Screening tools used for measuring depression among people with Type 1 and Type 2 diabetes: a systematic review

The Clinical Relevance of Diabetes Distress versus Major Depression in Type 2 Diabetes: A Latent Class Analysis from the Fremantle Diabetes Study Phase II

BACKGROUND

The nosological position and clinical relevance of the concept of diabetes distress (DD) are uncertain. The aim of this study was to use latent class analysis (LCA) to categorise classes of people with type 2 diabetes and to compare their characteristics.

METHODS

Data from 662 participants in the longitudinal observational Fremantle Diabetes Study Phase II were analysed. LCA identified latent subgroups based on individual responses to the Patient Health Questionnaire-9, the Generalised Anxiety Disorder Scale, and the 5-item Problem Areas in Diabetes Scale.

RESULTS

Four classes were identified: Class 1 (65.7%, no symptoms), Class 2 (14.0%, DD), Class 3 (12.6%, subsyndromal depression (SSD)), and Class 4 (7.6%, major depression (MD)). Multinomial regression analysis with Class 1 as reference showed significant associations between the DD class and Southern European and Asian ethnic background, HbA1c, and BMI. The SSD class was significantly associated with HbA1c, cerebrovascular disease, and coronary heart disease (CHD). The MD class had significant associations with age (inversely), Southern European ethnic background, HbA1c, BMI, and CHD. In conclusion, LCA identified a pure DD group comprising 14.0% of participants. The only variable uniquely associated with the DD class was Asian ethnic background.

CONCLUSION

Although identification of DD may have some utility in assessing the psychological wellbeing of individuals with type 2 diabetes, it adds little to the assessment of depressive disorder and its significant clinical sequalae.

Patient-reported outcome measures in diabetes outpatient care: a scoping review

BACKGROUND

Patient-reported outcome (PRO) measures are increasingly used in clinical diabetes care to increase patient involvement and improve healthcare services. The objectives were to identify instruments used to measure PROs in outpatient diabetes clinics and to investigate the use of these PRO measures alongside the experiences of patients and healthcare personnel in a clinical setting.

RESEARCH DESIGN AND METHODS

A scoping review was conducted according to the framework of Arksey and O'Malley with scoping searches of Cinahl, EMBASE, Medline and Health and Psychosocial Instruments. Studies reporting on adults with diabetes in a clinical setting where the PRO measure response directly affected patient care were eligible for inclusion.

RESULTS

In total, 35 197 citations were identified, of which 7 reports presenting 4 different PRO measures were included in the review. All four of the included items measured psychosocial aspects of diabetes, and three included elements of the Problem Areas in Diabetes scale. All the patients were satisfied with the use of PRO measures in clinical care, whereas the level of satisfaction among healthcare personnel with PRO measures varied within and among studies.

CONCLUSIONS

The limited number of eligible studies in this review suggests that research on PRO measures for diabetes outpatient care is scarce. Patients welcome the opportunity to express their concerns through the systematic collection of PRO measures, and some healthcare personnel value the broader insight that PRO measures provide into the impact of diabetes on patients' lives. However, the heterogeneity among services and among patients challenges the implementation of PRO measures. Research is needed to explore how PRO measures in clinical outpatient care affect healthcare personnel workflow.

REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/46AHC.

Association between type 2 diabetes mellitus and depression among Korean midlife women: a cross-sectional analysis study

BACKGROUND

The prevalence of depression is higher among midlife women, and they have less control over their diabetes during the menopausal transition. However, there is limited evidence on the association between type 2 diabetes mellitus and depression among Korean women in their midlife. This study aimed to examine the association between type 2 diabetes mellitus and depression and explore the levels of awareness and treatment of depression among Korean midlife women with T2DM.

METHODS

This is a cross-sectional analysis study conducted using data from the Korea National Health and Nutrition Examination Surveys of 2014, 2016, and 2018. Korean women aged 40-64 years who randomly participated in the surveys were included, and 4,063 midlife women were selected as study participants. The diabetes progression status of the participants was classified into diabetes, pre-diabetes, and non-diabetes. Furthermore, the Patient Health Questionnaire-9 was used for screening depression. Participants' awareness rate, treatment rate among incident cases of depression, and treatment rate among awareness cases of depression were also analyzed. For data analysis, the Rao-Scott χ2 test, multiple logistic regression, and linear regression were conducted using SAS 9.4 software program.

RESULTS

The prevalence of depression significantly differed between diabetes, pre-diabetes, and non-diabetes groups. However, depression awareness, treatment/incident, and treatment/awareness rates did not differ statistically between the diabetes progression status groups. Compared to the non-diabetes group, diabetes group had a higher odds ratio of depression after adjusting for general and health-related factors. Thus, the diabetes group had significantly higher PHQ-9 scores than the non-diabetes group after adjusting for covariates.

CONCLUSIONS

Women in their midlife who have type 2 diabetes mellitus tend to have higher levels of depressive symptoms and are at risk of depression. However, we found no significant differences between diabetes and non-diabetes regarding the awareness and treatment rates of depression in South Korea. We recommend that future studies focus on developing clinical practice guidelines aimed at additional screening and intervention for depression in midlife women with type 2 diabetes mellitus to ensure prompt treatment and improved outcomes.

Emotional distress, self-management, and glycemic control among participants enrolled in the glycemia reduction approaches in diabetes: A comparative effectiveness (GRADE) study

OBJECTIVE

We examined emotional distress in relation to metformin adherence, overall diabetes self-management, and glycemic control among adults with early type 2 diabetes (T2DM) enrolled in the GRADE study.

METHODS

Linear regression models examined cross-sectional associations of baseline depression symptoms and diabetes distress with adherence to metformin, self-management, and HbA1c, adjusting for covariates. Cognitive-affective (e.g., sadness) and somatic (e.g., sleep/appetite disturbance) depression symptoms and diabetes distress subscales were also examined.

RESULTS

This substudy of 1,739 GRADE participants (56 % Non-Hispanic White, 18 % Non-Hispanic Black, 17 % Hispanic, 68 % male, mean[SD] age = 57.96[10.22] years, diabetes duration = 4.21[2.81] years, and HbA1c = 7.51[0.48]) found that the prevalence of clinically significant depression and diabetes distress was 8.7 % and 25 %, respectively. Fully adjusted models showed that depression symptoms were associated with lower self-management (p < 0.0001); this effect was only significant for somatic symptoms. Diabetes distress was associated with lower adherence (p = 0.0001) and self-management (p < 0.0001); effects were significant for all subscales, except physician-related distress. No significant relationships of total depression symptom severity or diabetes distress with HbA1c were found.

CONCLUSIONS

Depression symptoms and diabetes distress were robustly associated with problematic diabetes self-management among participants in GRADE. These findings highlight the need for routine assessment of depression symptoms and diabetes distress early in T2DM care.

Adjusted Cutoff Scores Increase Sensitivity of Depression Screening Measures in Adolescents With Type 1 Diabetes

OBJECTIVE

To measure the acceptability and diagnostic accuracy of commonly used depression screening measures to determine ideal cutoff scores that sensitively identify depressive disorders in adolescents with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

One hundred adolescents (12-17 years old) completed a reference standard, semistructured diagnostic interview and both long and short versions of five commonly used depression screening measures in the United States. To assess feasibility and acceptability, we used screener completion time and participant ratings, respectively. We used descriptive statistics, area under the receiver operating characteristic (ROC) curve analyses, and paired-sample area differences under the ROC curve to assess each measure's diagnostic validity against our reference standard and to determine ideal cutoff scores for this sample.

RESULTS

Adolescents had a mean age of 15.0 ± 1.7 years, time since T1D diagnosis of 6.0 ± 4.1 years, and glycated hemoglobin (HbA1c) of 8.9 ± 1.8%. Sixty percent of adolescents were male, 15% endorsed a current depressive disorder, and 15% endorsed lifetime suicidality. Measures demonstrated low sensitivity (0.33-0.67) to detect current depressive disorders using preexisting cutoff scores. However, adjusted cutoff scores increased sensitivity and reduced false negatives. All depression screening measures demonstrated "good" to "excellent" predictive validity, and the Children's Depression Inventory-2 Short version demonstrated significantly greater diagnostic accuracy than the Patient Health Questionnare-2 item version for adolescents.

CONCLUSIONS

Clinics should consider using screening measures with the greatest diagnostic accuracy as identified in this study and adjusting measure cutoff scores to increase sensitivity and reduce false negatives.

A Systematic Review and Meta-Analysis of the Prevalence and Risk Factors of Depression in Type 2 Diabetes Patients in China

Background

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in China. Depression in patients with T2DM interferes with blood glucose management, leads to poor treatment outcomes, and has a high risk of dementia and cardiovascular event. We conducted this systematic review and meta-analysis to evaluate the prevalence of depression in patients with T2DM in China and explore potential risk factors associated with depression in T2DM.

Methods

We conducted a literature search in MEDLINE/PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature Database (CBM), the China National Knowledge Infrastructure (CNKI), the Chinese Science and Technology Periodical Database (VIP), and the Wanfang Database from their inception to February 25, 2022 to include population-based, cross-sectional surveys that investigated the prevalence of depression in Chinese T2DM patients and studied possible risk factors. Gray literature and reference lists were also manually searched. We used the Agency for Healthcare Research and Quality methodology checklist to assess the risk of bias in the included studies. Two reviewers screened studies, extracted data, and evaluated the risk of bias independently. The primary outcome was the pooled prevalence of depression in Chinese T2DM patients, and the secondary outcomes included potential risk factors for depression in T2DM patients. R (version 3.6.1) and Stata (version 12.0) software were used for data synthesis.

Results

We included 48 reports that identified 108,678 subjects. Among the included reports, 4 were rated as low risk of bias, 40 moderate risks of bias, and 4 high risks of bias. The prevalence of depression in T2DM patients in China was 25.9% (95% CI 20.6%-31.6%). The prevalence of depression was higher in women (OR = 1.36, 95% CI 1.19-1.54), subjects ≥60 years (OR = 1.56, 95% CI 1.14-2.14), with a primary school or lower education (vs. middle or high school education (OR = 1.49, 95% CI 1.16 - 1.92); vs. college degree or higher education (OR = 1.84, 95% CI 1.16 - 2.92), with a duration of T2DM ≥ 10 years (OR = 1.68, 95% CI 1.11-2.54), with complications (OR = 1.90, 95% CI 1.53-2.36), insulin users (OR = 1.46, 95% CI 1.09-1.96) and individuals living alone (OR = 2.26, 95% CI 1.71-2.98). T2DM patients with current alcohol use had a lower prevalence of depression (OR = 0.70, 95% CI 0.58-0.86). Prevalence varied from 0.8 to 52.6% according to different instruments used to detect depression.

Conclusion

The prevalence of depression in T2DM patients is remarkable in China. Potential risk factors of depression in T2DM patients included women, age ≥ 60 years, low educational level, complications, duration of diabetes ≥ 10 years, insulin use, and living alone. High-quality epidemiological investigations on the prevalence of depression in Chinese T2DM patients are needed to better understand the status of depression in T2DM.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42020182979.

Can the management of depression in type 2 diabetes be democratized?

Both type 2 diabetes and depression are common and are projected to increase. There is increasing evidence for a bidirectional relationship between the two. Diabetes is a risk factor for depression; contrariwise, individuals with depression are at greater risk of developing diabetes. They are a burden for both the individual and the society. Co-existent depression worsens diabetic control because of obesity, insulin resistance and the adverse metabolic effects of anti-diabetes medicines. In addition, compliance to lifestyle measures required for diabetes is also compromised such as following a specific diet, taking proper medications on time, getting metabolic parameters assessed and maintaining a sleep cycle. Depression occurs in many grades; mild depression is more common in diabetes than frank or full-blown depression leading to suicide. Unfortunately, there are not enough trained and accessible mental health professionals such as psychologists or psychiatrists to deal with the increasing burden of depression in diabetes. Therefore, alternate models for management of mild to moderate depression are required. There is evidence that a team-approach by employing health care assistants can lower the risk of cardiac risk factors. INtegrating DEPrEssioN and Diabetes treatmENT study was carried out to determine whether the team-approach using non-health care professionals could be effective in managing mild to moderate depression and to study its effects on metabolic parameters among subjects with type 2 diabetes mellitus. The international study, carried out in four independent centers in India assessed the impact of a trained but not qualified non-psychiatrist in coordinating and forming a fulcrum between the patient, the family and the consultant endocrinologist/diabetologist. The interventions were fine-tuned to be culturally appropriate by qualitative interviews before they began. It was shown that the outcomes of both depression and diabetes could be improved by the employment of a clinical care coordinator. It is possible to scale up the studies to wider geographical areas and health-care organizations.

The prevalence of depression and its associated factors among patients with diabetes mellitus attending a tertiary clinic in Gaborone, Botswana

Background

Depression is one of the commonest co-existing medical conditions among patients with diabetes mellitus (DM). A bidirectional relationship between depression and DM exists, complicating glycaemic control leading to an increase in diabetic complications. There is a dearth of information regarding the prevalence of depression and associated factors among patients with DM in Botswana.

Aim

This study aimed to determine the prevalence of depression and associated factors among patients with DM. The study also assessed the association between depression and glycaemic control.

Setting

A tertiary diabetic referral clinic in Gaborone, Botswana.

Method

A sample of 260 randomly selected patients with DM was recruited in this cross-sectional study. Socio-demographic and clinical characteristics of the patients were collected using a case report form. Depression was evaluated using the Patient Health Questionnaire (PHQ)-9 scale. Multivariate regression analysis was used to determine factors significantly associated with depression.

Results

The mean age (standard deviation [s.d.]) of study participants was 58.4 (11.8) years, and the majority, 160/260 (61.5%), were females. The prevalence of depression was 30.4% and significantly associated with female sex (adjusted odds ratio [AOR] = 5.529, p-value = 0.004), three or more diabetes-related hospitalisations (AOR = 3.886, p-value = 0.049) and inversely associated with systolic blood pressure (SBP) ≥ 140 mmHg (AOR = 0.11, p-value = 0.001).

Conclusion

Depression is a common problem among patients with DM in our setting. Routine screening of depression in diabetic patients to enable early detection and treatment is recommended.

Effect of depression on progression to end-stage renal disease or pre-end-stage renal disease death in advanced diabetic nephropathy: A prospective cohort study of the Diabetes Study from the Center of Tokyo Women's Medical University

AIMS/INTRODUCTION

This study aimed to determine the effect of depression on the progression to end-stage renal disease (ESRD) and pre-ESRD death in patients with advanced diabetic nephropathy.

MATERIALS AND METHODS

This single-center prospective cohort study enrolled Japanese patients with type 2 diabetes and advanced diabetic nephropathy. The total Patient Health Questionnaire-9 score was used to evaluate depression at baseline and classified patients into: no, mild and severe depression groups. The outcomes were ESRD, defined as initiation of renal replacement therapy, and pre-ESRD death. The relationship between the severity of depression and these outcomes was analyzed using a competing risks model, defining each outcome as the competing risk of the other outcome.

RESULTS

Of the 486 patients with a mean estimated glomerular filtration rate of 37.1 ± 21.1 mL/min/1.73 m2 , 345 were men. During the median follow up of 4.4 years, 164 patients progressed to ESRD and 50 died. The cumulative incidence function of ESRD was significantly higher in the severe depression group (Gray's test, P = 0.003). The ESRD risk increased by 12.4% and 45.1% in patients with mild and severe depression, respectively, compared with those without depression, although these differences did not reach statistical significance in the multivariate subdistribution hazard model (P = 0.450 and 0.161, respectively). The cumulative incidence of death was similar for the study groups.

CONCLUSION

Depression potentially has a weak impact on progression to ESRD, however, the presence of comorbidities might have the possibility to reduce the effect of depression on the renal outcome in patients with advanced diabetic nephropathy.

Development and Validation of the Depression Inventory for Type 1 Diabetes (DID-1)

People with type 1 diabetes (T1D) are more likely to have depression than the general population and their prognosis is worse. Unfortunately, the characteristics of persons with T1D lead to inadequate screening for depression in this population. To aid in the detection of depression in this population, this study was undertaken to develop a depressive symptoms assessment instrument specific to patients with T1D and to examine its psychometric properties. A total of 207 people with T1D participated in this study. The reliability of the new scale was assessed using Cronbach’s alpha and the Spearman-Brown split-half coefficient. The Depression Inventory for type 1 Diabetes (DID-1), composed of 45 items on a Likert scale (1–7), shows high internal and temporal consistency, as well as adequate concurrent, convergent and discriminant validity. Factor analysis identified 7 factors (Symptoms of depression, Diminished interest, Hopelessness and dissatisfaction, Guilt, Fear, frustration and irritability, Defenselessness, and Interference in daily life) that explained 61.612% of the total variability. The cut-off score for diagnosis was set at 155 points. It was concluded that the DID-1 scale is a reliable, valid and useful tool for the assessment of depressive symptoms, eliminating the bias of other nonspecific diabetes scales.

Measurement invariance testing of the patient health questionnaire-9 (PHQ-9) across people with and without diabetes mellitus from the NHANES, EMHS and UK Biobank datasets

BACKGROUND

The prevalence of depression is higher among those with diabetes than in the general population. The Patient Health Questionnaire (PHQ-9) is commonly used to assess depression in people with diabetes, but measurement invariance of the PHQ-9 across groups of people with and without diabetes has not yet been investigated.

METHODS

Data from three independent cohorts from the USA (n=1,886 with diabetes, n=4,153 without diabetes), Quebec, Canada (n= 800 with diabetes, n= 2,411 without diabetes), and the UK (n=4,981 with diabetes, n=145,570 without diabetes), were used to examine measurement invariance between adults with and without diabetes. A series of multiple group confirmatory factor analyses were performed, with increasingly stringent model constraints applied to assess configural, equal thresholds, and equal thresholds and loadings invariance, respectively. One-factor and two-factor (somatic and cognitive-affective items) models were examined.

RESULTS

Results demonstrated that the most stringent models, testing equal loadings and thresholds, had satisfactory model fit in the three cohorts for one-factor models (RMSEA = .063 or below and CFI = .978 or above) and two-factor models (RMSEA = .042 or below and CFI = .989 or above).

LIMITATIONS

Data were from Western countries only and we could not distinguish between type of diabetes.

CONCLUSIONS

Results provide support for measurement invariance between groups of people with and without diabetes, using either a one-factor or a two-factor model. While the two-factor solution has a slightly better fit, the one-factor solution is more parsimonious. Depending on research or clinical needs, both factor structures can be used.

The Changing Nature of Mortality and Morbidity in Patients with Diabetes

The number of adults living with diabetes has increased substantially globally over the past 40 years, driven by a combination of increased age-standardized prevalence, population growth, aging, and increases in obesity prevalence. Patients with diabetes in high-income countries are living longer, with large declines in vascular disease mortality rates. This appears to be resulting in a diversification of cause of death, complications, and comorbidities that those with diabetes live with. This has large implications for prevention and management approaches, which should be reviewed to update the breadth of conditions that patients with diabetes are at excess risk of throughout their life. These trends have not yet been seen in low- and middle-income countries, where evidence is also more scarce.

An Empirical Study on Diabetes Depression over Distress Evaluation Using Diagnosis Statistical Manual and Chi-Square Method

Diabetes distress is an alternative disorder that is often associated with depression syndromes. Psychosocial distress is an alternative disorder that acts as a resistance to diabetes self-care management and compromises diabetes control. Yet, in Nigeria, the focus of healthcare centers is largely inclined toward the medical aspect of diabetes that neglects psychosocial care. In this retrospective study, specific distress was measured by the Diabetes Distress Screening (DDS) scale, and depression was analyzed by the Beck Depression Inventory (BDI) and Diagnosis Statistics Manual (DSM) criteria in type 2 diabetes mellitus (T2DM) patients of Northwestern Nigeria. Additionally, we applied the Chi-square test and linear regression to measure the forecast prevalence ratio and evaluate the link between the respective factors that further determine the odd ratios and coefficient correlations in five nonintrusive variables, namely age, gender, physical exercise, diabetes history, and smoking. In total, 712 sample patients were taken, with 51.68% male and 47.31% female patients. The mean age and body mass index (BMI) was 48.6 years ± 12.8 and 45.6 years ± 8.3. Based on the BDI prediction, 90.15% of patients were found depressed according to the DSM parameters, and depression prevalence was recorded around 22.06%. Overall, 88.20% of patients had DDS-dependent diabetes-specific distress with a prevalence ratio of 24.08%, of whom 45.86% were moderate and 54.14% serious. In sharp contrast, emotion-related distress of 28.96% was found compared to interpersonal (23.61%), followed by physician (16.42%) and regimen (13.21%) distress. The BDI-based matching of depression signs was also statistically significant with p < 0.001 in severe distress patients. However, 10.11% of patients were considered not to be depressed by DSM guidelines. The statistical evidence indicates that depression and distress are closely correlated with age, sex, diabetes history, physical exercise, and smoking influences. The facts and findings in this work show that emotional distress was found more prevalent. This study is significant because it considered several sociocultural and religious differences between Nigeria and large, undeveloped, populated countries with low socioeconomic status and excessive epidemiological risk. Finally, it is important for the clinical implications of T2DM patients on their initial screenings.

Cut-off points for Polish-language versions of depression screening tools among patients with Type 2 diabetes

AIMS

Screening tools can help improve the detection of depression in patients with diabetes, yet the psychometric properties of most translations of scales, which are originally published in English, have not been assessed. Thus we studied the screening performance of widely used depression measures.

METHOD

We applied the cut-off points of the English-language versions of the Beck Depression Inventory (BDI); Hospital Anxiety and Depression Scale (HADS); Depression in Diabetes Self-Rating Scale (DDS-RS); Brief Self-Rating Scale of Depression and Anxiety (BS-RSDA); and Problematic Areas in Diabetes Survey (PAID), all of which were used to assess diabetes-specific distress in a sample of 101 patients with Type 2 diabetes. The Mini International Neuropsychiatric Interview and the Hamilton Depression Rating Scale (HDRS) were used to diagnose depression.

RESULTS

When the English cut-off points were used, the tools had varied values of both sensitivity and specificity. When the best cut-off points were used, all measures had either very good or good sensitivity. Taking into account their length, the HADS and the BS-RSDA seem to be the best among the screening tools.

CONCLUSIONS

Effective initial diagnosis of depression in patients with diabetes during a routine medical visit requires the use of screening tools that have adequate cut-off points. The analyses presented in this article show that screening tools should be validated and the cut-off points that are used should be population-specific.

Diabetes-related distress and daily cortisol output in people with Type 2 diabetes

AIMS

Diabetes-related distress is common in Type 2 Diabetes and is linked with poor diabetes control. However, mechanisms underlying this association are unclear. One pathway that could be involved is neuroendocrine dysfunction, as Type 2 Diabetes is associated with altered diurnal cortisol output. This study investigated the link between diabetes-related distress and diurnal cortisol output.

METHODS

134 people with Type 2 Diabetes provided 5 cortisol samples over the course of a day. Multivariate linear regression models were used to assess whether overall and sub-domains of diabetes-related distress measured by the Diabetes Distress Scale, predicted cortisol parameters (waking cortisol, cortisol awakening response, cortisol slope and evening cortisol).

RESULTS

Physician-related distress was associated with greater waking (B = 2.747, p = .015) and evening cortisol (B = 1.375, p = .014), and a blunted cortisol awakening response (B = -3.472, p = .038) adjusting for age, sex, income, body mass index, smoking and time of awakening. No associations were detected for overall distress, emotional, interpersonal or regimen distress.

CONCLUSION

Physician-related distress was associated with alterations in daily cortisol output. Longitudinal research is required to understand how physician-related distress is associated with diurnal cortisol patterning over time.

Depression prevalence in Type 2 diabetes is not related to diabetes-depression symptom overlap but is related to symptom dimensions within patient self-report measures: a meta-analysis

AIM

Depression is common in Type 2 diabetes, yet rates vary. Overlap between symptoms of depression and diabetes may account for this variability in depression prevalence rates. We examined to what extent depression prevalence was a function of the proportion of depression-diabetes symptom overlap (items within symptom dimensions) and sample characteristics.

METHODS

Electronic and hand searching of published and unpublished works identified 147 eligible papers. Of 3656 screened, 147 studies (149 samples, N = 17-229 047, mean sample age 25.4-82.8 years, with 152 prevalence estimates), using 24 validated depression questionnaires were selected. Sample size, publication type, sample type, gender, age, BMI, HbA_1c , depression questionnaire and prevalence rates were extracted.

RESULTS

Prevalence rates ranged from 1.8% to 88% (mean = 28.30%) and were higher in younger samples, samples with higher mean HbA_1c and clinic samples. Diabetes-depression symptom overlap did not affect prevalence. A higher proportion of anhedonia, cognition, cognitive, negative affect and sleep disturbance symptoms, and a lower proportion of somatic symptoms were consistently associated with higher depression prevalence.

CONCLUSIONS

The lack of an overall effect of diabetes-depression symptom overlap might suggest that assessment of depression in Type 2 diabetes is generally not confounded by co-occuring symptoms. However, questionnaires with proportionally more or fewer items measuring other symptom categories were associated with higher estimates of depression prevalence. Depression measures that focus on the cardinal symptoms of depression (e.g. negative affect and cognition), limiting symptoms associated with increasing diabetes symptomatology (e.g. sleep disturbance, cognitive) may most accurately diagnose depression.

Effect of Telephone-Delivered Collaborative Goal Setting and Behavioral Activation vs Enhanced Usual Care for Depression Among Adults With Uncontrolled Diabetes: A Randomized Clinical Trial

IMPORTANCE

Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care.

OBJECTIVE

To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat.

INTERVENTIONS

Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status.

MAIN OUTCOMES AND MEASURES

Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures.

RESULTS

Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01).

CONCLUSIONS AND RELEVANCE

Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01572389.

Assessing screening instruments and thresholds to detect risk of depression in diabetes patients, a brief report

Over the last decades several self-report instruments have been developed to identify diabetes at risk for depression. In a sample of diabetes outpatients, we assessed the accuracy of three widely-used instruments, and recommend the instruments with the best sensitivity and specificity for identifying diabetes in need of early treatment for depression.

Diagnostic accuracy of depression questionnaires in adult patients with diabetes: A systematic review and meta-analysis

BACKGROUND

Comorbid depression is common among patients with diabetes and has severe health consequences, but often remains unrecognized. Several questionnaires are used to screen for depression. A systematic review and meta-analysis regarding the diagnostic accuracy of depression questionnaires in adults with diabetes is unavailable. Our aim was to conduct a systematic review and meta-analysis to evaluate the diagnostic accuracy of depression questionnaires in adults with type 1 or type 2 diabetes.

METHODS

PubMed, Embase and PsycINFO were searched from inception to 28 February 2018. Studies were included when the diagnostic accuracy of depression questionnaires was assessed in a diabetes population and the reference standard was a clinical interview. Data extraction was performed by one reviewer and checked by another. Two reviewers independently conducted the quality assessment (QUADAS-2). Diagnostic accuracy was pooled in bivariate random effects models. The main outcome was diagnostic accuracy, expressed as sensitivity and specificity, of depression questionnaires in an adult diabetes population. This study is reported according to PRISMA-DTA and is registered with PROSPERO (CRD42018092950).

RESULTS

A total 6,097 peer-reviewed articles were screened. Twenty-one studies (N = 5,703 patients) met the inclusion criteria for the systematic review. Twelve different depression questionnaires were identified, of which the CES-D (n = 6 studies) and PHQ-9 (n = 7 studies) were the most frequently evaluated. Risk of bias was unclear for multiple domains in the majority of studies. In the meta-analyses, five (N = 1,228) studies of the CES-D (≥16), five (N = 1,642) of the PHQ-9 (≥10) and four (N = 822) of the algorithm of the PHQ-9 were included in the pooled analysis. The CES-D (≥16) had a pooled sensitivity of 85.0% (95%CI, 71.3-92.8%) and a specificity of 71.6% (95%CI, 62.5-79.2%); the PHQ-9 (≥10) had a sensitivity of 81.5% (95%CI, 57.1-93.5%) and a specificity of 79.7% (95%CI, 62.1-90.4%). The algorithm for the PHQ-9 had a sensitivity of 60.9% (95%CI, 52.3-90.8%) and a specificity of 64.0% (95%CI, 53.0-93.9%).

CONCLUSIONS

This review indicates that the CES-D had the highest sensitivity, whereas the PHQ-9 had the highest specificity, although confidence intervals were wide and overlapping. The algorithm for the PHQ-9 had the lowest sensitivity and specificity. Given the variance in results and suboptimal reporting of studies, further high quality studies are needed to confirm the diagnostic accuracy of these depression questionnaires in patients with diabetes.

Randomized Trial of a Tailored Cognitive Behavioral Intervention in Type 2 Diabetes With Comorbid Depressive and/or Regimen-Related Distress Symptoms: 12-Month Outcomes From COMRADE

OBJECTIVE

This study evaluated the effect of cognitive behavioral therapy (CBT) plus lifestyle counseling in primary care on hemoglobin A_1c (HbA_1c) in rural adult patients with type 2 diabetes (T2D) and comorbid depressive or regimen-related distress (RRD) symptoms.

RESEARCH DESIGN AND METHODS

This study was a randomized controlled trial of a 16-session severity-tailored CBT plus lifestyle counseling intervention compared with usual care. Outcomes included changes in HbA_1c, RRD, depressive symptoms, self-care behaviors, and medication adherence across 12 months.

RESULTS

Patients included 139 diverse, rural adults (mean age 52.6 ± 9.5 years; 72% black; BMI 37.0 ± 9.0 kg/m²) with T2D (mean HbA_1c 9.6% [81 mmol/mol] ± 2.0%) and comorbid depressive or distress symptoms. Using intent-to-treat analyses, patients in the intervention experienced marginally significant improvements in HbA_1c (-0.92 ± 1.81 vs. -0.31 ± 2.04; P = 0.06) compared with usual care. However, intervention patients experienced significantly greater improvements in RRD (-1.12 ± 1.05 vs. -0.31 ± 1.22; P = 0.001), depressive symptoms (-3.39 ± 5.00 vs. -0.90 ± 6.17; P = 0.01), self-care behaviors (1.10 ± 1.30 vs. 0.58 ± 1.45; P = 0.03), and medication adherence (1.00 ± 2.0 vs. 0.17 ± 1.0; P = 0.02) versus usual care. Improvement in HbA_1c correlated with improvement in RRD (r = 0.3; P = 0.0001) and adherence (r = -0.23; P = 0.007).

CONCLUSIONS

Tailored CBT with lifestyle counseling improves behavioral outcomes and may improve HbA_1c in rural patients with T2D and comorbid depressive and/or RRD symptoms.

Is It Distress, Depression, or Both? Exploring Differences in the Diabetes Distress Scale and the Patient Health Questionnaire in a Diabetes Specialty Clinic

IN BRIEF Patients (n = 314) completed the Patient Health Questionnaire and the Diabetes Distress Scale as part of standard care. Although most patients (70.4%) had no symptoms of depression or diabetes-related distress, 23.9% scored high on the distress questionnaire in at least one of its four domains. Regular screening for distress related to the demands of living with diabetes is crucial in identifying and preventing poor health outcomes associated with diabetes-related distress.

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.

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.

Type 2 diabetes and influence of diabetes-specific distress on depression

AIMS

Common psycho-social emotional reactions of patients with diabetes may be termed as diabetes-specific distress which is conceptually distinctive from depression. In patients with type 2 diabetes, different screening methods for depression may get influenced by simultaneous presence of diabetes distress. This study was planned to assess magnitude and relationship of depression and diabetes specific distress in patients with type 2 diabetes.

METHODS

Two hundred and fifty (250) adult patients with type 2 diabetes (T2DM) were assessed for depression based on Beck Depression Inventory (BDI) and Diagnostic and Statistical Manual, Fourth edition (DSM IV) criteria. Diabetes specific distress was assessed as per Diabetes Distress Scale (DDS) score.

RESULTS

Among study population of 250 adult T2DM patients, based on BDI score, 97 (38.8%) patients were found to suffer from depression and based on DSM IV criteria, prevalence of depression was 29.2%. A total of 62 (24.8%) patients were found to suffer from diabetes specific distress based on DDS score. Patients with severe diabetes specific distress had associated matching of symptoms with mild depression based on BDI score which was also statistically significant (p < 0.0001). However, these same individuals were non-depressed as per DSM-IV criteria.

CONCLUSION

Recognizing depression with self-administered questionnaires may be influenced by concomitant presence of symptoms due to diabetes specific distress. Therefore, proper diagnosis of depression may be established by structured clinical interview and psycho-social management of type 2 diabetes should possibly include both assessment of depression and diabetes specific distress.

Clinical risk factors for depressive syndrome in Type 2 diabetes: the Fremantle Diabetes Study

AIMS

To identify early clinical predictors of depressive syndrome in people with Type 2 diabetes.

METHODS

Depressive syndrome was assessed in 325 individuals with Type 2 diabetes 15 years after a baseline assessment, which included information on antidepressant use and depressive symptoms obtained using a quality-of-life scale. Follow-up current and lifetime depressive syndrome were assessed using the nine-item Patient Health Questionnaire and the Brief Lifetime Depression Scale and taking account of antidepressant use. Analyses were conducted inclusive and exclusive of antidepressant use where Patient Health Questionnaire criteria were not met.

RESULTS

At baseline, the participants were aged 57.2±9.3 years and the median (interquartile range) diabetes duration was 2.2 (0.6-6.0) years. After a mean of 14.7±1.1 years' follow-up, 81 participants (24.9%) had depressive syndrome (14.8% defined by the Patient Health Questionnaire, 10.2% defined by antidepressants) and 31.4% reported lifetime depression, and in 10.2% of participants this preceded diabetes onset. With logistic regression (inclusive of antidepressants), follow-up depressive syndrome was negatively associated with education level [odds ratio 0.39 (95% CI 0.20-0.75)] and antidepressant use [odds ratio 0.11 (95% CI 0.03-0.36)] and was positively associated with depression history before diabetes onset [odds ratio 2.79 (95% CI 1.24-6.27)]. In the model exclusive of antidepressants, depressive syndrome was positively associated with baseline depressive symptoms [odds ratio 2.57 (95% CI 1.32-5.03)] and antidepressant use [odds ratio 3.54 (95% CI 1.20-10.42)] and was negatively associated with education level [odds ratio 0.39 (95% CI 0.19-0.81)].

CONCLUSIONS

Risk factors for depressive syndrome can be identified early after the onset of Type 2 diabetes. The early presence of depressive symptoms or its treatment and/or history of depression are likely indicators of vulnerability. Early risk stratification for late depressive syndrome is feasible in people with Type 2 diabetes and could assist with depression treatment or prevention.

Psychoeducation against depression, anxiety, alexithymia and fibromyalgia: a pilot study in primary care for patients on sick leave

OBJECTIVES

Feasibility testing of a psychoeducational method -The Affect School and Script Analyses (ASSA) - in a Swedish primary care setting. Exploring associations between psychological, and medically unexplained physical symptoms (MUPS).

DESIGN

Pilot study.

SETTING

Three Swedish primary care centers serving 20,000 people.

INTERVENTION

8 weekly 2-hour sessions with a 5-7 participant group led by two instructors - followed by 10 individual hour-long sessions.

SUBJECTS

Thirty-six patients, 29 women (81%), on sick-leave due to depression, anxiety, or fibromyalgia.

OUTCOME MEASURES

Feasibility in terms of participation rates and expected improvements of psychological symptoms and MUPS, assessed by self-report instruments pre-, one-week post-, and 18 months post-intervention. Regression coefficients between psychological symptoms and MUPS.

RESULTS

The entire 26-hour psychoeducational intervention was completed by 30 patients (83%), and 33 patients (92%) completed the 16-hour Affect School. One-week post-intervention median test score changes were significantly favorable for 27 respondents, with p < .05 after correction for multiple testing for 9 of 11 measures (depression, anxiety, alexithymia, MUPS, general health, self-affirmation, self-love, self-blame, and self-hate); 18 months post intervention the results remained significantly favorable for 15 respondents for 7 of 11 measures (depression, alexithymia, MUPS, general health, self-affirmation, self-love, and self-hate).

CONCLUSIONS

A psychoeducational method previously untested in primary care for mostly women patients on sick-leave due to depression, anxiety, or fibromyalgia had >80% participation rates, and clear improvements of self-assessed psychological symptoms and MUPS. The ASSA intervention thus showed adequate feasibility in a Swedish primary care setting. Key Points  A pilot study of a psychoeducational intervention - The Affect School and Script Analyses (ASSA) - was performed in primary care   • The intervention showed feasibility for patients on sick-leave due to depression, anxiety, or fibromyalgia   • 92% completed the 8 weeks/16 hours Affect School and 83% completed the entire 26-hour ASSA intervention   • 9 of 11 self-reported measures improved significantly one-week post intervention   • 7 of 11 self-reported measures improved significantly 18 months post-intervention.

The utility of the Diabetes Anxiety Depression Scale in Type 2 diabetes mellitus: The Fremantle Diabetes Study Phase II

BACKGROUND

Previous research using latent class analysis (LCA) identified classes of people with type 2 diabetes and specific profiles of depression and anxiety. Since LCA-derived anxious depression strongly predicts cardiovascular outcomes and mortality but cannot be applied to individuals, we developed a validated combined depression-anxiety metric, the Diabetes Anxiety Depression Scale (DADS), for potential clinical application in people with type 2 diabetes.

METHODS

1,337 participants with type 2 diabetes from the observational community-based Fremantle Diabetes Study Phase II completed the Patient Health Questionnaire 9-item version (PHQ-9) to assess symptoms of depression, and the Generalised Anxiety Disorder Scale (GADS) to assess symptoms of anxiety. A single score was calculated by adding all the PHQ-9 items and the four GADS items used for the LCA. Cut-off scores were calculated with Receiver Operating Characteristic (ROC) area under the curve (AUC).

RESULTS

The optimum cut-off scores in terms of sensitivity, specificity, positive and negative predictive value were 18 points for major anxious depression and 8 points for minor anxious depression. A score of 8-17 was associated with a significantly increased incidence of coronary heart disease, whereas a score 18-39 was associated with an increase in both coronary heart disease and cardiovascular mortality.

CONCLUSIONS

The DADS has strong psychometric validity in the identification of mixed depression-anxiety in type 2 diabetes, and may contribute to cardiovascular risk prediction.

Measurement properties of depression questionnaires in patients with diabetes: a systematic review

Purpose

To conduct a systematic review on measurement properties of questionnaires measuring depressive symptoms in adult patients with type 1 or type 2 diabetes.

Methods

A systematic review of the literature in MEDLINE, EMbase and PsycINFO was performed. Full text, original articles, published in any language up to October 2016 were included. Eligibility for inclusion was independently assessed by three reviewers who worked in pairs. Methodological quality of the studies was evaluated by two independent reviewers using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Quality of the questionnaires was rated per measurement property, based on the number and quality of the included studies and the reported results.

Results

Of 6286 unique hits, 21 studies met our criteria evaluating nine different questionnaires in multiple settings and languages. The methodological quality of the included studies was variable for the different measurement properties: 9/15 studies scored ‘good’ or ‘excellent’ on internal consistency, 2/5 on reliability, 0/1 on content validity, 10/10 on structural validity, 8/11 on hypothesis testing, 1/5 on cross-cultural validity, and 4/9 on criterion validity. For the CES-D, there was strong evidence for good internal consistency, structural validity, and construct validity; moderate evidence for good criterion validity; and limited evidence for good cross-cultural validity. The PHQ-9 and WHO-5 also performed well on several measurement properties. However, the evidence for structural validity of the PHQ-9 was inconclusive. The WHO-5 was less extensively researched and originally not developed to measure depression.

Conclusion

Currently, the CES-D is best supported for measuring depressive symptoms in diabetes patients.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1782-y) contains supplementary material, which is available to authorized users.

Systematic review with meta-analysis: the impact of a depressive state on disease course in adult inflammatory bowel disease

BACKGROUND

Despite a higher prevalence of psychosocial morbidity in Inflammatory Bowel Disease (IBD), the association between depressive state and disease course in IBD is poorly understood.

AIM

To investigate the impact of depressive state on disease course in IBD.

METHODS

We conducted a systematic review in MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and PsychINFO for prospective studies evaluating the impact of baseline depressive state on subsequent disease course in adult IBD.

RESULTS

Eleven studies matched our entry criteria, representing 3194 patients with IBD. Three reported on patients with ulcerative colitis (UC), four included patients with Crohn's disease (CD) exclusively, and four studies included both UC and CD. Five studies reported an association between depressive state and disease course. None of the UC-specific studies found any association. In three of four CD-specific studies, a relationship between depressive state and worsening disease course was found. In four of five studies including patients in remission at baseline, no association between depressive state and disease course was found. Pooled analysis of IBD studies with patients in clinical remission at baseline identified no association between depressive state and disease course (HR 1.04, 95%CI: 0.97-1.12).

CONCLUSION

There is limited evidence to support an association between depressive state and subsequent deterioration in disease course in IBD, but what data that exist are more supportive of an association with CD than UC. Baseline disease activity may be an important factor in this relationship. Further studies are needed to understand the relationship between mental health and outcomes in IBD.

Diabetes Distress or Major Depressive Disorder? A Practical Approach to Diagnosing and Treating Psychological Comorbidities of Diabetes

The presence of major depressive disorder (MDD) in people with diabetes may be up to three times more common than in the general population. People with diabetes and major depressive disorder have worse health outcomes and higher mortality rates. Diabetes distress refers to an emotional state where people experience feelings such as stress, guilt, or denial that arise from living with diabetes and the burden of self-management. Diabetes distress has also been linked to worse health outcomes. There are multiple treatment options for MDD including pharmacotherapy and cognitive behavioral approaches. Providers treating patients with diabetes must be aware of the frequent comorbidity of diabetes, diabetes distress, and depression and manage patients using a multidisciplinary team approach. This article discusses the epidemiology, pathophysiology, and bi-directional relationship of diabetes and depression and provides a practical, patient-centered approach to diagnosis and management.

Tangled Up in Blue: Unraveling the Links Between Emotional Distress and Treatment Adherence in Type 2 Diabetes

OBJECTIVE

We conducted comprehensive assessments of emotional distress to examine relations with diabetes medication adherence over time.

RESEARCH DESIGN AND METHODS

Ethnically and socioeconomically diverse adults treated for type 2 diabetes completed validated self-reports (SRs) for diabetes distress and depression, were administered semistructured depression interviews, and provided blood samples for A1C. Medication adherence among 104 participants was electronically monitored (EM) over the subsequent 3 months; validated SRs of medication adherence were also obtained. Hierarchical linear regression evaluated independent effects of diabetes distress and depression on adherence.

RESULTS

Mean ± SD 3-month medication adherence was 76.1% ± 25.7% for EM and 83.7% ± 21.9% for SR. Higher levels of SR (P < 0.001) and interview-based (P < 0.05) depressive symptom severity (P < 0.05) and diabetes-related distress (P < 0.01) showed a significant bivariate association with EM and SR nonadherence. Regression models showed baseline diabetes distress was a significant independent predictor of EM (β = -0.29; P = 0.001) and SR adherence (β = -0.24; P < 0.02) at follow-up. SR depression was an independent predictor of EM and SR adherence and reduced the effects of diabetes distress to nonsignificance. Subsequent models indicated this effect was driven by somatic rather than cognitive-affective symptoms of depression. Results were consistent but weaker for interview-based depressive symptoms.

CONCLUSIONS

Findings support diabetes-related distress and depression symptom severity as risk factors for type 2 diabetes medication nonadherence. Somatic symptoms captured by depression measures, but not cognitive-affective symptoms, independently predict nonadherence and should be further investigated as a potential link between emotional distress and nonadherence.

Prevalence of depression in Type 1 diabetes and the problem of over-diagnosis

AIMS

To determine the prevalence of depression and diabetes distress in adults with Type 1 diabetes and the rate of false-positives when compared with rates of major depressive disorder.

METHODS

The sample consisted of 368 individuals with Type 1 diabetes, aged > 19 years. Individuals completed: the eight-item Patient Health Questionnaire depression scale (PHQ8), which was coded using four scoring criteria (scores > 10, >12 and >15, and Diagnostic and Statistical Manual of Mental Disorders 5 (DSM) algorithm scores); the Type 1 Diabetes Distress Scale; and the Structured Clinical Interview for DSM Disorders (SCID) to assess major depressive disorder.

RESULTS

The prevalence rates of depression according to the eight-item Patient Health Questionnaire were: score >10, 11.4%; score >12, 7.1%; score >15, 3.8%; and positive algorithm result, 4.6%. The prevalence of major depressive disorder was 3.5%; and the prevalence of at least moderate diabetes distress was 42.1%. Depending on the criterion used, the false-positive rate when using the Patient Health Questionnaire compared with the results when using the SCID varied from 52 to 71%. Of those classified as depressed on the PHQ-8 or Structured Clinical Interview for DSM Disorders, between 92.3 and 96.2% also reported elevated diabetes distress. No significant association was found between any group classed as having depression according to the PHQ8 or the SCID and HbA_1c concentration. Depression was significantly associated with more other life stress, more complications and a lower level of education.

CONCLUSIONS

We found an unexpectedly low rate of current depression and major depressive disorder in this diverse sample of adults with Type 1 diabetes, and a very high rate of false-positive results using the Patient Health Questionnaire. Considering the high prevalence of diabetes distress, much of what has been considered depression in adults with Type 1 diabetes may be attributed to the emotional distress associated with managing a demanding chronic disease and other life stressors and not necessarily to underlying psychopathology.

Adiposity is inversely associated with hippocampal volume in African Americans and European Americans with diabetes

AIMS

To assess associations between body mass index (BMI), waist circumference (WC), and computed tomography-determined volumes of pericardial, visceral, and subcutaneous adipose tissue with magnetic resonance imaging-(MRI) based cerebral structure and cognitive performance in individuals with type 2 diabetes (T2D).

METHODS

This study was performed in 348 African Americans (AAs) and 256 European Americans (EAs) with T2D. Associations between adiposity measures with cerebral volumes of white matter (WMV), gray matter (GMV), white matter lesions, hippocampal GMV, and hippocampal WMV, cognitive performance and depression were examined using marginal models incorporating generalized estimating equations. All models were adjusted for age, sex, education, smoking, HbA1c, hypertension, statins, cardiovascular disease, MRI scanner (MRI outcomes only), and time between scans; some neuroimaging measures were additionally adjusted for intracranial volume.

RESULTS

Participants were 59.9% female with mean (SD) age 57.7(9.3)years, diabetes duration 9.6(6.8)years, and HbA1c 7.8(1.9)%. In AAs, inverse associations were detected between hippocampal GMV and both BMI (β [95% CI]-0.18 [-0.30, -0.07], P=0.0018) and WC (-0.23 [-0.35, -0.12], P=0.0001). In the full bi-ethnic sample, inverse associations were detected between hippocampal WMV and WC (P≤0.0001). Positive relationships were observed between BMI (P=0.0007) and WC (P<0.0001) with depression in EAs.

CONCLUSIONS

In patients with T2D, adiposity is inversely associated with hippocampal gray and white matter volumes.

Comorbid Anxiety and Depression and Their Impact on Cardiovascular Disease in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

BACKGROUND

The aims were to determine whether anxious depression, defined by latent class analysis (LCA), predicts cardiovascular outcomes in type 2 diabetes and to compare the predictive power of anxious depression with Diagnostic & Statistical Manual Versions IV and 5 (DSM-IV/5) categories of depression and generalized anxiety disorder (GAD).

METHODS

Prospective observational study of 1,337 type 2 participants. Baseline assessment with the 9-item Patient Health Questionnaire and the GAD Scale; LCA-defined groups with minor or major anxious depression based on anxiety and depression symptoms. Cox modeling used to compare the independent impact of: (1) LCA anxious depression, (2) DSM-IV/5 depression, (3) GAD on incident cardiovascular events and deaths after 4 years.

RESULTS

LCA minor and major anxious depression was present in 21.9 and 7.8% of participants, respectively, DSM-IV/5 minor and major depression in 6.2 and 6.1%, respectively, and GAD in 4.8%. There were 110 deaths, 31 cardiovascular deaths, and 199 participants had incident cardiovascular events. In adjusted models, minor anxious depression (Hazard ratio (95% confidence intervals): 1.70 (1.15-2.50)) and major anxious depression (1.90 (1.11-3.25)) predicted incident cardiovascular events and major anxious depression also predicted cardiovascular mortality (4.32 (1.35-13.86)). By comparison, incident cardiovascular events were predicted by DSM-IV/5 major depression (2.10 (1.22-3.62)) only and cardiovascular mortality was predicted by both DSM-IV/5 major depression (3.56 (1.03-12.35)) and GAD (5.92 (1.84-19.08)).

CONCLUSIONS

LCA-defined anxious depression is more common than DSM-IV/5 categories and is a strong predictor of cardiovascular outcomes in type 2 diabetes. These data suggest that this diagnostic scheme has predictive validity and clinical relevance.

Prevalence of depression in patients with type 2 diabetes attended in primary care in Spain

OBJECTIVES

To estimate the prevalence of known and undiagnosed depression in patients with type 2 diabetes attended in primary care setting in Spain, and to determine the factors associated with the presence of depression.

METHODS

This was a cross-sectional and multicenter study performed in a random sample of patients with type 2 diabetes attended in 21 primary care centers. Depressive symptoms were measured with the self-administered Patient Health Questionnaire (PHQ-9).

RESULTS

A total of 411 patients were analyzed (mean age 70.8 (SD 10.3) years; 53.8% women). 29.2% of patients met the diagnostic criteria of depression, of whom 17% had known depression and 12.2% undiagnosed depression (PHQ-9 score ≥10, without a previous diagnosis of depression). Depression was more common in women (43.4%; 95% confidence interval [CI] 34.5-52.3%), widow (33.3%; 95% CI 27.9-38.7%), and hypothyroidism (12.5%; 95% CI 8.7-16.3%). Cardiovascular risk factors, the degree of control, complications related to diabetes, antidiabetic therapy and the number of drugs were not associated with the presence of depression.

CONCLUSIONS

The prevalence of depression was high in patients with type 2 diabetes. However, in approximately 40% of patients depression was undiagnosed. The complications related to diabetes and antidiabetic therapy were not associated with the presence of depression.

Mood and metabolism: Anhedonia as a clinical target in Type 2 diabetes

Epidemiological evidence suggests a bidirectional relationship between depression and Type 2 diabetes mellitus. In Type 2 diabetes, depression affects behavioural factors such as diet and physical activity that promote positive energy balance and influence diabetes outcomes. Examinations of depressive symptoms by dimension have suggested that anhedonia, the inability to anticipate, seek, choose and enjoy reward, may be of particular clinical importance. Structural and functional brain changes in Type 2 diabetes distributed throughout the principally dopaminergic reward circuitry suggest a neurobiological basis for motivational and decisional aspects of anhedonia. Interrelated neuroendocrine, bio-energetic, oxidative and inflammatory changes suggest mechanisms underlying neuronal damage and dopaminergic deficits. A consequential shift in effort-related reward choices and their effects on energy expenditure, self-care and eating behaviours is suggested to affect Type 2 diabetes outcomes. The clinical implications for screening and psychopharmacology of depressive symptoms in people with Type 2 diabetes are discussed.

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

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

Elucidating the Biological Mechanisms Linking Depressive Symptoms With Type 2 Diabetes in Men: The Longitudinal Effects of Inflammation, Microvascular Dysfunction, and Testosterone

OBJECTIVE

This prospective cohort study sought to examine key biological measures linking depressive symptoms with Type 2 diabetes, specifically inflammation, microvascular dysfunction, and androgens.

METHODS

A cohort of 688 men without diabetes who were 35 years or older were followed up for 5 years. Venous interleukin-6, high-sensitivity C-reactive protein, sE-selectin, endogenous total testosterone, fasting glucose, and glycated hemoglobin (HbA1c) were quantified at baseline and 5 years later. Depressive symptoms were assessed using the Beck Depression Inventory-I, and men were categorized into persistent, remitted, incident, and nondepressed groups (reference). Logistic regression was used to determine odds ratios (ORs) for diabetes adjusted for propensity score calculated from 18 established risk factors.

RESULTS

Diabetes developed in 112 men (16.3% of sample). Persistent depressive symptoms were associated with diabetes (adjusted OR = 2.45, 95% confidence interval [CI] = 1.16-5.20, p = .019). Baseline testosterone (OR = 0.43, 95% CI = 0.22-0.81, p = .01) and follow-up testosterone (OR = 0.51, 95% CI = 0.31-0.84, p = .008) were inversely associated with Type 2 diabetes. Annualized HbA1c was positively associated with annualized change in cognitive Beck Depression Inventory symptoms (β = 0.14, p = .001) and inversely associated with annualized change in testosterone (β = -0.10, p = .014). Annualized change in fasting glucose was associated with sE-selectin (β = 0.12, p < .001) and somatic depressive symptoms (β = -0.12, p = .002).

CONCLUSIONS

The findings suggest that lower endogenous total testosterone levels and persistent depressive symptoms were associated with Type 2 diabetes risk and HbA1c in men over a 5-year period.

Lifetime depression history and depression risk in type 2 diabetes: A case-control study

AIMS

To assess whether a personal history of depression assists in risk prediction for depression in type 2 diabetes.

METHODS

Age- and sex-matched participants with and without diabetes from the Busselton Health Survey were assessed for current and previous depression using the 9-item Patient Health Questionnaire and the Brief Lifetime Depression Scale (BLDS). In the diabetic participants, the temporal relationship between first depression episode and diabetes onset was also explored.

RESULTS

In 184 paired participants (age 70.2±10.1years, 50% female), those with diabetes had a higher prevalence of any current depression (12.5% vs 4.3%, P<0.01) and lifetime history of major depression (30.6% vs 21.1%, P=0.06) compared to those without diabetes. After adjustment, lifetime major depression history was independently associated with any current depression in the combined sample (odds ratio (95% CI): 5.55 (3.09-9.98), P<0.001), in those with diabetes (4.17 (2.00-8.71), P<0.001), in those without diabetes (8.29 (3.24-21.23), P<0.001) and in diabetes whether sub-divided by depression first occurring before or after diabetes onset (before: 3.16 (1.38-7.24), P=0.007; after: 2.77 (1.00-7.70), P=0.051).

CONCLUSIONS

Obtaining a lifetime history of major depression using the BLDS assists in depression risk prediction in type 2 diabetes regardless of whether depression preceded diabetes onset or not.

Socioeconomic status and glycemic control in adult patients with type 2 diabetes: a mediation analysis

OBJECTIVE

The purpose of this study is to examine the contribution of health behaviors (self-management and coping), quality of care, and individual characteristics (depressive symptoms, self-efficacy, illness representations) as mediators in the relationship between socioeconomic status (SES) and glycemic control.

METHODS

A sample of 295 adult patients with type 2 diabetes was recruited at the end of a diabetes education course. Glycemic control was evaluated through glycosylated hemoglobin (HbA1c). Living in poverty and education level were used as indicators of SES.

RESULTS

Bootstrapping analysis showed that the significant effects of poverty and education level on HbA1c were mediated by avoidance coping and depressive symptoms. The representation that diabetes is unpredictable significantly mediated the relationship between living in poverty and HbA1c, while healthy diet mediated the relationship between education level and HbA1c.

CONCLUSIONS

To improve glycemic control among patients with low SES, professionals should regularly screen for depression, offering treatment when needed, and pay attention to patients' illness representations and coping strategies for handling stress related to their chronic disease. They should also support patients in improving their self-management skills for a healthy diet.

Longitudinal relationship of diabetes-related distress and depressive symptoms: analysing incidence and persistence

AIM

To investigate the longitudinal bi-directionality of diabetes-related distress and depressive symptoms.

METHODS

A total of 509 patients receiving intensified insulin therapy completed the Centre for Epidemiological Studies Depression scale questionnaire for the assessment of depressive symptoms as well as the Problem Areas in Diabetes questionnaire for the assessment of diabetes-related distress at baseline and at 6-month follow-up. Separate logistic and linear regression analyses for incidence and persistence were performed with demographic (age, gender, BMI) and medical (diabetes type, HbA1c , diabetes duration, late complications) control variables.

RESULTS

Diabetes-related distress at baseline increased the risk of the incidence of elevated depressive symptoms by 2.56-fold (odds ratio 2.56; 95% CI 1.15-5.72; P = 0.02) when controlling for demographic and medical variables. In addition, diabetes-related distress at baseline doubled the chance of the persistence of elevated depressive symptoms (odds ratio 2.04, 95% CI 1.04-3.99; P = 0.04) when controlling for demographic and medical variables. The chance of having persistent elevated diabetes-related distress was increased 5.94-fold (odds ratio 5.94, 95% CI 2.60-13.59; P < 0.0001) when elevated depressive symptoms were present at baseline. None of the medical variables had an influence on incidence or persistence.

CONCLUSIONS

Diabetes-related distress was identified as a risk factor for the incidence and persistence of depressive symptoms. Reducing diabetes-related distress could help to prevent the development of elevated depressive symptoms. Furthermore, depressive symptoms were identified as an amplifier for diabetes-related distress. Diabetes-related distress and depressive symptoms were independent risk factors for each other and should be monitored in routine care to disentangle their influence.

Relationships between Cognitive Performance, Neuroimaging and Vascular Disease: The DHS-MIND Study

BACKGROUND

Type 2 diabetes mellitus increases the risk of cognitive decline and dementia, and elevated burdens of vascular disease are hypothesized to contribute to this risk. These relationships were examined in the Diabetes Heart Study-MIND using a battery of cognitive tests, neuroimaging measures and subclinical cardiovascular disease (CVD) burden assessed by coronary artery calcified (CAC) plaque. We hypothesized that CAC would attenuate the association between neuroimaging measures and cognition performance.

METHODS

Associations were examined using marginal models in this family-based cohort of 572 European Americans from 263 families. All models were adjusted for age, gender, education, type 2 diabetes and hypertension, with some neuroimaging measures additionally adjusted for intracranial volume.

RESULTS

Higher total brain volume was associated with better performance on the Digit Symbol Substitution Task and Semantic Fluency (both p ≤ 7.0 × 10(-4)). Higher gray matter volume was associated with better performance on the Modified Mini-Mental State Examination and Semantic Fluency (both p ≤ 9.0 × 10(-4)). Adjusting for CAC caused minimal changes to the results.

CONCLUSIONS

Relationships exist between neuroimaging measures and cognitive performance in a type 2 diabetes-enriched European American cohort. Associations were minimally attenuated after adjusting for subclinical CVD. Additional work is needed to understand how subclinical CVD burden interacts with other factors and impacts relationships between neuroimaging and cognitive testing measures.

The INTERPRET-DD study of diabetes and depression: a protocol

AIM

People with diabetes are at an increased risk of developing depression and other psychological disorders. However, little is known about the prevalence, correlates or care pathways in countries other than the UK and the USA. A new study, the International Prevalence and Treatment of Diabetes and Depression Study (INTERPRET-DD) aims to address this dearth of knowledge and identify optimal pathways to care across the globe.

METHOD

INTERPRET-DD is a 2-year longitudinal study, taking place in 16 countries' diabetes outpatients' facilities, investigating the recognition and management of depressive disorders in people with Type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognized (undocumented) depression on clinical outcomes and emotional well-being are being investigated.

RESULTS

Initial evidence indicates that a range of pathways to care exist, with few of them based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both the symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use.

CONCLUSIONS

Our study will increase the understanding of the impact of comorbid diabetes and depression and identify the most appropriate (country-specific) pathways via which patients receive their care. It addresses an important public health problem and leads to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with comorbid diabetes and depression.

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.

Apathy in older patients with type 2 diabetes

OBJECTIVE

To determine the prevalence, incidence, persistence, likely causes, and consequences of apathy in patients with Type 2 diabetes and to compare the prevalence with a healthy control sample.

DESIGN

Cross-sectional comparison of diabetic and nondiabetic samples; longitudinal follow-up of diabetic sample.

SETTING

Academic research department.

PARTICIPANTS

Non-demented, older patients with long-standing Type 2 diabetes (N = 122) recruited from a community-based cohort study and 69 healthy volunteers.

MEASUREMENTS

Clinical assessments of apathy and potential causative conditions, repeated in the diabetic sample after 16.7 ± 2.5 months. Informant rated symptoms from the 14-item Apathy Scale were used to generate apathy diagnoses based on standardized criteria. Cognition was assessed by Mini-Mental State Examination (MMSE) and Clinical Dementia Rating (CDR).

RESULTS

The diabetic and comparison samples had the same age and MMSE scores, but the diabetic sample had a higher frequency of depression, cerebrovascular history, and cognitive deficits. Apathy was more prevalent in diabetes (diabetic 13.9% versus control sample 1.4%, p = 0.005) and was independently associated with CDR 0.5 status (OR [95% CI]: 3.66 [1.25-19.70]) and depression (8.48 [2.74-26.21]). In 108 diabetic patients who were followed up, incident apathy occurred in 7.4% of cases, and persisted in 50% of those with baseline apathy. Baseline apathy was independently associated with lnHbA1c levels (β: 0.20, t = 2.29, df = 119, p = 0.024; model R(2) = 0.10) and incident/persistent apathy was associated with greater risk of cognitive decline (6.72 [1.19-37.87]).

CONCLUSION

Apathy is a frequent neuropsychiatric syndrome in older patients with Type 2 diabetes, and is associated with poor glycaemic control and cognitive decline.

Depression in persons with diabetes by age and antidiabetic treatment: a cross-sectional analysis with data from the Hordaland Health Study

BACKGROUND

Persons with diabetes have increased risk of depression, however, studies addressing whether the risk varies by age and type of antidiabetic treatment have yielded conflicting results. The aim of this study was to investigate if the association between diabetes and depression varied by type of antidiabetic treatment in a large community based sample of middle-aged (40-47 years) and older adults (70-72 years).

METHODS

Data from 21845 participants in the Hordaland Health Study (HUSK) were analyzed in a cross-sectional design. Diabetes was assessed by self-report and classified as un-medicated, treated by oral antidiabetic agents or by insulin. Depression was defined as a score ≥ 8 on the depression subscale of the Hospital Anxiety and Depression Scale and/or self-reported use of antidepressant agents. Associations between diabetes and depression were estimated using logistic regression.

RESULTS

Persons in their forties with diabetes had a doubled prevalence of depression (OR: 1.96 (95% C.I.: 1.35, 2.83)) compared to persons without diabetes, while a lower and non-significant association was found among persons in their seventies. Persons in their forties with orally treated diabetes had about three times higher prevalence of depression (OR: 2.92 (95% C.I.: 1.48, 5.77)) after adjustment for gender, BMI, physical activity, alcohol consumption and education, compared to non-diabetic persons in the same age-group. No association between depression and insulin or un-medicated diabetes was found.

CONCLUSIONS

Clinicians should be aware that persons in their forties with orally treated diabetes are at a marked increased risk of depression.

A new measure of multimorbid illness and treatment representations: the example of diabetes and depression

BACKGROUND

Depression is two to three times more common in people with diabetes than in the general population. Although multimorbid diabetes and depression is associated with poor health outcome, existing research has focused on patients׳ understanding and management of each condition in isolation. This study describes the development and validation of the Diabetes and Depression Representation and Management Questionnaire (DDRMQ), a measure of understanding, management and medication beliefs in people with diabetes and depression.

METHODS

In Study 1, DDRMQ items were developed through further analysis of an earlier qualitative study and refined through 18 cognitive interviews. In Study 2, 334 adults with diabetes and depression from general practices, diabetes clinics and support groups completed the DDRMQ, demographic questions and validating measures.

RESULTS

Factor analysis of the DDRMQ using principal axis factoring resulted in a 35 item scale organised into ten subscales. The modified measure had adequate internal and test-retest reliability. Initial evidence of construct validity was also demonstrated.

LIMITATIONS

Low participant response rates and the high percentage of well-educated white participants limit the generalisability of results. As Study 2 was cross-sectional, future research is needed to establish if different ways of thinking about and managing diabetes and depression can predict patient outcome.

CONCLUSIONS

The DDRMQ is the first measure of patient understanding, management and medication beliefs in people with established diagnoses of both diabetes and depression. The DDRMQ will facilitate an increased awareness of the patient experience of diabetes and depression and help inform patient centred care and intervention development for people with multiple conditions.