Danielle Hessler

Diabetes Distress but Not Clinical Depression or Depressive Symptoms Is Associated With Glycemic Control in Both Cross-Sectional and Longitudinal Analyses

OBJECTIVE To determine the concurrent, prospective, and time-concordant relationships among major depressive disorder (MDD), depressive symptoms, and diabetes distress with glycemic control. RESEARCH DESIGN AND METHODS In a noninterventional study, we assessed 506 type 2 diabetic patients for MDD (Composite International Diagnostic Interview), for depressive symptoms (Center for Epidemiological Studies-Depression), and for diabetes distress (Diabetes Distress Scale), along with self-management, stress, demographics, and diabetes status, at baseline and 9 and 18 months later. Using multilevel modeling (MLM), we explored the cross-sectional relationships of the three affective variables with A1C, the prospective relationships of baseline variables with change in A1C over time, and the time-concordant relationships with A1C. RESULTS All three affective variables were moderately intercorrelated, although the relationship between depressive symptoms and diabetes distress was greater than the relationship of either with MDD. In the cross-sectional MLM, only diabetes distress but not MDD or depressive symptoms was significantly associated with A1C. None of the three affective variables were linked with A1C in prospective analyses. Only diabetes distress displayed significant time-concordant relationships with A1C. CONCLUSIONS We found no concurrent or longitudinal association between MDD or depressive symptoms with A1C, whereas both concurrent and time-concordant relationships were found between diabetes distress and A1C. What has been called “depression” among type 2 diabetic patients may really be two conditions, MDD and diabetes distress, with only the latter displaying significant associations with A1C. Ongoing evaluation of both diabetes distress and MDD may be helpful in clinical settings.

When Is Diabetes Distress Clinically Meaningful? Establishing cut points for the Diabetes Distress Scale

OBJECTIVE To identify the pattern of relationships between the 17-item Diabetes Distress Scale (DDS17) and diabetes variables to establish scale cut points for high distress among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Recruited were 506 study 1 and 392 study 2 adults with type 2 diabetes from community medical groups. Multiple regression equations associated the DDS17, a 17-item scale that yields a mean-item score, with HbA1c, diabetes self-efficacy, diet, and physical activity. Associations also were undertaken for the two-item DDS (DDS2) screener. Analyses included control variables, linear, and quadratic (curvilinear) DDS terms. RESULTS Significant quadratic effects occurred between the DDS17 and each diabetes variable, with increases in distress associated with poorer outcomes: study 1 HbA1c (P < 0.02), self-efficacy (P < 0.001), diet (P < 0.001), physical activity (P < 0.04); study 2 HbA1c (P < 0.03), self-efficacy (P < 0.004), diet (P < 0.04), physical activity (P = NS). Substantive curvilinear associations with all four variables in both studies began at unexpectedly low levels of DDS17: the slope increased linearly between scores 1 and 2, was more muted between 2 and 3, and reached a maximum between 3 and 4. This suggested three patient subgroups: little or no distress, <2.0; moderate distress, 2.0–2.9; high distress, ≥3.0. Parallel findings occurred for the DDS2. CONCLUSIONS In two samples of type 2 diabetic patients we found a consistent pattern of curvilinear relationships between the DDS and HbA1c, diabetes self-efficacy, diet, and physical activity. The shape of these relationships suggests cut points for three patient groups: little or no, moderate, and high distress.

Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial

PURPOSE Peer health coaches offer a potential model for extending the capacity of primary care practices to provide self-management support for patients with diabetes. We conducted a randomized controlled trial to test whether clinic-based peer health coaching, compared with usual care, improves glycemic control for low-income patients who have poorly controlled diabetes. METHOD We undertook a randomized controlled trial enrolling patients from 6 public health clinics in San Francisco. Twenty-three patients with a glycated hemoglobin (HbA1C) level of less than 8.5%, who completed a 36-hour health coach training class, acted as peer coaches. Patients from the same clinics with HbA1C levels of 8.0% or more were recruited and randomized to receive health coaching (n = 148) or usual care (n = 151). The primary outcome was the difference in change in HbA1C levels at 6 months. Secondary outcomes were proportion of patients with a decrease in HbA1C level of 1.0% or more and proportion of patients with an HbA1C level of less than 7.5% at 6 months. Data were analyzed using a linear mixed model with and without adjustment for differences in baseline variables. RESULTS At 6 months, HbA1C levels had decreased by 1.07% in the coached group and 0.3% in the usual care group, a difference of 0.77% in favor of coaching (P = .01, adjusted). HbA1C levels decreased 1.0% or more in 49.6% of coached patients vs 31.5% of usual care patients (P = .001, adjusted), and levels at 6 months were less than 7.5% for 22.0% of coached vs 14.9% of usual care patients (P = .04, adjusted). CONCLUSIONS Peer health coaching significantly improved diabetes control in this group of low-income primary care patients.

REDEEM: A Pragmatic Trial to Reduce Diabetes Distress

OBJECTIVE To compare three interventions to reduce diabetes distress (DD) and improve self-management among non–clinically depressed adults with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS In REDEEM, 392 adults with T2DM and DD were randomized to computer-assisted self-management (CASM), CASM plus DD-specific problem solving (CAPS), or a computer-administered minimal supportive intervention. Primary outcomes were Diabetes Distress Scale (DDS) total, the Emotional Burden (EB) and Regimen Distress (RD) DDS subscales, and diet, exercise, and medication adherence. RESULTS Significant and clinically meaningful reductions in DD (DDS, EB, and RD) and self-management behaviors occurred in all three conditions (P < 0.001), with no significant between-group differences. There was, however, a significant group × baseline distress interaction (P < 0.02), in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions. RD generated the most distress and displayed the greatest distress reduction as a result of intervention. The pace of DD reduction varied by patient age: older patients demonstrated significant reductions in DD early in the intervention, whereas younger adults displayed similar reductions later. Reductions in DD were accompanied by significant improvements in healthy eating, physical activity, and medication adherence, although not by change in HbA1c. CONCLUSIONS DD is malleable and highly responsive to intervention. Interventions that enhance self-management also reduce DD significantly, but DD-specific interventions may be necessary for patients with high initial levels of DD. Future research should identify the minimal, most cost-effective interventions to reduce DD and improve self-management.

PREDICTING DIABETES DISTRESS in PATIENTS WITH TYPE 2 DIABETES: A LONGITUDINAL STUDY

Aims  Diabetes distress (DD) is a condition distinct from depression that is related to diabetes outcomes. In those without distress initially, little is known about what indicators place patients at risk for subsequent distress over time.

Brief report: Associations between emotional competence and adolescent risky behavior

The current study examines associations between emotional competence (i.e., awareness, regulation, comfort with expression) and adolescent risky behavior. Children from a longitudinal study participated at age 9 and 16 (N=88). Semi-structured interviews were conducted with children about their emotional experiences and coded for areas of emotional competence. Associations were examined for the emotions of sadness and anger concurrently during adolescence, and longitudinally from middle childhood to adolescence. Results suggested that children with poor emotional awareness and regulation had a higher likelihood of using hard drugs. Difficulty regulating emotions was associated with having more sexual partners, and both emotion regulation and expression difficulties were associated with greater behavioral adjustment problems. Results were consistent across the concurrent and longitudinal findings and pointed to anger as an important emotion. Findings suggest that childrens emotional competence may serve as a useful point of intervention to decrease risky behavior in adolescence.

Understanding the sources of diabetes distress in adults with type 1 diabetes

AIMS To identify the unique sources of diabetes distress (DD) for adults with type 1 diabetes (T1D). METHODS Sources of DD were developed from qualitative interviews with 25 T1D adults and 10 diabetes health care providers. Survey items were then developed and analyzed using both exploratory (EFA) and confirmatory CFA) analyses on two patient samples. Construct validity was assessed by correlations with depressive symptoms (PHQ8), complications, HbA1C, BMI, and hypoglycemia worry scale (HWS). Scale cut-points were created using multiple regression. RESULTS An EFA with 305 U.S. participants yielded 7 coherent, reliable sources of distress that were replicated by a CFA with 109 Canadian participants: Powerlessness, Negative Social Perceptions, Physician Distress, Friend/Family Distress, Hypoglycemia Distress, Management Distress, Eating Distress. Prevalence of DD was high with 41.6% reporting at least moderate DD. Higher DD was reported for women, those with complications, poor glycemic control, younger age, without a partner, and non-White patients. CONCLUSIONS We identified a profile of seven major sources of DD among T1D using a newly developed assessment instrument. The prevalence of DD is high and is related to glycemic control and several patient demographic and disease-related patient characteristics, arguing for a need to address DD in clinical care.

Using the Teamlet Model to improve chronic care in an academic primary care practice.

BackgroundTeam care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.ObjectivesTo implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.DesignProcess and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.ParticipantsFirst year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.InterventionHealth coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.MeasurementsMeasurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.ResultsTeamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001).ConclusionsThe Teamlet Model may improve chronic care in academic primary care practices.

Women's condom use assertiveness and sexual risk-taking: Effects of alcohol intoxication and adult victimization

This experiment examined relationships among adulthood victimization, sexual assertiveness, alcohol intoxication, and sexual risk-taking in female social drinkers (N=161). Women completed measures of sexual assault and intimate partner violence history and sexual assertiveness before random assignment to 1 of 4 beverage conditions: control, placebo, low dose (.04%), or high dose (.08%). After drinking, women read a second-person story involving a sexual encounter with a new partner. As protagonist of the story, each woman rated her likelihood of condom insistence and unprotected sex. Victimization history and self-reported sexual assertiveness were negatively related. The less sexually assertive a woman was, the less she intended to insist on condom use, regardless of intoxication. By reducing the perceived health consequences of unprotected sex, intoxication indirectly decreased condom insistence and increased unprotected sex. Findings extend previous work by elucidating possible mechanisms of the relationship between alcohol and unprotected sex - perceived health consequences and situational condom insistence - and support the value of sexual assertiveness training to enhance condom insistence, especially since the latter relationship was robust to intoxication.

Patient perspectives on once‐weekly medications for diabetes

Aim: To examine patient beliefs, preferences and concerns regarding a once‐weekly (QW) glucose‐lowering medication option.