The association of depression and diabetes across methods, measures, and study contexts.

BACKGROUND: Empirical research has revealed a positive relationship between type 2 diabetes mellitus and depression, but questions remain regarding timing of depression measurement, types of instruments used to measure depression, and whether "depression" is defined as clinical depression or depressive symptoms. The present study sought to establish the robustness of the depression-diabetes relationship across depression definition, severity of depressive symptoms, recent depression, and lifetime depression in a nationally representative dataset and a large rural dataset. METHODS: The present examination, conducted between 2014 and 2015, used two large secondary datasets: the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2008 (n = 3072) and the Arthritis, Coping, and Emotion Study (ACES) from 2002 to 2006 (n = 2300). Depressive symptoms in NHANES were measured using the Patient Health Questionnaire 9-item survey (PHQ-9). ACES used the Center for Epidemiologic Studies-Depression Scale (CES-D) to measure depressive symptoms and the Composite International Diagnostic Interview (CIDI) to measure diagnosable depression. Diabetes was modelled as the dichotomous outcome variable (presence vs. absence of diabetes). Logistic regression was used for all analyses, most of which were cross-sectional. Analyses controlled for age, ethnicity, sex, education, and body mass index, and NHANES analyses used sample weights to account for the complex survey design. Additional analyses using NHANES data focused on the addition of health behavior variables and inflammation to the model. RESULTS: NHANES. Every one-point increase in depressive symptoms was associated with a 5% increase in odds of having diabetes [OR: 1.05 (CI: 1.03, 1.07)]. These findings persisted after controlling for health behaviors and inflammation. ACES. For every one-point increase in depressive symptom score, odds of having diabetes increased by 2% [OR: 1.02 (CI: 1.01, 1.03)]. Recent (past 12 months) depression [OR: 1.49, (CI: 1.03, 2.13)] and lifetime depression [OR: 1.40 (CI: 1.09, 1.81)] were also significantly associated with having diabetes. CONCLUSIONS: This study provides evidence for the robustness of the relationship between depression or depressive symptoms and diabetes and demonstrates that depression occurring over the lifetime can be associated with diabetes just as robustly as that which occurs more proximal to the time of study measurement.

Medication risk communication during rheumatology office visits.

OBJECTIVE: We used a multidimensional framework to describe the types of information about medication risks that rheumatologists provide to rheumatoid arthritis (RA) patients during routine office visits. METHODS: We analyzed 1,094 audiotaped rheumatology office visits involving 450 RA patients. Each patient had up to 3 visits audiotaped. In conjunction with each office visit, patients also completed a self-administered questionnaire and interview and the rheumatologists provided ratings of patient health status. RESULTS: The number of medication risks discussed per visit ranged from 0-18, with a mean ± SD of 3.23 ± 2.93. The rheumatologist initiated ∼80% of the medication risk discussions. Approximately one-fourth of the discussions (25.6%) were limited to an assessment of whether or not the patient was experiencing a medication side effect. More risks were discussed during visits when changes to the patient's regimen were discussed than when no changes were discussed (X= 3.93, SD = 3.10 and X = 2.20, SD = 2.34, respectively; P < 0.0001). When medications were being proposed for addition to the patient's regimen, the most frequently discussed risk dimensions were the importance of monitoring (30%), probability (29.8%), things the patient should do to minimize risk (25.5%), and risk severity (21.8%). CONCLUSION: Most discussions of medication risks that we observed were quite limited and often restricted to an assessment of whether the patient was experiencing side effects from their current medications. The amount of information that is optimal and how to tailor information to the preferences and abilities of individual patients remain important areas for future research.

Patient-rheumatologist communication concerning prescription medications: getting to the gist.

OBJECTIVE: Fuzzy trace theory was used to develop a coding scheme that captures the gist that patients extract from information about medication risks and benefits and to explore the extent to which different patients extract different gist representations from the same information. METHODS: Data were collected from 2003-2007 in a study that included audiotape recording office visits that rheumatoid arthritis (RA) patients had with their rheumatologists. Each patient (n = 365) had up to 3 visits audiotape recorded. The audiotapes were transcribed to facilitate content analysis. Four patients with RA who did not participate in the original study guided development of the coding scheme and used it to code the transcripts. RESULTS: The coding scheme contains 14 gist themes centering on medication effectiveness, need, and safety. There was considerable variation among the gist coders in the specific themes they extracted from individual transcripts. We observed the greatest intercoder agreement for the 4 gist theme variables related to whether the rheumatologist wanted to make changes to the medication regimen. Furthermore, the coders rarely used the "not clear" category to code these 4 variables. In contrast, intercoder agreement for the remaining gist themes, which were designed to capture issues central to the communication of information about medication risks and benefits, was low and the "not clear" category was used more frequently. CONCLUSION: Our study findings suggest that different people exposed to the same information may form different gist representations. Patient-provider communication concerning medication risks and benefits might be enhanced by better understanding the factors that influence the gist extraction process.

The role of symptoms and self-efficacy in predicting physical activity change among older adults with arthritis.

BACKGROUND: Physical and psychological symptoms limit physical activity for people with arthritis. This study examined if self-efficacy mediated a relationship between symptom and physical activity (PA) frequency change. METHODS: This was a secondary analysis of older adults with arthritis and joint pain in a trial of a lifestyle PA program (n = 339). Measures were depressive symptoms, pain, fatigue, arthritis self-efficacy, PA self-efficacy, and PA frequency. A panel model was used to analyze relationships at baseline and changes at 20 weeks. RESULTS: The mean age was 68.8 years. At baseline, depression and fatigue were associated with arthritis self-efficacy (ß = -.34 and -.24) and, in turn, PA self-efficacy (ß = .63); PA self-efficacy was associated with PA (ß = .15). Pain and depression changes were associated with arthritis self-efficacy change (ß = -.20 and -.21) and, in turn, PA self-efficacy (ß = .32) change; PA self-efficacy change was associated with PA change (ß = .36). CONCLUSION: Change in symptom severity affected change in PA frequency. These relationships appeared to operate through self-efficacy. Over time, pain appeared to have a stronger relationship than fatigue with self-efficacy and PA. These findings support strategies to help people with arthritis strengthen their confidence for symptom coping and PA participation.

Differences in effectiveness of the active living every day program for older adults with arthritis.

OBJECTIVE: The authors explored whether demographic and psychosocial variables predicted differences in physical activity for participants with arthritis in a trial of Active Living Every Day (ALED). METHOD: Participants (N = 280) from 17 community sites were randomized into ALED or usual care. The authors assessed participant demographic characteristics, self-efficacy, outcome expectations, pain, fatigue, and depressive symptoms at baseline and physical activity frequency at 20-wk follow-up. They conducted linear regression with interaction terms (Baseline Characteristic × Randomization Group). RESULTS: Being female (p ≤ .05), less depressed (p ≤ .05), or younger (p ≤ .10) was associated with more frequent posttest physical activity for ALED participants than for those with usual care. Higher education was associated with more physical activity for both ALED and usual-care groups. DISCUSSION: ALED was particularly effective for female, younger, and less depressed participants. Further research should determine whether modifications could produce better outcomes in other subgroups.

Brief Fear of Movement Scale for osteoarthritis.

OBJECTIVE: Fear of movement has important clinical implications for individuals with osteoarthritis (OA). This study aimed to establish a brief fear of movement scale for use in OA. Items from the Tampa Scale for Kinesiophobia (TSK) were examined. METHODS: The English version of the TSK was examined in a community-based sample (n = 1,136) of individuals with OA of the hip or knee. Exploratory and confirmatory factor analyses were used to determine the number and content of the dimensions of fear of movement. Factorial invariance was tested across subgroups of sex, race, education, and OA severity. Convergent validity with measures of pain, physical functioning, and psychological functioning was examined. RESULTS: Factor analyses identified a single-factor 6-item scale that measures activity avoidance due to pain-related fear of movement (confirmatory factor analysis indices of model fit: root mean square error of approximation = 0.04, standardized root mean square residual = 0.01, comparative fit index = 0.99, and Tucker-Lewis Index = 0.99). The 6-item scale demonstrated factorial invariance across sex, race, levels of education, and OA severity, suggesting that this scale performs consistently across diverse groups of individuals with OA. Convergent validity with measures of pain (ß = 0.30-0.41), physical functioning (ß = 0.44-0.48), and psychological functioning (ß = 0.36-0.37) was also demonstrated. CONCLUSION: The Brief Fear of Movement Scale identified in this study provides a promising and valid approach for assessing fear of movement in individuals with OA. This brief scale demonstrated several important strengths, including a small number of items, sound psychometric properties, and consistent performance across diverse groups of individuals with OA.

Use and perceived credibility of medication information sources for patients with a rare illness: differences by gender.

Patients with rare illnesses may use medication information sources that are appreciably different from those used by patients with more common illnesses. This article's purpose is to describe vasculitis patients' most frequently used medication information sources, determine which sources patients perceive as credible, and explore gender differences in source use and perceived credibility. Using an online questionnaire, patients (n = 232) indicated how often they obtained medication information from 12 sources during the previous year and rated the credibility of 6 sources. The authors used multivariate analysis of covariance and follow-up contrasts to test for gender differences in source use and conducted t tests to compare patients' perceived credibility ratings. Patients used physicians and the Internet most often to obtain medication information and rated them as the most credible sources. Male patients used their spouse/partner more often and rated them as more credible than did female patients. Female patients were more likely to use medication package inserts and the Internet and were less likely to use nurses than were male patients. There appear to be similarities and differences between the information-seeking behaviors of vasculitis patients and other patient populations. Because male patients view their spouse/partner as a credible information source, providers may want to involve the spouse/partner in prescription decision making.

Results of a randomized trial testing messages tailored to participant-selected topics among female college students: physical activity outcomes.

BACKGROUND: A better understanding of identifying tailoring variables would improve message design. Tailoring to a behavior that a participant selects as one they would like to work on may increase message relevance, and thus effectiveness. This trial compared 3 groups: message tailored to physical activity as a participant-selected topic (choice), message tailored to physical activity as an expert-determined topic (expert), or nontailored message (comparison). METHODS: 408 female college students received web-delivered computer-tailored messages on physical activity. Outcomes were immediate and 1-month follow-up changes in psychosocial, goal-related, and behavioral variables related to physical activity. RESULTS: Participants were predominately non-Hispanic White (73.8%). Change in self-efficacy and goal commitment at immediate follow-up and vigorous physical activity at 1-month follow-up was greater in the expert versus comparison group. Change in goal commitment at immediate follow-up was lower in the choice versus expert group. In the expert group, those choosing physical activity as their selected topic perceived the goal to be easier at immediate follow-up compared with those receiving unmatched messages. CONCLUSIONS: Findings supported tailoring to an expert-determined topic. However, based on the beneficial change in perceived goal difficulty when topics matched, future research should encourage synchrony between participant-selected topics and expert recommendations.

The effect of conflicting medication information and physician support on medication adherence for chronically ill patients.

OBJECTIVE: This article explores the effect of conflicting information, defined as contradictory information about medication topics from different sources, on medication adherence in a sample of chronically ill patients. We specifically investigate whether conflicting information and physician support directly affect medication adherence or whether the effect is mediated by adherence self-efficacy and outcome expectations for medications. METHODS: Vasculitis patients (n = 228) completed two on-line questionnaires which contained measures of conflicting information, adherence self-efficacy, outcome expectations, physician support, and medication adherence. We conducted a mediation analysis using a bootstrapping approach to generate point estimates and 95% confidence intervals to test the significance of each mediated effect. RESULTS: A majority of patients (51.3%) received conflicting medication information. Conflicting information had a direct negative effect on medication adherence, which was not mediated by self-efficacy or outcome expectations. Alternatively, self-efficacy mediated the positive effect of physician support on medication adherence. CONCLUSION: Patients who encounter conflicting medication information are less adherent to their medications. The presence of a supportive physician may counteract the negative effect of conflicting medication information. PRACTICE IMPLICATIONS: Physicians should initiate conversations about conflicting medication information with their patients. Consensus-based guidelines that address medication discrepancies may also reduce the availability of conflicting information.

Effect of couple illness perception congruence on psychological adjustment in women with rheumatoid arthritis.

OBJECTIVE: To characterize similarities and differences in illness perceptions between women with rheumatoid arthritis (RA) and their husbands, and examine whether illness perception congruence predicted wives' subsequent psychological adjustment. DESIGN: Women with RA and their husbands (N=190 couples) recruited from community and clinical settings completed mailed surveys at baseline and 4-month follow-up. MAIN OUTCOME MEASURES: Data for this investigation included illness perceptions in partners and illness severity, marital variables, and psychological adjustment in wives. RESULTS: In general, wives and husbands had similar views of RA. Couple congruence concerning women's personal control over RA and its cyclic nature predicted better psychological adjustment in women 4 months later. Post hoc tests showed better psychological adjustment in wives from couples with similar optimistic beliefs about personal control, illness coherence, and RA consequences, when compared to those in couples with similar pessimistic beliefs. Furthermore, when partners disagreed about RA's consequences, wives fared better when husbands overestimated rather than underestimated their beliefs. In contrast, couple congruence about the emotions and timeline of RA was unrelated to adjustment. CONCLUSION: It may be important for husbands to understand wives' views on their control over RA and its cyclic nature. Furthermore, wives may benefit when they share optimistic views with their husbands about RA, and when their husbands avoid underestimating RA's consequences. Developing interventions to enhance partners' illness understanding may be beneficial.

Development and initial evaluation of a measure of self-management for adults with antineutrophil cytoplasmic antibody-associated small-vessel vasculitis.

OBJECTIVE: To develop a measure of illness self-management for adults living with antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel vasculitis (ANCA-SVV) and to gather evidence of its reliability and validity. METHODS: Development of the Vasculitis Self-Management Scale (VSMS) was guided by previous research on self-management in other chronically ill populations, a review of the current treatment literature for ANCA-SVV, interviews with patients, and consultation with experts. A total of 205 patients living with ANCA-SVV or a closely related condition then completed the VSMS, along with measures of sociodemographic and clinical variables, social desirability bias, and general adherence to medical recommendations, using a self-administered mailed questionnaire. A principal components analysis was conducted on the VSMS items. Internal consistency reliability and construct validity of the resulting subscales were assessed. Forty-four patients completed the VSMS a second time, for the purpose of assessing test-retest reliability. RESULTS: Analyses suggested an 8-factor solution. The final VSMS consisted of 43 items representing these 8 behavioral domains. Correlations among the 8 domains were null to modest in magnitude. The internal consistency reliability of the 8 subscales ranged from minimally acceptable (alpha = 0.67) to excellent (alpha = 0.94), and correlations between subscale scores at time 1 and time 2 suggested good temporal stability. Preliminary evidence for validity was mixed. CONCLUSION: These findings suggest that the VSMS is a promising method for assessing illness self-management in adults with ANCA-SVV. More research exploring the validity of the measure is warranted.

The relationship between spirituality and depressive symptoms: testing psychosocial mechanisms.

Although many studies suggest lower rates of depressive symptoms in those who report greater spirituality, few have investigated the mechanisms by which spirituality might relate to depressive symptoms. The current study aimed to elucidate potential psychosocial mechanisms that link these 2 variables. Data were drawn from a community-dwelling stratified sample of 630 racially diverse adults in rural North Carolina. Spirituality was assessed by 6 items of the Daily Spiritual Experiences Scale. Depressive symptoms were measured using 4 subscales from the Center for Epidemiological Studies-Depression. Hypothesized mediators were optimism, volunteering, and perceived social support. Structural equation modeling was used to test whether proposed mediators explain a link between spirituality and depressive symptoms. The model demonstrated a satisfactory fit. Spirituality was indirectly related to depressive symptoms. More specifically, spirituality was significantly associated with optimism and volunteering but not with social support, and optimism, volunteering and perceived social support were significantly associated with depressive symptoms. The link between spirituality and depressive symptoms is indirect. The relationship is mediated by optimism, volunteering, and social support. Findings present research and practice implications.

"Una mujer trabaja doble aqui": Vignette-based focus groups on stress and work for Latina blue-collar women in eastern North Carolina.

Latina women are a growing percentage of the working population, and very little is known about their health needs and interests. The purpose of this article is to share qualitative research results gathered from Latina women with a particular focus on exploring stress and health. This project was a substudy of Health Works in the Community, a 5-year CDC-funded multiple risk-factor reduction trial using participatory action research approaches to address smoking, healthy eating, stress, and physical activity among blue-collar women from 12 manufacturing work sites in rural, eastern North Carolina. Five focus groups were conducted with trained, bilingual facilitators using a vignette-based moderator guide that appeared particularly effective with this population. Results from the focus groups are used to make recommendations for future research with Latinas and for developing effective work-site-based interventions to address issues of stress and health within this population.

Spirituality and depressive symptoms in a racially diverse US sample of community-dwelling adults.

The role of spirituality in depression is understudied. We examined the relationship between one dimension of spirituality, spiritual experiences, and depressive symptoms, and evaluated whether differences in gender, race, age, and stress moderated the relationship. The study was conducted with a community-based sample of 630 racially diverse middle-aged and older adults. Structural equation modeling was used to estimate a model linking spiritual experiences to depressive symptoms while controlling for demographic and health variables. Spiritual experiences were operationalized using six items of the Daily Spiritual Experiences Scale. Sample items included, "I feel God's presence," and, "I feel comfort in my religion or spirituality." The model achieved satisfactory goodness of fit. Spiritual experiences were significantly associated with fewer depressive symptoms, and age as well as stress moderated the association, but not gender and race. Spirituality appears to be a psychosocial resource against depressive symptoms, although the results must be confirmed in longitudinal investigations.

Factors associated with potentially inappropriate drug utilization in a sample of rural community-dwelling older adults.

BACKGROUND: Many medications present special risks when used by older adults (ie, those aged > or = 65 years) and are considered potentially inappropriate for this population. The Beers criteria are often used to identify such medications. Past research has documented that use of Beers drugs is common among older adults. OBJECTIVE: The aim of this work was to examine factors associated with potentially inappropriate drug use among rural community-dwelling older adults using a conceptual framework adapted from the Andersen-Newman behavioral model of health service use. METHODS: This was a population-based, cross-sectional survey. Data were collected via face-to-face home interviews between 2002 and 2004. Rural community-dwelling older adults residing in a single county in North Carolina were eligible. Potentially inappropriate drug use was operationalized using the Beers criteria. Data concerning predisposing (ie, age, sex, race, education, and marital status), enabling (ie, social support and insurance status), need (ie, disability and history of major depression, hypertension, osteoarthritis, back problems, or other comorbidities), and utilization factors (ie, number of medications used) were collected. RESULTS: Data were gathered from 892 people, with information on medication use available for 800. Two hundred thirteen of these 800 participants (26.6%) used > or = 1 Beers drug. Compared with individuals who used no Beers drugs, those who used > or = 1 Beers drug reported lower levels of social support (odds ratio [OR], 0.94; 95% CI, 0.90-0.99) and higher levels of disability (OR, 1.48; 95% CI, 1.11-1.97), used more medications (OR, 1.07; 95% CI, 1.01-1.13), and were more likely to have a history of major depression (OR, 1.67; 95% CI, 1.05-2.66), hypertension (OR, 1.58; 95% CI, 1.07-2.33), osteoarthritis (OR, 1.58; 95% CI, 1.09-2.29), and back problems (OR, 1.72; 95% CI, 1.19-2.47). CONCLUSION: As suggested by the Andersen-Newman model, the risk of potentially inappropriate drug use is highest among those with the greatest medication needs, as evidenced by poorer health status in this sample of rural community-dwelling older patients.

Encouraging patient adherence: primary care physicians' use of verbal compliance-gaining strategies in medical interviews.

Compliance-gaining strategies refer to subtle differences in ways people use language when their goal is to influence someone else's behavior. This stands in contrast to other kinds of persuasion aimed only at influencing others beliefs and attitudes. We have developed a new method of coding what physicians say when they are trying to influence patients' behaviors. This method applies theory and methods from the fields of interpersonal influence, linguistics and social psychology. We tested the reliability of this new method by randomly selecting 37 audiotaped medical interviews collected for an unrelated study [J. Gen. Int. Med., 9 (1994) 402] and having three coders independently identify physician compliance-gaining utterances and then independently apply one of 57 codes to each utterance. These codes also were categorized on two underlying dimensions reflecting whether the physician (1) framed the compliance-gaining utterance in a direct or indirect way, and (2) did or did not give a justification for that direct or indirect request. Reliability among coders and coders agreement with the final utterance identification and coding decisions, measured as per cent agreement among coders and/or, where appropriate, by Cohen's kappa were good to excellent. Most physicians' strategies were indirect and incomplete. For female patients, physicians used significantly more strategies, including more indirect strategies, complete strategies, "prescriptions" and "demands". For male patients, physicians used a greater percent of direct strategies, including "procedural demands". This method provides a reliable and promising new technique for observing naturally occurring physician compliance-gaining speech.

Gender differences in psychosocial reactions to cystic fibrosis carrier testing.

Gender differences involving genetic testing have become a topic of research as feminist critiques assert that women may be affected differently, and possibly more significantly, than men by genetic carrier testing information. It is possible that men and women differ in their reactions to learning whether they are or are not a carrier of a specific mutation. It is also possible that men and women may differ in their reactions to different methods of genetic testing. Data on gender differences in reactions to cystic fibrosis (CF) carrier testing in a high-risk population and to gender differences in reactions to home-based as opposed to clinic-based testing are reported. This analysis suggests that at least for CF carrier testing, men and women do differ in terms of their risk perceptions, negative psychological affect, perceptions about themselves, and the convenience of testing. However, there was only one difference between men's and women's reactions to the method of testing. A better understanding of gender differences in response to carrier testing, as well as to interactions between gender and methods of genetic testing, may inform better approaches to carrier testing and to considering alternative methods of such testing.

Effects of an osteoporosis prevention program incorporating tailored educational materials.

PURPOSE: To evaluate the effects of two interventions on calcium intake and exercise and assess whether intervention effects varied as a function of participants' stage of change. DESIGN: The study used a 2 by 2 factorial research design. Baseline, 3-, 6-, and 12-month follow-up data were collected. SETTING: Twelve counties in western North Carolina. SUBJECTS: Of 714 women recruited, 547 (76.6%) completed all data collection procedures. INTERVENTION: One intervention, conducted at the individual level, compared the effects of tailored vs. nontailored educational materials. The tailored educational intervention was delivered via two packets of written materials and one telephone counseling session. The written materials and counseling session were tailored according to participants' current calcium intake and exercise level, perceived adequacy of these behaviors, stage of change, behavioral goals, and perceived barriers to change. A community-based intervention was also evaluated. This intervention, implemented in 6 of the 12 counties, included establishing an Osteoporosis Resource Center, conducting a workshop on osteoporosis prevention, and offering free bone density screening. MEASURES: Outcome measures were calcium intake and exercise level. Stage of change was assessed as a moderating variable. RESULTS: Irrespective of intervention group, among women not consuming adequate calcium at baseline, intake increased an average of about 500 mg/d over the course of the study. Changes involving exercise were more modest. Repeated measures regression analyses were used to evaluate intervention effects. The effect of the tailored educational intervention varied, in appropriate ways, among women in different stages of change at baseline (F2,527 = 6.37, p < .002). Among women in the Engaged stage, the tailored intervention was associated with a greater increase in calcium intake. In contrast, among women who were obtaining adequate calcium at baseline (i.e., Action stage), the tailored intervention appeared to forestall inappropriate increases in calcium intake. The community-based intervention had no consistent effects on calcium intake, either alone, or in combination with the tailored intervention. Finally, neither intervention had an effect on exercise, either alone or in combination. CONCLUSIONS: Limited support for the superiority of tailored vs. nontailored educational interventions was found. The differential effects observed could be due to the telephone counseling received by women in the Tailored Education Group, however.