Epidemiology of depression in diabetes: international and cross-cultural issues

Meeting the Challenge of Diabetes in Ageing and Diverse Populations: A Review of the Literature from the UK

The impact of type 2 diabetes on ageing societies is great and populations across the globe are becoming more diverse. Complications of diabetes unequally affect particular groups in the UK older people, and people with a South Asian background are two population groups with increased risk whose numbers will grow in the future. We explored the evidence about diabetes care for older people with South Asian ethnicity to understand the contexts and mechanisms behind interventions to reduce inequalities. We used a realist approach to review the literature, mapped the main areas where relevant evidence exists, and explored the concepts and mechanisms which underpinned interventions. From this we constructed a theoretical framework for a programme of research and put forward suggestions for what our analysis might mean to providers, researchers, and policy makers. Broad themes of cultural competency; comorbidities and stratification; and access emerged as mid-level mechanisms which have individualised, culturally intelligent, and ethical care at their heart and through which inequalities can be addressed. These provide a theoretical framework for future research to advance knowledge about concordance; culturally meaningful measures of depression and cognitive impairment; and care planning in different contexts which support effective diabetes care for aging and diverse populations.

Self-reported depression and anxiety symptoms and usage of computers and mobile phones among working-age Finns

The aim of the work is to study self-reported depression and anxiety symptoms among working-age Finns using logistical regression models. The study was carried out as a cross-sectional study by posting a questionnaire to 15,000 working-age persons. The responses (6121) revealed that 101 (1.7%) Finnish working-age persons suffered depression very often and 77 (1.3%) suffered anxiety very often during the last 12 months. Symptoms uncovered in the comparative analysis of respondents who had quite often or more often depression to respondents who had less depression showed differentiation. The same result was obtained in the analysis of self-reported anxiety symptoms. With the logistical regression models (from depression and anxiety), we found associations between physical symptoms (in shoulder) and depression and between different mental symptoms and anxiety or depression. In the future, it is important to take into accout that persons with physical symptoms can also have mental symptoms (depression or anxiety).

Country variations in depressive symptoms profile in Asian countries: Findings of the Research on Asia Psychotropic Prescription (REAP) studies

INTRODUCTION

This study was to assess differences in the symptom profile of depressive illness across various countries/territories in Asia. The study was a part of the Research on Asia Psychotropic Prescription project. The participating countries/territories include China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Singapore, Taiwan, and Thailand.

METHODS

The pattern of depressive symptoms in 1,400 subjects with depressive disorder from 42 psychiatric centers in 10 Asian countries/territories was assessed. We collected information on socio-demographic and clinical characteristics with a standardized protocol and data collection procedure.

RESULTS

The most common presentations of depressive symptoms were persistent sadness, loss of interest, and insomnia. Similar findings were found regardless of the region, country, or its income level. Patients with depressive disorder from high-income countries presented significantly more with vegetative symptom cluster (P < 0.05), while those from the upper middle-income countries had significantly more with both mood (P < 0.001) and cognitive symptom clusters (P < 0.01). In lower middle-income countries, patients with depressive symptoms had significantly less mood symptom cluster (P < 0.001) but significantly more cognitive symptom cluster (P < 0.05).

DISCUSSION

This study demonstrates that in Asia, despite variations in the initial symptom reported by the patients, across different countries/territories, core depressive symptoms remain the same. Variations have been found in presentation of depressive symptoms with regards to the level of income of countries. Physical or vegetative symptoms were reported more by centers in higher income countries, while depressive cognition and suicidal thoughts/acts were more frequently reported from lower income countries.

Recognising female sexual dysfunction as an essential aspect of effective diabetes care

The following literature review will focus on sexual dysfunction in women living with diabetes, drawing on international studies in this specialist field. The key aim of this paper is generate a greater understanding and recognition of the issues facing these women and to determine a more proactive approach to identification, consultation and potential treatment options. The main findings highlight the unique role practitioners have with women with diabetes and how to facilitate partnership working. Nurses have the most frequent contact with people living with diabetes in any healthcare system. Nurses' knowledge about sexuality in relation to diabetes should improve patient education, recognition and could signal undiagnosed or increased risk of sexual dysfunction to enable treatment so care can be optimised accordingly (Sivrikaya et al., 2014).

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

The association between depression, quality of life, and the health care expenditure of patients with diabetes mellitus in Uganda

BACKGROUND

Depression is one of the commonest neuropsychiatric disorders in patients with diabetes mellitus (DM) and is associated with poor glycaemic control, vascular complications, a low quality of life and increased health care expenditure. Co-morbid DM and depression remains poorly identified and inadequately treated in sub-Saharan Africa.

METHODS

We conducted a cross-sectional survey of 437 patients with DM at 3 DM clinics in Uganda. Participants were assessed for depression, blood sugar levels, diabetic neuropathy, quality of life, and health care expenditures.

RESULTS

The prevalence of depression was 34.8%. Depressed participants were more likely to be suicidal [OR=3.81, (CI 2.87-5.04)], younger [OR=3.98 CI (1.20-13.23)], un-employed [OR=1.99(CI 1.04-3.81)], and having lost a spouse [OR=2.36 (CI 1.29-4.31)]. Overall quality of life was poor [OR=0.67 (CI 0.47-0.96)], they scored poorer in the physical [OR=0.97, (CI 0.95-0.99)], psychological [OR=1.05 (CI 1.03-1.07)], and environmental [OR=0.97, (CI 0.95-0.99)] domains. They had an increased likelihood of incurring direct out-of-pocket payments for health care services [OR=1.56 (CI 1.03-2.36)], and were more likely to be impoverished [OR=1.52 (CI 1.01-2.28)].

LIMITATION

The cross sectional nature of this study makes it difficult to examine causation. More studies are required in order to better understand the associations and impact of the factors examined above on patient outcomes.

CONCLUSIONS

Depression is highly prevalent among patients with DM in Uganda, and is associated with a number of adverse outcomes. A holistic approach that focuses on the depression management among patients with diabetes is recommended.

[Emotional distress and quality of life in people with diabetes and their families]

OBJECTIVE

The daily experience of living with diabetes can adversely affect the quality of life of people with diabetes and their families. We present the results for Spain of the DAWN2 study related to quality of life and wellbeing of patients and their families.

METHODS

The DAWN2 study is an observational, cross-sectional study. In the present study, we used the Spanish sample of patients (N=502) and their relatives (N=123).

RESULTS

A total of 13.9% of patients were at risk of possible depression while 50.0% of people with diabetes and 45.5% of family members reported a high level of diabetes-related emotional stress.

CONCLUSIONS

People with diabetes experience high levels of stress and the psychosocial impact of diabetes also affects family members.

Association of severe hypoglycemia with depressive symptoms in patients with type 2 diabetes: the Fukuoka Diabetes Registry

OBJECTIVE

Although many studies have investigated the clinical characteristics of patients with diabetes with depression in Western populations, there is a lack of information regarding other ethnicities. We studied the association between clinical characteristics and depressive symptoms in Japanese patients with type 2 diabetes.

METHODS

A total of 4218 Japanese patients with type 2 diabetes who were not taking antidepressants were divided into four groups according to the Center for Epidemiologic Studies Depression Scale (CES-D) score. The relationship between the severity of depressive symptoms and clinical parameters was examined cross-sectionally.

RESULTS

After multivariate adjustments, the severity of depressive symptoms was significantly associated with body mass index, leisure-time physical activity, current smoking, sleep duration, sucrose intake, skipping breakfast, insulin use, severe hypoglycemia, dysesthesia of both feet, history of foot ulcer, photocoagulation, ischemic heart disease, and stroke. ORs for severe hypoglycemia increased significantly with the CES-D score in 2756 sulfonylurea and/or insulin-treated patients after multivariate adjustment including age, sex, duration of diabetes, glycated hemoglobin, insulin use, self-monitoring of blood glucose, leisure-time physical activity, skipping breakfast, dysesthesia of both feet, ischemic heart disease, and stroke (CES-D score ≤9, referent; 10-15, OR 1.64; 16-23, OR 2.09; ≥24, OR 3.66; p for trend <0.01).

CONCLUSIONS

Severe hypoglycemia was positively associated with the severity of depressive symptoms in Japanese patients with type 2 diabetes independent of glycemic control, insulin therapy, lifestyle factors, and diabetic complications. As both severe hypoglycemia and depression are known risk factors for morbidity and mortality in patients with diabetes, clinicians should be aware of this association.

UMIN CLINICAL TRIAL REGISTRY

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Prevalence and influencing factors of co-morbid depression in patients with type 2 diabetes mellitus: a General Hospital based study

BACKGROUND

Depression and diabetes have been recognized as major public health issues in China, however, no studies to date examined the factors associated with the development of depression in patients with diabetes in China. This study aimed to estimate the prevalence of co-morbid depression among adults with type 2 diabetes mellitus (DM) and to examine the influence factors of co-morbid depression in a group of patients with type 2 DM.

METHODS

The study was conducted from March l to May 31, 2012, in the Department of Endocrinology of the First Affiliated Hospital of the General Hospital of the People's Liberation Army (PLA). A systematic random sample of 412 type 2 DM patients aged over 18 years was selected. A structured questionnaire was used for collecting the information about socio-demographic data, lifestyle factors and clinical characteristics. Depression and social support was evaluated by using the Chinese version of Beck Depression Inventory (BDI) and Social Support Rate Scale (SSRS), respectively. Weights and heights were measured. Hemoglobin A1c (HbA1c) was abstracted from each patient directly after the interview.

RESULTS

Of the total sample, 142 patients had depression according to the BDI scores (BDI scores ≥14), the prevalence of co-morbid depression in this study population was 5.7 % (142/2500). Of which, 56 had major depression (BDI ≥ 21), and 86 had moderate depression (BDI ≥ 14&BDI < 21). Logistic regression analysis indicated that a high HbA1c level, a high BMI, low quality health insurance, and being single, were significantly associated with the development of depression. However, a family history of diabetes and a high social support level are likely protective factors.

CONCLUSIONS

The prevalence of co-morbid depression was 5.7 % among Chinese subjects with type 2 DM in this study. High HbA1c level, high BMI score, being single, low social support level, and low quality health insurance were associated with the presence of depression. These findings support a recommendation for routine screening and management in China for depression in patients with diabetes, especially for those in primary care, to reduce the number of the depressed or the misrecognized depressed diabetic patients.

The association of type 2 diabetes patient and spouse illness representations with their well-being: a dyadic approach

BACKGROUND

The aim of this study was to examine the relation between certain illness representations and the physical and psychological well-being of persons with type 2 diabetes mellitus and their spouses.

PURPOSE

In this study, we examined the relation of type 2 diabetes patients and their spouses' representations of illness consequences and timeline (chronicity and cyclicality/predictability) to the physical and psychological well-being of both. The interaction between patient and spouse illness representations was also studied.

METHODS

A dyadic analysis approach was employed, while the Actor-Partner Interdependence Model was used to examine dyadic effects. One hundred and sixty-eight individuals nested in 84 couples participated.

RESULTS

Regarding illness representations, both actor (i.e., the effects of a person's own characteristics on own outcomes) and partner (i.e., the effects of the partner's characteristics on a person's outcomes) effects were identified but only for patients' well-being. Certain significant interactions were also found: patients' timeline-cyclical representations were weakly associated with their anxiety and depression symptoms when spouses perceived diabetes as less unpredictable. Also, spouses' perceptions of consequences were more strongly related to their anxiety when patients perceived diabetes as less burdensome.

CONCLUSIONS

Overall, the findings indicate a type of synergy between patient and spouse illness representations. They also emphasize the interdependence between diabetes patients and their partners, and the need to examine adaptation to illness within a dyadic-regulation framework as well.

Associations between DSM-IV mental disorders and diabetes mellitus: a role for impulse control disorders and depression

AIMS/HYPOTHESIS

No studies have evaluated whether the frequently observed associations between depression and diabetes could reflect the presence of comorbid psychiatric conditions and their associations with diabetes. We therefore examined the associations between a wide range of pre-existing Diagnostic Statistical Manual, 4th edition (DSM-IV) mental disorders with self-reported diagnosis of diabetes.

METHODS

We performed a series of cross-sectional face-to-face household surveys of community-dwelling adults (n = 52,095) in 19 countries. The World Health Organization Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Diabetes was indicated by self-report of physician's diagnosis together with its timing. We analysed the associations between all mental disorders and diabetes, without and with comorbidity adjustment.

RESULTS

We identified 2,580 cases of adult-onset diabetes mellitus (21 years +). Although all 16 DSM-IV disorders were associated with diabetes diagnosis in bivariate models, only depression (OR 1.3; 95% CI 1.1, 1.5), intermittent explosive disorder (OR 1.6; 95% CI 1.1, 2.1), binge eating disorder (OR 2.6; 95% CI 1.7, 4.0) and bulimia nervosa (OR 2.1; 95% CI 1.3, 3.4) remained after comorbidity adjustment.

CONCLUSIONS/INTERPRETATION

Depression and impulse control disorders (eating disorders in particular) were significantly associated with diabetes diagnosis after comorbidity adjustment. These findings support the focus on depression as having a role in diabetes onset, but suggest that this focus may be extended towards impulse control disorders. Acknowledging the comorbidity of mental disorders is important in determining the associations between mental disorders and subsequent diabetes.

Type A behavior and risk of all-cause mortality, CAD, and CAD-related mortality in a type 1 diabetic population: 22 years of follow-up in the Pittsburgh Epidemiology of Diabetes Complications Study

OBJECTIVE

To determine whether type A behavior predicts all-cause mortality and incident coronary artery disease (CAD) in a type 1 diabetic population.

RESEARCH DESIGN AND METHODS

Follow-up data (22 years) from the Pittsburgh Epidemiology of Diabetes Complications (EDC) study of childhood-onset type 1 diabetes were analyzed for the 506 participants who completed the Bortner Rating Scale (measuring type A behavior) and Beck Depression Inventory (BDI) at baseline (1986-1988). CAD comprised myocardial infarction as determined by hospital records/Q waves on electrocardiogram (ECG), CAD death (determined by a mortality classification committee), angiographic stenosis, ischemic ECG, and angina.

RESULTS

There were 128 deaths (25.3%) during follow-up. Univariate analysis showed an inverse relationship between Bortner scores and all-cause mortality (P=0.01), which remained significant after allowing for age, sex, duration, HbA1c, education, smoking, BMI, and physical activity (P=0.03). However, the addition of BDI scores attenuated the relationship (P=0.11) with a significant interaction (P=0.03) such that any protective effect against mortality was limited among individuals with lower BDI scores (bottom three quintiles) (P=0.07), whereas no effect was seen in those with higher BDI scores (P=0.97). Bortner scores showed only a borderline association with incident CAD (P=0.09).

CONCLUSIONS

Those with higher type A behavior have lower all-cause mortality in our type 1 diabetic population, an effect that interacts with depressive symptomatology such that it is only operative in those with low BDI scores. Further research should focus on understanding this interaction.

The comorbidity between depression and diabetes

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