Associations between HbA1c Reduction and Change in Depressive Symptoms following Glucose-lowering Treatment in Adults: A Systematic Review of Intervention Studies

INTRODUCTION

Hyperglycemia constitutes a likely pathway linking diabetes and depressive symptoms; lowering glycemic levels may help reduce diabetes-comorbid depressive symptoms. Since randomized controlled trials can help understand temporal associations, we systematically reviewed the evidence regarding the potential association of hemoglobin HbA1c lowering interventions with depressive symptoms.

METHODS

PubMed, PsycINFO, CINAHL, and EMBASE databases were searched for randomized controlled trials evaluating HbA1c-lowering interventions and including assessment of depressive symptoms published between 01/2000-09/2020. Study quality was evaluated using the Cochrane Risk of Bias tool. PROSPERO registration: CRD42020215541.

RESULTS

We retrieved 1,642 studies of which twelve met our inclusion criteria. Nine studies had high and three unclear risks of bias. Baseline depressive symptom scores suggest elevated depressive symptoms in five studies. Baseline HbA1c was <8.0% (<64 mmol/mol) in two, 8.0-9.0% (64-75 mmol/mol) in eight, and ≥10.0% (≥86 mmol/mol) in two studies. Five studies found greater HbA1c reduction in the treatment group; three of these found greater depressive symptom reduction in the treatment group. Of four studies analyzing whether the change in HbA1c was associated with the change in depressive symptoms, none found a significant association. The main limitation of these studies was relatively low levels of depressive symptoms at baseline, limiting the ability to show a lowering in depressive symptoms after HbA1c reduction.

CONCLUSIONS

We found insufficient available data to estimate the association between HbA1c reduction and depressive symptom change following glucose-lowering treatment. Our findings point to an important gap in the diabetes treatment literature. Future clinical trials testing interventions to improve glycemic outcomes might consider measuring depressive symptoms as an outcome to enable analyses of this association.

"It's changed my life not to have the continual worry of being warm" - health and wellbeing impacts of a local fuel poverty programme: a mixed-methods evaluation

BACKGROUND

Living in a cold home and being fuel poor can contribute to adverse physical and mental health. Energy efficiency interventions are considered the simplest ways of tackling fuel poverty and preventing associated negative health, wellbeing, and socio-economic consequences. The overall aim of the current study was to provide a greater understanding of the impact of a locally administered programme, which funded the installation of major heating/insulation measures in areas of high fuel poverty, on the health and wellbeing of beneficiaries of the programme.

METHODS

A mixed-methods approach to explore the health and wellbeing impacts of a fuel poverty programme in East Sussex that took place between October 2016 and March 2018. Beneficiaries completed the Warwick-Edinburgh Mental Wellbeing Scale before and after any heating/insulation work had been completed in their home. Beneficiaries were also asked to retrospectively rate their health pre- and post-installation. Interviews with 23 beneficiaries of the programme were conducted to explore in-depth the impact of the programme on people's health and wellbeing and the wider social determinants of health.

RESULTS

A major heating/insulation measure was installed in 149 homes. The majority of measures installed were boilers (57.7%) and new central heating systems (32.2%). Self-rated health and wellbeing were significantly higher post-installation. Interviewees described clear examples of the positive impacts on physical health and wellbeing such as fewer chest infections, reduced pain, feeling less anxious and depressed, and generally feeling happier and more relaxed. Interviews also highlighted broader areas of impact such as reduced social isolation and increased use of domestic space. Many of the beneficiaries also reported a reduction in their energy bills since their new heating systems had been installed.

CONCLUSIONS

The findings from the evaluation suggest that the installation of major heating or insulation measures such as new boilers have substantial benefits for the health and wellbeing of beneficiaries. The findings also suggest that the programme had a positive impact on wider determinants of health including reduction in stress and isolation that are likely to be part of the pathways between fuel poverty interventions and mental and physical health outcomes.

The bidirectional longitudinal association between depressive symptoms and HbA1c : A systematic review and meta-analysis

AIM

To investigate whether there is a bidirectional longitudinal association of depression with HbA_1c .

METHODS

We conducted a systematic literature search in PubMed, PsycINFO, CINAHL and EMBASE for observational, longitudinal studies published from January 2000 to September 2020, assessing the association between depression and HbA_1c in adults. We assessed study quality with the Newcastle-Ottawa-Scale. Pooled effect estimates were reported as partial correlation coefficients (r_p ) or odds ratios (OR).

RESULTS

We retrieved 1642 studies; 26 studies were included in the systematic review and eleven in the meta-analysis. Most studies (16/26) focused on type 2 diabetes. Study quality was rated as good (n = 19), fair (n = 2) and poor (n = 5). Of the meta-analysed studies, six investigated the longitudinal association between self-reported depressive symptoms and HbA_1c and five the reverse longitudinal association, with a combined sample size of n = 48,793 and a mean follow-up of 2 years. Higher levels of baseline depressive symptoms were associated with subsequent higher levels of HbA_1c (partial r = 0.07; [95% CI 0.03, 0.12]; I² 38%). Higher baseline HbA_1c values were also associated with 18% increased risk of (probable) depression (OR = 1.18; [95% CI 1.12,1.25]; I² 0.0%).

CONCLUSIONS

Our findings support a bidirectional longitudinal association between depressive symptoms and HbA_1c . However, the observed effect sizes were small and future research in large-scale longitudinal studies is needed to confirm this association. Future studies should investigate the role of type of diabetes and depression, diabetes distress and diabetes self-management behaviours. Our results may have clinical implications, as depressive symptoms and HbA_1c levels could be targeted concurrently in the prevention and treatment of diabetes and depression.

REGISTRATION

PROSPERO ID CRD42019147551.

Estimating the percentage of European MSM eligible for PrEP: insights from a bio-behavioural survey in thirteen cities

OBJECTIVES

This paper aims to estimate the percentage of European men who have sex with men (MSM) who may benefit from pre-exposure prophylaxis (PrEP), applying the three most widely used HIV risk indices for MSM (MSM Risk Index, Menza score, San Diego Early Test (SDET) score) and drawing on a large-scale multisite bio-behavioural survey (Sialon II).

METHODS

The Sialon II study was a bio-behavioural survey among MSM implemented in 13 European cities using either time-location sampling or respondent-driven sampling. Biological and behavioural data from 4901 MSM were collected. Only behavioural data of HIV-negative individuals were considered. Three widely used risk indices to assess HIV acquisition risk among MSM were used to estimate individual HIV risk scores and PrEP eligibility criteria.

RESULTS

4219 HIV-negative MSM were considered. Regardless the HIV risk score used and the city, percentages of MSM eligible for PrEP were found to range between 5.19% and 73.84%. Overall, the MSM Risk Index and the Menza score yielded broadly similar percentages, whereas the SDET Index provided estimates constantly lower across all cities. Although all the three scores correlated positively (r>0.6), their concordance was highly variable (0.01<CCC<0.62).

CONCLUSION

Our findings showed the impact of different scoring systems on the estimation of the percentage of MSM who may benefit from PrEP in European cities. Although our primary aim was not to compare the performance of different HIV risk scores, data show that a considerable percentage of MSM in each city should be offered PrEP in order to reduce HIV infections. As PrEP is highly effective at preventing HIV among MSM, our findings provide useful, practical guidance for stakeholders in implementing PrEP at city level to tackle HIV infections in Europe.

Parent-child conversations associated with alcohol-related risk behaviours in young people (13-17 years) in the UK: a cross-sectional study

OBJECTIVE

To investigate different types of parent-child conversations associated with young people's (13-17 years) alcohol-related risk behaviours.

DESIGN

Secondary analysis of the 2016 Drinkaware Monitor Survey. This survey employed a cross-sectional design and collected data using self-completion questionnaires.

SETTING

UK-wide.

PARTICIPANTS

561 parent-child pairs were included in the analysis. The nationally representative quota sample was weighted by reference to the UK population.

METHODOLOGY

Data were analysed using purposeful selection modelling (adjusted OR (AOR), 95% CIs). RISK BEHAVIOURS: 'Whether have ever drank' and 'whether vomited as a result of alcohol'.

RESULTS

50% (277/553) of young people reported drinking a whole alcoholic drink, and 22% (60/277) of these experienced vomiting as a result. After adjusting for age and gender, the likelihood of ever having drank alcohol was significantly increased among the following young people: those whose parents believed they knew a little about how much they drink (AOR 1.80, 95% CI 1.04 to 3.13) or that some/most/all friends drink (AOR 3.82, 95% CI 2.40 to 6.08); those given gentle reminders about taking care when drinking alcohol (AOR 1.82, 95% CI 1.15 to 2.88), practical advice (AOR 2.09, 95% CI 1.20 to 3.64) or designated time, led by the parent, to instil care around alcohol through a formal sit-down (AOR 1.79, 95% CI 1.07 to 2.99). The likelihood was reduced for parents aged 40-49 years (AOR 0.52, 95% CI 0.31 to 0.89) and conversations providing information (AOR 0.53, 95% CI 0.29 to 0.98). Vomiting was significantly associated with some/most/all friends drinking alcohol (AOR 3.65, 95% CI 1.08 to 12.30), parent's beliefs about child's frequency of drinking alcohol (AOR 1.26, 95% CI 1.02 to 1.54), parental harmful/dependency drinking (AOR 3.75, 95% CI 1.13 to 12.50) and having a formal sit-down conversation (AOR 2.15, 95% CI 0.99 to 4.66).

CONCLUSIONS

We found evidence of mostly negative associations between young people's risk behaviours and different types of parent-child conversations. Conversations providing information were linked to a reduced tendency to have ever drunk alcohol. All other types of conversations were negatively associated with risk behaviours. Psychological reactance and conversation quality possibly explain these findings.

Care planning for aggression management in a specialist secure mental health service: An audit of user involvement

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de-escalation methods documented in care plans; and (iv) ascertain the extent to which the de-escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de-escalation methods documented in the care plans revealed five de-escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de-escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de-escalation documentation suggests that some staff fundamentally misunderstand de-escalation.

Implementing the National Service Framework for Long-Term (Neurological) Conditions: service user and service provider experiences

PURPOSE

This research explored the experiences of service users and providers during the implementation of the National Service Framework (NSF) for Long-Term (Neurological) Conditions (LTNCs).

METHOD

A participatory qualitative research design was employed. Data were collected using 50 semi-structured interviews with service users, 25 of whom were re-interviewed on three occasions. Forty-five semi-structured interviews were also conducted with service providers who worked with individuals with LTNCs. Interviews focused on health, well-being and quality of life in relation to service provision, access and delivery. Data were thematically analysed individually and collaboratively during two data analysis workshops.

RESULTS

Three major themes were identified that related to the implementation of the NSF: "Diagnosis and treatment", "Better connected services" and "On-going rehabilitation". Service users reported that effective care was provided when in hospital settings but such treatments often terminated on return to their communities despite on-going need. In hospital and community settings, service providers indicated that they lacked the support and resources to provide continuous care, with patients reaching a crisis point before referral to specialist care.

CONCLUSION

This research highlighted a range of issues concerning the recent UK-drive towards patient-centred approaches within healthcare, as service users were disempowered within the LTNC care pathway. Moreover, service providers indicated that resource constraints limited their ability to provide long-term, intensive and integrated service provision.

IMPLICATIONS FOR REHABILITATION

Our research suggests that many service users with long-term neurological conditions experienced disconnections between services within their National Service Framework care pathway. For health and social care practitioners, a lack of continuity within a care pathway was suggested to be most pertinent following immediate care and moving to rehabilitative care. Our findings also indicate that service providers lack the necessary financial resources and staffing capacity to provide on-going and comprehensive rehabilitation. This article aims to help practitioners better understand particular issues during the implementation of the National Service Framework for long-term neurological conditions from the perspectives of service users and service providers.

An explanation for enhanced perceptions of attractiveness after alcohol consumption

Acute alcohol consumption increases ratings of attractiveness to faces. This may help to explain increased frequencies of sexual encounters during periods of alcohol intoxication. At least in part, such increased attraction may be the result of alcohol consumption decreasing ability to detect bilateral asymmetry, presumably because of the reductions in the levels of visual function. We tested the hypotheses that acute alcohol consumption decreases ability to detect asymmetry in faces and reduces preference for symmetrical faces over asymmetrical faces. Twenty images of a pair of faces and then 20 images of a single face were displayed on a computer, one at a time. Participants were instructed to state which face of each of the face pairs displayed was most attractive and then whether the single face being displayed was symmetrical or not. Data were collected near campus bars at Roehampton University. Sixty-four self-selecting students who undertook the study were classified as either sober (control) or intoxicated with alcohol. For each face pair or single face displayed, participant response was recorded and details of the alcohol consumption of participants that day were also obtained. Sober participants had a greater preference for symmetrical faces and were better at detecting whether a face was symmetrical or otherwise, supporting the hypotheses. A further, unexpected finding was that males made fewer mistakes than did females when determining whether individual faces were asymmetrical. The reduced ability of inebriated people to perceive asymmetry may be an important mechanism underlying the higher ratings of facial attractiveness they give for members of the opposite sex and hence their increased frequency of mate choice.

Perception of Slope in Photographs

Perceptions of characteristics of space such as slope, distance, and depth are frequently inaccurate, both in the real world and in pictures. We carried out experiments to study factors that influence the accuracy of perceived slope in photographs. Slopes varied in angle from 5° to 45° inclinations against the horizontal, and in the information available to the observer (outline shape and texture characteristics). We found that perceived slope is correlated with real slope ( r=0.99), but that observers consistently overestimate slope. The latter depends not only on the available information, but also on the focal length of the lens with which slopes were photographed. Overestimation is less pronounced for the wide-angle lens compared to the standard lens. A comparison of free viewing and viewing from the correct station-point showed that the latter leads to less overestimation of slope. Since the viewing distance was too far under free viewing, the results are compatible with geometrical optics. In a further experiment the effects of magnification and minification were studied by deliberately viewing the photographs from fixed points closer or further away than the station-point; this led to an increase and decrease in overestimation, respectively. Finally, results are frequently dependent on task characteristics: magnitude judgements of photographs without an anchoring point can only be accurate to a level of scale. Thus using an action-based matching task may lead to more accurate slope perception. We therefore carried out a comparison experiment using a matching task to check for the generality and action-dependence of our results. Practical implications for the use of photographs as surrogates for natural viewing are discussed.

Self help programme for anxiety in general practice: controlled trial of an anxiety management booklet

Behavioural methods of treating anxiety have been shown to be highly effective but are not widely available in general practice where most people suffering from anxiety are treated. This study reports a development in service delivery which is simple, inexpensive and does not make great time demands on general practitioners or require them to extend their training and expertise. The study shows that for patients suffering from panic disorder or generalized anxiety disorder the use of an anxiety management booklet in addition to their usual treatment from their general practitioner produces clinically and statistically significant improvements. Of particular importance is the speed of response to the booklet. Within the first two weeks those patients who received the booklet were significantly less anxious than the controls. The booklet was acceptable to patients and recommendations are made about how to incorporate it into clinical practice.

Additional conclusions on diazepam injectable precipitate: GC-MS confirmation

The precipitate which forms upon dilution of diazepam injection with aqueous vehicles is shown conclusively to be diazepam and not benzoates. The results are based on GC-MS analysis of the precipitate as compared with a synthetic mixture of benzoic acid-diazepam.