Diabetes and mental health

Socioeconomic disparities in the prevalence of depression and anxiety, and their associations with diabetes in rural southwest China

BACKGROUND

This study examines how the prevalence of depression and anxiety symptoms differ by socioeconomic status and explores their associations with diabetes in rural southwest China.

METHODS

Data were collected from a cross-sectional health interview and examination survey of 5,005 adults aged ≥ 35 years in rural southwest China. Height, weight, waist circumference, and fasting blood glucose measurement were taken. Depression and anxiety symptoms were assessed using Zung's Self-rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS), respectively. An individual socioeconomic position (SEP) index was constructed using principal component analysis.

RESULTS

The overall prevalence of depression, anxiety, comorbid depression and anxiety symptoms, and diabetes was 5.4%, 12.8%, 4.0%, and 9.6%, respectively. Females had higher prevalence of depression (7.3% vs. 3.4%, P < 0.01), anxiety (17.4% vs. 8.1%, P < 0.01), and comorbid depression and anxiety symptoms (5.8% vs. 2.3%, P < 0.01) than males. Han ethnicity participants had a higher prevalence of depression, anxiety, and comorbid depression and anxiety symptoms than ethnic minority participants (P < 0.01). Individuals with a lower education level and lower SEP were more likely to experience depression, anxiety, and comorbid depression and anxiety symptoms (P < 0.01), while individuals with good access to medical services were more likely to exhibit depression symptoms and comorbid depression and anxiety symptoms (P < 0.05). Multivariable logistic regression analysis found that individuals with depression symptoms (OR = 1.78, 95% CI: 1.25 to 2.53), anxiety symptoms (OR = 1.66, 95% CI: 1.30 to 2.16), and comorbid depression and anxiety symptoms (OR = 1.61, 95% CI: 1.07 to 2.44) all had a greater probability of having diabetes (P < 0.01); depression symptoms had the strongest association with diabetes prevalence (P < 0.01).

CONCLUSIONS

There are significant socioeconomic differences in the prevalence of depression and anxiety in rural southwest China, and both depression and anxiety symptoms have strong associations with diabetes. Future diabetes prevention and management strategies should focus on individuals with depression, anxiety, and comorbid depression and anxiety symptoms.

Mind in Metabolism - A Comprehensive Literature Review on Diabetes and its Connections to Obsessive Compulsive Disorder, Schizophrenia, and Bipolar Disorder

PURPOSE OF REVIEW

The co-occurrence of diabetes and mental illnesses such as bipolar disorder (BD), obsessive-compulsive disorder (OCD), and schizophrenia creates significant barriers for both people with diabetes (PWD) and their healthcare teams. This literature review provides an analysis of the relationship between diabetes and mental illnesses through exploring epidemiology, shared risk factors, and clinical implications. The aim is to enhance the understanding of these complex comorbidities to guide and improve future research and clinical practice.

RECENT FINDINGS

Recent research suggests a strong link between mental illness, metabolic syndrome, and diabetes. Studies show that BD has a robust relationship with metabolic disease and the antipsychotic medications used in treatment for many mental illnesses are strongly associated with weight gain and metabolic disease. However, there is limited research exploring the bidirectional relationship that diabetes has with BD, schizophrenia, and OCD. While research exists on the link between diabetes and mental conditions such as depression and anxiety, little research has examined schizophrenia, OCD and BD. The findings noted in this review suggest gaps in treatment options, healthcare services, and social support. While this paper provides a foundation for future progress, advancement in this field will require a collaborative effort from researchers, healthcare professionals, and community outreach programs to effectively close the gaps in care noted in these patient populations.

Differences in mental health status between individuals living with diabetes, and pre-diabetes in Qatar: A cross-sectional study

Aims

The aims of this study was to determine the prevalence and to compare depression and anxiety screening scores by type of diabetes: type 2 diabetes mellitus (T2DM), type 1 diabetes mellitus (T1DM), and pre-diabetes. The secondary aim was to examine sex differences in screening scores by type of diabetes.

Methods

This cross-sectional study was conducted in Doha, Qatar using primary data collection (N = 150), and stratified random sampling at a diabetes primary healthcare center. The study tool collected demographic information and used validated mental health screening tools for depressive symptoms "Patient Health Questionnaire-9 (PHQ-9)", and for anxiety symptoms "Generalized Anxiety Disorder 7 (GAD-7)".

Results

The prevalence of moderate to severe depressive and anxiety scores was highest in the prediabetes group (20 % and 14 % respectively). There were increased PHQ-9 scores in the pre-diabetes group compared to T2DM (p-value <0.05). No statistically significant differences in depressive symptom scores were found when comparing the pre-diabetes group with T1DM, and T1DM with T2DM. When looking at sex differences, there were no statistically significant differences between T1DM and pre-diabetes males and females, however PHQ-9 and GAD-7 scores in T2DM females were poorer compared to T2DM males.

Conclusion

The results of our study found patients living with pre-diabetes, and females with T2DM are vulnerable populations who should be screened for mental health disorders. Early screening for mental health disorders for individuals diagnosed with prediabetes, T1DM, and T2DM should be routinely conducted to potentially improve health outcomes.

Prevalence of Mental, Behavioral, and Developmental Disorders Among Children and Adolescents with Diabetes, United States (2016-2019)

OBJECTIVE

To assess the association of diabetes and mental, behavioral, and developmental disorders in youth, we examined the magnitude of overlap between these disorders in children and adolescents.

STUDY DESIGN

In this cross-sectional study, we calculated prevalence estimates using the 2016-2019 National Survey of Children's Health. Parents reported whether their child was currently diagnosed with diabetes or with any of the following mental, behavioral, or developmental disorders: attention-deficit/hyperactivity disorder, autism spectrum disorder, learning disability, intellectual disability, developmental delay, anxiety, depression, behavioral problems, Tourette syndrome, or speech/language disorder. We present crude prevalence estimates weighted to be representative of the US child population and adjusted prevalence ratios (aPRs) adjusted for age, sex, and race/ethnicity.

RESULTS

Among children and adolescents (aged 2-17 years; n = 121 312), prevalence of mental, behavioral, and developmental disorders varied by diabetes status (diabetes: 39.9% [30.2-50.4]; no diabetes: 20.3% [19.8-20.8]). Compared with children and adolescents without diabetes, those with diabetes had a nearly 2-fold higher prevalence of mental, behavioral, and developmental disorders (aPR: 1.72 [1.31-2.27]); mental, emotional, and behavioral disorders (aPR: 1.90 [1.38-2.61]) and developmental, learning, and language disorders (aPR: 1.89 [1.35-2.66]).

CONCLUSIONS

These results suggest that approximately 2 in 5 children and adolescents with diabetes have a mental, behavioral, or developmental disorder. Understanding potential causal pathways may ultimately lead to future preventative strategies for mental, behavioral, and developmental disorders and diabetes in children and adolescents.

Mode of treatments and achievement of treatment targets among type 2 diabetes patients with different comorbidities - a register-based retrospective cohort study in Finland

AIMS

Type 2 diabetes (T2D) is a progressive disease often associated with comorbidities that complicate the management of T2D and affect the achievement of treatment targets. However, adherence to guidelines and individualized treatments can potentially improve treatment outcomes. This study assessed the association between different glucose lowering and lipid lowering medication lines and the achievement of treatment targets with different comorbidities among a T2D cohort in North Karelia, Finland (2011-12 to 2015-16).

METHODS

The data on all diagnosed T2D patients (n = 10,190) in North Karelia were collated retrospectively from regional electronic health records (EHRs). Analyses were performed considering the age, sex, and comorbidities such as cardiovascular diseases (CVD) and any mental disorders (AMD). We analyzed the trends in using glucose lowering and lipid lowering medications and the effect of changes in medication on the achievement of treatment targets among different patient groups.

RESULTS

Metformin was the most common treatment in all patient groups. The use of only metformin declined and the use of metformin and/or other non-insulin medications increased during the follow-up. A Combination of insulin and non-insulin medication was mostly used by T2D patients with both cardiovascular diseases and mental disorders (T2D + CVD + AMD), and the use of insulin increased among this group in follow-up. Achievement of the glucose treatment target deteriorated even after the intensification of medication among all patient groups during the follow-up. A considerably higher number of patients with T2D + AMD and T2D + CVD + AMD did not use lipid lowering medication when compared to the T2D + CVD patients both at baseline and follow-up. However, the achievement of the LDL treatment target improved during the follow-up.

CONCLUSION

Achievement of the glucose target deteriorated even after the intensification of treatment, and especially among patients with multiple diseases. Many T2D patients with AMD and CVD remained without lipid lowering medication, which needs further attention.

Changes in non-communicable diseases, diet and exercise in a rural Bangladesh setting before and after the first wave of COVID-19

Prevalence of non-communicable diseases (NCDs) is high in rural Bangladesh. Given the complex multi-directional relationships between NCDs, COVID-19 infections and control measures, exploring pandemic impacts in this context is important. We conducted two cross-sectional surveys of adults ≥30-years in rural Faridpur district, Bangladesh, in February to March 2020 (survey 1, pre-COVID-19), and January to March 2021 (survey 2, post-lockdown). A new random sample of participants was taken at each survey. Anthropometric measures included: blood pressure, weight, height, hip and waist circumference and fasting and 2-hour post-glucose load blood glucose. An interviewer-administered questionnaire included: socio-demographics; lifestyle and behavioural risk factors; care seeking; self-rated health, depression and anxiety assessments. Differences in NCDs, diet and exercise were compared between surveys using chi2 tests, logistic and linear regression; sub-group analyses by gender, age and socio-economic tertiles were conducted. We recruited 950 (72.0%) participants in survey 1 and 1392 (87.9%) in survey 2. The percentage of the population with hypertension increased significantly from 34.5% (95% CI: 30.7, 38.5) to 41.5% (95% CI: 38.2, 45.0; p-value = 0.011); the increase was more pronounced in men. Across all measures of self-reported health and mental health, there was a significant improvement between survey 1 and 2. For self-rated health, we observed a 10-point increase (71.3 vs 81.2, p-value = 0.005). Depression reduced from 15.3% (95% CI: 8.4, 26.1) to 6.0% (95% CI: 2.7, 12.6; p-value = 0.044) and generalised anxiety from 17.9% (95% CI: 11.3, 27.3) to 4.0% (95% CI: 2.0, 7.6; p-value<0.001). No changes in fasting blood glucose, diabetes status, BMI or abdominal obesity were observed. Our findings suggest both positive and negative health outcomes following COVID-19 lockdown in a rural Bangladeshi setting, with a concerning increase in hypertension. These findings need to be further contextualised, with prospective assessments of indirect effects on physical and mental health and care-seeking.

The Feasibility of a Primary Care Based Navigation Service to Support Access to Health and Social Resources: The Access to Resources in the Community (ARC) Model

INTRODUCTION

We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model.

METHODS

We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator.

RESULTS

Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s).

CONCLUSION

The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients' access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211).

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

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

Psychological and Cognitive Barriers to Diabetes-Related Foot Complication Treatment: Clinicians' Perspectives

This study investigated clinicians' perspectives about cognitive functioning and mental health in individuals with diabetes-related foot complications (DRFCs), and how these impact the clinicians' treatment of the patients' conditions. Psychological and cognitive impairments may be more pronounced in individuals with DRFCs compared with the general diabetes mellitus population. Understanding these factors will identify potential barriers to DRFC treatment adherence and effective disease self-management. Fourteen multidisciplinary clinicians (Mean_age = 37.86 years; standard deviation = 9.26; range = 27-51) were recruited from a metropolitan hospital diabetic foot unit. Semistructured interviews were conducted with each clinician, followed by the completion of a brief quantitative questionnaire. Interview data were analyzed thematically. Six themes that encompassed factors affecting DRFC treatment were identified: (1) psychological and cognitive characteristics; (2) the person in the environment; (3) illness and self-identity; (4) burden of chronic disease; (5) engaging with treatment; and (6) the clinician and health system response. Quantitative questionnaire results coincided with qualitative findings, with endorsement of global psychological and cognitive impairment in individuals with DRFC, which considerably affected their ability to engage in treatment. From the perspectives of clinicians working with patients with DRFCs, psychological, cognitive, and social factors have a considerable influence on DRFC treatment and self-management. Further investigation of these factors and their interrelationships is necessary to enhance treatment adherence in individuals with DRFCs.

Management and Treatment of Patients With Major Depressive Disorder and Chronic Diseases: A Multidisciplinary Approach

In patients with physical chronic diseases, the prevalence of major depressive disorder (MDD) is approximately 2- to 3-fold higher than in the general population, and it can reach up to 20-40%. The comorbidity of MDD with chronic medical diseases is associated with poorer quality of life, increased medical symptom burden, poor adherence to self-care regimens, increased risk of functional impairment, morbidity, and mortality, and also higher medical costs. Despite this evidence, in routine practice, psychological issues and concerns are frequently inadequately managed. This consensus document proposes that a proper diagnosis, a multidisciplinary approach, and a personalized treatment plan would allow patients with MDD and chronic comorbidities to be more compliant, to improve the outcomes, to reduce possible relapses in the long term, and to prevent or better manage complications and adverse events. This proposal might be useful for any health professionals who deal with patients with chronic diseases, as it can help to pay more attention to the emotional impact of these conditions, in particular in terms of depressive symptoms.

"To die is better for me", social suffering among Syrian refugees at a noncommunicable disease clinic in Jordan: a qualitative study

BACKGROUND

The conflict in Syria has required humanitarian agencies to implement primary-level services for non-communicable diseases (NCDs) in Jordan, given the high NCD burden amongst Syrian refugees; and to integrate mental health and psychosocial support into NCD services given their comorbidity and treatment interactions. However, no studies have explored the mental health needs of Syrian NCD patients. This paper aims to examine the interaction between physical and mental health of patients with NCDs at a Médecins Sans Frontières (MSF) clinic in Irbid, Jordan, in the context of social suffering.

METHODS

This qualitative study involved sixteen semi-structured interviews with Syrian refugee and Jordanian patients and two focus groups with Syrian refugees attending MSF's NCD services in Irbid, and eighteen semi-structured interviews with MSF clinical, managerial and administrative staff. These were conducted by research staff in August 2017 in Irbid, Amman and via Skype. Thematic analysis was used.

RESULTS

Respondents describe immense suffering and clearly perceived the interconnectedness of their physical wellbeing, mental health and social circumstances, in keeping with Kleinman's theory of social suffering. There was a 'disconnect' between staff and patients' perceptions of the potential role of the NCD and mental health service in alleviating this suffering. Possible explanations identified included respondent's low expectations of the ability of the service to impact on the root causes of their suffering, normalisation of distress, the prevailing biomedical view of mental ill-health among national clinicians and patients, and humanitarian actors' own cultural standpoints.

CONCLUSION

Syrian and Jordanian NCD patients recognise the psychological dimensions of their illness but may not utilize clinic-based humanitarian mental health and psychosocial support services. Humanitarian agencies must engage with NCD patients to elicit their needs and design culturally relevant services.

Association of mental disorders and quality of diabetes care - A six-year follow-up study of type 2 diabetes patients in North Karelia, Finland

AIMS

To compare the quality of diabetes care among type 2 diabetes patients with and without mental disorders during six-year follow-up in North Karelia, Finland.

METHODS

All type 2 diabetes patients (n = 10190) were analysed using the electronic health records data from 2011-12 to 2015-16. The diabetes care was evaluated using the measurement activity and the achievement of the treatment targets for HbA1c and LDL.

RESULTS

Monitoring of HbA1c and LDL levels improved among all patient groups, except the dementia patients. The proportion of those achieving the HbA1c target declined and those achieving the LDL target improved in all patient groups. Differences in the changes of achievement of the target HbA1c level among patients with dementia and depression were observed when compared with those having only type 2 diabetes.

CONCLUSIONS

This study highlights the challenge of glucose level management as the age and comorbidities of the patients related to the care and achievements of the treatment targets. Mental disorders that are likely to affect patients' adherence to medication and other treatments should be taken into account and more support for self-care should be provided to such patients. Improvement in the achievement of LDL target address the progress in the prevention of macrovascular complications.

Living Well With Type 1 Diabetes for 40 Years or More

Background

Although many studies explore the experiences of persons with type 1 diabetes, most examine the experience of children, adolescents, or persons in transition to adulthood. Few studies focus on the person living long term with type 1 diabetes.

Purpose

The purpose of this study was to explore the facilitators and barriers for people living well with type 1 diabetes over the long term.

Methods

An inductive interpretive description approach was used to explore living with type 1 diabetes for a duration of 40 years or more. Qualitative semistructured interviews with a convenience sample (n = 8) were conducted.

Results

Four dialectic themes were identified: accommodating and battling the disease, convenience and constraint of technology and treatment, self-reliance and reliance on others, and external and personal knowledge.

Conclusions

Recommendations for the health-care team emphasize person-centered care with acknowledgment of the person as expert and as more than their condition. Further research with this population would strengthen the implications for practice. Specifically, research is needed on diabetes distress, losses experienced due to diabetes, how to meet their educational needs, and how to tap into their expertise for the benefit of those with type 1 following them.

The Diabetes and Emotional Health Handbook and Toolkit for Health Professionals Supporting Adults With Type 1 and Type 2 Diabetes: Formative Evaluation

BACKGROUND

Health professionals have expressed unmet needs, including lacking the skills, confidence, training, and resources needed to properly attend to the psychological needs of people with diabetes.

OBJECTIVE

Informed by needs assessments, this study aimed to develop practical, evidence-based resources to support health professionals to address the emotional needs of adults with type 1 or type 2 diabetes.

METHODS

We developed a new handbook and toolkit informed by formative evaluation, including literature reviews, stakeholder consultation and review, and a qualitative study. In the qualitative study, health professionals participated in interviews after reading sections of the handbook and toolkit.

RESULTS

The literature review uncovered that psychological problems are common among adults with diabetes, but health professionals lack resources to provide related support. We planned and drafted resources to fill this unmet need, guided by stakeholder consultation and an Expert Reference Group (ERG). Before finalizing the resources, we implemented feedback received from stakeholders (ERG, health professionals, academics, and people with diabetes). The resulting resources were the practical, evidence-based Diabetes and Emotional Health handbook and toolkit. A total of 19 health professionals took part in the qualitative study about the handbook and toolkit. They viewed the resources favorably, felt empowered to support people with diabetes experiencing psychological problems, and felt motivated to share the resources with others. Some gave examples of how they had used the handbook in clinical practice. A perceived highlight was the inclusion of a process model outlining 7 steps for identifying and supporting people with emotional problems: the 7 A's model. With funding from the National Diabetes Services Scheme (NDSS), more than 2400 copies of Diabetes and Emotional Health have been distributed. It is freely available on the Web. The NDSS is an initiative of the Australian Government administered with the assistance of Diabetes Australia.

CONCLUSIONS

The new evidence-based resources are perceived by stakeholders as effective aids to assist health professionals in providing emotional support to adults with diabetes. The 7 A's model may have clinical utility for routine monitoring of other psychological and health-related problems, as part of person-centered clinical care.

Determinants of Readiness for Adopting Healthy Lifestyle Behaviors Among Indigenous Adolescents with Type 2 Diabetes in Manitoba, Canada: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to determine whether the readiness for adopting healthy lifestyle behaviors was associated with mental health and comorbid conditions in youth with T2D.

METHODS

A cross-sectional comparison of various measures of mental health (distress, stress, resilience) and comorbid conditions (glycated hemoglobin, adiposity, hypertension) was conducted within a cohort of indigenous youth with T2D living in Canada, stratified according to their readiness to adopt healthy lifestyle behaviors based on Prochaska's transtheoretical model.

RESULTS

Within the entire cohort (n = 162), only 14% were considered ready to adopt all healthy lifestyle behaviors. The readiness to adopt all lifestyle behaviors was associated with higher positive mental health (47 vs. 39 units; P < 0.05) and sense of mastery (40 vs. 37 units; P < 0.05), lower perceived stress (27 vs. 29 units; P < 0.05) and distress (8 vs. 10 units; P < 0.05), and better glycemic control (HbA1c: 8.4 ± 2.6% vs. 9.7 ± 2.8%; P < 0.05) compared with youth who were not ready to adopt all lifestyle behaviors.

CONCLUSIONS

The readiness for adopting healthy lifestyle behaviors is low among adolescents with T2D. Being ready to adopt healthy lifestyle behaviors is associated with better mental health and glycemic control.

Self-management levels of diet and metabolic risk factors according to disease duration in patients with type 2 diabetes

BACKGROUND/OBJECTIVES

Metabolic risk factors should be managed effectively in patients with type 2 diabetes mellitus (T2DM) to prevent or delay diabetic complications. This study aimed to compare the self-management levels of diet and metabolic risk factors in patients with T2DM, according to the duration of illness, and to examine the trends in self-management levels during the recent decades.

SUBJECTS/METHODS

Data were collected from the Korea National Health and Nutrition Examination Surveys (KNHANES, 1998-2014). In our analysis, 4,148 patients with T2DM, aged ≥ 30 years, were categorized according to the duration of their illness (< 5 years, 5-9 years, and ≥ 10 years). Demographic and lifestyle information was assessed through self-administered questionnaires, and biomarker levels (e.g., fasting glucose level, blood pressure, or lipid level) were obtained from a health examination. Dietary intake was assessed by a 24-recall, and adherence level to dietary guidelines (meal patterns and intake levels of calories, carbohydrates, vegetable/seaweed, sodium, and alcohol) were assessed. Multivariable generalized linear regression and unconditional logistic regression models were used to compare the prevalence rates of hyperglycemia, dyslipidemia, and hypertension according to the duration of patients' illness, accounting for the complex survey design of the KNHANES.

RESULTS

In the multivariable adjusted models, patients with a longer duration (≥ 10 years) of T2DM had a higher prevalence of hyperglycemia than those with a shorter duration of T2DM (< 5 years) (odds ratio 2.20, 95% confidence interval 1.61-3.01, P for trend < 0.001). We did not observe any associations of disease duration with the prevalence of hypertension and dyslipidemia. In addition, the adherence levels to dietary recommendations did not significantly differ according to disease duration, except adherence to moderate alcohol consumption. There were significant decreasing trends in the prevalence of hyperglycemia in patients with a duration of illness ≥ 10 years (P for trend = 0.004).

CONCLUSION

Although the proportion of patients with adequate control of glucose levels has improved in recent decades, poorer self-management has been found in those with a longer disease duration. These findings suggest the need for well-planned and individualized patient education programs to improve self-management levels and quality of life by preventing or delaying diabetic complications.

Barriers to Self-Management in Depressed Women With Type 2 Diabetes

Purpose To describe the impact of family functioning on the self-management of type 2 diabetes (T2DM) and depression in a subsample of women who completed a randomized clinical trial using vitamin D3 (5000 or 50,000 IUs weekly) for depression treatment. Background Women are at higher risk for increased severity of T2DM when experiencing depression. Methods Narrative inquiry was used. A semi-structured interview was conducted to understand helpful strategies and barriers in managing T2DM and depression. In addition, women were asked their meaning of family quality of life (FQOL). Results Twenty-one women participated after completion of the six-month final visit in the randomized clinical trial. The mean age was 55.2 years. Participants were 24% Hispanic, 48% African-American, and 52% Caucasian. The major themes generated related to family issues that impacted their self-management, yet participants did not want to "bring fault" to their families. Three themes emerged: (a) experience of family hardships-"it's been hard for me," (b) lack of disclosure to family about being depressed-"no point in talking to them," and (c) the need for connectedness with family and others-"the way it used to be… close as a family." Conclusion Family-centered approaches could address barriers to self-management. A "family lens" for practice and research may improve health outcomes.

A Canadian Cross-Sectional Survey on Psychosocial Supports for Adults Living With Type 1 or 2 Diabetes: Health-Care Providers' Awareness, Capacity and Motivation

OBJECTIVES

Addressing psychosocial issues is critical for diabetes self-management. This work explores health-care professionals' (HCPs') 1) perceived relevance of various psychosocial issues in diabetes management and 2) confidence in working on these issues within their services.

METHODS

An online cross-sectional survey was developed based on the Capacity-Opportunity-Motivation Behaviour Model. It assessed self-rated confidence in supporting patients with psychosocial issues (capability), perceived relevance of these issues (motivation) and facilitators of skill development (opportunity). An e-mail invitation was sent to all Diabetes Canada's professional members, conference delegates and committee members. Qualitative responses were analyzed using thematic analysis.

RESULTS

Of the 260 responses received (25% response rate), many were Diabetes Canada professional members (83%) and/or certified diabetes educators (66%). The largest professional groups in the sample were registered nurses (44%) and registered dietitians (33%). All psychosocial issues were perceived as somewhat or extremely important by at least 80% of respondents (range, 80% to 97%). However, HCPs were less confident in supporting their patients with these psychosocial issues; significantly fewer respondents reported that they felt somewhat or extremely confident (range, 26% to 62%). Depression (80%) and anxiety (80%) were the issues in which guidance was most desired. Most respondents wanted some form of formal self-management support training (83%). Preferred training methods included in-person workshops (56%), webinars (56%) and conference sessions (51%).

CONCLUSIONS

Motivation to address psychosocial issues in diabetes was high, but capacity to do so and opportunity to learn how were both low. These findings can be used to develop a targeted strategy to help address this gap.

Hepatic Safety of Atypical Antipsychotics: Current Evidence and Future Directions

The newer atypical antipsychotic agents (AAPs) represent an attractive therapeutic option for a wide range of psychotic disorders, including schizophrenia and bipolar mania, because of the reduced risk of disabling extrapyramidal symptoms. However, their growing use has raised questions about their tolerability over the endocrine, metabolic, and cardiovascular axes. Indeed, atypical antipsychotic drugs are associated, to differing extents, with mild elevation of aminotransferases related to weight gain, AAP-induced metabolic syndrome, and nonalcoholic fatty liver disease. Although the hepatic safety of new AAPs seems improved over that of chlorpromazine, they can occasionally cause idiosyncratic liver injury with varying phenotypes and, rarely, lead to acute liver failure. However, AAPs are a group of heterogeneous, chemically unrelated compounds with distinct pharmacological and pharmacokinetic properties and substantially different safety profiles, which precludes the notion of a class effect for hepatotoxicity risk and highlights the need for an individualized therapeutic approach. We discuss the current evidence on the hepatotoxicity potential of AAPs, the emerging underlying mechanisms, and the limitations inherent to this group of drugs for both establishing a proper causality assessment and developing strategies for risk management.

Evaluating Diabetes Care for Patients With Serious Mental Illness Using the Chronic Care Model: A Pilot Study

People with serious mental illness (SMI) have a higher incidence of type 2 diabetes mellitus (T2DM) and shorter life span due to medical health problems. The chronic care model (CCM) has been used to improve care of patients with T2DM. One clinical organization that provided primary care to patients with SMI had excellent diabetes outcomes but did not have information on how they achieved those outcomes. Thus, we conducted a pilot study chart review for 30 patients with T2DM and SMI to determine how well the clinic’s system aligned with the overall CCM components and which components correlated with diabetes control. We also evaluated use of the CCM using the Assessment of Chronic Illness Care provider survey. Results showed that the clinic had an overall basic implementation level of the CCM, which allows opportunity for improvement. Two elements of the CCM were correlated with hemoglobin A_1C and both were in an unexpected direction: self-management support in the variable of percentage of visits that included patient-specific goal-setting (rs = .52; P = .004) and delivery system design in the variable of number of nurse practitioner visits per study period (r_s = .43; P = .02). These findings suggest that the clinic may have made more concentrated efforts to manage diabetes for patients who were not in good diabetes control. Providers noted the influence of SMI and social service organization support on these patients’ clinical outcomes. The findings will be reexamined after a fuller implementation of the CCM to further improve management in this population.

Neuropathy and presence of emotional distress and depression in longstanding diabetes: Results from the Canadian study of longevity in type 1 diabetes

AIM

To determine the association of neuropathy and other complications with emotional distress and depression among patients with longstanding type 1 diabetes (T1DM).

METHODS

Canadians with ≥50years of T1DM completed a questionnaire including assessment of distress and depression by the Problem Areas in Diabetes Scale (PAID) and Geriatric Depression Scale (GDS), respectively. Complications were determined using the Michigan Neuropathy Screening Instrument (Questionnaire Component), fundoscopy reports, renal function tests, and self-reported peripheral-(PVD) and cardiovascular (CVD) disease. Associations were analyzed by Poisson regression.

RESULTS

Among 323 participants, 137 (42.4%) had neuropathy, 113 (36.5%) nephropathy, 207 (69.5%) retinopathy, 95 (29.4%) CVD, and 31 (9.8%) PVD. The neuropathy subgroup had higher prevalence of distress (13 (9.5%) vs. 6 (3.3%), p=0.029) and depression (34 (24.9%) vs. 12 (6.5%), p<0.001). Adjusting for diabetes complications, neuropathy was associated with higher PAID (adjusted RR 1.44 (95% CI 1.14-1.82), p=0.003) and GDS scores (adjusted RR1.57 (1.18-2.11), p=0.002). Independent of potential confounders, neuropathy remained associated with higher PAID (adjusted RR 1.39 (1.10-1.76), p=0.006) and GDS scores (adjusted RR 1.37 (1.03-1.83), p=0.032). Associations with neuropathy were not fully explained by neuropathic pain.

CONCLUSION

Compared to other complications, neuropathy had the greatest association with distress and depression in longstanding T1DM, independent of pain. Strategies beyond pain management are needed to improve quality of life in diabetic neuropathy.

Sex and gender considerations in Canadian clinical practice guidelines: a systematic review

BACKGROUND

The importance of sex and gender in the diagnosis and management of health conditions is well established, but the extent to which this evidence is integrated into clinical practice guidelines remains unknown. We aimed to determine the proportion of Canadian clinical practice guidelines that integrate evidence on sex and gender considerations.

METHODS

We searched the Canadian Medical Association's CPG Infobase, PubMed, all provincial/territorial websites and websites of professional organizations for English- and French-language Canadian clinical practice guidelines published between January 2013 and June 2015 on selected conditions identified as priorities by policy-makers and practitioners. Citations and text were searched electronically using keyword terms related to sex and gender. Three investigators independently analyzed and categorized the content of text-positive clinical practice guidelines based on clinical relevance for practitioners.

RESULTS

Of the 118 clinical practice guidelines that met the inclusion criteria, 79 (66.9%) were text-positive for sex and/or gender keywords; 8 (10%) of the 79 used the keywords only in relation to pregnancy. Of the remaining 71 guidelines, 25 (35%) contained sex-related diagnostic or management recommendations. An additional 5 (7%) contained recommendations for sex-specific laboratory reference values, 29 (41%) referred to differences in epidemiologic features or risk factors only, and 12 (17%) contained nonrelevant mentions of search keywords. Twenty-five (35%) of the text-positive guidelines used the terms "sex" and/or "gender" correctly.

INTERPRETATION

Recommendations related to sex and gender are inconsistently reported in Canadian clinical practice guidelines. Guidelines such as the Sex and Gender Equity in Research guidelines may help inform the meaningful inclusion of sex and gender evidence in the development of clinical practice guidelines.

Diabetes Distress Among Persons With Type 1 Diabetes

Purpose The purpose of this study is to evaluate associations between diabetes distress and a range of psychological health behaviors and concerns among persons with type 1 diabetes for the benefit of enhancing early identification and intervention of at-risk individuals. Methods Persons with type 1 diabetes (n = 268; 57.1% female, 91.0% white, 76.8% <18 years of age, average A1C 8.4%) completed the 2-item Diabetes Distress Screening Scale (DDS2) and a battery of psychometrically sound instruments measuring satisfaction with life, self-esteem, self-efficacy, depression, perfectionism, body image satisfaction, dietary restraint and eating, and shape and weight concerns. Each subscale score was compared within age groups (<18 years vs ≥18 years) between groups (diabetes distress level [low, moderate, high]) using analysis of variance (with Bonferroni correction or the Kruskal-Wallis test if the variables were not normally distributed). Results For both age groups, high diabetes distress was independently associated with greater A1C values, higher depression scores and eating, and shape and weight concerns than those with low or moderate distress. For patients <18 years of age, those with high diabetes distress scored lower on measures of satisfaction with life, self-esteem, and self-efficacy and higher on dietary restraint and several areas of perfectionism than those with low or moderate distress. Conclusions Individuals with type 1 diabetes who have high diabetes distress also report higher A1C values and poorer psychological health concerns. A brief diabetes distress questionnaire can help to identify those who need additional screening, education and support, and treatment for overall health and well-being.

A Longitudinal Investigation of Anxiety and Depressive Symptomatology and Exercise Behaviour Among Adults With Type 2 Diabetes Mellitus

OBJECTIVES

Evidence suggests that symptoms of depression and anxiety predict lower exercise behaviour and, inversely, that less exercise predicts higher symptomatology. The present longitudinal study examined this reciprocal association in adults with type 2 diabetes mellitus. We predicted that symptoms of anxiety or depression would intensify over time as a consequence of lower exercise frequency and, similarly, that exercise frequency would decrease as a consequence of greater symptoms of anxiety or depression.

METHODS

We studied 1691 adults with type 2 diabetes who provided baseline measures in 2011 and 2 subsequent annual assessments (Follow-up 1 and Follow-up 2). Symptoms of depression and anxiety were measured using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, respectively. A single item assessed exercise frequency in the past month (in days).

RESULTS

Separate 3-wave cross-lagged path models for symptoms of anxiety and depression tested the reciprocal associations. Contrary to our hypotheses, the reciprocal associations were not supported and, by extension, the predicted secondary associations were not tested. In sum, only depressive symptoms negatively predicted subsequent exercise frequency (Follow-up 1 and Follow-up 2).

CONCLUSIONS

Symptoms of depression were prospectively associated with lower exercise frequency, which is consistent with evidence from population-based studies that identify depressive symptoms as a barrier to exercise participation.

Type 2 Diabetes: Model of Factors Associated with Glycemic Control

OBJECTIVES

The purpose of this study was to evaluate the related factors and their intercorrelated impacts on glycemic control in people with type 2 diabetes mellitus.

METHODS

Patients with type 2 diabetes were recruited for this study during their regular clinic visits at a major medical centre in Iran. Glycated hemoglobin (A1C) levels were used as the indicator of glycemic control. Regression analysis was used to determine the relationships between glycemic control and demographics, self-care behaviours, resources and affective variables. Moreover, the associations between diabetes-related distress and measured variables were tested.

RESULTS

Three hundred eighty people with type 2 diabetes completed the study. The mean duration of diabetes was 8.94±6.57 years, and the mean A1C levels were 7.78%±1.7%. Diabetes-related distress was significantly associated with A1C levels, controlling for all other variables (p=0.01). On the other hand, depression (p<0.001), self-management (p<0.001), anxiety (p<0.001) and patient-physician relationship (p=0.023) were significantly associated with diabetes-related distress.

CONCLUSIONS

Diabetes-related distress was found to be associated with glycemic control in people with type 2 diabetes, whereas age, depression, anxiety, self-management and family and social support may affect glycemic control indirectly through diabetes-related distress. Thus, it is important to assess and, if appropriate, treat people with diabetes for diabetes-related distress in order to identify and help them overcome barriers to optimal glycemic control.

First-episode affective psychosis and lipid monitoring: survival analysis of the first abnormal lipid test

AIM

This study aimed to assess the probability of developing a lipid test abnormality over time, among first-time users of antipsychotic medications with affective psychosis.

METHODS

Survival analysis was used to analyse data from an early intervention in psychosis programme for the first 53 consecutive and eligible cases of patients between the ages of 14 and 40 years who had a diagnosis of affective psychosis. Data on initiation of antipsychotic medications and lipid laboratory test results were abstracted from chart reviews.

RESULTS

Within the first 18 months of receiving antipsychotic medications, the probability of surviving without an abnormal lipid test was only 25% (confidence interval 95%: 13.1%, 40.4%). The median time to the development of an abnormal test was 8 months for males and 12 months for females (P < 0.001).

CONCLUSIONS

Additional studies are needed to document the incidence over time of abnormal lipid tests to inform clinicians about the optimal frequency of monitoring.

Place and health in diabetes: the neighbourhood environment and risk of depression in adults with type 2 diabetes

BACKGROUND

Depression is a common co-illness in people with diabetes. Evidence suggests that the neighbourhood environment impacts the risk of depression, but few studies have investigated this effect in those with diabetes. We examined the effect of a range of neighbourhood characteristics on depression in people with Type 2 diabetes.

METHODS

This cohort study used five waves of data from 1298 participants with Type 2 diabetes from the Diabetes Health Study (2008-2013). We assessed depression using the Patient Health Questionnaire. We measured neighbourhood deprivation using census data; density of services using geospatial data; level of greenness using satellite imagery; and perceived neighbourhood characteristics using survey data. The effect of neighbourhood factors on risk of depression was estimated using survival analysis, adjusting for sociodemographic variables. We tested effect modification by age, sex and socio-economic characteristics using interaction terms.

RESULTS

More physical activity facilities, cultural services and a greater level of greenness in the neighbourhood were associated with a lower risk of depression in our sample, even after adjusting for confounders. Material deprivation was associated with increased risk of depression, particularly in participants who were older or retired.

CONCLUSIONS

Characteristics of neighbourhoods were associated with the risk of depression in people with Type 2 diabetes and there were vulnerable subgroups within this association. Clinicians are encouraged to consider the neighbourhood environment of their patients when assessing the risk of depression. Future intervention research is need for health policy recommendations.

Are Behavioural Interventions Doomed to Fail? Challenges to Self-Management Support in Chronic Diseases

Self-management and self-management support are concepts very familiar to those of us in diabetes care. These concepts require openness to understanding the behaviours of persons with diabetes broadly, not only behaviours restricted to the biomedical perspective. Understanding the importance of health behaviour change and working within the Expanded Chronic Care Model define the context within which self-management support should occur. The purpose of this perspective is to identify a potential limitation in existing self-management support initiatives. This potential limitation reflects provider issues, not patient issues; that is, true self-management support might require changes by healthcare providers. Specifically, although behavioural interventions within the context of academic research studies are evidence based, behaviour change interventions implemented in general practice settings might prove less effective unless healthcare providers are able to shift from a practice based on the biomedical model to a practice based on the self-management support model. The purpose of this article is to facilitate effective self-management support by encouraging providers to switch from a model of care based on the expert clinician encountering the uninformed help seeker (the biomedical model) to one guided by collaboration grounded in the principles of description, prediction and choice. Key to understanding the value of making this shift are patient-centered communication principles and the tenets of complexity theory.

Depression and type 2 diabetes: a causal association?

There is a controversy regarding whether depression and type 2 diabetes are causally linked. To assess this issue, we review key findings for the association between depression and diabetes, and its underlying mechanisms. Findings from meta-analyses of cohort studies show a modestly sized bidirectional association between depression and type 2 diabetes (ie, depression predicts diabetes onset and diabetes predicts future depression). However, depression-related biological alterations in the hypothalamic-pituitary-adrenal cortex axis and the sympathetic nervous system, and subclinical inflammation, are not consistently linked with increased diabetes risk. The evidence for an association between depression and glycaemic traits (eg, glucose, insulin, insulin sensitivity, and insulin secretion) is also mixed. Diabetes increases the risk of depression to the same extent as do other chronic disorders (eg, cardiac diseases, osteoarthritis, lung disease, and poor hearing). At present, the available evidence suggests that pathophysiological changes preceding the onset of type 2 diabetes might not cause depression, nor might depression directly increase the risk of developing type 2 diabetes. Despite insufficient robust causal evidence, treating physicians should be aware of the co-occurrence of depression and type 2 diabetes.