Investigation of anxiety and depression symptom co-morbidity in a community sample with type 2 diabetes: Associations with indicators of self-care

Transcultural adaptation and theoretical models validation of the Spanish version of the Self-Care of Diabetes Inventory

Background

For patients with diabetes mellitus, self-care is crucial because it prevents complications and helps preserve quality of life. Clinicians and researchers require effective tools for assessing self-care behaviors across various dimensions to identify individual needs and maximize resource allocation. The aim of this study was to evaluate the validity and reliability of the Spanish version of the Self-Care of Diabetes Inventory (SCODI).

Methods

Two hundred eighteen participants with DMT1 and DMT2 who were recruited through convenience sampling from a university hospital participated in our cross-sectional study. After translation and cultural adaptation, the enrolled patients answered the questions. We performed an exploratory factor analysis (EFA) on each of the SCODI scales and Confirmatory factor analysis (CFA) was performed using our models which appropriate fit indices.

Results

The original structure of the four-dimensions tool was confirmed. The overall consistency across the four scales was assessed by Cronbach's alpha: self-care maintenance (0.766), self-care monitoring (0.790), self-care management (0.771), and self-care confidence (0.936). The model fit yielded a chi-square index of 1.028 with 773 degrees of freedom. Confirmatory factor analysis showed a good fit, thereby affirming the reliability of the model.

Conclusion

The internal consistency and reliability of the SCODI Spanish version are deemed adequate. This tool is appropriate when it is desired to evaluate the self-care practices of Spanish persons suffering from diabetes due to its good psychometric qualities.

The relationship between patient empowerment and related constructs, affective symptoms and quality of life in patients with type 2 diabetes: a systematic review and meta-analysis

Introduction

The aim of this systematic review is to assess the relationship between patient empowerment and other empowerment-related constructs, and affective symptoms and quality of life in patients with type 2 diabetes.

Methods

A systematic review of the literature was conducted, according to the PRISMA guidelines. Studies addressing adult patients with type 2 diabetes and reporting the association between empowerment-related constructs and subjective measures of anxiety, depression and distress, as well as self-reported quality of life were included. The following electronic databases were consulted from inception to July 2022: Medline, Embase, PsycINFO, and Cochrane Library. The methodological quality of the included studies was analyzed using validated tools adapted to each study design. Meta-analyses of correlations were performed using an inverse variance restricted maximum likelihood random-effects.

Results

The initial search yielded 2463 references and seventy-one studies were finally included. We found a weak-to-moderate inverse association between patient empowerment-related constructs and both anxiety (r = -0.22) and depression (r = -0.29). Moreover, empowerment-related constructs were moderately negatively correlated with distress (r = -0.31) and moderately positively correlated with general quality of life (r = 0.32). Small associations between empowerment-related constructs and both mental (r = 0.23) and physical quality of life (r = 0.13) were also reported.

Discussion

This evidence is mostly from cross-sectional studies. High-quality prospective studies are needed not only to better understand the role of patient empowerment but to assess causal associations. The results of the study highlight the importance of patient empowerment and other empowerment-related constructs such as self-efficacy or perceived control in diabetes care. Thus, they should be considered in the design, development and implementation of effective interventions and policies aimed at improving psychosocial outcomes in patients with type 2 diabetes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020192429, identifier CRD42020192429.

Effects of structured exercises on selected psychological domains in individuals with type 2 diabetes mellitus in Southern Ethiopia institution-based study

Background

Psychological disorders are common among individuals with type 2 diabetes mellitus. The effect of exercise training on psychological disorders like anxiety and depression has not been well studied in Ethiopia. The objective of this study was to assess the effect of structured aerobic and resistance exercises on psychological domains among people with type 2 diabetes mellitus in southern Ethiopia.

Method

We began by approaching 97 type 2 diabetic patients who regularly attend follow-up clinics. The 24 study participants were randomly assigned to one of four groups: aerobic exercise (n = 6), resistance exercise (n = 6), combined aerobic and resistance exercise (n = 6), and control group (n = 6). For each arm, the interventions were a structured workout package that was completed without interrupting usual clinical follow-up. The control groups, on the other hand, were kept as follow-up clinical cases with daily routine work. A paired t-test was performed to compare the means and mean differences of each exercise group’s pretest and posttest. A Tukey’s post hoc test was performed to compare mean differences between groups. The significance level was set at P < 0.05.

Result

A more significant change was obtained in the combined aerobic and resistance exercise on anxiety and depression (p = 0.006), social dysfunction (p = 0.009), loss of confidence (p = 0.012) in particular, and psychological wellbeing (p = 0.010) in general. Resistance exercise alone had a significant impact on social dysfunction (p = 0.010), anxiety and depression (p = 0.017), and psychological well-being (p = 0.012) in general. Changes in social dysfunction (p = 0.010), anxiety and depression (p = 0.030), and psychological well-being (p = 0.018) were also influenced by aerobic exercise. The study found no significant change in depression and anxiety among control groups.

Conclusion

As a result, the combined effect of aerobic and resistance exercise had a greater influence on improving anxiety and depression, social dysfunction, loss of confidence in particular, and psychological well-being in general among patients with type 2 diabetes. In other words, the present evidence proves the betterment of combined aerobic and resistance exercises alone followed by resistance exercise alone and aerobic exercise alone compared with non-exercise groups seems to upgrade psychological wellbeing by setting up three main benefits named as: (1) anti-anxiety and depression effects; (2) anti-social dysfunction effects; and (3) anti-loss of confidence effects. This suggests that patients with diabetes who exercise regularly enhance their psychological well-being.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00574-3.

Prevalence of Mental Health Disorders among Elderly Diabetics and Associated Risk Factors in Indonesia

This cross-sectional study aimed to explore mental health disorders (MHD) prevalence among elderly diabetics in Indonesia. Data were extracted from the 2018 national basic health survey in Indonesia (abbreviated as RISKESDAS). The survey involved households randomly selected from 34 provinces, 416 districts, and 98 cities in Indonesia, with 1,017,290 respondents. The number of subjects selected in this study was 2818 elderly diabetic subjects. MHD was determined by self-reporting assessment. Secondary data acquired from RISKESDAS 2018 data involved age, sex, urban–rural residence status, marital status, educational level, employment status, obesity, hypertension, heart disease, stroke, family history of MHD, and DM duration. Binary logistic regression with a backward stepwise method was used to analyze the risk factors related to MHD. MHD prevalence among elderly diabetics in Indonesia was 19.3%. Factors associated with MHD among elderly diabetics were being female (prevalence odds ratio (POR) = 1.64; 95% CI: 1.126–2.394), married (POR = 0.05; 95% CI: 0.031–0.084), less education (POR = 3.37; 95% CI: 1.598–10.355), and stroke (POR = 1.61; 95% CI: 1.183–2.269). MHD prevalence among elderly diabetics in Indonesia was 19.3%, suggesting that screening for psychological problems and educating elderly diabetic patients is essential. Unmarried female elderly diabetics with less education and stroke were altogether more likely to experience MHD.

Psychosocial and cognitive multimorbidity and health-related quality of life and symptom burden in older adults with atrial fibrillation: The systematic assessment of geriatric elements in atrial fibrillation (SAGE-AF) cohort study

Background:

Depression, anxiety, and cognitive impairments occur in up to 40 % of adults with AF and are associated with poorer health-related quality of life (HRQoL) and higher symptom burden. However, it is unknown how often these impairments co-occur, or multimorbidity, and how multimorbidity effects HRQoL and symptom burden.

Methods:

Patients with AF age ≥65 years with a CHA₂DS₂VASC risk score ≥ 2 and eligible for oral anticoagulation therapy were recruited from five clinics in a prospective cohort study. Participants completed validated measures of depression (PHQ9) and anxiety (GAD7), cognitive impairment (MoCA), and HRQOL and AF symptom burden (AFEQT). Multinomial logistic regression was used.

Results:

Participants (N = 1244, 49 % female) were on average 76 ± 7 years; 86 % were non-Hispanic white. Approximately 35 % of participants had 1 impairment, 17 % had 2 impairments and 8% had 3 impairments; 39 % had none of the 3 impairments examined. Compared to participants with no impairments, patients with 1, 2 and 3 impairments had higher odds of poor HRQoL (adjusted OR [AOR] = 1.77, 95 % CI 1.21, 2.60; AOR = 6.64, 95 % CI 4.43, 9.96; and AOR = 7.50, 95 % CI 4.40, 12.77, respectively) and those with 2 and 3 impairments had higher odds of high symptom burden (AOR = 3.69 95 % CI 2.22, 6.13; and AOR = 5.41 95 % CI 2.85, 10.26).

Conclusions:

Psychosocial/cognitive multimorbidity is common among older adults with AF and is associated with poor HRQoL and high symptom burden. Clinicians might consider incorporating psychosocial and cognitive screens into routine care as this may identify a high-risk population.

Association between subthreshold depression and self-care behaviours in adults with type 2 diabetes: A protocol for a cross-sectional study

AIMS AND OBJECTIVES

To examine the association between subthreshold depression and self-care behaviours in adults with type 2 diabetes (T2D) attending a tertiary healthcare service.

BACKGROUND

Diabetes is a global public health problem. Self-care behaviours are a fundamental element in managing diabetes as adherence to self-care activities is associated with improved glycaemic control. Depression in T2D is associated with decreased adherence to self-care behaviours. Adults with subthreshold depression in diabetes may have difficulties in achieving metabolic control. Further, people with subthreshold depression have an increased risk of developing major depression. Few studies have examined the association between subthreshold depression and self-care behaviours.

DESIGN

A cross-sectional study.

METHODS

The study will be conducted among 384 adults diagnosed with T2D for at least a year attending their routine outpatient appointment at Tribhuvan University Teaching Hospital in Nepal. Convenience sampling will be used to recruit study participants. Data will be collected via face-to-face interviews and a medical record review. Self-care behaviours will be assessed using the Summary of Diabetes Self-care activities and subthreshold depression will be determined using the Patient Health Questionnaire- 9. Covariates in the study include sociodemographic and clinical factors, diabetes knowledge, perceived social support and self-efficacy. This paper complies with the STROBE reporting guideline for cross-sectional studies.

RESULTS

We will use multiple linear regression to examine the association between subthreshold depression and each self-care behaviours (i.e. diet, physical activity, foot care, blood glucose testing and medication) and total self-care behaviour.

CONCLUSIONS

Effective management of diabetes requires adherence to self-care behaviours. The findings of the study will help in identifying an effective way to improve diabetes self-care.

RELEVANCE TO CLINICAL PRACTICE

Our observations will inform nursing research and practice by providing evidence about how subthreshold depression may influence self-care behaviours.

Effect of Study Design and Survey Instrument to Identify the Association Between Depressive Symptoms and Physical Activity in Type 2 Diabetes, 2000-2018: A Systematic Review

Introduction

Previous studies have used a variety of survey measurement options for evaluating the association between physical activity (PA) and depressive symptoms, raising questions about the types of instruments and their effect on the association. This study aimed to identify measures of PA and depressive symptoms and findings of their association given diverse instruments and study characteristics in type 2 diabetes (T2DM).

Methods

Online databases, Medline, Embase, CINAHL, and PsycINFO were searched on July 20, 2018, and January 8, 2019. Our systematic review included observational studies from 2000 to 2018 that investigated the association between PA and depressive symptoms in T2DM.

Results

Of 2294 retrieved articles, 28 studies were retained in a focused examination and comparison of the instruments used. There were a range of standard measures, 10 for depressive symptoms and 7 for PA, respectively. Patient Health Questionnaire (PHQ) for depressive symptoms and study-specific methods for PA were the most popular. Overall, 71.9% found a significant association between PA and depressive symptoms. Among studies classified as high quality or reliability, the figure was 81.8%.

Conclusion

A majority of the sample found an association between depressive symptoms and PA, which is fairly consistent across study characteristics. The findings provide the evidence for the health benefits of PA on reducing depressive symptoms in persons with T2DM, suggesting active engagement in PA for effective diabetes management. However, guidelines for objective measurements and well-designed prospective studies are needed to strengthen the evidence base and rigor for the association and its directionality.

Self-care research: Where are we now? Where are we going?

BACKGROUND AND OBJECTIVE

The beneficial effects of self-care include improved well-being and lower morbidity, mortality, and healthcare costs. In this article we address the current state of self-care research and propose an agenda for future research based on the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019. The vision of this Center is a world where self-care is prioritized by individuals, families, and communities and is the first line of approach in every health care encounter. The mission of the Center is to lead the self-care research endeavor, improving conceptual clarity and promoting interdisciplinary work informed by a shared vision addressing knowledge gaps. A focused research agenda can deepen our theoretical understanding of self-care and the mechanisms underlying self-care, which can contribute to the development of effective interventions that improve outcomes.

METHODS

During conference discussions, we identified seven major reasons why self-care is challenging, which can be grouped into the general categories of behavior change and illness related factors. We identified six specific knowledge gaps that, if addressed, may help to address these challenges: the influence of habit formation on behavior change, resilience in the face of stressful life events that interfere with self-care, the influence of culture on self-care behavioral choices, the difficulty performing self-care with multiple chronic conditions, self-care in persons with severe mental illness, and the influence of others (care partners, family, peer supporters, and healthcare professionals) on self-care.

PLANS TO ACHIEVE RESULTS

To achieve the vision and mission of the Center, we will lead a collaborative program of research that addresses self-care knowledge gaps and improves outcomes, create a supportive international network for knowledge transfer and support of innovations in self-care research, and support and train others in self-care research. Beyond these specific short-term goals, important policy implications of this work are discussed.

Comorbid elevated symptoms of anxiety and depression in adults with type 1 or type 2 diabetes: Results from the International Diabetes MILES Study

AIMS

We examined: (a) the prevalence of comorbid elevated symptoms of anxiety/depression; (b) its demographic/clinical correlates; (c) associations with self-care behaviors, by diabetes type.

METHODS

Cross-sectional self-report data of 6590 adults with diabetes (42% type 1; 58% type 2) from the Australian and Dutch Diabetes MILES studies were used. Elevated symptoms of anxiety/depression were defined as GAD-7 ≥ 10/PHQ-9 ≥ 10.

RESULTS

In both diabetes types, comorbid elevated symptoms of anxiety/depression were present in 9% and symptoms of anxiety alone in 2%; symptoms of depression alone were present in 8% of adults with type 1 diabetes and 11% with type 2 diabetes. Shorter diabetes duration (type 1 only) was the only characteristic that distinguished those with comorbid elevated symptoms of anxiety/depression but not those with symptoms of anxiety/depression alone from the reference group (no/minimal symptoms of anxiety/depression). Those with comorbid elevated symptoms of anxiety/depression had increased odds of sub-optimal diabetes self-care behaviors compared with the reference group, with higher odds than those with symptoms of anxiety or depression alone.

CONCLUSIONS

Comorbid elevated symptoms of anxiety/depression affected one in ten respondents, who also had increased odds of suboptimal diabetes self-care. Those with shorter type 1 diabetes duration may be at increased risk.

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.

The role of concordant and discordant comorbidities on performance of self-care behaviors in adults with type 2 diabetes: a systematic review

Background: Most patients with Type 2 diabetes (T2D) have high number of comorbid chronic conditions that can affect their self-care abilities. Guidelines for diabetes self-care behaviors are disease specific with little attention given to managing T2D with other comorbidities. Identifying comorbidities that either improve or potentially diminish the individual's capacity to perform effective self-care behaviors is essential to enhance clinical outcomes. One such framework conceptualizes comorbidities as concordant or discordant with diabetes pathophysiological pathways and care goals. Objective: The purpose of this systematic review was to examine the role of diabetes-concordant and discordant chronic conditions on the performance of self-care behaviors in adults with T2D. Methods: A comprehensive literature search was undertaken to identify published English language articles through the following five electronic databases: PubMed, CINAHL, PsycINFO, ISI Web of Science, and EMBASE. Quantitative studies published from March 2006 to April 2018 were included. Quality of evidence was evaluated using the Joanna Briggs Institutes Critical Appraisal Tools (JBI-CAT) and rated using Quality Assessment Tool for Quantitative Studies (QATQS). Results: The initial database search identified 1,136 articles but only 33 studies that met the inclusion criteria were included. The most common concordant comorbidity was hypertension while depression was the most common discordant condition. Adherence to medications was the most frequent diabetes self-care behavior reported and tended to be higher among concordant comorbidities. The findings showed mixed results concerning the effect of some concordant comorbidities such as hypertension, hyperlipidemia, retinopathy, and heart failure on diabetes self-care behaviors. But, there is agreement across studies that diabetes-discordant comorbidities have a more detrimental effect on self-care behaviors. Conclusions: Concordant comorbidities may improve diabetes self-care, but the evidence is inconclusive. Future research using well designed studies are needed to examine the complex relationship between diabetes self-care and comorbidities.

Comorbid depressive and anxiety symptoms and the risk of type 2 diabetes: Findings from the Lifelines Cohort Study

BACKGROUND

Prior studies indicate that depression is a risk factor for type 2 diabetes (T2D), though there is considerable heterogeneity in reported estimates. Identifying homogeneous subgroups of depression strongly associated with T2D may be beneficial. This study examined associations between depression and anxiety comorbidity with the risk of T2D.

METHODS

78,025 participants from the Lifelines Cohort Study (age range = 30-75 years) without diabetes at baseline were included in this study. The Mini-International Neuropsychiatric Interview assessed depressive and anxiety symptoms at baseline. Incident T2D was assessed by self-report or hemoglobin A1c levels during an approximately 3.8-year follow-up period. Risk of T2D was compared across four groups (no depressive or anxiety symptoms, depressive symptoms alone, anxiety symptoms alone, comorbid depressive/anxiety symptoms) using mixed effects logistic regression analyses adjusted for sociodemographic, lifestyle, and cardiometabolic characteristics.

RESULTS

1,096 participants developed diabetes. Compared to those without depressive or anxiety symptoms (n = 74,467), those with comorbid depressive and anxiety symptoms (n = 743) were more likely to develop T2D (n = 28, OR = 2.12, 95% CI = 1.22-3.68). Depressive symptoms alone (n = 650) and anxiety symptoms alone (n = 2,165) were not significantly associated with T2D (n = 23 and n = 24, respectively, developed diabetes). Those with comorbid symptoms were also more likely to develop T2D compared to those with depressive symptoms alone (OR = 2.86, 95% CI = 1.25-6.54).

LIMITATIONS

Depressive and anxiety symptom assessments were based on a screening tool. Hemoglobin A1c data were only available for a subset of participants.

CONCLUSIONS

Depression with comorbid anxiety may be a subgroup of depression that is strongly associated with the risk of T2D.

Gaps in health behaviours and use of preventive services between patients with diabetes and the general population: a population-based cross-sectional study

OBJECTIVES

Although both the prevalence and treatment rate of diabetes have increased, the degree of adherence to healthy behaviours by patients with diabetes has not yet been comprehensively evaluated. This study examines the differences in health management and mental health status according to diabetes status and awareness of that diagnosis.

METHODS

This was a cross-sectional study of 14 655 people using data from the Korean National Health and Nutrition Examination Study 2010-2012, which used sampling weights. Multiple logistic regression analyses were used to compare health-risk behaviours, preventive healthcare utilisation and mental health status according to diabetes diagnosis and awareness of the disease.

RESULTS

Compared with people without diabetes, people with diabetes had comparably worse smoking status (adjusted OR (aOR) 1.09, 95% CI 0.92 to 1.30), insufficient physical activity (aOR 1.09, 95% CI 0.95 to 1.24) and were less likely to receive cancer screenings and regular health check-ups (aOR 0.75, 95% CI 0.66 to 0.85). Furthermore, compared with people unaware of their diabetes, people aware of their diabetes had lower odds of physical inactivity (aOR 0.66, 95% CI 0.45 to 0.99) and greater odds of receiving colon cancer screening (aOR 1.55, 95% CI 1.17 to 2.05) and influenza vaccination (aOR 1.56, 95% CI 1.15 to 2.11).

CONCLUSIONS

People with diabetes were no better in terms of health behaviours and preventive healthcare utilisation than those who were without diabetes. Further efforts and political attention to ensure the delivery of quality care for people with diabetes are needed.

Associations among comorbid anxiety, psychiatric symptomatology, and diabetic control in a population with serious mental illness and diabetes: Findings from an interventional randomized controlled trial

Objective Serious mental illness and type II diabetes mellitus have a high comorbidity, and both have a higher prevalence of anxiety disorders compared to the general population. Targeted Training in Illness Management is a group-based self-management training approach which targets serious mental illness and type II diabetes mellitus concurrently. This analysis examines data from a randomized controlled trial of Targeted Training in Illness Management intervention to examine the impact of comorbid anxiety on baseline psychiatric symptomatology and diabetic control, and on longitudinal treatment outcomes. Methods We conducted secondary analyses on data from a prospective, 60-week, randomized controlled trial testing Targeted Training in Illness Management versus treatment as usual in 200 individuals with serious mental illness and diabetes. Primary outcomes included measures related to serious mental illness symptoms, functional status, general health status, and diabetes control. Measures were compared between those participants with anxiety disorders versus those without anxiety at baseline as well as over time using linear mixed effects analyses. Results Forty seven percent of the participants had one or more anxiety disorders. At baseline, those with an anxiety diagnosis had higher illness severity, depressive, and other psychiatric symptomatology and disability. Diabetic control (HbA1c) was not significantly different at baseline. In the longitudinal analyses, no significant mean slope differences over time (group-by-time interaction effect) between those with anxiety diagnoses and those without in treatment as usual group were found for primary outcomes. Within the Targeted Training in Illness Management arm, those with anxiety disorders had significantly greater improvement in mental health functioning. Those with anxiety comorbidity in the Targeted Training in Illness Management group demonstrated significantly lower HbA1c levels compared to no anxiety comorbidity and also demonstrated a greater improvement in HbA1c over the first 30 weeks compared to those without anxiety comorbidity. Conclusion Comorbid anxiety in serious mental illness and type II diabetes mellitus population is associated with increased psychiatric symptomatology and greater disability. Individuals from this population appear to experience greater improvement in functioning from baseline with the Targeted Training in Illness Management intervention. Anxiety comorbidity in the serious mental illness and type II diabetes mellitus population does not appear to have a negative impact on diabetic control. These complex relationships need further study. Clinical Trials Registration ClinicalTrials.gov: Improving outcomes for individuals with serious mental illness and diabetes (NCT01410357).

Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association

Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.