Leonard E. Egede

Diabetes and depression: global perspectives.

BACKGROUND Diabetes and depression are highly prevalent conditions and have significant impact on health outcomes. This study reviewed the literature on the prevalence, burden of illness, morbidity, mortality, and cost of comorbid depression in people with diabetes as well as the evidence on effective treatments. METHODS Systematic review of the literature on the relationship between diabetes and depression was performed. A comprehensive search of the literature was performed on Medline from 1966 to 2009. Studies that examined the association between diabetes and depression were reviewed. A formal meta-analysis was not performed because of the broad area covered and the heterogeneity of the studies. Instead, a qualitative aggregation of studies was performed. RESULTS Diabetes and depression are debilitating conditions that are associated with significant morbidity, mortality, and healthcare costs. Coexisting depression in people with diabetes is associated with decreased adherence to treatment, poor metabolic control, higher complication rates, decreased quality of life, increased healthcare use and cost, increased disability and lost productivity, and increased risk of death. CONCLUSION The coexistence of diabetes and depression is associated with significant morbidity, mortality, and increased healthcare cost. Coordinated strategies for clinical care are necessary to improve clinical outcomes and reduce the burden of illness.

Longitudinal effects of depression on glycemic control in veterans with Type 2 diabetes

OBJECTIVES To examine the longitudinal effects of depression on glycemic control in veterans with Type 2 diabetes. METHODS Data on 11,525 veterans with Type 2 diabetes were analyzed. A person-period dataset for each subject to cover 3-month intervals (36 time intervals) from April 1997 to March 2006 was created. Subjects were classified as depressed based on ICD-9 codes for depression. General linear mixed model regression was used to examine changes over time in HbA(1c) levels and whether the changes from baseline were different in depressed and nondepressed diabetic veterans, sequentially adjusting for baseline age, demographic variables and comorbidities (coronary heart disease, stroke and hypertension). Pooled t-tests were used to compare unadjusted mean HbA(1c) at each time point across the depressed and nondepressed groups. SAS was used for statistical analysis. RESULTS Ninety-seven percent were men, 48% were white, 27% were blacks and 25% were other. Mean age was 66 years and mean follow-up period was 4.1 years. Six percent (696/11,525) of the sample had diagnosed depression. Unadjusted mean HbA(1c) values were significantly higher in depressed vs. nondepressed subjects at all time points. The adjusted mean HbA(1c) values over time in the final mixed model were significantly higher in depressed vs. nondepressed subjects (mean difference of 0.13; 95% CI [0.03; 0.22]; P=.008). In all adjusted models, differences in mean HbA(1c) values were significantly higher in depressed vs. nondepressed subjects with Type 2 diabetes. CONCLUSION This study of veterans with Type 2 diabetes demonstrates that there is a significant longitudinal relationship between depression and glycemic control as measured by HbA(1c) and that depression is associated with persistently higher HbA(1c) levels over time.

Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: A critical review.

There is a great deal of research on the prevalence, correlates, and treatment of PTSD in the general population. However, we know very little about the manifestation and consequences of PTSD in more complicated patient populations. The purpose of the current paper is to provide a comprehensive review of PTSD within the context of severe mental illness (SMI; i.e., schizophrenia spectrum disorders, mood disorders). Extant data suggest that trauma and PTSD are highly prevalent among individuals with SMI relative to the general population, and both are associated with adverse clinical functioning and increased healthcare burden. However, trauma and PTSD remain overlooked in this population, with low recognition rates in public-sector settings. Additionally, there are few data on the clinical course and treatment of PTSD among individuals with SMI. Particularly lacking are longitudinal studies, randomized controlled treatment trials, and studies using ethno-racially diverse samples. Furthermore, there is a need to better understand the interplay between trauma, PTSD, and severe forms of mental illness and to further develop and disseminate evidence-based PTSD treatments in this population. The current state of the literature and future directions for practice are discussed.

Benefits of continuous subcutaneous insulin infusion in children with type 1 diabetes

OBJECTIVE To examine the effect of continuous subcutaneous insulin infusion (CSII) therapy on parameters affecting long-term outcome in type 1 diabetes. Study design Height, weight, body mass index, insulin dose, glycosylated hemoglobin (HbA(1C)), and blood glucose data from home meter downloads were collected prospectively for analysis in 51 children (age, 10.7+/-3.1 years, mean+/-SD) throughout the 12 months before and after introducing CSII. RESULTS Before pump initiation, HbA(1C) was relatively stable, but it fell to 7.7+/-0.2% (P<.001) within 3 months of CSII and remained decreased (7.9+/-0.1%) at 12 months (P<.01). In contrast, weight standard deviation score increased before CSII (from 0.50+/-0.13 to 0.60+/-0.13, P<.05), but remained unchanged (0.61+/-0.11) in the year thereafter. Although severe hypoglycemia (<50 mg/dL) was reduced in the entire cohort, HbA(1C) improved primarily in young children and teenagers. Comparison of glycemic responders (HbA(1C) <7.5, or a decrease >1% on CSII, n=23) with nonresponders demonstrated no differences with respect to gender, socioeconomic status, weight standard deviation score, body mass index, initial HbA(1C), frequency of hypoglycemia, or number of education visits before CSII. CONCLUSION Continuous subcutaneous insulin infusion is effective in lowering HbA(1C) and the occurrence of severe nocturnal hypoglycemia without excessive weight gain in most children with type 1 diabetes. HbA(1C) response to CSII is poorer in preadolescents than in young children or teenagers.

Racial/Ethnic Differences in Influenza Vaccination Coverage in High-Risk Adults

OBJECTIVES This study identified racial/ethnic disparities in influenza vaccination in high-risk adults. METHODS We analyzed data on influenza vaccination in 7655 adults with high-risk conditions, using data from the 1999 National Health Interview Survey (NHIS). We stratified data by age and used multiple logistic regression to adjust for gender, education, income, employment, and health care access. RESULTS After control for covariates, White patients with diabetes, chronic heart conditions, and cancer had a higher prevalence of influenza vaccination than did Black patients with the same conditions. Similarly, White patients with 2 or more high-risk conditions were more likely to receive the influenza vaccine than Black patients with the same conditions. CONCLUSIONS Significant racial/ethnic differences exist in influenza vaccination of high-risk individuals, and missed vaccination opportunities seem to contribute to the less-than-optimal influenza vaccination coverage in the United States.

The effect of depression on self-care behaviors and quality of care in a national sample of adults with diabetes.

OBJECTIVE To examine the effect of minor and major depression on self-care behaviors and quality of care among adults with diabetes. METHODS Data from 16,754 participants with diabetes in the 2006 Behavioral Risk Factor Surveillance Survey were examined. Multiple logistic regression was used to assess the independent association between depression status and indices of (1) self-care behaviors and (2) quality of diabetes care received, after accounting for confounders. RESULTS Individuals with minor (OR 0.69, 95% CI 0.57-0.84) and major (OR 0.50, 95% CI 0.39-0.64) depression were less likely to engage in leisure-time physical activity. Individuals with minor (OR 1.51, 95% CI 1.18-1.94) and major (OR 1.66, 95% CI 1.28-2.15) depression were more likely to be current smokers. With regard to quality of care, individuals with minor (OR 0.81, 95% CI 0.66-0.99) and major (OR 0.70, 95% CI 0.54-0.89) depression were less likely to receive an annual dilated eye exam. Additionally, individuals with minor (OR 0.79, 95% CI 0.65-0.95), but not major (OR 0.85, 95% CI 0.67-1.09) depression, were less likely to receive a flu shot in the past 12 months. CONCLUSIONS In adults with diabetes, both minor and major depression are associated with decreased self-care behavior and quality of care.

Validation of an Information-Motivation-Behavioral Skills Model of Diabetes Self-Care (IMB-DSC)

OBJECTIVE Comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We applied the Information-Motivation-Behavioral Skills (IMB) model, a well-validated, comprehensive health behavior change framework, to diabetes self-care. METHODS Patients with diabetes were recruited from an outpatient clinic. Information gathered pertained to demographics, diabetes knowledge (information); diabetes fatalism (personal motivation); social support (social motivation); and diabetes self-care (behavior). Hemoglobin A1C values were extracted from the patient medical record. Structural equation models tested the IMB framework. RESULTS More diabetes knowledge (r=0.22 p<0.05), less fatalistic attitudes (r=-0.20, p<0.05), and more social support (r=0.27, p<0.01) were independent, direct predictors of diabetes self-care behavior; and through behavior, were related to glycemic control (r=-0.20, p<0.05). CONCLUSIONS Consistent with the IMB model, having more information (more diabetes knowledge), personal motivation (less fatalistic attitudes), and social motivation (more social support) was associated with behavior; and behavior was the sole predictor of glycemic control. PRACTICE IMPLICATIONS The IMB model is an appropriate, comprehensive health behavior change framework for diabetes self-care. The findings indicate that in addition to knowledge, diabetes education programs should target personal and social motivation to effect behavior change.

Racial/Ethnic Differences in Multiple Self-Care Behaviors in Adults with Diabetes

ObjectiveTo assess racial/ethnic differences in multiple diabetes self-care behaviors.DesignCross-sectional study.Participants21,459 participants with diabetes in the 2003 Behavioral Risk Factor Surveillance survey.MeasurementsThe study assessed self-care behaviors including physical activity, fruits/vegetables consumption, glucose testing, and foot examination, as well as a composite of the 4 self-care behaviors across racial/ethnic groups. Multiple logistic regression was used to assess the independent association between race/ethnicity, the composite variable, and each self-care behavior controlling for covariates. STATA was used for statistical analysis.ResultsOverall, 6% engaged in all 4 self-care behaviors, with a range of 5% in non-insulin users to 8% in insulin users. Blacks were less likely to exercise (OR 0.63, 95% CI 0.51, 0.79), while Hispanics and “others” were not significantly different from whites. Hispanics (OR 0.64, 95% CI 0.49, 0.82) and others (OR 0.69, 95% CI 0.49, 0.96) were less likely to do home glucose testing, while blacks were not significantly different from whites. Blacks (OR 1.42, 95% CI 1.12, 1.80) were more likely to do home foot examinations, while Hispanics and others were not significantly different from whites. Blacks (OR 0.56, 95% CI 0.36, 0.87) were less likely to engage in all 4 behaviors, while Hispanics and others were not significantly different from whites. There were no significant racial/ethnic differences in fruit and vegetable consumption.ConclusionsFew patients engage in multiple self-care behaviors at recommended levels, and there are significant racial/ethnic differences in physical activity, dietary, and foot care behaviors among adults with diabetes.

Diabetes Self-Management in African Americans: An Exploration of the Role of Fatalism

PURPOSE This study was conducted to explore the concept of fatalism in relation to diabetes self-management behavior in African Americans with type 2 diabetes. METHODS Participants (n=39) were recruited from a clinic sample of African Americans with type 2 diabetes. Seven focus groups were conducted; the sessions were recorded, transcribed, and analyzed to identify themes related to fatalism and diabetes self-management. The ISAS paradigm (individual, symbols, audience, situation), a social psychology theory, provided the theoretical framework for the study. RESULTS Four dimensions of fatalism were identified: the meaning of diabetes, the illness experience, the individuals coping response, and the individuals religious and spiritual beliefs. For the participants in this study, fatalism seemed to characterize the nature of the interaction between the individual with diabetes and others, the meanings they attached to such interactions, and the decision to adopt an effective or ineffective diabetes self-management behavior. CONCLUSIONS Fatalism was associated with diabetes self-management in African Americans with diabetes and was multidimensional in this population; the construct appeared to differ conceptually from the perspective of current measures.

Medication Nonadherence in Diabetes: Longitudinal effects on costs and potential cost savings from improvement

OBJECTIVE To examine the longitudinal effects of medication nonadherence (MNA) on key costs and estimate potential savings from increased adherence using a novel methodology that accounts for shared correlation among cost categories. RESEARCH DESIGN AND METHODS Veterans with type 2 diabetes (740,195) were followed from January 2002 until death, loss to follow-up, or December 2006. A novel multivariate, generalized, linear, mixed modeling approach was used to assess the differential effect of MNA, defined as medication possession ratio (MPR) ≥0.8 on healthcare costs. A sensitivity analysis was performed to assess potential cost savings at different MNA levels using the Consumer Price Index to adjust estimates to 2012 dollar value. RESULTS Mean MPR for the full sample over 5 years was 0.78, with a mean of 0.93 for the adherent group and 0.58 for the MNA group. In fully adjusted models, all annual cost categories increased ∼3% per year (P = 0.001) during the 5-year study time period. MNA was associated with a 37% lower pharmacy cost, 7% lower outpatient cost, and 41% higher inpatient cost. Based on sensitivity analyses, improving adherence in the MNA group would result in annual estimated cost savings ranging from ∼