealed 58 categories reported as problem categories: 39 categories in the non-HD group and 50 categories in the HD group. Construct validity evaluation showed that longer DM duration and poor glycemic control contributes to increased problems.

CONCLUSIONS

Content and construct validity of the ICF-CS for DM was supported from the DMN patients' perspective. Some categories of the "Environmental factors" component need further studies to be appropriate.

The comorbidity between depression and diabetes

Comorbidity of depression and diabetes is common, and each disorder has a negative impact on the outcome of the other. The direction of causality is not certain as each disorder seems to act as both a risk factor and consequence for the other in longitudinal studies. This bidirectional association is possibly mediated by shared environmental and genetic risk factors. Comorbid depression is associated with reduced adherence to medication and self-care management, poor glycaemic control, increased health care utilization, increased costs and elevated risk of complications, as well as mortality in patients with diabetes. Psychological and pharmacological interventions are shown to be effective in improving depression symptoms; however, collaborative care programs that simultaneously manage both disorders seem to be most effective in improving diabetes-related outcomes.

IL-1β, IL-6, IL-8, IL-10, IFN-γ, TNF-α and its relationship with lipid parameters in patients with major depression

There is some evidence that an immune response with an increased production of proinflammatory cytokines frequently accompanies major depression. The aim of this study was to determine the serum levels of interleukines (IL-1β, IL-6, IL-8, IL-10), tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ) and immonuglobulines (IgG, IgA and IgM) levels and to examine the relationships between all above parameters and lipid parameters. The study group included 30 patients and 30 healthy volunteers. Although total cholesterol, HDL-cholesterol, and IgM levels were increased significantly (p < 0.05) in patients and compared to those of the controls, no statistically significant differences (p > 0.05) were observed with other parameters. IFN-γ were positively correlated with total cholesterol (r = 0.425; P = 0.019) and LDL-cholesterol (r = 0.391; P = 0.032) levels in patients. Other cytokines and immunoglobulins did not show any correlation with lipid parameters. It was concluded that although no differences was observed in cytokines and immunoglobulin levels in the present study, the dysregulation of the lipids and immune system including the cytokine network is associated with the etiology and pathophysiology of major depressive disorders.

Contributions of diabetic macro-vascular complications and hip fracture to depression onset in elderly patients with diabetes: an 8-year population-based follow-up study

OBJECTIVE

To prospectively examine the roles of diabetic macro-vascular complications and hip fracture in association with depression onset in Taiwan's elderly diabetic population.

METHODS

A representative sample of elderly diabetic patients (n=144,216) identified in 2000 were linked to National Health Insurance claims (2000-2007) to ascertain the diagnoses of depression in both outpatient and inpatient settings. The person-year approach with Poisson assumption was used to estimate the hazard rates. Using Cox proportional hazard regression model, we evaluated the relative risk of depression in relation to diabetic macro-vascular complications and hip fracture. The additive effects from the above medical conditions were also assessed.

RESULTS

The 8-year cumulative risk of depression was 5.08%, representing an incidence density of 8.40 per 1000 patient-years. Hazard ratio (HR) with 95% confidence interval (CI) for the elderly diabetes associated with cardiovascular disease (CVD), hip fracture, and lower extremity amputation was 1.13 (1.04-1.23), 1.10 (0.91-1.34), and 1.25 (0.95-1.65), respectively. Additionally, we found that the more the complications or hip fracture, the higher the risk of depression onset in elderly diabetes.

CONCLUSION

The increased number of diabetic macro-vascular complications and hip fracture is significantly associated with a higher risk of depression onset in elderly diabetes. Future studies should be conducted to assess the feasibility and cost-effectiveness of intensive depression screening program in elderly diabetes suffering from macro-vascular complications and hip fracture.

Depression in diabetes mellitus: to screen or not to screen? A patient-centred approach

Background

Comorbid major depressive disorder (MDD) occurs frequently in diabetes mellitus and is associated with high symptom burden, disability and costs. Effective treatments are available but persons with diabetes with comorbid MDD are generally under-detected. A survey showed that comorbid MDD should be identified in a systematic way, such as by screening.

Aim

To identify and describe possible strategies to screen for MDD in persons with diabetes.

Method

After a survey exploring patients’ needs, a description of best practice is provided based on a review of the literature and clinical experience.

Results

Valid instruments for screening are the Center for Epidemiological Studies-Depression Scale (CES-D), the Beck Depression Inventory (BDI), and the Patient Health Questionnaire (PHQ-9). Research shows that screening and informing patients and physicians about comorbid MDD in diabetes is inadequate and more intensive treatment as follow-up is needed to change treatment and outcomes. Screening should identify patients willing and able to follow treatment if comorbid MDD is detected and should be followed by a stepwise approach to tailor treatment to patient need and ability.

Conclusion

Screening is best performed in a clinical setting, not by mail, and may be achieved by healthcare professionals using a collaborative care model.

Metabolic correction in the management of diabetic peripheral neuropathy: improving clinical results beyond symptom control

Current Clinical Management Guidelines of Diabetic Peripheral Neuropathy (DPN) are based on adequate glucose control and symptomatic pain relief. However, meticulous glycemic control could delay the onset or slow the progression of diabetic neuropathy in patients with DM type 2, but it does not completely prevent the progression of the disease. Complications of DPN as it continues its natural course, produce increasing pain and discomfort, loss of sensation, ulcers, infections, amputations and even death. In addition to the increased suffering, disability and loss of productivity, there is a very significant economic impact related to the treatment of DPN and its complications. In USA alone, it has been estimated that there are more than 5,000,000 patients suffering from DPN and the total annual cost of treating the disease and its complications is over $10,000 million dollars. In order to be able to reduce complications of DPN, it is crucial to improve or correct the metabolic conditions that lead to the pathology present in this condition. Pathophysiologic mechanisms implicated in diabetic neuropathy include: increased polyol pathway with accumulation of sorbitol and reduced Na+/K+-ATPase activity, microvascular damage and hypoxia due to nitric oxide deficit and increased oxygen free radical activity. Moreover, there is a decrease in glutathione and increase in homocysteine. Clinical trials in the last two decades have demonstrated that the use of specific nutrients can correct some of these metabolic derangements, improving symptom control and providing further benefits such as improved sensorium, blood flow and nerve regeneration. We will discuss the evidence on lipoic acid, acetyl-L-carnitine, benfotiamine and the combination of active B vitamins L-methylfolate, methylcobalamin and piridoxal-6-phosphate. In addition, we discuss the role of metformin, an important drug in the management of diabetes, and the presence of specific polymorphic genes, in the risk of developing DPN and how metabolic correction can reduce these risks.

Risk factors for depressive symptoms in a large population on chronic hemodialysis

Despite their significant influence on the quality of life, depressive symptoms are not usually included as a clinical parameter in the evaluation of hemodialysis patients. We aimed to identify depressive symptoms and associated risk factors in a large group of individuals with end-stage renal disease (ESRD) on chronic hemodialysis. This was a cross-sectional study of 400 consecutive patients. Cases were analyzed according to the presence/absence of depressive symptoms. All individuals were investigated by interview, and all variables were measured concurrently. Depressive symptoms were evaluated by the Beck Depression Inventory (BDI-II ≥16) and sleep quality by the Pittsburgh Sleep Quality Index (PSQI > 5). Among the 400 patients (59% male), depressive symptoms were present in 77 (19.3%). Depressive symptoms were more common in women and were independently associated with poor sleep quality (P = <0.005), unemployment (P = 0.001), diabetes (P = 0.02), hypoalbuminemia (P = 0.01), low education (P = 0.03), and pruritus (P = 0.04). Women with ESRD on chronic hemodialysis are at increased risk of depression. Furthermore, unemployment and the presence of diabetes, hypoalbuminemia, low education, and pruritus are significantly associated with depressive symptoms. Depressive symptoms are also independently associated with poor quality sleep and studies about the effects of sleep hygiene therapy on depressive symptoms are warranted.