Lifetime Duration of Depressive Disorders in Patients With Type 2 Diabetes

Insulin resistance: The role in comorbid type 2 diabetes mellitus and depression

Insulin resistance (IR) plays a significant role in the pathophysiology of comorbid type 2 diabetes mellitus (T2DM) and depression (CDD) through multifaceted mechanisms, including dysregulation of insulin signaling (both central and peripheral), neuroendocrine disturbances (hypothalamic-pituitary-adrenal axis dysfunction and monoaminergic neurotransmission impairment), chronic inflammation, oxidative stress, disruption of the microbiota-gut-brain axis, reduced brain-derived neurotrophic factor levels, and altered synaptic plasticity. These IR-related pathways may predispose individuals to depressive symptoms or exacerbate existing mood disorders. A comprehensive understanding of these mechanisms is critical for developing integrated therapeutic strategies that concurrently target metabolic and psychiatric dysfunction. Antidepressant medications exhibit divergent effects on glucose metabolism. Tricyclic antidepressants, particularly amitriptyline and nortriptyline, worsen metabolic profiles by exacerbating IR, promoting weight gain, and inducing hyperglycemia, thereby increasing diabetes risk with prolonged use. Consequently, tricyclic antidepressants should be avoided in metabolically vulnerable populations unless alternatives are unavailable. Mirtazapine presents a paradoxical profile-while its appetite-stimulating effects often lead to weight gain (a known IR risk factor), some evidence suggests potential β-cell function preservation, necessitating cautious use of mirtazapine in individuals with metabolic syndrome. Among selective serotonin reuptake inhibitors, fluoxetine and escitalopram demonstrate favorable metabolic effects, including improved insulin sensitivity and glycemic control, though hypoglycemia risk (particularly with concomitant sulfonylureas) warrants monitoring. Bupropion, a norepinephrine-dopamine reuptake inhibitor, uniquely promotes weight loss and enhances glycemic control, making it a preferred option for depression comorbid with obesity or T2DM. Agomelatine, with its neutral metabolic profile and circadian rhythm-modulating properties, represents a safer alternative for patients with metabolic concerns. Concurrently, certain antidiabetic agents show promise in managing depression. Metformin and sodium-glucose cotransporter-2 inhibitors may be prioritized for diabetic patients at risk for depression, while glucagon-like peptide-1 receptor agonists appear particularly beneficial for obesity-related mood disturbances. Thiazolidinediones offer value in treatment-resistant cases, whereas insulin secretagogues should be used cautiously in psychiatrically vulnerable individuals. Future research should prioritize three key directions: (1) Mechanistic investigations using advanced neuroimaging to elucidate the contribution of IR to depressive phenotypes and evaluate novel interventions (such as intranasal insulin); (2) Precision medicine approaches incorporating biomarkers, including genetic polymorphisms, inflammatory markers, and gut microbiome signatures, to optimize antidepressant selection and develop personalized treatment algorithms; and (3) Therapeutic innovation, including dual GLP-1/GIP agonists and anti-inflammatory-antidepressant combinations, as well as integrating digital health technologies (e.g., continuous glucose monitoring coupled with mood tracking), will enable real-time, data-driven management. These advances will be instrumental in establishing integrated care paradigms for this comorbidity, which intertwines metabolic and psychiatric conditions.

The Interconnected Complexity of Diabetes and Depression

Diabetes and depression have a bidirectional relationship, with negative impacts on glycemia, self-care, long-term complications, quality of life, and mortality. This review highlights key aspects of the interconnected and complex relationship between diabetes and depression, including how it affects health outcomes, depression duration and recurrence, age-specific manifestations, and recommendations for screening and nonpharmacological treatment.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Echouffo-Tcheugui JB, Eichorst B, Ekhlaspour L, Garg R, Hassanein M, Khunti K, Lal R, Lingvay I, Matfin G, Middelbeek RJ, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Tanenbaum ML, Urbanski P, Bannuru RR. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, Bannuru RR, Beverly EA, Bruemmer D, Collins BS, Darville A, Ekhlaspour L, Hassanein M, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Association of glycemic control with hypertension in patients with diabetes: a population-based longitudinal study

BACKGROUND

Diabetes increases the risk of hypertension morbidity, but whether this association is varied with glycemic control remains unknown. We aimed to examine the association of glycemic control with hypertension among individuals with diabetes.

METHODS

Data was from the China Health and Retirement Longitudinal Study (CHARLS) between 2011 and 2018. Participants were categorized as having adequate glycemic control (HbA1c < 7%) and inadequate glycemic uncontrol (HbA1c ≥ 7%) by combining blood glucose tests and physician's diagnoses in 2011. Incident hypertension was ascertained through self-reported physician diagnoses from 2011 to 2018. Cox proportional hazards regression models were used to examine the effect of glycemic control on hypertension.

RESULTS

Among 436 participants with diabetes in this study, 102 met the glycemic control standard, and 334 were insufficient glycemic control. During 7 years of follow-up, 141 individuals developed hypertension. Compared with adequate glycemic control, the hazard ratio of inadequate glycemic control on hypertension was 1.54 (95% CI, 1.07-2.21) in the multivariate model. Additionally, the influence of glycemic control on hypertension varied based on educational attainment and the presence of depressive symptoms (P for interaction < 0.05).

CONCLUSIONS

Insufficient glycemic control was associated with a higher risk of hypertension among individuals with diabetes. Notably, the effect of glycemic control on hypertension was more pronounced among those with lower educational attainment and those exhibiting depressive symptoms. These findings underscore the significance of vigilant glycemic monitoring, educational background considerations, and mental health assessments in managing diabetic individuals.

GLP-1 plays a protective role in hippocampal neuronal cells by activating cAMP-CREB-BDNF signaling pathway against CORT+HG-induced toxicity

Major depressive disorder (MDD) with diabetes mellitus (DM) significantly reduces the quality of the patient's life, and currently, there is no effective treatment. This study explored the feasibility of Glucagon-like peptide-1 (GLP-1) in treating MDD combined with DM. The protective effects of GLP-1 on mouse hippocampal neuronal cell line HT22 cultured with corticosterone (CORT) and high glucose (HG) were assessed. HT22 cells were cultured with CORT + HG to construct a cell model of MDD combined with DM. Cell viability and cell apoptosis/necrocytosis were detected by CCK-8 assay and flow cytometry/confocal laser scanning microscopy, respectively, after treatment with GLP-1. In addition, BDNF and neurotransmitter levels, lactic dehydrogenase (LDH) and glucose levels, and proteins of cAMP-CREB-BDNF signal pathway in the culture supernatants were measured through an enzyme-linked immunosorbent assay and colorimetric assays and Western blot, respectively. The ideal intervention combination to construct a cell model of MDD combined with DM was CORT 200 μM and HG 50 mM for 48 h. After treatment of 50 nM GLP-1 for 48 h, the model+50 nM GLP-1 group's apoptosis and necrocytosis rates and LDH and glucose concentrations in the culture supernatants decreased significantly compared with the model group. However, the BDNF, 5-hydroxytryptamine (5-HT), dopamine (DA), norepinephrine (NE), PKA, p-CREB, and p-Trkb concentrations in the culture supernatants increased significantly. GLP-1 functioned against CORT + HG-induced toxicity by activating the cAMP-CREB-BDNF signaling pathway in hippocampal neuronal cells.

Diabetes and Depression: Strategies to Address a Common Comorbidity Within the Primary Care Context

Diabetes and depression represent a prevalent, bidirectional, and impactful comorbidity that affects patient and family quality of life, glycemic self-management, long-term diabetes complications, usage of medical services, medical costs, and early mortality. Primary care providers (PCPs) are frequently the first medical providers to observe changes in mood and diabetes management, as well as the primary point of contact for making referrals to specialty providers (e.g. endocrinology, psychiatry). PCPs play a critical role in screening, evaluating, and treating these conditions. Critical to fostering and maintaining a position of trust and patient engagement in medication recommendations is the use of person-centered, nonjudgmental language used by the provider within the clinical encounter. Key strategies for the management of these conditions include the following: routine screening for depressive symptoms, securing access to behavioral health professionals, either within or beyond the primary care setting, collaboration with diabetes care and education specialists to support problem-solving of diabetes self-management, and monitoring the use and effectiveness of antidepressant medications.

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.

Probiotics for the treatment of depression and its comorbidities: A systemic review

Depression is one of the most common psychiatric conditions, characterized by significant and persistent depressed mood and diminished interest, and often coexists with various comorbidities. The underlying mechanism of depression remain elusive, evidenced by the lack of an appreciate therapy. Recent abundant clinical trials and animal studies support the new notion that the gut microbiota has emerged as a novel actor in the pathophysiology of depression, which partakes in bidirectional communication between the gut and the brain through the neuroendocrine, nervous, and immune signaling pathways, collectively known as the microbiota-gut-brain (MGB) axis. Alterations in the gut microbiota can trigger the changes in neurotransmitters, neuroinflammation, and behaviors. With the transition of human microbiome research from studying associations to investigating mechanistic causality, the MGB axis has emerged as a novel therapeutic target in depression and its comorbidities. These novel insights have fueled idea that targeting on the gut microbiota may open new windows for efficient treatment of depression and its comorbidities. Probiotics, live beneficial microorganisms, can be used to modulate gut dysbiosis into a new eubiosis and modify the occurrence and development of depression and its comorbidities. In present review, we summarize recent findings regarding the MGB axis in depression and discuss the potential therapeutic effects of probiotics on depression and its comorbidities.

Post hoc depression analysis from a pharmacist-led diabetes trial

Introduction

Diabetes and depression may present concurrently, and clinical pharmacists are well equipped to manage these conditions. Clinical pharmacists were grant funded to implement a diabetes-focused randomized controlled trial in a Federally Qualified Health Center. The objective of this analysis is to evaluate if glycemic control and depressive symptoms improve for patients with diabetes and depression with additional management from clinical pharmacists compared with those receiving the standard of care.

Methods

This is a post hoc subgroup analysis of a diabetes-focused randomized controlled trial. Pharmacists enrolled patients with type 2 diabetes mellitus (T2DM) and a glycated hemoglobin (A1C) greater than 8% and randomly assigned them to 1 of 2 cohorts, one managed by the primary care provider alone and one with additional care from the pharmacist. Pharmacists completed encounters with patients who have T2DM with or without depression to comprehensively optimize pharmacotherapy while tracking glycemic and depressive outcomes throughout the study.

Results

A1C improved from baseline to 6 months in patients with depressive symptoms who received additional care from pharmacists by -2.4 percentage points (SD, 2.41) compared with a -0.1 percentage point (SD, 1.78) reduction in the control arm (P  .0081), and there was no change in depressive symptoms.

Discussion

Patients with T2DM and depressive symptoms experienced better diabetes outcomes with additional pharmacist management compared with a similar cohort of patients with depressive symptoms, managed independently by primary care providers. These patients with diabetes and comorbid depression received a higher level of engagement and care from the pharmacists, which led to more therapeutic interventions.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Domesticating the condition: Design lessons gained from a marathon on how to cope with barriers imposed by type 1 diabetes

Through analytical autoethnographic analysis of marathon preparation, this study examines challenges faced by people with Type 1 Diabetes (T1D) who engage in high-performance sports. Autoethnographer and second-person perspectives (T1D runners, family members, and health providers) were collected through introspective activities (autoethnographic diary and in-depth interviews) to understand the T1D runner's coping experience. Six insights involved in T1D self-management were identified and analyzed with reference to related design tools (prototyping, archetyping and journey mapping). Finally, we conclude with a discussion of how endurance physical activity (PA) such as running helps to "domesticate" T1D, a term coined to reflect the difficulties that T1D presents for PA accomplishment and how T1D runners' experiences give them an opportunity to overcome PA barriers promoting physical culture and enriching further health psychology studies.

Transcutaneous auricular vagal nerve stimulation inhibits limbic-regional P2X7R expression and reverses depressive-like behaviors in Zucker diabetic fatty rats

Zucker diabetic fatty (ZDF) rats develop type 2 diabetes (T2D) along with depressive-like behaviors. Transcutaneous auricular vagal nerve stimulation (taVNS) has antidiabetic and antidepressant-like effects in ZDF rats; however, the underlying antidepressant-like mechanisms are unclear. The purinergic receptor P2X7R, which is related to inflammation and depression, is upregulated in the limbic brain regions of depressed patients and rodents and is considered as a potential therapeutic target. Thus, this study aimed to provide preliminary evidence at the molecular level of taVNS antidepressant-like effect in ZDF rats through testing their limbic-regional P2X7R expression. ZDF rats were subjected to taVNS and transcutaneous non-vagal nerve stimulation (tnVNS). Body weight and blood glucose levels were monitored weekly. Depressive-like behaviors were evaluated with the open-field test (OFT) and forced swimming test (FST). Limbic-regional P2X7R expression was examined by western blotting (WB). P2X7R expressing cells were detected by immunohistochemistry (IHC). Compared to their lean littermates (ZL rats), ZDF rats developed obesity, hyperglycemia, and depressive-like behaviors with elevated limbic-regional P2X7R expression. taVNS but not tnVNS lowered body weight, reduced and stabilized blood glucose levels, suppressed limbic-regional P2X7R expression, and reversed the depressive-like behaviors. P2X7R was found primarily expressed in ZDF rats' limbic-regional astrocytes. In conclusion, taVNS inhibits ZDF rats' limbic-regional P2X7R expression, which may be one of the taVNS antidepressant-like mechanisms.

American Diabetes Association Professional Practice Committee. 5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Flash Glucose Monitoring Improves Glucose Control in People with Type 2 Diabetes Mellitus Receiving Anti-diabetic Drug Medication

OBJECTIVE

To investigate the effects of Flash Glucose Monitoring (FGM) on glucose profile in people with Type 2 Diabetes Mellitus (T2DM) receiving anti-diabetic drug medication.

METHODS

This is a prospective non-randomized uncontrolled study. 111 people with T2DM were enrolled and received FGM for 14 days. There was no change of anti-diabetic medication during the 14 days. The plasma glucose concentration on day 2 was used as baseline and the day 13 was considered as study end point. The parameters to compare were mean plasma glucose (MPG), glucose variations, and incidence of hypoglycemia during the FGM period. The multivariate linear stepwise regression analysis was applied to determine the independent factors that affect MPG difference.

RESULTS

This study analyzed the data of a total of 111 people with T2DM (male 60 and female 51). The general clinical data of these patients were as follows: age: 65.0±6.7 years old; duration of diabetes: 11.6±6.8 years; HbA1c: 61.2±13.3 mmol/mol; body mass index (BMI): 25.2±3.2 kg/m². Using FGM, people with T2DM were able to change daily diet and exercise through which significant reductions in MPG on days 12 or 13 were achieved as compared with that of day 2 (P=0.04 or P=0.003, respectively). The glucose variations, such as standard deviation (SD) of plasma glucose, coefficient of variation (CV), and mean amplitude of glycemic excursion (MAGE), progressively declined starting from day 6 as compared with baseline (P=0.016, P=0.003, or P=0.012, respectively). The incremental area over the curve (AOC) of the hypoglycemia (<3.9 mmol/L) had a significant reduction starting from the day 3 (P=0.001). When people with T2DM were divided into 3 groups based on the tertile of HbA1c (high, middle, and low concentrations), the reduction of MPG in patients with high concentration of HbA1c were much larger than that in middle and low concentration group patients (P=0.001 for both). The incidence of hypoglycemia was improved in the low concentration group (P=0.017). The optimal frequency of scanning time required to maintain euglycemia was 11.7 times/day as calculated by the receiver operating characteristic (ROC) analysis.

CONCLUSION

Using FGM to monitor glucose concentration at 11.7 times/day, people with T2DM can achieve a better glucose control in addition to anti-diabetic drug medication through changing daily diet and exercise, especially in patients with high concentration of HbA1c (>66.1 mmol/mol).

50 Years of Behavioral Science in Diabetes: A 2020 Vision of the Future

This article is adapted from a speech Dr. de Groot delivered in June 2020 as President, Health Care & Education, of the American Diabetes Association at the Association's 80th Scientific Sessions, which was held online as a result of coronavirus disease 2019. Dr. de Groot is an Associate Professor of Medicine in the Division of Endocrinology, Diabetes and Metabolism at Indiana University (IU) School of Medicine. She serves as the Acting Director of the IU Diabetes Translational Research Center. Dr. de Groot is the 2020 recipient of the Rachmiel Levine Medal for Leadership from the American Diabetes Association.In the year 2020, we marked the 50th anniversary of the field of behavioral science in diabetes in the modern era. Over this relatively short period of time, this field has charted the psychosocial landscape of prediabetes and diabetes by establishing the prevalence and impact of emotional and behavioral aspects of diabetes. Interventions to address these conditions have been developed that span the T2 to T4 translational research spectrum ranging from the intrapsychic to population-based interventions. Policies ranging from standards of care to Medicare benefits have been implemented. A review of research in the area of diabetes and depression is provided as an example of innovations in this field. Behavior is the foundation of all interventions we make in diabetes and prediabetes. As a mature science, it is critical to stemming the tide of diabetes and its outcomes. To make additional strides, we must rebalance our focus and augment funding for behavioral interventions for individuals, communities, and health care systems in conjunction with other forms of treatment.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

50 Years of Behavioral Science in Diabetes: A 2020 Vision of the Future

Editor's Note: This article is adapted from a speech Dr. de Groot delivered in June 2020 as President, Health Care & Education, of the American Diabetes Association. She delivered her address at the Association's 80th Scientific Sessions, which was held online as a result of the coronavirus disease 2019.

Depression in Youth-Onset Type 2 Diabetes

PURPOSE OF REVIEW

The current review summarizes extant knowledge regarding the prevalence of depression in youth-onset type 2 diabetes (T2D) and how depression might impact glycemic control through stress-related behavioral and physiological mechanisms. The current review also discusses depression intervention studies in adult-onset T2D, as there are no such studies in youth-onset T2D, and provides recommendations for clinical research.

RECENT FINDINGS

The prevalence of elevated depression symptoms in youth-onset T2D is approximately 20%. Some studies suggest depression may negatively impact glycemic control through inadequate medication adherence and disordered eating, but there is a dearth of studies investigating associations with depression and physical activity/sedentary time, sleep, and stress-related physiological mechanisms. In adult-onset T2D, evidence-based behavioral interventions tailored to address diabetes-related issues have shown positive effects for depression and glycemic control. Future research is needed to characterize the epidemiology of depression in youth-onset T2D and test interventions to improve depression, glycemic control, and health outcomes in this specific pediatric population.

P2X7 receptor mediates NLRP3 inflammasome activation in depression and diabetes

The increasing prevalence of depression and diabetes mellitus has become a major public health problem worldwide. Studies have shown that people with diabetes are at a high risk of being diagnosed with depression, and diabetes complicates depression treatment by promoting the deterioration of glycemic control, reducing self-care ability and quality of life, and causing severe functional disability and early mortality. Moreover, health deterioration dramatically increases the financial cost of social and health care system. Thus, how to treat depression, diabetes, and diabetes complicated by depression has become one of the world’s urgent concerns. The activation of nod-like receptor family pyrin domain containing 3 (NLRP3) is closely related to mental illness. This finding provides a new perspective for studying depression. NLRP3 plays an important role in the development of diabetes. In this review, we elaborate the definition and epidemiology of depression, diabetes, and diabetic depression and introduce the functional characteristics of an NLRP3 inflammasome and upstream P2X7 receptor. Moreover, related research on NLRP3 inflammasomes and P2X7 receptors is summarized and used as a reference for confirming that the excessive activation of P2X7- NLRP3 leads to the increased release of inflammatory cytokines, such as IL-1β, in depression and diabetes. We provide insights into the P2X7–NLRP3–IL-1β pathway as an important pathological mechanism and novel therapeutic target in diabetes and depression. Given that the P2X7–NLRP3–IL-1β pathway may play an important role in diabetes confounded by comorbid depression, the possibility of intervention with baicalin is proposed.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

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.

Effects of Light Therapy on Mood and Insulin Sensitivity in Patients With Type 2 Diabetes and Depression: Results From a Randomized Placebo-Controlled Trial

OBJECTIVE

Depression is common in patients with type 2 diabetes and adversely affects quality of life and diabetes outcomes. We assessed whether light therapy, an antidepressant, improves mood and insulin sensitivity in patients with depression and type 2 diabetes.

RESEARCH DESIGN AND METHODS

This randomized, double-blind, placebo-controlled trial included 83 patients with depression and type 2 diabetes. The intervention comprised 4 weeks of light therapy (10,000 lux) or placebo light therapy daily at home. Primary outcomes included depressive symptoms (Inventory of Depressive Symptomatology [IDS]) and insulin sensitivity (M-value derived from the results of a hyperinsulinemic-euglycemic clamp). Secondary outcomes were related psychological and glucometabolic measures.

RESULTS

Intention-to-treat analysis showed that light therapy was not superior to placebo in reducing depressive symptoms (-3.9 IDS points [95% CI -9.0 to 1.2]; P = 0.248) and had no effect on insulin sensitivity (0.15 mg/kg*min [95% CI -0.41 to 0.70]; P = 0.608). Analyses incorporating only those participants who accurately adhered to the light therapy protocol (n = 51) provided similar results, but did suggest positive effects of light therapy on depression response rates (≥50% reduction in IDS points) (26% more response; P = 0.031). Prespecified analysis showed effect moderation by baseline insulin sensitivity (P = 0.009) and use of glucose-lowering medication (P = 0.023). Light therapy did not affect depressive symptoms in participants with higher insulin sensitivity or those who use only oral glucose-lowering medication or none at all, but it did produce a relevant effect in participants with lower insulin sensitivity (-12.9 IDS points [95% CI -21.6 to -4.2]; P = 0.017) and a trend toward effectiveness in those using insulin (-12.2 IDS points [95% CI -21.3 to -3.1]; P = 0.094). Light therapy was well tolerated.

CONCLUSIONS

Although this trial is essentially inconclusive, secondary analyses indicate that light therapy might be a promising treatment for depression among a subgroup of highly insulin-resistant individuals with type 2 diabetes.

Depressive symptoms, health behaviors and risk of diabetes in Chinese mid-aged and older adults

OBJECTIVE

While diabetes links with comorbidity of depression, there is no evidence in China regarding whether health behaviors modified the effect of depressive symptoms on diabetes. This study examined the influence of depressive symptoms on the incident diabetes, and investigated whether health behavior was a moderator in the depression-diabetes relationship in Chinese mid-aged and older adults.

METHODS

Using data from the China Health and Retirement Longitudinal 2011-2015 Study, the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10) short form was used to measure depressive symptoms in 47,671 Chinese mid-aged and older adults. Diabetes was diagnosed through self-reported measures. We used random effect logistic regression models to examine the effect of depressive symptoms on the incidence of depressive symptoms.

RESULTS

Participants with depressive symptoms were more likely to suffer from diabetes than their non-depressive symptoms counterparts, with an odds ratio (OR) of 1.33 (95% CI: 1.13, 1.58). We found that unhealthy behaviors moderated the influence of depressive symptoms on risk of diabetes (OR = 1.01, 95% CI = 1.01, 1.02), indicating that depressive symptoms patients with two or more unhealthy behaviors had a higher risk of diabetes compared with their peers without unhealthy behaviors.

CONCLUSION

Our findings suggested that depressive symptoms were a risk factor in developing diabetes, and that response to this factor varied by individuals' health behaviors. Clinicians should be aware of increased risk of elevated diabetes in population with depressive symptoms and consider routine screening for depressive symptoms among them.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Diabesity and mood disorders: Multiple links through the microbiota-gut-brain axis

The global prevalence of diabesity is on the rise, and the clinical, social and economic health burden arising from this epidemic is aggravated by a significant co-morbidity of diabesity with neuropsychiatric disease, particularly depression. Importantly, not only is the prevalence of mood disorders elevated in patients with type 2 diabetes, depressed patients are also more prone to develop diabetes. This reciprocal relationship calls for a molecular and systemic analysis of diabesity-brain interactions to guide preventive and therapeutic strategies. The analysis we are presenting in this review is modelled on the microbiota-gut-brain axis, which provides the brain with information from the gut not only via the nervous system, but also via a continuous stream of microbial, endocrine, metabolic and immune messages. This communication network offers important clues as to how obesity and diabetes could target the brain to provoke neuropsychiatric disease. There is emerging evidence that the gut microbiota is orchestrating a multiplicity of bodily functions that are intimately related to the immune, metabolic and nervous systems and that gut dysbiosis spoils the homeostasis between these systems. In our article we highlight two groups of molecular links that seem to have a significant bearing on the impact of diabesity on the brain. On the one hand, we focus on microbiota-related metabolites such as short-chain fatty acids, tryptophan metabolites, immune stimulants and endocannabinoids that are likely to play a mediator role. On the other hand, we discuss signalling molecules that operate primarily in the brain, specifically neuropeptide Y, brain-derived neurotrophic factor and γ-amino butyric acid, that are disturbed by microbial factors, obesity and diabetes and are relevant to mental illness. Finally, we address the usefulness of diet-related interventions to suspend the deleterious relationship between diabesity and mood disorders.

Subthreshold depression among diabetes patients in Beijing: Cross-sectional associations among sociodemographic, clinical, and behavior factors

BACKGROUND

This study explores the prevalence of subthreshold depression (SubD) and its association with factors in type 2 diabetes mellitus (T2DM) patients.

METHODS

This cross-sectional study involved 808 outpatients with T2DM from ten hospitals in Beijing between September 2015 and January 2016. All participants completed the Patient Health Questionnaire 9-item (PHQ-9) to evaluate depressive status, with scores between 5 and 14 considered SubD. Conditional logistic regression was conducted to investigate the variables associated with SubD in T2DM patients.

RESULTS

T2DM patients with SubD comprised 11.6% (n = 94) of the sample. The odd ratios for the variables having significant positive associations with SubD were: being a women (OR = 1.90; 95%CI: 1.09-3.32), divorced/widowed (OR = 3.27; 95%CI: 1.46-7.30), comorbidity of cerebrovascular disease (OR = 2.00; 95%CI: 1.06-3.76), more diabetic complications (OR = 8.04; 95%CI: 2.77-23.31), and higher HbA1c in men (OR = 2.41; 95%CI: 1.25-4.64). Being older (OR = 0.78; 95%CI: 0.62-0.98), exercising more (OR = 0.44; 95%CI: 0.22-0.91) and poverty (OR = 0.36; 95%CI: 0.19-0.69) were negatively related to SubD.

LIMITATIONS

The sample was mainly recruited from hospital settings, which limits generalization. The study's cross-sectional design precludes making causal inferences.

CONCLUSIONS

The proportion of SubD was estimated to be 11.6% among T2DM patients in Beijing. Having more diabetic complications and being divorced/widowed made the odds of having SubD 8-fold and 3-fold higher than not having it, respectively. The relationship between SubD and diabetes necessitates early screening for milder forms of depression, which can alleviate the social burden and individual impairment from major depression or other chronic diseases.

Prevalence and correlates of depressive disorders in people with Type 2 diabetes: results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study, a collaborative study carried out in 14 countries

AIMS

To assess the prevalence and management of depressive disorders in people with Type 2 diabetes in different countries.

METHODS

People with diabetes aged 18-65 years and treated in outpatient settings were recruited in 14 countries and underwent a psychiatric interview. Participants completed the Patient Health Questionnaire and the Problem Areas in Diabetes scale. Demographic and medical record data were collected.

RESULTS

A total of 2783 people with Type 2 diabetes (45.3% men, mean duration of diabetes 8.8 years) participated. Overall, 10.6% were diagnosed with current major depressive disorder and 17.0% reported moderate to severe levels of depressive symptomatology (Patient Health Questionnaire scores >9). Multivariable analyses showed that, after controlling for country, current major depressive disorder was significantly associated with gender (women) (P<0.0001), a lower level of education (P<0.05), doing less exercise (P<0.01), higher levels of diabetes distress (P<0.0001) and a previous diagnosis of major depressive disorder (P<0.0001). The proportion of those with either current major depressive disorder or moderate to severe levels of depressive symptomatology who had a diagnosis or any treatment for their depression recorded in their medical records was extremely low and non-existent in many countries (0-29.6%).

CONCLUSIONS

Our international study, the largest of this type ever undertaken, shows that people with diabetes frequently have depressive disorders and also significant levels of depressive symptoms. Our findings indicate that the identification and appropriate care for psychological and psychiatric problems is not the norm and suggest a lack of the comprehensive approach to diabetes management that is needed to improve clinical outcomes.

3. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Dietary Intervention for Glucose Tolerance In Teens (DIG IT): Protocol of a randomized controlled trial using health coaching to prevent youth-onset type 2 diabetes

BACKGROUND

Youth-onset type 2 diabetes (T2D) is a disease that is newly emerging and behavioral strategies for its prevention are limited. Interventions that target the lifestyle behaviors of adolescents, to improve poor dietary quality and reduce excessive sedentariness, promise to reduce the risk of developing T2D. Health coaching is effective for promoting healthy behaviors in patients who have chronic disease, but few experimental studies are in adolescents. This randomized controlled trial, in adolescents with prediabetes, will determine the effectiveness of a health coaching intervention to facilitate adoption of healthy diet and activity behaviors that delay or prevent development of T2D.

METHODS/DESIGN

The Dietary Intervention for Glucose Tolerance In Teens (DIG IT) trial will involve an evaluation of a health coaching intervention in adolescents with prediabetes. Eligible participants will be randomized to receive 6months of health coaching or a single dietary consultation that is standard-of-care. The primary outcome will be 2-hour oral glucose tolerance test concentration. Secondary outcomes will include measures of glycemia and insulin action as well as dietary, physical activity and sedentary behaviors measured using an electronic food record, and by inclinometer. Data will be collected before and after the intervention (at 6months) and at 12months (to assess sustainability).

DISCUSSION

This trial will determine whether a health coaching intervention, a personalized and low-cost approach to modify dietary and activity behaviors, is effective and sustainable for prevention of youth-onset T2D, relative to standard-of-care. Health coaching has the potential to be widely implemented in clinical or community settings.