Underdiagnosed and undertreated depression among racially/ethnically diverse patients with type 2 diabetes

Mental health burdens among North American Asian adults living with chronic conditions: a systematic review

Asians are likely to experience a high burden of chronic conditions, including, but not limited to, diabetes, cardiovascular disease, and cancer, due to differences in biologic, genetic, and environmental factors across Asian ethnic groups. A diagnosis of any chronic condition can contribute to increased mental health burdens, including depression, psychological distress, and posttraumatic stress disorder (PTSD). However, few studies have examined these comorbid conditions across distinct Asian ethnic groups-an important limitation given the differences in social, cultural, and behavioral drivers of mental health burdens within and across Asian ethnicities. To understand the disparities in mental health burdens among Asians living with a chronic health condition, we conducted a systematic literature review of relevant, peer-reviewed publication databases to identify studies reporting on mental health burdens (e.g., depression, anxiety, distress, PTSD) in distinct Asian ethnic groups in North America. Thirteen studies met the inclusion criteria for this review and collectively demonstrated a high burden of depression, psychological distress, and PTSD among Asians living with chronic conditions. Moreover, there were distinct disparities in mental health burdens across chronic conditions and across Asian ethnic groups. Despite the detrimental impact of poor mental health on chronic disease-specific outcomes, such as death and poor quality of life, few data exist that characterize mental health outcomes among Asian ethnicities living in North America with chronic conditions. Future work should prioritize estimating the national prevalence of mental health outcomes among adults with chronic conditions, by Asian ethnicities, to inform culturally tailored interventions to address this public health burden.

Subjective and Performance-Based Cognition and Their Associations with Head Injury History in Older Former National Football League Players

PURPOSE

Investigate the association between self-reported subjective and performance-based cognition among older (50-70 years) former professional American football players, as well as the relationship of cognitive measures with concussion history and years of football participation, as a proxy for repetitive head impact exposure.

METHODS

Among older former National Football League (NFL) players ( N = 172; mean age = 60.69 ± 5.64), associations of subjective (Patient Reported Outcome Measurement Information System Cognitive Function-Short Form) and performance-based cognitive measures (Brief Test of Adult Cognition by Telephone [BTACT] Executive Function and Episodic Memory indices) were assessed via univariable and multivariable regression models, with a priori covariates of depression and race. A similar univariate and multivariable regression approach assessed associations between concussion history and years of football participation with subjective and performance-based cognitive measures. In a sample subset ( n = 114), stability of subjective cognitive rating was assessed via partial correlation.

RESULTS

Subjective ratings of cognition were significantly associated with performance-based assessment, with moderate effect sizes (episodic memory ηp2 = 0.12; executive function ηp2 = 0.178). These associations were weakened, but remained significant ( P s < 0.05), with the inclusion of covariates. Greater concussion history was associated with lower subjective cognitive function ( ηp2 = 0.114, P < 0.001), but not performance-based cognition. The strength of association between concussion history and subjective cognition was substantially weakened with inclusion of covariates ( ηp2 = 0.057). Years of participation were not associated with measures of subjective or objective cognition ( P s > 0.05).

CONCLUSIONS

These findings reinforce the importance of comprehensive evaluation reflecting both subjective and objective measures of cognition, as well as the consideration of patient-specific factors, as part of a comprehensive neurobehavioral and health assessment of older former contact sport athletes.

Impact of psychological impairment on quality of life and work impairment in severe asthma

BACKGROUND

Psychological impairment, such as anxiety and depression, is common in severe asthma. However, the impact of psychological impairment on asthma-specific quality of life (ASQOL) and work impairment has not been assessed within Southeast-Asia. Furthermore, previous ASQOL questionnaires contained items overlapping with asthma control, making it challenging to isolate the relationship between psychological impairment with ASQOL and asthma control, respectively.

OBJECTIVE

To evaluate the relationship between psychological impairment with ASQOL and work impairment in severe asthma.

METHODS

This is a cross-sectional study of severe asthma at Singapore General Hospital. We assessed ASQOL, psychological impairment, work impairment and asthma control using validated questionnaires. An ASQOL questionnaire not containing items evaluating asthma symptoms was selected to reduce overlap with asthma control. Medical records were used to obtain other asthma characteristics and healthcare utilization patterns.

RESULTS

Amongst 111 patients, 37% had psychological impairment based on Hospital Anxiety and Depression Scale. Poorer ASQOL was associated with anxiety (p = .013) after controlling for demographic characteristics, asthma control and comorbidities. Anxiety symptoms were associated with greater health concerns while depression symptoms were associated with sleep difficulty and physical limitations. Having depressive symptoms was associated with an additional 16% impairment of total work hours (p = .038). Psychological impairment was not associated with spirometry results or healthcare utilization. Ethnicity significantly predicted both ASQOL and work impairment.

CONCLUSIONS

In severe asthma, patients with psychological impairment have poorer ASQOL and greater work impairment than those without psychological impairment. There is an urgent need to mitigate this problem.

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.

Pharmacotherapeutic strategies for managing comorbid depression and diabetes

Introduction: The increasing prevalence of comorbid depression and diabetes exerts a heavy burden on global health. Co-occurrence of depression and diabetes is common, affecting 14% to 35.8% of patients with diabetes, leading to a higher mortality and morbidity rate, more micro- and macro-vascular diseases and more cognitive decline. Areas covered: In this paper, the authors address various areas from epidemiology, the association between depression and diabetes, treatment strategies and future directions based on the currently available literature to provide novel insight into the pharmacotherapeutic management of comorbid depression and diabetes. Expert opinion: Pharmacotherapy can help patients with comorbid depression and diabetes by relieving depressive symptoms and improving glycemic control. When combined with psychological therapy, as a collaborative care effort, pharmacological therapy based on selective serotonin reuptake inhibitors (SSRIs) is recommended for comorbid depression with diabetes. Furthermore, studies with larger sample sizes that can help to define different subtypes of diabetes and severity of depression are needed so that clinicians can draw up a precise and applicable management guidelines for the personalized therapy of these diseases.

Development and Implementation of Psychiatric Services in a Student-Operated Clinic

This article chronicles the development and implementation of Monday Psychiatry Clinic, a psychiatry component of a medical student-operated free clinic (The Monday Clinic) in Dallas, Texas, providing assessment data systematically collected in the clinic. The established clinical purpose of Monday Psychiatry Clinic is to assess common psychiatric disorders and refer patients in need to appropriate sources of care. This clinic provided leadership education and volunteering opportunities to medical students who learned to interact with patients with psychiatric concerns, established clinical interviewing skills, and became familiar with psychiatric diagnostic criteria. More than one-third of the patients screened positive for depression, alcohol, or drug problems, and one-fourth of the patients with a positive screen were diagnosed with one of these disorders. All patients with identified problems were referred for the appropriate level of care.

Design and content validation of a set of SMS to promote seeking of specialized mental health care within the Allillanchu Project

BACKGROUND

The aim of this study was to design and develop a set of, short message service (SMS) to promote specialized mental health care seeking within the framework of the Allillanchu Project.

METHODS

The design phase consisted of 39 interviews with potential recipients of the SMS, about use of cellphones, and perceptions and motivations towards seeking mental health care. After the data collection, the research team developed a set of seven SMS for validation. The content validation phase consisted of 24 interviews. The participants answered questions regarding their understanding of the SMS contents and rated its appeal.

RESULTS

The seven SMS subjected to content validation were tailored to the recipient using their name. The reminder message included the working hours of the psychology service at the patient's health center. The motivational messages addressed perceived barriers and benefits when seeking mental health services. The average appeal score of the seven SMS was 9.0 (SD±0.4) of 10 points. Participants did not make significant suggestions to change the wording of the messages.

CONCLUSIONS

Five SMS were chosen to be used. This approach is likely to be applicable to other similar low-resource settings, and the methodology used can be adapted to develop SMS for other chronic conditions.

Peruvian Mental Health Reform: A Framework for Scaling-up Mental Health Services

BACKGROUND

Mental, neurological, and substance (MNS) use disorders are a leading cause of disability worldwide; specifically in Peru, MNS affect 1 in 5 persons. However, the great majority of people suffering from these disorders do not access care, thereby making necessary the improvement of existing conditions including a major rearranging of current health system structures beyond care delivery strategies. This paper reviews and examines recent developments in mental health policies in Peru, presenting an overview of the initiatives currently being introduced and the main implementation challenges they face.

METHODS

Key documents issued by Peruvian governmental entities regarding mental health were reviewed to identify and describe the path that led to the beginning of the reform; how the ongoing reform is taking place; and, the plan and scope for scale-up.

RESULTS

Since 2004, mental health has gained importance in policies and regulations, resulting in the promotion of a mental health reform within the national healthcare system. These efforts crystallized in 2012 with the passing of Law 29889 which introduced several changes to the delivery of mental healthcare, including a restructuring of mental health service delivery to occur at the primary and secondary care levels and the introduction of supporting services to aid in patient recovery and reintegration into society. In addition, a performance-based budget was approved to guarantee the implementation of these changes. Some of the main challenges faced by this reform are related to the diversity of the implementation settings, eg, isolated rural areas, and the limitations of the existing specialized mental health institutes to substantially grow in parallel to the scaling-up efforts in order to be able to provide training and clinical support to every region of Peru.

CONCLUSION

Although the true success of the mental healthcare reform will be determined in the coming years, thus far, Peru has achieved a number of legal, policy and fiscal milestones, thereby presenting a unique and fertile environment for the expansion of mental health services.

Contributors to Patients' Ratings of Quality of Care Among Ethnically Diverse Patients with Type 2 Diabetes

We examined racial/ethnic differences in patients' ratings of components of interpersonal quality [participatory decision making (PDM) style, being treated as an equal partner, and feelings of trust], and evaluated the association between each of these components and patients' ratings of overall healthcare quality among non-Hispanic white (NHW), Vietnamese American, and Mexican American patients with type 2 diabetes. The findings indicated that although all three components were significantly associated with ratings of overall healthcare quality, the significant interactions between race/ethnicity and both PDM style (β = -0.09, p < 0.01) and equal partner (β = -0.06, p < 0.05) for the Vietnamese American patients suggested that the relationship between these components and patients' ratings of healthcare quality were less strong among Vietnamese American patients than among the NHW patients. Understanding racial/ethnic differences in the components of interpersonal quality that are associated with patients' ratings of overall healthcare quality is an important step for improving patients' experiences of their own care.

Comparison of integrated behavioral health treatment for internalizing psychiatric disorders in patients with and without Type 2 diabetes

INTRODUCTION

Type 2 diabetes is often comorbid with internalizing mental health disorders and associated with greater psychiatric treatment resistance. Integrating psychotherapy into primary care can help treat internalizing disorders generally. We explored whether such treatment had comparable effectiveness in patients with and without Type 2 diabetes.

METHOD

Participants were 468 consecutive adults (23% male; 62% Hispanic, Mage = 41.46 years) referred by medical staff for psychotherapy appointments to address internalizing symptoms (e.g., depression). After each visit, patients completed a self-report measure and clinicians assessed patient symptom severity. These data and demographics extracted from electronic medical records were analyzed using descriptive and multilevel modeling analyses.

RESULTS

Patients with and without diabetes were similar in types of internalizing disorders experienced and baseline clinician- and self-reported symptomology. Multilevel modeling suggested improvements in self-reported symptomology was comparable across patient groups; however, only patients without diabetes significantly improved according to clinician reports.

DISCUSSION

Although findings suggested integrated psychotherapy resulted in comparable patient-reported reductions of internalizing symptoms, these effects were not evident in clinician reports of diabetic patients. Possible reasons for this discrepancy (e.g., reporting biases) are discussed. Integrated psychotherapy for internalizing disorders may be effective for Type 2 diabetic patients, though caution is warranted. (PsycINFO Database Record

Racial/Ethnic Differences in Predictors of Mental Health Treatment in Persons with Comorbid Diabetes and Depression

Diabetes and depression are two of the most frequently diagnosed health conditions in the United States and often co-occur. The present study examines racial/ethnic differences in predictors of mental health service use among a national sample of African Americans, Hispanics, and non-Hispanic Whites with a self-reported diabetes and depression diagnosis. Multiple logistic regression was used to analyze a cross-sectional sample (N = 3377) of the 2012 National Health Interview Survey (NHIS), a nationally representative, cross-sectional survey. African Americans were less likely to have visited a mental health professional in the last 12 months (odds ratio [OR] = .634, confidence interval [CI] [0.429, 0.911]). Significant odds ratios also uncovered results for the "never married" (OR = 1.737, CI [1.322, 2.281]) category. Also for the entire sample, being 55 years or older (OR = .352, CI [0.234, 0.533]) was found to be strongly associated with mental health service use for individuals with diabetes. Being unemployed or not in the labor force increased the odds of mental health service use in persons with diabetes and depression, whereas having less than a high school diploma or Graduate Equivalency Diploma decreased odds of visits (OR = .611, CI [0.394, 0.945]) as did not having health insurance (OR = .540, CI [0.365, 0.800]). Racial/ethnic variation in mental health service utilization exists among persons with self-reported diabetes and depression. Due to the challenges associated with comorbid depression and diabetes, as well as the impact depression can have on diabetes self-management, it is imperative that more strategies for managing both depression and diabetes be explored.

Comorbid mental and physical health and health access in Cambodian refugees in the US

Little research has been conducted on the prevalence of physical health problems in Cambodian refugees and the relationship between their mental and physical health. We identified the relationship between mental and physical health problems and barriers to healthcare access in Cambodian refugee adults. We used a cross-sectional survey design with a snowball sample of 136 Cambodian refugee adult residents of Connecticut and Western Massachusetts. 61% reported being diagnosed with three or more physical conditions and 73% with depression, posttraumatic stress disorder (PTSD) or both. Language and transportation problems were the primary barriers to accessing care. Participants with probable comorbid PTSD and depression had 1.850 times more physical health problems than those without either condition (p > .001; CI 1.334-2.566). Age moderated this relationship. Participants who had been diagnosed with both depression and PTSD reported a consistent number of health conditions across the age span while those who had no mental health conditions or only one of the two reported fewer health conditions when they were younger and more when they were older. These two groups were significantly different from the group reporting both. There is a significant relationship between chronic comorbid mental and physical health diseases affecting Cambodian refugees resettled in the US Having comorbid depression and PTSD puts Cambodian refugees at risk for physical health problems no matter their age. It is vital that those treating Cambodian genocide survivors identify and treat their prevalent comorbid health conditions. Language and transportation barriers must be addressed to improve access to mental and physical health care in this population.

Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities

In Latin America, cardiovascular disease (CVD) mortality rates will increase by an estimated 145% from 1990 to 2020. Several challenges related to social strains, inadequate public health infrastructure, and underfinanced healthcare systems make cardiometabolic conditions and non-communicable diseases (NCDs) difficult to prevent and control. On the other hand, the region has high mobile phone coverage, making mobile health (mHealth) particularly attractive to complement and improve strategies toward prevention and control of these conditions in low- and middle-income countries. In this article, we describe the experiences of three Centers of Excellence for prevention and control of NCDs sponsored by the National Heart, Lung, and Blood Institute with mHealth interventions to address cardiometabolic conditions and other NCDs in Argentina, Guatemala, and Peru. The nine studies described involved the design and implementation of complex interventions targeting providers, patients and the public. The rationale, design of the interventions, and evaluation of processes and outcomes of each of these studies are described, together with barriers and enabling factors associated with their implementation.

Type 2 Diabetes and Depression

Purpose

The purpose of the current study was to determine the feasibility, acceptability, and preliminary effectiveness of an integrated self-management intervention that simultaneously targets diabetes and depression self-management in a primary care clinic that serves the Latino immigrant community.

Methods

The integrated intervention included behavioral activation and motivational interviewing techniques. It was developed with patient, family member, and provider stakeholders, and it comprised 6 individual sessions, followed by 2 monthly booster sessions. Eighteen Latino immigrants participated in an open trial of the intervention. A1C levels were examined at baseline and postintervention. Participants also completed measures of depression, diabetes self-management behaviors, patient activation, and diabetes-related self-efficacy and gave open-ended feedback about the intervention.

Results

Feasibility of delivering the intervention in the primary care setting and acceptability to the target population were demonstrated. Among participants completing the intervention, A1C levels decreased significantly from baseline. A significant reduction in depressive symptoms and an improvement in diabetes self-management behaviors, patient activation, and diabetes-related self-efficacy were observed. Qualitative responses from participants indicated unilateral positive responses to the intervention and endorsed its continuation in the clinic.

Conclusions

This pilot trial demonstrated the feasibility and acceptability of an integrated self-management intervention for diabetes and depression. In addition, preliminary data suggest that the intervention may have a positive impact on diabetes and depression-related outcomes. Further evaluation is warranted.

Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design

Depression frequently negatively affects patient overall self-care and social stress management within United States safety net care systems. Rates of major depression are significantly high among low-income predominantly Hispanic/Latino with chronic illness, such as diabetes and heart disease. The study design of the A Helping Hand to Activate Patient-Centered Depression Care among Low-income Patients (AHH) randomized clinical trial aims to enhance patient depression care receipt and overall bio-psychosocial self-care management. The AHH trial is conducted in collaboration with three Los Angeles County Department of Health Services (DHS) safety net clinics that provide Patient-Centered Medical Home (PCMH) care. The study compares AHH intervention (AHH) in which community-based bilingual promotoras provide in-person or telephone patient engagement and intervention aimed to reduce the burden and strain on patients, families, and care providers by assessing, enhancing, and facilitating patient depression and co-morbid illness self-care management skill, and activating patient communication with clinic medical providers versus DHS PCMH team usual care (PCMHUC). AHH independent bilingual recruiters screened 1957 and enrolled 348 predominantly Hispanic/Latino patients, of whom 296 (85%) had diabetes, 14 (4%) with heart disease, and 38 (11%) with both diseases. Recruiters identified depressed patients by baseline Patient Health Questionnaire-9 scores of 10 or more, completed baseline assessments, and randomized patients to either AHH or PCMHUC study group. The comprehensive assessments will be repeated at 6 and 12months by an independent bilingual follow-up interviewer. Baseline and outcome data include mental health assessment and treatment receipt, co-morbid illness self-care, social relationships, and environmental stressor assessments.

Type 2 Diabetes and Depression

Purpose

The purpose of the current study was to engage a local primary care clinic community that serves the Latino immigrant population to obtain their input regarding the design and implementation of a proposed integrated behavioral intervention that will simultaneously target T2DM and depression self-management in this high risk patient population.

Methods

Nine key informant interviews and 3 focus groups were conducted. Key informant interviews were conducted with the medical director, a primary care provider, a diabetes educator, and a medical assistant from each site, as well as the counselor who serves both sites. Fourteen patients with T2DM who screened positive for depression and 7 of their family members participated in the focus groups. Key informants and focus group participants were asked about patient challenges with diabetes management, the role of depression in T2DM, their impressions of the proposed intervention, and motivators and barriers to participation in the intervention.

Results

Commonly reported challenges with diabetes management included the struggle with healthy eating and information exchange upon diagnosis. T2DM and depression were seen as interrelated and described by many as having a cyclical relationship. Key informants and focus group participants uniformly supported the proposed intervention and recommended the involvement of family members.

Conclusions

Results of this study support the need and acceptability of individualized behavioral interventions that target T2DM and depression simultaneously.

High rates of depressive symptoms in low-income urban Hispanics of Caribbean origin with poorly controlled diabetes: correlates and risk factors

Little is known about diabetes and depression in disadvantaged urban Hispanic subgroups, particularly those of Caribbean origin. Using data from 360 urban Hispanics of Caribbean origin with poorly controlled diabetes, our objectives were to examine the prevalence and correlates of depressive symptoms and depression using the Euro-D, and the association of depressive symptoms and depression with diabetes self-management and clinical parameters of diabetes control, employing multivariate analyses. The prevalence of depression was 52.8%. Higher levels of depressive symptoms were related to female gender (p &lt; .0001), antidepressant use (p &lt; .0001), stressful life events (p &lt; .0001), SSI (p = .0011), lower education (p &lt; .0001), lower statin use (p = .0014), and less walking (p = .0152). Depression (Euro-D > 3), was associated significantly with female gender (OR = 2.30, 95%CI = 1.38- 3.82), SSI (OR = 2.44, 95%CI = 1.45-4.12), antidepressant use (OR = 2.94, 95%CI = 1.54-5.64), and stressful life events (OR = 1.93, 95%CI = 1.52-2.44). Depressive symptoms and depression were related to markers of adversity and two indicators of diabetes self-management, but not clinical parameters of diabetes control.

Internet-delivered cognitive behaviour therapy for depression in people with diabetes: study protocol for a randomised controlled trial

INTRODUCTION

Depression substantially contributes to the personal burden and healthcare costs of living with diabetes mellitus (DM). Comorbid depression and DM are associated with poorer quality of life, poorer self-management and glycemic control, increased risk for DM complications and higher mortality rates, and higher health service utilization. Depression remains under-recognized and undertreated in people with DM, which may, in part, result from barriers associated with accessing face-to-face treatment. This study will examine the efficacy of an internet-based cognitive behaviour therapy programme for major depressive disorder (iCBT-MDD) in people with DM.

METHODS AND ANALYSIS

A CONSORT 2010 compliant, registered randomised controlled trial of the intervention (iCBT-MDD) versus a treatment as usual control group will be conducted. The study will include 100 adults aged 18 years and over with a diagnosis of type 1 or type 2 DM and self-reported symptoms that satisfy MDD which will enable us to detect a statistically significant difference with a group effect size of 0.6 at a power of 80% and significance level of p=0.05. Participants will be randomised to receive the iCBT-MDD programme immediately, or to wait 10 weeks before accessing the programme. Primary outcomes will be self-reported depression severity, DM-related distress, and glycemic control (glycosylated hemoglobin). Secondary outcomes will be general distress and disability, generalized anxiety, lifestyle behaviours, somatization, eating habits, alcohol use, and acceptability of the iCBT programme to participants, and practicality for clinicians. Data will be analyzed with linear mixed models for each outcome measure.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee of St Vincent's Hospital Australia have given ethics approval (HREC/13/SVH/291). Results will be disseminated via peer-reviewed publication and social media channels of Australian Diabetes Consumer Representative Bodies.

TRIAL REGISTRATION NUMBER

The trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12613001198718).

The association of depression and anxiety with glycemic control among Mexican Americans with diabetes living near the U.S.-Mexico border

BACKGROUND

The prevalence of diabetes is alarmingly high among Mexican American adults residing near the U.S.-Mexico border. Depression is also common among Mexican Americans with diabetes, and may have a negative influence on diabetes management. Thus, the purpose of the current study was to evaluate the associations of depression and anxiety with the behavioral management of diabetes and glycemic control among Mexican American adults living near the border.

METHODS

The characteristics of Mexican Americans with diabetes living in Brownsville, TX (N = 492) were compared by depression/anxiety status. Linear regression models were conducted to evaluate the associations of depression and anxiety with BMI, waist circumference, physical activity, fasting glucose, and glycated hemoglobin (HbA1c).

RESULTS

Participants with clinically significant depression and/or anxiety were of greater age, predominantly female, less educated, more likely to have been diagnosed with diabetes, and more likely to be taking diabetes medications than those without depression or anxiety. In addition, anxious participants were more likely than those without anxiety to have been born in Mexico and to prefer study assessments in Spanish rather than English. Greater depression and anxiety were associated with poorer behavioral management of diabetes (i.e., greater BMI and waist circumference; engaging in less physical activity) and poorer glycemic control (i.e., higher fasting glucose, HbA1c).

CONCLUSIONS

Overall, depression and anxiety appear to be linked with poorer behavioral management of diabetes and glycemic control. Findings highlight the need for comprehensive interventions along the border which target depression and anxiety in conjunction with diabetes management.

Technology-facilitated depression care management among predominantly Latino diabetes patients within a public safety net care system: comparative effectiveness trial design

Health disparities in minority populations are well recognized. Hispanics and Latinos constitute the largest ethnic minority group in the United States; a significant proportion receives their care via a safety net. The prevalence of diabetes mellitus and comorbid depression is high among this group, but the uptake of evidence-based collaborative depression care management has been suboptimal. The study design and baseline characteristics of the enrolled sample in the Diabetes-Depression Care-management Adoption Trial (DCAT) establishes a quasi-experimental comparative effectiveness research clinical trial aimed at accelerating the adoption of collaborative depression care in safety net clinics. The study was conducted in collaboration with the Los Angeles County Department of Health Services at eight county-operated clinics. DCAT has enrolled 1406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares usual care with a collaborative care team support model and a technology-facilitated depression care model that provides automated telephonic depression screening and monitoring tailored to patient conditions and preferences. Call results are integrated into a diabetes disease management registry that delivers provider notifications, generates tasks, and issues critical alerts. All subjects receive comprehensive assessments at baseline, 6, 12, and 18 months by independent English-Spanish bilingual interviewers. Study outcomes include depression outcomes, treatment adherence, satisfaction, acceptance of assessment and monitoring technology, social and economic stress reduction, diabetes self-care management, health care utilization, and care management model cost and cost-effectiveness comparisons. DCAT's goal is to optimize depression screening, treatment, follow-up, outcomes, and cost savings to reduce health disparities.

Patient complexity and risk factor control among multimorbid patients with type 2 diabetes: results from the R2D2C2 study

BACKGROUND

Among patients with type 2 diabetes, it is not known whether risk factor control is better or worse for those who also have heart disease, depression, multiple other comorbidities, and associated management challenges.

OBJECTIVE

To examine the relationship between this complex constellation of multimorbidities, adherence to treatment and risk factor control among patients with type 2 diabetes, independent of regimen intensity.

RESEARCH DESIGN

Observational cross-sectional study.

SUBJECTS

A total of 1314 patients with diabetes from the Reducing Racial Disparities in Diabetes Coached Care (R2D2C2) Study.

MEASURES

A composite cardiometabolic risk factor profile was the dependent variable. Independent variables included a composite measure of patient complexity, patient-reported adherence to treatment, history of coronary heart disease (CHD), and intensity of medication regimen.

RESULTS

A higher proportion of the most complex patient-reported problems with adherence compared with the least complex patients (83.5% vs. 43.3%, P<0.001). Compared with those without a history of CHD, fewer patients with CHD-reported problems with medication adherence (59.3% vs. 69.3%, P<0.01) and had better risk factor control, independent of complexity and regimen intensity. Better risk factor control was independently associated with less patient complexity (P=0.003) and to history of CHD (P=0.01).

CONCLUSIONS

The presence of a complex illness profile was associated with poorer control of risk factors. Those with CHD were more adherent to treatment and had better risk factor control. The occurrence of CHD may present an opportunity for physicians to emphasize risk factor management. Diabetes patients with a complex illness profile may be at highest risk for cardiovascular events and in greatest need of prevention of cardiac disease.

TRIAL REGISTRATION

Clinicaltrial.gov identifier: NCT01123239.

Depression and diabetes: the role and impact of models of health care systems

OBJECTIVES

Depression and diabetes often occur together and their comorbidity has a significant and detrimental impact on health outcomes. The aims of this paper are to review the existing international literature on approaches to health care for comorbid depression and diabetes and draw out the key conclusions for both research and future development in health care delivery.

METHODS

Narrative review of the literature with synthesis by an international team of authors.

RESULTS

The synthesized findings are discussed under four main headings: specialty and generalist care; models for co-ordinating and integrating care; community approaches to service delivery; and the role of health policy.

LIMITATIONS

The review only included literature published in English.

CONCLUSIONS

Translating basic and clinical research findings into improved treatment and outcomes of those with depression and diabetes remains a substantial challenge. There is little research on the difficulties of identifying and implementing best practice into routine health care. Systems need to be designed so that evidence-based interventions are provided in a timely way, with appropriate professional expertise where required.

Nursing's role in courage development in patients facing complications of diabetes

The purpose of this study was to explore the experience of nurses in relation to courage development in patients with disabling complications of diabetes. The phenomenon of courage has been explored in philosophy, theology, literature, and other fields of inquiry rooted in the humanities. Nursing inquiry has not often been directed toward an exploration of courage, although coping, compassion, caring, and other experiences integral to the nurse-patient relationship have been examined. The holistic view of the cascading effect of complications on the individual patient is often overlooked. This qualitative study used phenomenological inquiry and included face-to-face interviews of nurses to explore their experience in assisting patients in the development of courage. The experience of courage is investigated as it relates to a specific group of patients who have complications of diabetes. Four categories representing the unique opportunities for courage development by nurses were generated. These categories included education, advocacy, relationship building, and humanization. Each category described nursing intentions and actions and taken together formed an essential structure of courage development. Conclusions indicated that nurses recognize and are able to describe their role in courage development. Implications for improved health through deliberate caring nursing interventions, aimed at courage development, are presented.

Serious psychological distress and diabetes: a review of the literature

With the development of a measure of serious psychological distress (SPD) in 2002, more attention is being paid to the association of SPD with diabetes outcomes and processes of care. We review the literature on the relationship between SPD and diabetes processes of care and outcomes, as well as the literature on the relationship between specific mental health diagnoses and diabetes processes of care and outcomes during the 2010 to 2011 period. There is an extensive literature on the association of mental health diagnoses with diabetes outcomes, especially for depression. Because the Kessler scale measures a much broader range of mental health issues than any specific DSM-IV/Structured Clinical Interview for DSM Disorders diagnosis and is designed to assess SPD at the population level, additional research needs to be conducted both in clinical settings and using large administrative datasets to examine the association between SPD and diabetes outcomes and processes of care.

Language concordance and patient-physician communication regarding mental health needs

Language-related communication barriers between minority patients and their physicians may contribute to racial and ethnic disparities in mental health care. Accordingly, the current study sought to examine whether perceived mental health needs and discussion of these needs differed as a function of race or ethnicity and language concordance in older Latinos and Asian and Pacific Islanders (APIs). Using the 2007 California Health Interview Survey, the analytical sample included Latinos and APIs aged 55 and older (N = 2,960) who reported having seen a primary care provider within the past 2 years. Multivariable logistic regression was used to examine differences according to race or ethnicity and language concordance status (three groups: English-language concordant, other-language concordant, language discordant) in perceived mental health needs and discussion of those needs with a physician, adjusting for respondents' sociodemographic characteristics and mental health status. There were no significant differences in respondents' perceptions of their mental health needs across race or ethnicity or level of language concordance status (Ps > .41), although there were significant differences in whether respondents had discussed their mental health needs with their physicians according to participant race or ethnicity and language concordance status (adjusted odds ratio = 0.47, P = .04). Specifically, Spanish language-concordant Latinos were just as likely to discuss their mental health needs with their physicians as English language-concordant Latinos. In contrast, Asian language-concordant APIs were less likely to discuss their mental health needs with their physicians than English language-concordant APIs. There were no significant differences between language-discordant and English language-concordant older adults in predicting discussion of mental health concerns. These findings underscore the importance of overcoming language-related and cultural barriers to improve patient-provider discussions of older adults' mental health needs.