Diabetes-specific emotional distress in people with Type 2 diabetes: a comparison between primary and secondary care.

AIMS: To compare levels of diabetes distress in people with Type 2 diabetes treated in primary and secondary care and to examine demographic and clinical correlates that may explain potential differences in levels of distress between care settings. METHODS: People with Type 2 diabetes from 24 primary care practices (n = 774) and three secondary care clinics (n = 526) completed the Problem Areas In Diabetes questionnaire. Data on HbA1c levels and diabetes complications were derived from medical charts. Hierarchical ordinal regression analysis was used to investigate which correlates could explain the potential differences in level of diabetes distress between care settings. RESULTS: Diabetes distress levels and the prevalence of elevated diabetes distress were considerably lower in the participants treated in primary care (mean (SD) total diabetes distress score 8 (11); 4% of participants with a Problem Areas In Diabetes score ≥ 40) than in secondary care (mean (SD) total diabetes distress score 23 (21); 19% of participants with a Problem Areas In Diabetes score ≥ 40, P < 0.001). In addition to care setting, the following variables were also independently related to diabetes distress: younger age, ethnic minority status, using insulin, having a higher HbA1c level, having a higher BMI and the presence of neuropathy. Other diabetes complications were not independently associated with diabetes distress. CONCLUSIONS: In primary care, lower levels of diabetes distress were reported than in secondary care. The difference in diabetes distress between care settings can be largely, but not fully, explained by specific demographic and clinical characteristics. These results need to be interpreted with caution as they are based on two separate studies, but do call into question the need to screen for diabetes distress in people with Type 2 diabetes in primary care.

Differential associations between depressive symptoms and glycaemic control in outpatients with diabetes.

AIMS: Depression is common in people with diabetes, and related to higher HbA(1c) levels. Depression, however, is a heterogeneous construct that involves a variety of symptoms. As little is known about the associations of individual depressive symptoms with HbA(1c), we explored these associations in outpatients with diabetes. METHODS: The study was conducted in three tertiary diabetes clinics in the Netherlands. At baseline, the presence of the nine depressive symptoms that are listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was assessed with the nine-item Patient Health Questionnaire (PHQ-9). At baseline and after a 1-year follow-up, HbA(1c) was derived from the medical charts. RESULTS: A total of 288 out of 646 subjects with diabetes (45%) reported one or more depressive symptom(s). Depressed mood (ß = 0.11, P = 0.005), sleeping difficulties (ß = 0.16, P < 0.001), appetite problems (ß = 0.15, P < 0.001) and suicidal ideation (ß = 0.14, P = 0.001) were significantly related to higher baseline HbA(1c) values. Furthermore, depressed mood (ß = 0.09, P = 0.03) sleeping difficulties (ß = 0.12, P = 0.004), appetite problems (ß = 0.11, P = 0.01) and psychomotor agitation/retardation (ß = 0.09, P = 0.04) were significantly related to higher HbA(1c) values at 1-year follow-up. Associations were more pronounced in Type 1 diabetes than in Type 2 diabetes. None of the depressive symptoms were related to change in HbA(1c) over time, except suicidal ideation. CONCLUSION: In people with diabetes, several individual depressive symptoms were related to higher HbA(1c) levels. These associations persisted over time. More research is needed to investigate potential mechanistic pathways.

Psychometric and screening properties of the WHO-5 well-being index in adult outpatients with Type 1 or Type 2 diabetes mellitus.

OBJECTIVE: The 5-item World Health Organization well-being index is a commonly used measure of emotional well-being, but research on psychometric properties in outpatients with diabetes is scarce. We examined psychometric and screening properties for depression of this index in a large sample of Dutch outpatients with diabetes. METHODS: Patients with Type 1 (n = 384) and Type 2 (n = 549) diabetes from three outpatient clinics completed the WHO-5 index, the nine-item Patient Health Questionnaire, the Problem Areas in Diabetes survey and the Short Form-12 health survey. Internal consistency of the WHO-5 index was determined by Cronbach's alpha. The factor structure was tested by confirmatory factor analysis. Concurrent validity was assessed by correlations with the Patient Health Questionnaire, Problem Areas in Diabetes and the Short Form-12 mental component scores. Sensitivity and specificity of the WHO-5 index as depression screener were tested against two existing Patient Health Questionnaire cut-off scores for depression using receiver operating characteristic curves. RESULTS: A one-factor structure of the WHO-5 index was verified by confirmatory factor analysis for patients with Type 1 and Type 2 diabetes. Moderate to strong correlations were observed between the WHO-5 index and the Patient Health Questionnaire scores, the Problem Areas in Diabetes scores and the Short Form-12 mental component scores (r = 0.55-0.69, P < 0.001). Receiver operating characteristic curves showed that a WHO-5 index cut-off of < 50 performed best as an indication for likely depression, with sensitivity compared with a Patient Health Questionnaire score ≥ 10 and ≥ 12 of 79% and 88%, respectively, and specificity of 88% and 76%, respectively. CONCLUSIONS: The WHO-5 index is a short, psychometrically sound measure of emotional well-being that appears suitable for use as screening test for likely depression in outpatients with Type 1 and Type 2 diabetes.

Limited effect of screening for depression with written feedback in outpatients with diabetes mellitus: a randomised controlled trial.

AIMS/HYPOTHESIS: The aim of this study was to test the effectiveness of a screening procedure for depression (SCR) vs care as usual (CAU) in outpatients with diabetes. The primary outcome measured was depression score and the secondary outcomes were mental healthcare consumption, diabetes-distress and HbA(1c). MATERIALS AND METHODS: In a multicentre parallel randomised controlled trial, 223 outpatients with diabetes, who had an elevated depression score, were randomly assigned to SCR (n = 116) or CAU (n = 107), using computer generated numbers. SCR-patients were invited for a Composite International Diagnostic Interview (CIDI) to diagnose depression and/or anxiety (interviewers were not blinded for group assignment). As part of the intervention, patients and their physicians were informed of the outcome of the CIDI in a letter and provided with treatment advice. At baseline and 6 month follow-up, depression and diabetes-distress were measured using the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Problem Areas in Diabetes survey (PAID). HbA(1c) levels were obtained from medical charts. RESULTS: Mean CES-D depression scores decreased from baseline to 6 months in both groups (24 ± 8 to 21 ± 8 [CAU] and 26 ± 7 to 22 ± 10 [SCR] respectively [p < 0.001]), with no significant differences between groups. Neither diabetes-distress nor HbA(1c) changed significantly within and between groups. The percentage of patients receiving mental healthcare increased in the SCR group from 20% to 28%, compared with 15% to 18% in the CAU group. CONCLUSIONS/INTERPRETATION: Depression screening with written feedback to patient and physician does not improve depression scores and has a limited impact on mental healthcare utilisation, compared with CAU. It appears that more intensive depression management is required to improve depression outcomes in patients with diabetes.

Diabetes-specific emotional distress mediates the association between depressive symptoms and glycaemic control in Type 1 and Type 2 diabetes.

OBJECTIVES: To investigate whether diabetes-specific emotional distress mediates the relationship between depression and glycaemic control in patients with Type 1 and Type 2 diabetes. RESEARCH DESIGN AND METHODS: Data were derived from the baseline assessment of a depression in diabetes screening study carried out in three tertiary diabetes clinics in the Netherlands. Most recent glycated haemoglobin (HbA(1c)) measurement was obtained from medical records. The Centre for Epidemiologic Studies Depression Scale (CES-D) and Problem Areas in Diabetes scale (PAID) were used to measure depression and diabetes-specific emotional distress respectively. Linear regression was performed to examine the mediating effect of diabetes-distress. RESULTS: Complete data were available for 627 outpatients with Type 1 (n = 280) and Type 2 (n = 347) diabetes. Analyses showed that diabetes-distress mediated the relation between depression and glycaemic control and not differently for both disease types. Post-hoc analyses revealed that patients depressed and distressed by their diabetes were in significantly poorer glycaemic control relative to those not depressed nor distressed (HbA(1c) 8.7 +/- 1.7 vs. 7.6 +/- 1.2% in those without depressive symptoms, 7.6 +/- 1.1% in depressed only and 7.7 +/- 1.1% in the distressed only, P < 0.001). Depressed patients without elevated diabetes-distress did not show a significantly increased risk of elevated HbA(1c). CONCLUSIONS: In explaining the association between depression and glycaemic control, diabetes-specific emotional distress appears to be an important mediator. Addressing diabetes-specific emotional problems as part of depression treatment in diabetes patients may help improve glycaemic outcomes.

Prevalence of comorbid depression is high in out-patients with Type 1 or Type 2 diabetes mellitus. Results from three out-patient clinics in the Netherlands.

AIMS: Depression is common in diabetes, but the scope of the problem and associated correlates are not well established in specialist diabetes care. We aimed to determine the prevalence of depression among adult outpatients with Type 1 (T1DM) or Type 2 diabetes (T2DM) using both self-report measures and a diagnostic interview, and to establish demographic and clinical characteristics associated with depressive affect. METHODS: A random sample of 2055 diabetes out-patients from three diabetes clinics was invited to participate. Depressive affect was assessed using the World Health Organization-5 Well Being Index (WHO-5), the Centre for Epidemiologic Studies-Depression scale (CESD) using predefined cut-off scores, and depressive disorder with the Composite International Diagnostic Interview (CIDI). Associations between depression and patient characteristics were explored using regression analyses. RESULTS: Seven hundred and seventy-two patients completed the depression questionnaires. About one-third of T1DM patients and 37-43% of T2DM patients reported depressive affect (WHO-5). The prevalence of depressive affect (CESD) was 25% and 30% for men and women with T1DM, and 35% and 38% for men and women with T2DM, respectively. Based on the CIDI, 8% of T1DM patients (no gender difference) and 2% of men and 21% of women with T2DM suffered from a depressive disorder. Depressive affect was associated with poor glycaemic control and proliferative retinopathy in T1DM, while non-Dutch descent, obesity and neuropathy were correlates in T2DM. CONCLUSIONS: Depressive symptoms and major depressive disorder constitute a common comorbid problem among Dutch out-patients with T1DM or T2DM and appear particularly common in migrants and women with T2DM.

A reduction in severe hypoglycaemia in type 1 diabetes in a randomized crossover study of continuous intraperitoneal compared with subcutaneous insulin infusion.

AIM: Continuous intraperitoneal insulin infusion (CIPII) with the DiaPort system using regular insulin was compared to continuous subcutaneous insulin infusion (CSII) using insulin Lispro, to investigate the frequency of hypoglycemia, blood glucose control, quality of life, and safety. METHODS: In this open, randomized, controlled, cross-over, multinational, 12-month study, 60 type 1 diabetic patients with frequent hypoglycemia and/or HbA1c > 7.0% with CSII were randomized to CIPII or CSII. The aim was to obtain the best possible blood glucose while avoiding hypoglycemia. RESULTS: The frequency of any hypoglycemia was similar (CIPII 118.2 (SD 82.6) events / patient year, CSII 115.8 (SD 75.7) p = 0.910). The incidence of severe hypoglycemia with CSII was more than twice the one with CIPII (CIPII 34.8 events / 100 patient years, CSII 86.1, p = 0.013). HbA1c, mean blood glucose, and glucose fluctuations were not statistically different. Treatment-related severe complications occurred mainly during CIPII: port infections (0.47 events / patient year), abdominal pain (0.21 events / patient year), insulin underdelivery (0.14 events / patient year). Weight gain was greater with CSII (+ 1.5 kg vs. - 0.1 kg, p = 0.013), quality of life better with CIPII. CONCLUSIONS: In type 1 diabetes CIPII with DiaPort reduces the number of severe episodes of hypoglycemia and improves quality of life with no weight gain. Because of complications, indications for CIPII must be strictly controlled. CIPII with DiaPort is an alternative therapy when CSII is not fully successful and provides an easy method of intraperitoneal therapy.

No evidence for increased self-reported cognitive failure in Type 1 and Type 2 diabetes: a cross-sectional study.

AIMS: Mild cognitive deficits have been determined in both types of diabetes using neurocognitive tests. Little is known about the degree to which patients complain about their cognitive functioning. This study set out to investigate the magnitude and correlates of self-reported cognitive failure in adult out-patients with Type 1 and Type 2 diabetes. METHODS: Subjective cognitive functioning was measured in 187 diabetic patients using the Cognitive Failures Questionnaire (CFQ). Demographic and clinical characteristics were retrieved from the medical records. The Patient Health Questionnaire 9 items (PHQ-9) was self-administered along with the CFQ to correct for the confounding effect of depression. RESULTS: Analyses were based on 55 patients with Type 1 diabetes and 100 patients with Type 2 diabetes. No difference in mean CFQ score was observed between Type 1 and Type 2 diabetic patients or between Type 1 diabetic patients and healthy control subjects. Female patients with Type 2 diabetes reported significantly fewer cognitive complaints compared with female healthy control subjects. None of the demographic variables and diabetes-related complications was associated with subjective cognitive complaints. A strong positive association was found between depression symptomatology and frequency of self-reported cognitive failure. CONCLUSIONS: Our study could not confirm elevated subjective cognitive complaints in a group of Type 1 and Type 2 diabetes patients, as might be expected given the observed elevated rates of mild cognitive dysfunction in patients with diabetes. Self-reported cognitive failure appears largely determined by depressive symptomatology. Therefore, affective status should be included in any cognitive assessment procedure.