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

Associations Between Suboptimal Social Determinants of Health and Diabetes Distress in Low-Income Patients on Medicaid

AIMS

To determine associations between suboptimal social determinants of health (SDoH) and diabetes distress in adults with diabetes on Medicaid.

METHODS

We surveyed adults with type 2 diabetes covered by Alabama Medicaid. Diabetes distress was assessed using the Diabetes Distress Scale. Suboptimal SDoH included food or housing insecurity; having < high school degree; being unemployed; and household income < $10,000/year. Unadjusted associations between individual SDoH and diabetes distress were examined using logistic regression. We also examined the association between the number of suboptimal SDoH and distress. Multivariable models controlled for age, sex, race, marital status, rurality, diabetes duration, social support, and insulin use.

RESULTS

In total, 433 patients participated (mean age, 50 years (SD 10.4); 80% female; 62% Black). Roughly 32% reported food insecurity, participants experienced a mean of 2 (SD, 0.9; range 0-5) suboptimal SDoH. There was increased odds of diabetes distress in participants who reported food insecurity (OR, 2.2; 95% CI, 1.36-3.65 and OR, 2.35; 95% CI, 1.40-3.93). For each additional suboptimal SDoH a patient experienced, they had increased odds of experiencing diabetes distress (OR, 1.50; CI, 1.15-2.01).

CONCLUSIONS

Participants with diabetes who reported food insecurity or experienced a higher number of suboptimal social determinants of health had an increased likelihood of experiencing diabetes distress.

Differential associations of somatic and cognitive-affective symptoms of depression with inflammation and insulin resistance: cross-sectional and longitudinal results from the Emotional Distress Sub-Study of the GRADE study

AIMS/HYPOTHESIS

Insulin resistance and inflammation are components of a biological framework that is hypothesised to be shared by type 2 diabetes and depression. However, depressive symptoms include a large heterogeneity of somatic and cognitive-affective symptoms, and this may obscure the associations within this biological framework. Cross-sectional and longitudinal data were used to disentangle the contributions of insulin resistance and inflammation to somatic and cognitive-affective symptoms of depression.

METHODS

This secondary analysis used data from the Emotional Distress Sub-Study of the GRADE trial. Insulin resistance and inflammation were assessed using the HOMA-IR estimation and high-sensitivity C-reactive protein (hsCRP) levels, respectively, at baseline and at the study visits at year 1 and year 3 (HOMA-IR) and every 6 months (hsCRP) for up to 3 years of follow-up. Depressive symptoms were assessed at baseline using the Patient Health Questionnaire (PHQ-8), and a total score as well as symptom cluster scores for cognitive-affective and somatic symptoms were calculated. For the cross-sectional analyses, linear regression analyses were performed, with inflammation and insulin resistance at baseline as dependent variables. For the longitudinal analyses, linear mixed-effect regression analyses were performed, with inflammation and insulin resistance at the various time points as dependent variables. In all analyses, depressive symptoms (total score and symptom cluster scores) were the independent variables, controlled for important demographic, anthropometric and metabolic confounders. For the analysis of insulin resistance (HOMA-IR), data from 1321 participants were analysed. For the analysis of inflammation (hsCRP), data from 1739 participants were analysed.

RESULTS

In cross-sectional analysis and after adjustment for potential confounders, a one-unit increase in PHQ-8 total score was significantly associated with a 0.8% increase in HOMA-IR (p=0.007), but not with hsCRP (0.6% increase, p=0.283). The somatic symptom score was associated with a 5.8% increase in HOMA-IR (p=0.004). Single-item analyses of depressive symptoms showed that fatigue (3.6% increase, p=0.002) and increased/decreased appetite (3.5% increase, p=0.009) were significantly associated with HOMA-IR cross-sectionally. The cognitive-affective symptom score was not significantly associated with HOMA-IR at baseline. In longitudinal analyses, a one-unit increase in PHQ-8 total score was significantly associated with a 0.8% increase in hsCRP over time (p=0.014), but not with HOMA-IR over time (0.1% decrease, p=0.564). Again, only the somatic symptom cluster was significantly associated with hsCRP over time (5.2% increase, p=0.017), while the cognitive-affective symptom score was not.

CONCLUSION/INTERPRETATION

The results highlight the associations of depressive symptoms with markers of inflammation and insulin resistance, both cross-sectionally and longitudinally, in individuals with type 2 diabetes. In particular, somatic symptoms of depression appear to be the driver of these associations, even after controlling for concomitant conditions, with a potential role for fatigue and issues with appetite.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01794143.

The interface of depression and diabetes: treatment considerations

This state-of-the-art review explores the relationship between depression and diabetes, highlighting the two-way influences that make treatment challenging and worsen the outcomes of both conditions. Depression and diabetes often co-occur and share genetic, lifestyle, and psychosocial risk factors. Lifestyle elements such as diet, physical activity, and sleep patterns play a role on the development and management of both conditions, highlighting the need for integrated treatment strategies. The evidence suggests that traditional management strategies focusing on either condition in isolation fall short of addressing the intertwined nature of diabetes and depression. Instead, integrated care models encompassing psychological support and medical management are recommended to improve treatment efficacy and patient adherence. Such models require collaboration across multiple healthcare disciplines, including endocrinology, psychiatry, and primary care, to offer a holistic approach to patient care. This review also identifies significant patient-related barriers to effective management, such as stigma, psychological resistance, and health literacy, which need to be addressed through patient-centered education and support systems. Future directions for research include longitudinal studies in diverse populations to further elucidate causal relationships and the exploration of novel therapeutic targets, as well as the effectiveness of healthcare models aimed at preventing the onset of one condition in individuals diagnosed with the other.

Medication adherence feedback with older adults with cognitive impairment: a mixed Methods study

Objective: Older adults with cognitive impairment are at risk of medication-taking errors. This study assessed the impact of providing medication adherence feedback to cognitively impaired older adults. Methods: Forty participants with mild cognitive impairment or mild dementia had their medication adherence electronically monitored for 8 weeks. They were provided with verbal and visual feedback about their adherence results. Initial participant reactions were elicited using a Motivational Interviewing approach, and self-reported behavior changes were assessed during a follow-up interview. Quantitative analyses assessed relationships among electronically monitored and self-rated adherence, initial reactions to adherence feedback, and subsequently reported medication self-management changes. Thematic analysis determined facilitators and barriers to making self-management changes. Results: Although self-rated adherence was high, electronic monitoring revealed that 20% of the sample had suboptimal adherence (took the recommended dose on <80% of monitored days). Fifty-three percent of the sample reported feeling surprised by their adherence results, and 45% endorsed initial motivation to change self-management behaviors. Motivated participants demonstrated worse electronically monitored adherence than unmotivated peers, and those who were surprised by their medication-taking errors expressed greater initial motivation to change. At follow-up, 50% reported having made changes, and 82.4% of them indicated that this study played a role. Facilitators of making changes included awareness of medication-taking errors and cognitive impairment, whereas barriers included lack of perceived difficulty/need. Conclusions: Adherence monitoring with feedback is feasible and impactful in cognitively impaired older adults. Increasing awareness of medication-taking errors fosters motivation to improve medication self-management and results in participant-reported behavior change.

Perceived glucose levels matter more than CGM-based data in predicting diabetes distress in type 1 or type 2 diabetes: a precision mental health approach using n-of-1 analyses

AIMS/HYPOTHESIS

Diabetes distress is one of the most frequent mental health issues identified in people with type 1 and type 2 diabetes. Little is known about the role of glucose control as a potential contributor to diabetes distress and whether the subjective perception of glucose control or the objective glycaemic parameters are more important for the experience. With the emergence of continuous glucose monitoring (CGM), this is a relevant question as glucose values are now visible in real-time. We employed a precision monitoring approach to analyse the independent associations of perceived and measured glucose control with diabetes distress on a daily basis. By using n-of-1 analyses, we aimed to identify individual contributors to diabetes distress per person and analyse the associations of these individual contributors with mental health at a 3 month follow-up.

METHODS

In this prospective, observational study, perceived (hypoglycaemia/hyperglycaemia/glucose variability burden) and measured glucose control (time in hypoglycaemia and hyperglycaemia, CV) were assessed daily for 17 days using an ecological momentary assessment (EMA) approach with a special EMA app and CGM, respectively. Mixed-effect regression analysis was performed, with daily diabetes distress as the dependent variable and daily perceived and CGM-measured metrics of glucose control as random factors. Individual regression coefficients of daily distress with perceived and CGM-measured metrics were correlated with levels of psychosocial well-being at a 3 month follow-up.

RESULTS

Data from 379 participants were analysed (50.9% type 1 diabetes; 49.6% female). Perceived glucose variability (t=14.360; p<0.0001) and perceived hyperglycaemia (t=13.637; p<0.0001) were the strongest predictors of daily diabetes distress, while CGM-based glucose variability was not significantly associated (t=1.070; p=0.285). There was great heterogeneity between individuals in the associations of perceived and measured glucose parameters with diabetes distress. Individuals with a stronger association between perceived glucose control and daily distress had more depressive symptoms (β=0.32), diabetes distress (β=0.39) and hypoglycaemia fear (β=0.34) at follow-up (all p<0.001). Individuals with a stronger association between CGM-measured glucose control and daily distress had higher levels of psychosocial well-being at follow-up (depressive symptoms: β=-0.31; diabetes distress: β=-0.33; hypoglycaemia fear: β=-0.27; all p<0.001) but also higher HbA1c (β=0.12; p<0.05).

CONCLUSIONS/INTERPRETATION

Overall, subjective perceptions of glucose seem to be more influential on diabetes distress than objective CGM parameters of glycaemic control. N-of-1 analyses showed that CGM-measured and perceived glucose control had differential associations with diabetes distress and psychosocial well-being 3 months later. The results highlight the need to understand the individual drivers of diabetes distress to develop personalised interventions within a precision mental health approach.

Patient-centered care in diabetes care-concepts, relationships and practice

We still do not have comprehensive knowledge of which framework of patient-centered care (PCC) is appropriate for diabetes care, which elements of PCC are evidence-based, and the mechanism by which PCC elements are associated with outcomes through mediators. In this review, we elaborate on these issues. We found that for diabetes care, PCC elements such as autonomy support (patient individuality), cooperation and collaboration (system-level approach), com-munication and education (behavior change techniques), emotional support (biopsychosocial approach), and family/other involvement and support are critically important. All of these factors are directly associated with different patient outcomes and indirectly associated with outcomes through patient activation. We present the practical implications of these PCC elements.

Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations.

RESULTS

At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence.

CONCLUSIONS

Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.

Diabetes causal attributions: Pathways to stigma and health

This study investigates the relationships among causal attributions, internalized stigma, and self-blame, along with downstream health and life satisfaction consequences for individuals with type 1 and type 2 diabetes. Data were analyzed from the Diabetes, Identity, Attributions, and Health study. Participants diagnosed with either type 1 or type 2 diabetes (N=363) were included in the analysis. Results indicated that the relationship between causal attributions and stigmatization was moderated by diabetes type. Path analyses, one for each diabetes type, revealed overall patterns linking causal attributions to internalized stigma and to self-blame, which were linked to ratings of reduced self-care, increased symptoms, and reduced life satisfaction. However, the specific paths diverged by diabetes type in important ways. Whereas higher genetic causal attributions were associated with more self-blame and stigmatization for type 1 diabetes, these attributions were associated with less self-blame and stigmatization for type 2 diabetes. The current work demonstrates the importance of causal attributions to overall health and illustrates how even in conditions with genetic attributions that are similar in magnitude, affected individuals may attach very different meaning to those attributions.

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.

Influence of depression on racial and ethnic disparities in diabetes control

INTRODUCTION

We tested the hypotheses that depression diagnoses influence racial and ethnic disparities in diabetes control and that mental health treatment moderates that relationship.

RESEARCH DESIGN AND METHODS

We created a national cohort of Veterans Health Administration (VHA) patients with diabetes using administrative data (n=815 067). Cross-sectional linear mixed effects regression models tested the hypothesized indirect effect of depression on poor diabetes control (glycosylated hemoglobin >9%) and tested whether mental health treatment (visits or antidepressant prescriptions) moderated the effect of depression (α=0.05). Results represent the percentage point difference in probability of poor diabetes control. Covariates included primary care visits, sex, age, and VHA facility.

RESULTS

Overall, 20% of the cohort had poor diabetes control and 22% had depression. Depression was more common among racial and ethnic minoritized groups. The probability of poor diabetes control was higher for most minoritized groups compared with White patients (largest difference: American Indian or Alaska Native patients, 5.2% (95% CI 4.3%, 6.0%)). The absolute value of the proportion of racial and ethnic disparities accounted for by depression ranged from 0.2% (for Hispanic patients) to 2.0% (for Asian patients), with similar effects when accounting for the moderating effect of mental health treatment. Patients with depression and 5+ mental health visits had a lower probability of poor diabetes control compared with those with fewer visits, regardless of antidepressant prescription status.

CONCLUSIONS

The influence of depression on disparities in diabetes control was small. High rates of depression among people with diabetes, especially among those from racial and ethnic minoritized groups, highlight a need to ensure equitable and coordinated care for both conditions, as the effects of mental health treatment may extend to the control of physical health conditions.

Understanding Alveolar echinococcosis patients' psychosocial burden and coping strategies-A qualitative interview study

BACKGROUND

Alveolar echinococcosis (AE) is a serious parasitic zoonotic disease that resembles malignancy with clinically silent infiltrative growth predominantly involving the liver. AE patients show high levels of comorbid psychological burden and fear of disease progression. This study aimed to examine AE patients' perspective on their disease-related psychosocial burden using qualitative methods.

METHODS

We conducted N = 12 semi-structured interviews with AE patients focusing on their disease-related psychosocial burden, coping strategies, information seeking behavior, and subjective illness concepts. To this end, AE patients from a previous quantitative cross-sectional study were invited to participate. After verbatim transcription, interviews were analyzed thematically.

RESULTS

After analysis, data was grouped into five main themes: A) Perceived disease-related burden, B) Coping with disease-related burden, C) Disease-related impact on their social environment, D) Facing the future with the disease, and E) Disease-related information seeking behavior and subjective illness concepts. All participants perceived AE as a severe disease with inextricably linked biological, psychological, and social effects. Key positive influences reported included the provision of information and access to informal and formal support, including the ability to lead active personal and professional lives for as long as possible. Self-directed, web-based information seeking often led to increased feelings of hopelessness and anxiety.

CONCLUSION

Our findings underscore the need to consider psychosocial morbidity in AE patient management. To reduce psychological burden, address disease-related apprehensions, and to prevent stigmatization, health professionals need to provide AE patients with comprehensive disease-related information to improve patient and social awareness.

The influence of weight on psychosocial well-being in diabetes

BACKGROUND

Individuals with diabetes experience a wide variety of psychosocial responses to their illness due, in part, to the nature of type 1 and type 2 diabetes. Variation in patient weight may play a central role in these differences, yet its influence on psychosocial variation is largely unknown. The current study investigates the relationship between patients' perceived weight status and aspects of psychosocial well-being among individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D).

METHODS

Individuals who were diagnosed with type 1 or type 2 diabetes were assessed via an online survey from the Diabetes, Identity, Attributions, and Health Study. Participants were categorized into a lower v. higher weight status group based on their self-reported perceived weight. Analyses of covariance were conducted to assess differences in measures of disease onset blame, diabetes stigma, and identity concerns among diabetes type and perceived weight status. Covariates included in our models were gender, age, education, and time since diagnosis. Bonferroni correction was used for post-hoc tests to assess any significant interactions found in our models.

RESULTS

Findings indicated that weight moderates multiple psychosocial outcomes pertinent to illness experience. Those with T2D and lower weight blamed themselves less for their disease onset, while those with higher weight felt blamed more for their disease onset by others, regardless of diabetes type. Individuals with T1D and higher weight were more frequently and more concerned about being mistaken for having the other disease type (i.e., T2D) compared to those with lower weight.

CONCLUSIONS

Weight is a key influence on the psychosocial outcomes for people with diabetes, but it operates differently in type 1 versus type 2 diabetes. By further examining the unique interaction between disease type and weight status we may be able to improve psychological well-being among affected individuals of all sizes.

Recurrent depression relates to worse outcomes than single episode depression among Hispanic adolescents with diabetes

BACKGROUND

Adolescents with type 1 diabetes (T1D) are at increased risk for depression. A history of recurrent depression (HRD) may relate to worse health outcomes than single-episode depression. However, no study has explored this issue among T1D adolescents.

PARTICIPANTS AND PROCEDURE

We examined differences in psychosocial and diabetes-related outcomes between T1D adolescents with (G1; n = 33) and without (G2; n = 18) HRD. Participants were 51 youths (aged 12-17 years) enrolled in a depression treatment study. Youths and one caregiver each completed several measures. Using MANOVA, followed by individual ANOVAs, and chi-square tests, we compared groups in continuous and categorical variables, respectively.

RESULTS

MANOVA results were significant, F(7, 43) = 3.97, p = .002. Adolescents from G1 obtained higher scores than youths in G2 in self-esteem/guilt problems, cognitive alterations, and sadness due to T1D. Their caregivers reported more burden and rated their offspring as having more internalizing problems, facing more barriers to complying with T1D treatment, and using a medical ID less frequently than their counterparts did. A higher percentage of G1 participants presented clinical anxiety and inadequate glycemic control, and reported a history of major depression. According to caregivers, a higher proportion of G1 members had experienced multiple diabetes-related hospitalizations, were non-compliant with insulin treatment, and lived in homes with a conflictive environment.

CONCLUSIONS

Our study documents important differences in outcomes between T1D youths with vs. without any HRD. Clinicians may need an intensive and integrative approach to treat mental and physical aspects of health among these patients.

Factors Associated With Diabetes Distress Among Patients With Poorly Controlled Type 2 Diabetes

Objective

Examine factors associated with increased diabetes distress (DD) among patients with type 2 diabetes with DD assessed by Diabetes Distress Scale (DDS) total and subscale scores (emotional burden, physician-related distress, regimen-related distress, and interpersonal distress).

Methods

Cross-sectional analysis of data from veterans with persistently poorly controlled diabetes mellitus. Multivariable linear regression models included baseline patient characteristics (independent variables) and DDS total and subscale scores (dependent variable).

Results

The cohort's (N = 248) mean age was 58 years (SD 8.3); 21% were female, 79% were non-White, and 5% were Hispanic/Latinx. Mean hemoglobin A1c (HbA1c) was 9.8%, and 37.5% had moderate to high DD. Hispanic/Latinx ethnicity (β=0.41; 95% CI 0.01, 0.80), baseline HbA1c (0.07; 95% CI 0.01,0.13), and higher Personal Health Questionnaire-8 (PHQ-8) scores (0.07; 95% CI 0.05, 0.09) were associated with higher total DD. Hispanic/Latinx ethnicity (0.79; 95% CI 0.25, 1.34) and higher PHQ-8 (0.05; 95% CI 0.03, 0.08) were associated with higher interpersonal-related distress. Higher HbA1c (0.15; 95% CI 0.06, 0.23) and higher PHQ-8 scores (0.10; 95% CI 0.07, 0.13) were associated with higher regimen-related distress. The use of basal insulin (0.28; 95% CI 0.001, 0.56) and higher PHQ-8 (0.02; 95% CI 0.001, 0.05) were associated with higher physician-related distress. Higher PHQ-8 (0.10; 95% CI 0.07, 0.12) was associated with higher emotional burden.

Conclusion

Hispanic/Latinx ethnicity, depressive symptoms, uncontrolled hyperglycemia, and insulin use were associated with higher risk for DD. Future research should explore these relationships, and interventions designed to reduce diabetes distress should consider accounting for these factors.

A systematic review of primary care-focused, self-reported medication adherence tools

BACKGROUND

Clinician recognition of nonadherence is generally low. Tools that clinicians have used to assess medication adherence are self-reported adherence instruments that ask patients questions about their medication use experience. There is a need for more structured reviews that help clinicians comprehensively distinguish which tool might be most useful and valuable for their clinical setting and patient populations.

OBJECTIVES

This systematic review aimed to (1) identify validated, self-reported medication adherence tools that are applicable to the primary care setting and (2) summarize selected features of the tools as an assessment of clinical feasibility and applicability.

METHODS

The investigators systematically reviewed MEDLINE via Ovid, Embase via Ovid, International Pharmaceutical Abstracts, and CINAHL from inception to December 1, 2020. Investigators independently screened 3394 citations, identifying 43 articles describing validation parameters for 25 unique adherence tools. After screening each tool, 17 tools met the inclusion criteria and were qualitatively summarized.

RESULTS

Findings highlight 25 various tool characteristics (i.e., descriptions, parameters and diseases, measures and validity comparators, and other information), which clinicians might consider when selecting a self-reported adherence tool with strong measurement validity that is practical to administer to patients. There was much variability about the nature and extent of adherence measurement. Considerable variation was noted in the objective measures used to correlate to the self-reported tools' measurements. There were wide ranges of correlation between self-reported and objective measures. Several included tools had relatively low to moderate criterion validities. Many manuscripts did not describe whether tools were associated with costs, had copyrights, and were available in other languages; how much time was required for patients to complete self-report tools; and whether patient input informed tool development.

CONCLUSION

There is a critical need to ensure that adherence tool developers establish a key list of tool characteristics to report to help clinicians and researchers make practical comparisons among tools.

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.

Impact of cognitive-affective and somatic symptoms in subthreshold depression transition in adults: Evidence from Depression Cohort in China (DCC)

BACKGROUND

Symptoms of subthreshold depression may differentially affect the illness transition. We examined the impact of cognitive-affective and somatic symptoms on different subthreshold depression transitions as well as risk factors influencing the aforementioned symptoms changes.

METHODS

Adults with subthreshold depression in the Depression Cohort in China were enrolled. Data collection was conducted at baseline, 6 and 12 months from 2019 to 2020. Cognitive-affective and somatic symptoms were assessed using the Patient Health Questionnaire-9. A total of 993 participants completed 12-month follow-up and were divided into persistent, intermittent and remission groups according to change in depressive symptoms. The longitudinal change of cognitive-affective and somatic symptoms in the three groups, as well as risk factors was analyzed using the generalized linear mixed-model.

RESULTS

There were 24.07 %, 34.04 % and 41.89 % of participants proceeding into persistent, intermittent and remission subthreshold depression groups, respectively. Cognitive-affective symptoms were the core symptoms for predicting the deterioration in persistent subthreshold depression (t = 2.48, P = 0.013), whereas somatic symptoms improved over time (t = -2.82, P = 0.005). Anxiety symptoms were the primary risk factors for worsening cognitive-affective symptoms (P < 0.001), following by insomnia symptoms, age, marital status, resilience and social functions. Somatic symptoms were affected by insomnia symptoms, anxiety symptoms and Body Mass Index successively.

LIMITATIONS

Major Depressive Episode was not explored in follow-up.

CONCLUSION

Cognitive-affective symptoms in subthreshold depression are at greater risk of illness deterioration. Future studies should endeavor to identify specific risk factors in different symptoms to forestall the transition from subthreshold to Major Depressive Disorder.

Novel targets for ameliorating energy metabolism disorders in depression through stable isotope-resolved metabolomics

The severe harm of depression to human health and life has attracted global attention, but the exact mechanism is not yet known due to the complicated pathogenesis. The existing antidepressants are far from ideal, indicating it is urgently needed to seek safe and effective drugs from a unique perspective. Based on the hypothesis of "mitochondrial dysfunction" proposed recently, we attempt to focus on the substrates supply of energy metabolism. We applied stable isotope-resolved metabolomics, and revealed that significantly decreased TCA cycle and abnormally increased gluconeogenesis pathway in CUMS rats. Pyruvate dehydrogenase (PDH) and pyruvate carboxylase (PC) maybe the key metabolic enzymes. This metabolic reprogramming was confirmed through ELISA assays and Western blot analysis. To explore the causes of substrates supply disorder in depression, we conducted the mitochondrial structure-function evaluation. Interestingly, the levels of the mitochondrial pyruvate carrier (MPC) decreased significantly, which is essential for the entry of pyruvic acid into the TCA cycle. Together, MPC, PDH and PC are expected to become potential novel therapeutic targets for treating depressive disorders. This research provides a unique insight for re-cognizing the pathological mechanisms of depression, the novel targets for development of ideal antidepressants, as well as a paradigm for deciphering abnormal metabolic pathways in other metabolic diseases.

Remember the past, plan for the future: How interactions between risk perception and behavior during the COVID-19 pandemic can inform future Canadian public health policy

The ongoing COVID-19 pandemic necessitated the implementation of numerous temporary public health policies, including social distancing, masking, and movement limitations. These types of measures require most citizens to follow them to be effective at a population level. This study examined population adherence to emergency public health measures using early data collected in the Spring of 2020, when all Canadian jurisdictions were under relatively strict measures. In total, 1,369 participants completed an online questionnaire package to assess adherence, perceptions of government response, and perceptions of COVID-19 risk. Results indicated that most Canadians were pleased with the government's handling of the early phases of the pandemic and immediately engaged new public health mandates. Willingness to change behaviors was unrelated to satisfaction with the government response. Similarly, behavioral adherence was also unrelated to satisfaction with government, or personal risk perceptions; however, adherence to public health guidelines was related to elevated psychological distress. As the pandemic continues, public health officials must balance the mental health of the population with the physical health concerns posed by COVID-19 when applying public health mandates.

Memory complaints moderate the concordance between self-report and electronically monitored adherence in adults with type 2 diabetes

AIMS

We examined the impact of memory complaints on the concordance between self-report (SR) and electronically monitored (EM) medication adherence, independent of depression symptoms, among adults with type 2 diabetes (T2D).

METHODS

Adults (N = 104, age = 56.6 ± 9.2; 64% female) completed a prospective and retrospective memory questionnaire (PRMQ) and a depression symptom interview at baseline. EM was tracked over 3 months and participants rated adherence using SR. Multiple linear regression evaluated PRMQ as a moderator of the relationship between EM and SR, adjusting for depression and other covariates.

RESULTS

PRMQ was correlated with lower SR (r = -0.31, p = 0.001), but not with EM. PRMQ moderated the relationship between SR and EM, independent of depression symptoms. At low levels of PRMQ, SR and EM were closely related (β = 0.76, p < 0.001); at high levels of PRMQ the relationship was weaker (β = 0.28, p = 0.02). Participants who under-reported their adherence (SR < EM) had higher PRMQ scores than more concordant reporters (p = 0.016).

CONCLUSIONS

SR and EM measures were less concordant among adults with T2D who endorsed higher PRMQ scores. Memory complaints may contribute to under-reporting of medication adherence in adults with T2D.

Relation between diabetes related distress and glycemic control: The mediating effect of adherence to treatment

AIMS

Diabetes related distress (DRD) is a negative emotional reaction to stresses associated with diabetes mellitus (DM) and its management. This study estimated the burden of DRD and self-reported adherence to treatment (SRAT) among patients with DM and investigated their relationship with glycemic control.

METHODS

A cross sectional study of consented 157 diabetics was conducted using the17-item Diabetes Distress Scale (DDS). It measures distress at four subscales: Emotional Burden (EB), Physician-related (PD), Regimen-related (RD) and Interpersonal Distress (ID). SRAT was assessed using Morisky's scale. Glycemic control was assessed using the most recent HbA1c results. Multivariable linear regression analysis was used for adjustment of confounders and bootstrap Confidence Interval was used to test for the occurrence of mediating effect.

RESULTS

Average age was 44.5 ± 16.0 years, 65% were females, 79% had type 2 DM and nearly 55% has had DM for more than 7 years and the average HbA1c was 8.9 ± 2.2%. Clinically significant DRD was reported by 37% of the participants, EB and RD in 40.8%, PD in 46.5%, and ID among 32.5%. Younger patients showed higher level of stress compared to older participants and patients with type 1 DM showed higher level of stress in all DRD domains. Only 46% of patients were defined as having satisfactory SRAT and improvement of SRAT significantly enhanced the glycemic control (r = -0.32, p < 0.01). DRD and low SRAT negatively correlated with HbA1c; increasing the DRD by one point may increase the HbA1c on average by 0.41 (C.I. 0.02-0.80) and will indirectly raise the HbA1c by 0.24 (C.I. 0.04-0.47) through the mediating effect of low SRAT.

CONCLUSION

DRD and low SRAT are commonly reported among DM patients and both are indirectly correlated. The mediating effect of low SRAT highlights the clinical role of DRD and clarifies the process by which distress affect the outcome of DM management.

Equity in Psychosocial Outcomes and Care for Racial and Ethnic Minorities and Socioeconomically Disadvantaged People With Diabetes

The role of social determinants of health (SDOH) in promoting equity in diabetes prevalence, incidence, and outcomes continues to be documented in the literature. Less attention has focused on disparities in psychosocial aspects of living with diabetes and the role of SDOH in promoting equity in psychosocial outcomes and care. In this review, the authors describe racial/ethnic and socioeconomic disparities in psychosocial aspects of living with diabetes, discuss promising approaches to promote equity in psychosocial care, and provide future research directions.

Coping with diabetes stress among adults in rural Dominican Republic: "I don't think about it"

OBJECTIVES

As type 2 diabetes prevalence increases across Latin America, understanding local approaches to coping with diabetes stress is essential to providing care that incorporates patients' values and preferences. This study explored a local phenomenon, "no le doy mente" (I don't think about it), used by adults with type 2 diabetes in the Dominican Republic to cope with diabetes stress.

METHODS

We conducted 19 qualitative in-depth interviews with adults with type 2 diabetes (10 men, 9 women) recruited from one rural clinic. Using an inductive analytic approach including iterative coding, memos, and matrices, we identified reasons, strategies, and perceived benefits of not thinking about type 2 diabetes among participants.

RESULTS

Participants described not thinking about diabetes as an active process to maintain a sense of normalcy despite significant life changes following diagnosis. They avoided thinking about diabetes by staying busy, proactively managing type 2 diabetes through diet and medication, and turning to their faith. Participants perceived that enacting no le doy mente helped to protect their overall health and well-being.

DISCUSSION

Future research should investigate provider perceptions of no le doy mente to align patient and provider communication and mindfulness-based stress reduction as a way to support people with type 2 diabetes avoid dwelling on negative thoughts about diabetes.

Barriers and enablers to screening and diagnosing diabetes distress and depression in people with type 2 diabetes mellitus: A qualitative evidence synthesis

AIM

Synthesise qualitative evidence of healthcare professionals' (HCP) experiences of diabetes distress and depression screening in people with type 2 diabetes (T2DM) in primary care to identify HCP barriers and enablers to screening implementation.

METHODS

Searched six electronic databases in October 2020 for qualitative studies exploring HCPs' experiences of diabetes distress and depression screening in T2DM populations. Applying a best-fit framework synthesis, data were coded to the theoretical domains framework (TDF), followed by thematic analysis of data that did not fit the TDF. Study quality and confidence in findings were assessed using CASP and GRADE-CERQual respectively.

FINDINGS

Of 4942 unique records identified, 10 articles were included. We identified fifteen barriers and enablers in 8 TDF domains and 1 new domain; people with T2DM factors. One barrier (poor awareness about the rationale for screening) and 2 enablers (perceived impacts on T2DM care, receiving financial reimbursement) were assessed as findings of high confidence.

CONCLUSION

HCPs experience many barriers and enablers to diabetes distress and depression screening among people with T2DM in primary care. Future interventions and policies should ensure HCPs understand the rationale for screening, highlight the benefits of screening, resource screening appropriately and address HCP group specific barriers.

A longitudinal study of the stress of poor glucose control and diabetes distress

Poor glucose control can be viewed as a stressor, possibly promulgating diabetes distress. We examined the relationship between perceived blood glucose control and diabetes distress over time using a partially controlled cross-lagged path analysis model. After controlling for demographics, control at 6 months was directly related to change in distress at 12 months. Subsequently, distress at 12 months was directly related to change in control at 18 months. Both 6-month control and distress had significant indirect effects on 18-month control and distress. This demonstrates the nuanced bi-directional relationship between the stress of poor perceived control and diabetes distress.

Spousal Influence on Diabetes Self-care: Moderating Effects of Distress and Relationship Quality on Glycemic Control

BACKGROUND

Spouses often attempt to influence patients' diabetes self-care. Spousal influence has been linked to beneficial health outcomes in some studies, but to negative outcomes in others.

PURPOSE

We aimed to clarify the conditions under which spousal influence impedes glycemic control in patients with type 2 diabetes. Spousal influence was hypothesized to associate with poorer glycemic control among patients with high diabetes distress and low relationship quality.

METHODS

Patients with type 2 diabetes and their spouses (N = 63 couples) completed self-report measures before patients initiated a 7-day period of continuous glucose monitoring. Mean glucose level and coefficient of variation (CV) were regressed on spousal influence, diabetes distress, relationship quality, and their two- and three-way interactions.

RESULTS

The three-way interaction significantly predicted glucose variability, but not mean level. Results revealed a cross-over interaction between spousal influence and diabetes distress at high (but not low) levels of relationship quality, such that spousal influence was associated with less variability among patients with low distress, but more among those with high distress. Among patients with high distress and low relationship quality, a 1 SD increase in spousal influence predicted a difference roughly equivalent to the difference between the sample mean CV and a CV in the unstable glycemia range.

CONCLUSIONS

This was the first study to examine moderators of the link between spousal influence and glycemic control in diabetes. A large effect was found for glucose variability, but not mean levels. These novel results highlight the importance of intimate relationships in diabetes management.

Diabetes distress and peripheral neuropathy are associated with medication non-adherence in individuals with type 2 diabetes in primary care

BACKGROUND

Psychosocial factors like diabetes distress and social support, as well as the presence of complications, affect an individual's self-management ability; however, their role in adherence behaviours is not yet clear. We examined the role of psychosocial factors and complications in non-adherence behaviours in individuals with diabetes in primary care.

METHODS

Baseline survey with nine-month follow up through medical records of patients with type 2 diabetes attending primary care. Medication adherence and diabetes distress were assessed using Morisky Green Levine Medication Adherence Scale and Problem Areas in Diabetes, respectively. Appointment adherence was assessed through medical records.

RESULTS

Of the 448 participants studied, 59.8% had medication non-adherence and 21.7% were non-adherent to scheduled appointments. PAID score (odds ratio (OR) 1.01, 95% confidence interval 1.00-1.03, p = 0.013), peripheral neuropathy (OR 1.99, 95%CI 1.18-3.37, p = 0.01), home glucose monitoring (OR 0.46, 95%CI 0.30-0.69, p < 0.001), HbA1c (OR 1.34, 95%CI 1.13-1.61, p = 0.001), and age (OR 0.96, 95%CI 0.93-0.98, p = 0.001) were associated with medication non-adherence. Indian ethnicity (OR 2.93, 95%CI 1.59-5.39, p = 0.001), secondary or higher education (OR 1.94, 95%CI 1.14-3.27, p = 0.014), and HbA1c (OR 1.38, 95%CI 1.18-1.63, p < 0.001) were associated with appointment non-adherence.

CONCLUSIONS

Non-adherence behaviours were prevalent and significantly associated with higher HbA1c. Medication non-adherence was more likely in younger individuals, those with higher diabetes distress or peripheral neuropathy. Appointment non-adherence was more likely in individuals of Indian ethnicity or those with higher education. Greater support for these groups may help improve adherence behaviours and outcomes.

New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study

AIMS

This study aimed to corroborate the main hypotetized dimensions of diabetes burnout, and its distinction from diabetes distress and depressive symptoms among adults with type 1 diabetes (T1D).

METHODS

A qualitative descriptive study was employed to collect data from 31 eligible participants using semi-structured individual phone interviews. Participants were recruited through purposive sampling among a larger sample of adults with T1D in a previous study. Data was analyzed using qualitative content analysis including immersion, reduction, and interpretation.

RESULTS

Exhaustion and detachment were frequent manifestations of diabetes burnout that often accompanied by instances during which participants experienced a loss of control over diabetes. Whereas individuals' support systems could either help or hinder diabetes burnout. Participants saw burnout as separate but closely related to distress and depressive symptoms, with some suggesting correlations among burnout, distress, and depressive symptoms, while others expressed that distress caused their burnout and depressive symptoms.

CONCLUSIONS

Diabetes burnout reflects a significant yet unexplored concept which might explain the complexities of suboptimal self-management and poor diabetes outcomes. Emerging evidence suggesting diabetes burnout as a distinct concept calls for more studies to mitigate diabetes burnout as an obstacle to optimal diabetes care.

Barriers and enablers to screening and diagnosing depression and diabetes distress in people with type 2 diabetes mellitus; protocol of a qualitative evidence synthesis

Background: Depression and diabetes distress are common in people with type 2 diabetes (T2DM). These conditions are independently associated with poorer T2DM outcomes and increased healthcare utilisation and costs. Questions remain regarding the most appropriate ways of initially detecting depression and diabetes distress in this group. Diabetes guidelines recommend depression screening in primary care for people with T2DM but their implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of these guidelines can improve understanding of aspects of the guidelines that work, and those which are more difficult to implement in practice. This study describes the protocol for a qualitative evidence synthesis of primary care health professionals’ perceived barriers and enablers to screen for and diagnose depression and diabetes distress in people with T2DM.

Methods and analysis: Primary qualitative studies will be identified using a systematic search of electronic databases and supplementary searching. We selected ‘best-fit framework synthesis’ as the approach to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical Appraisal Skills Programme) and the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative research), respectively.

Discussion: The planned review will provide the first, single point of reference of the available synthesised qualitative evidence on this topic. It will apply recommended approaches to ensure rigor and robustness of study and contribute meaningfully to understanding of how depression and diabetes distress can be initially detected in people with T2DM. This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) [registration number: CRD42019145483].

Barriers and enablers to screening and diagnosing depression and diabetes distress in people with type 2 diabetes mellitus; protocol of a qualitative evidence synthesis

Background: Depression and diabetes distress are common in people with type 2 diabetes (T2DM). These conditions are independently associated with poorer T2DM outcomes and increased healthcare utilisation and costs. Questions remain regarding the most appropriate ways of initially detecting depression and diabetes distress in this group. Diabetes guidelines recommend depression screening in primary care for people with T2DM but their implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of these guidelines can improve understanding of aspects of the guidelines that work, and those which are more difficult to implement in practice. This study describes the protocol for a qualitative evidence synthesis of primary care health professionals' perceived barriers and enablers to screen for and diagnose depression and diabetes distress in people with T2DM. Methods and analysis: Primary qualitative studies will be identified using a systematic search of electronic databases and supplementary searching. We selected 'best-fit framework synthesis' as the approach to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical Appraisal Skills Programme) and the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative research), respectively. Discussion: The planned review will provide the first, single point of reference of the available synthesised qualitative evidence on this topic. It will apply recommended approaches to ensure rigor and robustness of study and contribute meaningfully to understanding of how depression and diabetes distress can be initially detected in people with T2DM. This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) [registration number: CRD42019145483].

Distress and Type 2 Diabetes Self-Care: Putting the Pieces Together

BACKGROUND

Conflicting research emphasizes depression, diabetes distress, or well-being in relation to diabetes self-care and risk for poor health outcomes.

PURPOSE

The purpose of this study was to test whether a latent variable for general psychological distress derived from shared variance of depression symptoms, diabetes distress, and well-being predicts a latent variable of diabetes self-care and to examine evidence for unique effects once shared effects are adjusted for.

METHODS

Adults with suboptimally controlled diabetes were recruited from the South Bronx, NY, for a telephonic diabetes self-management support trial. Baseline diabetes self-care, medication adherence, depression symptoms, diabetes distress, and well-being were measured by validated self-report. Structural equation modeling specified a latent variable for general psychological distress derived from shared variance of depression symptoms, diabetes distress, and well-being. Diabetes self-care was a latent variable indicated by diet, glucose self-monitoring, and medication adherence.

RESULTS

Participants (N = 627, 65% female) were predominantly ethnic minority (70% Hispanic; 45% Black) and 77% reported household income <$20K/year. Mean (standard deviation) age = 56 (12) years; A1c = 9.1% (1.9%); body mass index = 32 (8) kg/m2. The latent variable for psychological distress was a robust predictor of poorer diabetes self-care (coefficient = -0.59 [confidence interval = -0.71, -0.46], p < .001) with good model fit. Unique paths from depression symptoms, diabetes distress, and well-being (all ps > .99) to self-care were not observed.

CONCLUSIONS

In this population of disadvantaged adults with suboptimally controlled diabetes, general psychological distress was strongly associated with poorer diabetes self-care and fully accounted for the effects of depression, diabetes distress, and positive well-being. This suggests that general distress may underlie previously reported associations between these constructs and diabetes self-care.

Effect of an 'implementation intention' intervention on adherence to oral anti-diabetic medication in Brazilians with type 2 diabetes

OBJECTIVE

To evaluate the effects of an implementation intention intervention on adherence to an oral anti-diabetic medication regime, diabetes-related distress and on glycemic control in patients with type 2 diabetes mellitus.

METHODS

A randomized, parallel-group, single-center controlled trial was conducted among adults with type 2 diabetes being managed at the primary care level. The intervention group (IG, n = 45) received an 'implementation intention' intervention; the control group (CG, n = 45) received standard care. Primary outcomes were the taking of oral anti-diabetic medication, global adherence and level of glycated hemoglobin. The secondary outcome was diabetes-related distress. Data were gathered at baseline and after 15 weeks.

RESULTS

The IG showed improvements in adherence to an oral anti-diabetic medication regime (p < 0.0001), glycemic control (p < 0.0001) and diabetes-related distress (p < 0.0001) relative to the CG.

CONCLUSIONS

The implementation intention intervention enhanced adherence to an oral anti-diabetic medication regime, which had positive effects on blood glucose levels and diabetes-related distress.

PRACTICE IMPLICATIONS

Adherence to an oral anti-diabetic medication regime can decrease blood glucose levels and diabetes-related distress and thus reduce complications of type 2 diabetes.

The assessment and management of quality of life of older adults with diabetes mellitus

Introduction: As the population ages, the number of older adults with diabetes mellitus will continue to rise. The burden of diabetes on older adults is significant due to the disease itself, its complications, and its treatments. This is compounded by geriatric syndromes such as frailty and cognitive dysfunction. Consequently, health and diabetes-related quality of life (QoL) are diminished.Areas covered: This article reviews the value of assessing QoL in providing patient-centered care and the associations between QoL measures and health outcomes. The determinants of QoL particular to diabetes and the older population are reviewed, including psychosocial, physical, and cognitive burdens of diabetes and aging and the impact of hypoglycemia on QoL. Strategies are described to alleviate these burdens and improve QoL, and barriers to multidisciplinary patient-centered care are discussed. QoL measurement instruments are reviewed.Expert opinion: The goals of treating diabetes and its complications should be considered carefully along with each patient's capacity to withstand the burdens of treatment. This capacity is reduced by socioeconomic, psychological, cognitive, and physical factors reduces this capacity. Incorporating measurement of HRQoL into clinical practices is possible, but deficiencies in the systems of health-care delivery need to be addressed to facilitate their use.

The Effects of a Digital Well-Being Intervention on Patients With Chronic Conditions: Observational Study

BACKGROUND

Chronic conditions account for 75% of health care costs, and the impact of chronic illness is expected to grow over time. Although subjective well-being predicts better health outcomes, people with chronic conditions tend to report lower well-being. Improving well-being might mitigate costs associated with chronic illness; however, existing interventions can be difficult to access and draw from a single theoretical approach. Happify, a digital well-being intervention program drawing from multiple theoretical traditions to target well-being, has already been established as an efficacious means of improving well-being in both distressed and nondistressed users.

OBJECTIVE

This study aimed to compare change in well-being over time after using Happify for users with and without a chronic condition.

METHODS

Data were obtained from Happify users, a publicly available digital well-being program accessible via website or mobile phone app. Users work on tracks addressing a specific issue (eg, conquering negative thoughts) composed of games and activities based on positive psychology, cognitive behavioral therapy, and mindfulness principles. The sample included 821 users receiving at least 6 weeks' exposure to Happify (ranging from 42 to 179 days) who met other inclusion criteria. As part of a baseline questionnaire, respondents reported demographic information (age and gender) and whether they had any of the prespecified chronic conditions: arthritis, diabetes, insomnia, multiple sclerosis, chronic pain, psoriasis, eczema, or some other condition (450 reported a chronic condition, whereas 371 did not). Subjective well-being was assessed with the Happify Scale, a 9-item measure of positive emotionality and life satisfaction. To evaluate changes in well-being over time, a mixed effects linear regression model was fit for subjective well-being, controlling for demographics and platform usage.

RESULTS

At baseline, users with a chronic condition had significantly lower subjective well-being (mean 38.34, SD 17.40) than users without a chronic condition (mean 43.65, SD 19.13). However, change trajectories for users with or without a chronic condition were not significantly different; both groups experienced equivalent improvements in well-being. We also found an effect for time from baseline (b=0.071; SE=0.010; P<.01) and number of activities completed (b=0.03; SE=0.009; P<.01), and a 2-way interaction between number of activities completed and time from baseline (b=0.0002; SE=0.00006; P<.01), such that completing more activities and doing so over increasingly longer periods produced improved well-being scores.

CONCLUSIONS

Data from this study support the conclusion that users with a chronic condition experienced significant improvement over time. Despite reporting lower subjective well-being on the whole, their change trajectory while using Happify was equivalent to those without a chronic condition. Consistent with past research, users who completed more activities over a longer period showed the most improvement. In short, the presence of a chronic condition did not prevent users from showing improved well-being when using Happify.

The Mediating Role of Diabetes Distress and Depressive Symptoms in Type 2 Diabetes Medication Adherence Gender Differences

Background. Medication adherence is negatively related to both diabetes distress (DD) and depressive symptoms (DS). Past research suggests gender differences in adherence, DD, and DS. A gap exists in determining if gender differences in adherence are mediated by DD and DS, or if gender moderates differences in adherence by DD/DS. Aims. This study investigated the relationship between gender, DD, DS, and medication adherence and tested for mediating and moderating effects on medication adherence among American Indian adults with type 2 diabetes. Method. The Maawaji idi-oog mino-ayaawin (Gathering for Health) study was a community-based participatory research collaboration with five American Indian tribes. Participants, randomly recruited from clinic records, shared information during computer-assisted personal interviews. This study includes the 166 participants who reported using medications to treat their diabetes. The relationship between gender, DD, DS, and medication adherence are explored. Possible mediating and moderating effects on medication were tested using regression and path analysis. Results. Females had higher levels of DD and DS and lower levels of medication adherence. Higher levels of DD and DS were both associated with lower medication adherence. No evidence was found that gender moderates the relationship between DD or DS and medication adherence. Instead, DD and DS mediated the relationship between gender and medication adherence. Conclusions. Medication adherence differences in male and female patients may be attributable to DD and DS. The present research highlights both DD and DS as targets for clinicians and researchers alike.

A qualitative study of the perceived effectiveness of refugee services among consumers, providers, and interpreters

This study explored the perceptions of accessibility and cultural effectiveness of refugee services in the northeast region of the United States from refugees, interpreters who work with refugees in accessing these services, and the providers of the refugee services. The study examined the perceptions of 51 refugees from 10 countries, five individual interviews with providers and 26 provider survey responses representing 31 different agencies, and four interviews from interpreters. Qualitative interviews were conducted using a semi-structured interview schedule, were audiotaped, and transcribed. Further data were collected through a survey. All data were analyzed using constant comparative analysis. Participants shared feelings of frustration that services seemed poorly coordinated among the agencies and that the agencies appeared ill-prepared for the unique experiences of separate refugee groups. The three perspectives of refugee service delivery, as a consumer, a provider, or an interpreter, shared the perception that there was not a mechanism for the different services to collaborate effectively with each other, to create a network of coordinated services that would enhance services while decreasing burdens on individual centers, nor was there a system to best prepare the centers for new refugees.

Anticholinergic/sedative drug burden predicts worse memory acquisition in older racially/ethnically diverse patients with type 2 diabetes mellitus

OBJECTIVE

Anticholinergic/sedative drug use, measured by the Drug Burden Index (DBI), is linked to cognitive impairment in older adults. Yet, studies on the DBI's association with neuropsychological functioning are lacking, especially in underserved groups at increased risk of cognitive impairment. We examined cross-sectional relationships between total DBI (DBI_T ) and an age-adjusted analogue (Adj DBI_T ) with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in diverse adults with type 2 diabetes mellitus (T2DM). Based on results of a prior study, we anticipated higher DBIs would be associated with worse memory at older ages.

METHODS

One hundred five adults with T2DM (age = 57 ± 9 years, 65% female, 62% Black, 27% Hispanic/Latino, Hb_A1c = 7.8 ± 1.8) participated. Although memory outcomes were normally distributed, DBI_T values were positively skewed. Spearman correlations assessed their bivariate relationships with RBANS. Adjusting for comorbidities, polypharmacy, Hb_A1c , and education, we tested the moderating effect of age on DBI-RBANS associations at mean ±1 standard deviations of age.

RESULTS

One third of the participants endorsed current sedative/anticholinergic use. Mean DBI_T was 0.385, and mean Adj DBI_T was 0.393 (ranges = 0.00-4.22). Drug burden negatively correlated with RBANS Immediate Memory (DBI_T r_s = -0.237, P = .013; Adj DBI_T r_s = -0.239, P = .014) but no other indices. There was a significant DBI*Age interaction; the negative effect of drug burden on Immediate Memory was significant for ages greater than or equal to 55 years old.

CONCLUSIONS

Sedative/anticholinergic drug exposure was prevalent in these diverse T2DM patients. Adjusting for covariates, greater drug burden was associated with worse memory acquisition among older adults only. Prospective studies should examine these relationships over time and assess whether dementia biomarkers affect the interaction.

Personality traits and the risk of coronary heart disease or stroke in women with diabetes - an epidemiological study based on the Women's Health Initiative

OBJECTIVE

We studied the associations between personality traits and the risk of coronary heart disease (CHD) or stroke in women with diabetes.

METHODS

From the Women's Health Initiative, 15,029 women aged 50 to 79 years at enrollment and with self-reported treated diabetes at baseline or follow-up, were followed for a mean of 10 years. Personality traits measured from validated scales included hostility, optimism, ambivalence over emotional expressiveness, and negative emotional expressiveness. Multivariable Cox proportional-hazards regression models were used to examine associations between personality traits and the risk of adjudicated CHD (nonfatal myocardial infarction and CHD death) or stroke outcomes. Progressively adjusted regression approach was used in the multivariable models to adjust for demographics, depression, anthropometric variables, and lifestyle factors.

RESULTS

A total of 1,118 incident CHD and 710 incident stroke cases were observed. Women in the highest quartile of hostility had 22% (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.01-1.48) increased risk for CHD compared with women in the lowest quartile of hostility. P values for trend were greater than 0.05. Stratified analysis by prevalent or incident diabetes showed that the highest quartile of hostility had 34% increased risk for CHD (HR 1.34, 95% CI 1.03-1.74) among women with incident diabetes. Other personality traits were not significantly associated with stroke or CHD.

CONCLUSIONS

Hostility was associated with incidence of CHD among postmenopausal women with diabetes, especially among incident diabetes. These results provide a basis for targeted prevention programs for women with a high level of hostility and diabetes.

Assessing the association of depression and anxiety with symptom reporting among individuals with type 2 diabetes

Depression and anxiety have been linked to increased somatic symptoms among individuals with type 2 diabetes (T2D), but their independent effects and role in symptom attributions remain unclear. This study examined depression and anxiety in relation to total symptoms and symptom attributions in a diverse sample of 120 adults with T2D. Multiple linear regression tested associations after controlling for medical comorbidities and insulin use. Clinician-rated depression (β = .53, p < .001), self-reported depression (β = .59, p < .001) and self-reported anxiety (β = .62, p < .001) were positively associated with total somatic symptoms. Models adjusting for depression and anxiety revealed significant independent effects for each, regardless of measurement method. In attribution models, only self-reported depression (β = .27, p = .003) was significantly associated with greater attribution to diabetes, whereas clinician-rated depression (β = .19, p = .047), self-reported depression (β = .38, p < .001) and anxiety (β = .28, p = .004) were associated with increased attribution to medications. In models adjusting for depression and anxiety, self-reported depression was a significant independent predictor of diabetes (β = .29, p = .023) and medication (β = .38, p = .004) attribution; anxiety was a significant predictor of medication attribution (β = .25, p = .039). Findings suggest depression and anxiety are implicated in overall increases in somatic symptom complaints and an increased tendency to attribute these symptoms to diabetes and side-effects of diabetes medications among adults with T2D.

Levels of personality functioning and not depression predict decline of plasma glucose concentration in patients with type 2 diabetes mellitus

AIMS

Psychosocial variables influence chronic diseases, such as type 2 diabetes mellitus. While there is evidence for a negative impact of depression, much less is known about stable, personality oriented factors. Aim of the study was to assess the impact of depression and personality functioning on glucose regulation in patients with type 2 diabetes.

METHODS

Seventy-five adult individuals with a first diagnosis of type 2 diabetes were consecutively recruited in an outpatient medical practice. Plasma glucose (HbA1c) was measured at initial contact, and after three and six months of a standardized disease management program. Depression was assessed by self-report (Patient Health Questionnaire, PHQ-D), levels of personality functioning with the screening version of the Operationalized Psychodynamic Diagnosis structure questionnaire (OPD-SQS).

RESULTS

Using mixed regression models, OPD-SQS scores were associated with lower baseline levels of HbA1c, but a less steep decline over time. PHQ-D scores were neither associated with intercept nor with slopes of HbA1c.

CONCLUSIONS

In type 2 diabetes, levels of personality functioning but not depression predicted decline in plasma glucose during the first six months of a standardized disease management program. Personality functioning may be especially important in chronic diseases that demand a high level of compliance and lifestyle change.

The effect of psychological distress on health outcomes: A systematic review and meta-analysis of prospective studies

Distress effects are widely examined in cross-sectional studies with less known about effects on future health. This review summarizes distress impacts on health among adults in prospective studies and describes available distress measurement tools. Four inter-disciplinary databases were searched. Effects of distress on mortality and other outcomes were reviewed and estimated in a meta-analysis. A total of 19 studies were assessed which incorporated 10 distress tools. Distress had a detrimental effect on health regardless of the population studied, distress tool used, and health outcome examined. There was an increased mortality risk among those reporting high versus low distress (pooled hazard ratio (95% confidence interval) = 1.29 (1.15-1.46)).

Depressive symptom dimensions and medication non-adherence in suboptimally controlled type 2 diabetes

AIMS

Research suggests differential effects for somatic and cognitive-affective depressive symptoms in predicting health outcomes. This study evaluated differential relations with medication non-adherence among disadvantaged, and predominantly immigrant adults with sub-optimally controlled type 2 diabetes (T2D).

METHODS

Health plan members taking oral diabetes medication and who had A1c ≥ 7.5% were recruited for a trial of telephonic self-management support. A subset (n = 376; age, M = 55.6 ± 7.2 years; A1c M = 9.1% ± 1.6) completed the Patient Health Questionnaire-8 (PHQ-8). Diabetes medication adherence was measured by self-report and claims-based records. Multivariable logistic regression modeled depressive symptoms and odds of non-adherence using pre-intervention data.

RESULTS

A positive PHQ-8 screen (OR = 2.72 [95%CI: 1.56-4.73]) and each standard deviation increase in PHQ-8 score (OR = 1.40 [95%CI: 1.11-1.75]) were associated with non-adherence, with no independent effects for somatic versus cognitive-affective symptoms. Exploration of individual symptoms identified three significantly associated with non-adherence in covariate-adjusted models; after adjustment for likely presence of clinical depression, only fatigue was independently associated with non-adherence (OR = 1.71 [95%CI: 1.06-2.77]).

CONCLUSIONS

Findings support depression symptom severity as a significant correlate of medication non-adherence among disadvantaged adults with T2D. Support was limited for differential associations for symptom dimensions, but findings suggest that fatigue may be associated with non-adherence independent of the likely presence of depression.

Diagnosis of gestational diabetes: a 'teachable moment'

AIMS

Research regarding the determinants of concordance with gestational diabetes mellitus (GDM) treatment is limited. Here, we test whether the psychosocial changes outlined in the teachable moments model, as proposed by McBride et al. (McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003; 18: 156-170) are associated with following GDM treatment recommendations.

METHODS

Fifty-nine women completed a baseline questionnaire (1 week after GDM diagnosis) in which they reported risk perception, social support, emotional response, the importance of their maternal identity and self-efficacy. One month later, participants reported their concordance with instructions regarding glucose monitoring, diet and, if applicable, medication. We used regression analysis to test for associations between the psychosocial factors measured at baseline and concordance at 1-month follow-up.

RESULTS

Those who perceived their risk as higher or felt supported by family or friends were more likely to report a high level of concordance with GDM treatment. Emotional response, identity salience and self-efficacy were not related to concordance.

CONCLUSIONS

Future interventions designed to increase concordance could benefit from a focus on risk perception and social support, as these factors appear to be most strongly associated with following GDM treatment recommendations.

Psychological burden and resilience factors in patients with Alveolar Echinococcosis - A cross-sectional study

BACKGROUND

Alveolar echinococcosis (AE) is a parasitic zoonosis resembling malignancy due to its clinically silent infiltrative growth, predominately in the liver. The comorbid psychological burden and fear of disease progression in AE patients have hardly been examined to date. The aim of this study was to evaluate depression, anxiety, quality of life, and fear of disease progression in AE patients.

METHODOLOGY/PRINCIPAL FINDINGS

In a cross-sectional study, n = 57 AE patients were invited to report on depression (PHQ-9), anxiety (GAD-7), somatic symptom load (SSS 8), trauma symptoms (PTSS-10), quality of life (SF-12) and on fear of disease progression (FoP-Q-SF) using validated psychometric instruments. Furthermore, attachment style was assessed (RQ-2). N = 47 patients completed the questionnaires (response rate 82.5%). Depression, anxiety, and somatic symptom load were above norm sample means, while physical quality of life was below norm sample means. Existing traumatic symptoms were comparable to those in cancer patients, while fear of disease progression even exceeded cancer patient scores. Patients with a secure attachment style showed less pronounced psychological burden than patients with other attachment styles. Adequate, guideline-based depression and anxiety treatment was very rarely installed.

CONCLUSION/SIGNIFICANCE

The present study revealed remarkable levels of psychological burden in AE patients. In our study sample, we discovered high depression and anxiety levels, a significant reduction of physical quality of life, and fear of disease progression. These results show how important it is for AE patients to be thoroughly assessed with regard to psychological symptoms and mental disorders so that those in need can receive sufficient psychosocial support and treatment according to official guidelines.

Physical symptom complaints, cognitive emotion regulation strategies, self-compassion and diabetes distress among adults with Type 2 diabetes

AIMS

Diabetes-related distress is common among adults with Type 2 diabetes and is consistently associated with poorer self-management and treatment outcomes. However, little is known about the psychological factors that may contribute to or protect against diabetes distress. This study examined illness burden, and positive and negative ways of thinking and relating to oneself in times of stress, as independent correlates of diabetes distress, cross sectionally and longitudinally.

METHOD

A total of 120 adults treated for Type 2 diabetes reported their physical symptom complaints, cognitive emotion regulation, self-compassion and diabetes distress at baseline; 110 completed a 3-month follow-up assessment of diabetes distress. Pearson correlations and multivariable linear regression tested baseline and longitudinal relationships.

RESULTS

Baseline diabetes distress was associated with greater use of negative cognitive emotion regulation strategies (r = 0.43, P < 0.01), greater tendency towards self-criticism, self-judgement and over-identification (r = 0.37, P < 0.01), and greater physical symptom burden (r = 0.50, P < 0.01). Baseline physical symptoms and negative cognitive emotion regulation were independently associated with baseline diabetes distress. Baseline physical symptoms and negative aspects of self-compassion significantly predicted diabetes distress over 3 months. Positive aspects of cognitive emotion regulation and self-compassion were not independently associated with diabetes distress cross sectionally or longitudinally.

CONCLUSION

Greater symptom burden along with the use of negative cognitive emotion regulation and negative aspects of self-compassion were independently associated with diabetes distress. If these relations are explained by causal influence, these modifiable factors could be fruitful targets for intervention research.

Cognitive-affective depressive symptoms and substance use among Latino and non-Latino White patients in HIV care: an analysis of the CFAR network of integrated clinical systems cohort

The disparity in viral suppression rates between Latino and non-Latino White patients in HIV care appears to be narrowing, but it is unclear if depression and substance use perpetuate this disparity. We analyzed electronic medical records from the CFAR network of integrated clinical systems cohort. First observations/enrollment data collected between 2007 and 2013 were analyzed, which included survey (race/ethnicity, depression, substance use, adherence) and clinical data (viral suppression). We estimated indirect effects with a regression-based bootstrapping method. In 3129 observations, Latinos and non-Latino Whites did not differ in depression or alcohol use (ORs 1.11, 0.99, ns), but did in drug use (OR 1.13, p < .001). For all patients, depression and substance use were indirectly associated with small increases (ORs 1.02-1.66) in the odds for a detectable viral load, via worse adherence. We conclude that variables not captured in EMR systems (e.g., health literacy, structural factors) may better explain viral suppression disparities that persist.

The associations between diabetes distress and self-efficacy, medication adherence, self-care activities and disease control depend on the way diabetes distress is measured: Comparing the DDS-17, DDS-2 and the PAID-5

AIMS

To examine whether diabetes distress (DD), when measured by three different instruments, was associated differently with self-efficacy, self-care activity, medication adherence and disease control in people with Type 2 diabetes mellitus.

METHODS

A cross-sectional study in three health clinics. DD was assessed with the 17-item Diabetes Distress Scale, the 2-item DDS-2 (DDS-2) and the 5-item Problem Areas in Diabetes Scale (PAID-5). Dependent variables included self-efficacy, self-care activities, medication adherence, HbA_1c, systolic and diastolic blood pressure (SBP, DBP). Multiple linear and logistic regression were used in analyses.

RESULTS

In total 338 participants (56% women), with a mean age of 61 years and diabetes duration of 9.8 years, were included. DDS-2 was an independent determinant of SBP (β = 1.89, 95% CI 0.14, 3.64), DBP (β = 1.19, 95% CI 0.16, 2.21) and blood pressure target (OR = 2.09, 95% CI 1.12, 3.83). PAID-5 was an independent determinant of medication adherence (adjusted β = -0.05, 95% CI -0.08, -0.01) and self-care activities (OR = 0.50, 95% CI 0.26, 0.99).

CONCLUSIONS

Associations of DD with important aspects of diabetes care are substantially influenced by confounders and depend on the way DD is measured. Our findings call for a judicious use of different DD measures in clinical practice and research. The study is registered on ClinicalTrials.gov (NCT02730754).

Disparities in Care Delivery and Outcomes in Young Adults With Diabetes

PURPOSE OF REVIEW

This review summarizes the literature on care and outcome disparities in young adults (YA) with type 1 and type 2 diabetes, and outlines remaining needs and suggestions to reduce disparities and improve care.

RECENT FINDINGS

Despite well-documented disparities and data from large national and international diabetes populations, the role that social determinants of health play in disease management is largely unstudied. Further, mechanisms of how these risk factors interact with the unique developmental needs of racial-ethnic minority and economically vulnerable young adults with diabetes remain unknown. Little intervention research has focused on improving outcomes in this vulnerable population. More research needs to focus on identifying and addressing risk factors in racial-ethnic minority and economically vulnerable young adults with diabetes. Interventions need to be adapted and developed to meet the unique needs of this high-risk population. Clinicians and healthcare systems must recognize the inequity in care and outcomes for this group and structure clinical programs and policies to promote their optimal care.

Distress and sleep quality in young amphetamine-type stimulant users with an affective or psychotic illness

Misuse of amphetamine-type stimulant (ATS) drugs may disrupt key neurodevelopmental processes in young people and confer protracted neurocognitive and psychopathological harm. ATS users with a co-occurring psychiatric illness are typically excluded from research, reducing generalisability of findings. Accordingly, we conducted a cross-sectional examination of key clinical, sleep, socio-occupational and neurocognitive measures in current, past and never users of ATS drugs who were accessing a youth mental health service (headspace) for affective- or psychotic-spectrum illnesses. Contrary to hypotheses, groups did not differ in psychotic symptomology, socio-occupational functioning or neurocognitive performance. Current ATS users were however significantly more distressed and reported poorer subjective sleep quality and greater subjective sleep disturbances than never users, with a trend toward greater depressive symptomology in current users. Regression analyses revealed that depressive symptoms, daily ATS use and socio-occupational functioning predicted distress, and depressive symptoms and distress predicted subjective sleep quality. Our findings suggest that distress and poor sleep quality reflect a particular pathophysiology among ATS-using patients, which may negatively impact treatment engagement. Delineating the factors that disrupt social and neurobiological development in young people (such as substance use) warrants further investigation, including longitudinal study.

The Impact of a Mobile Diabetes Health Intervention on Diabetes Distress and Depression Among Adults: Secondary Analysis of a Cluster Randomized Controlled Trial

Background

Diabetes is a complex, demanding disease that requires the constant attention of patients. The burden of self-management, including different medication regimens, routine self-care activities, and provider visits, has an impact on patients’ emotional well-being. Diabetes distress and depression are two important components of emotional well-being that may negatively affect diabetes outcomes.

Objective

The aim was to determine the impact of the 1-year Mobile Diabetes Intervention Study cluster randomized clinical trial on emotional well-being measured by diabetes distress and depression among adults with type 2 diabetes (T2D).

Methods

A total of 163 adults with not-well-managed T2D were enrolled from community primary care practices. Primary care practices were cluster randomized into either a usual care control group or intervention group. Intervention participants were given a mobile phone with coaching software including a Web portal to communicate with providers. A priori established secondary outcomes included distress measured by the Diabetes Distress Scale (DDS), with subscales measuring emotional burden, interpersonal distress, physician-related distress, and regimen-related distress, as well as depression measured by the Patient Health Questionnaire (PHQ-9). Linear mixed models were used to calculate the effect of the intervention on diabetes distress levels over time, both overall and separately by sex, and to determine if the intervention affected distress or depression. The impact of total DDS on changes in HbA_1c was also studied.

Results

There were no significant treatment group effects for DDS total (baseline: P=.07; differences over time: P=.38) or for depression (P=.06 over time). Significant declines in total DDS were observed over the 12-month intervention period (P=.01). Regimen-related distress significantly decreased for all study participants (P<.001), but no significant change over time was observed for emotional burden (P=.83), interpersonal distress (P=.64), or physician-related distress (P=.73). Women in both the usual care and intervention groups were more likely to have higher overall DDS, emotional burden, physician-related distress, and regimen-related distress, but not interpersonal distress. Women also reported higher baseline depression compared to men (P=.006). Overall, depression decreased over the treatment period (P=.007), but remained unaffected by group assignment (P=.06) or by sex (P=.97). Diabetes distress had no effect on the change in HbA_1c (P=.91) over the treatment period.

Conclusions

Although we found no definitive overall or sex-specific effect of the intervention on diabetes distress or depression, this study makes an important contribution to the understanding of mobile health interventions and the impact on emotional health. Our study verified previous work that although diabetes distress and depression are highly correlated, these measures are not evaluating the same construct. Design of future mobile technology provides an opportunity to personalize, contextualize, and intervene in the emotional well-being of persons with diabetes.

Trial Registration

Clinicaltrials.gov NCT01107015; https://clinicaltrials.gov/ct2/show/NCT01107015 (Archived by WebCite at http://www.webcitation.org/6vVgRCLAF)