Mary de Groot

ASSOCIATION OF DEPRESSION AND DIABETES COMPLICATIONS: A META-ANALYSIS

Objective The objective of this study was to examine the strength and consistency of the relationship between depression and diabetes complications in studies of type 1 and type 2 adult patients with diabetes. Method MEDLINE and PsycINFO databases were searched for articles examining depression and diabetes complications in type 1 and type 2 diabetes samples published between 1975 and 1999. Meta-analytic procedures were used. Studies were reviewed for diabetes type, sample size, statistical tests, and measures of diabetes complications and depression. Significance values, weighted effect sizes r, 95% confidence intervals (CI), and tests of homogeneity of variance were calculated for the overall sample (k = 27) and for subsets of interest. Results A total of 27 studies (total combined N = 5374) met the inclusion criteria. A significant association was found between depression and complications of diabetes (p < .00001, z = 5.94). A moderate and significant weighted effect size (r = 0.25; 95% CI: 0.22–0.28) was calculated for all studies reporting sufficient data (k = 22). Depression was significantly associated with a variety of diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction). Effect sizes were in the small to moderate range (r = 0.17 to 0.32). Conclusions These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.

Anxiety and Poor Glycemic Control: A Meta-Analytic Review of the Literature

Objective: To determine whether anxiety is associated with poor glycemic control in adults with type 1 or type 2 diabetes. Method: MEDLINE, PubMed, and PsycINFO databases were used to locate studies that measured the association of anxiety with glycemic control. Meta-analytic procedures were used to convert the findings to a common metric, compute effect sizes (ES), and statistically analyze the collective data. Results: The search procedures identified 12 studies, 11 (92 percent) of which satisfied the criteria for inclusion in the meta-analysis. In this overall group, anxiety was not associated with glycemic control (p = 0.19), although the ES was marginally statistically significant (ES = .09, 95 percent CI = 0.04 to 0.14). In studies that determined anxiety from diagnostic interviews, anxiety was associated with hyperglycemia (p = 0.003) and the ES was also statistically significant (ES: 0.25, 95 percent CI = 0.10 to 0.38). Conclusions: The existing literature suggests that anxiety disorders are associated with hyperglycemia in diabetic patients. Additional studies are required to confirm the magnitude of the relationship, to elucidate moderating and causal factors, and to determine whether successful treatment of anxiety improves glycemic control.

Psychological Adjustment to IDDM: 10-Year Follow-Up of an Onset Cohort of Child and Adolescent Patients

OBJECTIVE To evaluate the psychological adjustment of young adults with IDDM in comparison with similarly aged individuals without chronic illness. RESEARCH DESIGN AND METHODS An onset cohort of young adults (n = 57), ages 19–26 years, who have been followed over a 10-year period since diagnosis, was compared with a similarly aged group of young adults identified at the time of a moderately severe, acute illness (n = 54) and followed over the same 10-year period. The groups were assessed at 10-year follow-up in terms of 1) sociodemographic indices (e.g., schooling, employment, delinquent activities, drug use), 2) psychiatric symptoms, and 3) perceived competence. In addition, IDDM patients were examined for longitudinal change in adjustment to diabetes. RESULTS The groups differed only minimally in terms of sociodemographic indices, with similar rates of high school graduation, post-high school education, employment, and drug use. The IDDM group reported fewer criminal convictions and fewer non-diabetes-related illness episodes than the comparison group. There were no differences in psychiatric symptoms. However, IDDM patients reported lower perceived competence, with specific differences found on the global self-worth, sociability, physical appearance, being an adequate provider, and humor subscales. The IDDM patients reported improving adjustment to their diabetes over the course of the 10-year follow-up. CONCLUSIONS Overall, the young adults with IDDM appeared to be as psychologically well adjusted as the young adults without a chronic illness. There were, however, indications of lower self-esteem in the IDDM patients that could either portend or predispose them to risk for future depression or other difficulties in adaptation.

Glycemic control and major depression in patients with type 1 and type 2 diabetes mellitus

The current study evaluated the association of glycemic control and major depression in 33 type 1 and 39 type 2 diabetes mellitus patients. Type 1 patients with a lifetime history of major depression showed significantly worse glycemic control than patients without a history of psychiatric illness (t = 2.09; df = 31, p < 0.05). Type 2 diabetes patients with a lifetime history of major depression did not have significantly worse control than those with no history of psychiatric illness. Findings from this study indicate different relationships between lifetime major depression and glycemic control for patients with type 1 and type 2 diabetes. Treatment implications for glycemic control in type 1 and type 2 diabetes patients are discussed.

Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association

Complex environmental, social, behavioral, and emotional factors, known as psychosocial factors, influence living with diabetes, both type 1 and type 2, and achieving satisfactory medical outcomes and psychological well-being. Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life. To promote optimal medical outcomes and psychological well-being, patient-centered care is essential, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (1). Practicing personalized, patient-centered psychosocial care requires that communications and interactions, problem identification, psychosocial screening, diagnostic evaluation, and intervention services take into account the context of the person with diabetes (PWD) and the values and preferences of the PWD. This article provides diabetes care providers with evidence-based guidelines for psychosocial assessment and care of PWD and their families. Recommendations are based on commonly used clinical models, expert consensus, and tested interventions, taking into account available resources, practice patterns, and practitioner burden. Consideration of life span and disease course factors (Fig. 1) is critical in the psychosocial care of PWD. This Position Statement focuses on the most common psychological factors affecting PWD, including diabetes distress and psychological comorbidities, while also considering the needs of special populations and the context of care. Figure 1 Psychosocial care for PWD: life and disease course perspectives. *With depressed mood, anxiety, or emotion and conduct disturbance. **Personality traits, coping style, maladaptive health behaviors, or stress-related physiological response. \***|Examples include changing schools, moving, job/occupational changes, marriage or divorce, or experiencing loss. #### Recommendations

Diabetes and Depression

Diabetes and depression occur together approximately twice as frequently as would be predicted by chance alone. Comorbid diabetes and depression are a major clinical challenge as the outcomes of both conditions are worsened by the other. Although the psychological burden of diabetes may contribute to depression, this explanation does not fully explain the relationship between these 2 conditions. Both conditions may be driven by shared underlying biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors. Depression is frequently missed in people with diabetes despite effective screening tools being available. Both psychological interventions and antidepressants are effective in treating depressive symptoms in people with diabetes but have mixed effects on glycemic control. Clear care pathways involving a multidisciplinary team are needed to obtain optimal medical and psychiatric outcomes for people with comorbid diabetes and depression.

NIDDK International Conference Report on Diabetes and Depression: Current Understanding and Future Directions

Comorbid diabetes and depression are a major clinical challenge as the outcomes of each condition are worsened by the other. This article is based on the presentations and discussions during an international meeting on diabetes and depression convened by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in collaboration with the National Institute of Mental Health and the Dialogue on Diabetes and Depression. While the psychological burden of diabetes may contribute to depression in some cases, this explanation does not sufficiently explain the relationship between these two conditions. Shared biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, autonomic dysfunction, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors, are important to consider in understanding the link between depression and diabetes. Both individual psychological and pharmacological depression treatments are effective in people with diabetes, but the current range of treatment options is limited and has shown mixed effects on glycemic outcomes. More research is needed to understand what factors contribute to individual differences in vulnerability, treatment response, and resilience to depression and metabolic disorders across the life course and how best to provide care for people with comorbid diabetes and depression in different health care settings. Training programs are needed to create a cross-disciplinary workforce that can work in different models of care for comorbid conditions.

The Association of Lifetime Psychiatric Illness and Increased Retinopathy in Patients With Type I Diabetes Mellitus

Forty-nine patients with Type I diabetes mellitus were assessed to examine the relationship between lifetime prevalence of psychiatric illness and retinopathy severity. The subjects with a history of psychiatric illness had significantly worse retinopathy than the subjects without psychiatric illness. Eighty-nine percent of the subjects with severe nonproliferative retinopathy or proliferative retinopathy had a history of psychiatric illness, predominantly affective illness. In addition, the subjects with a history of psychiatric illness had significantly higher current glycohemoglobin levels than those with no psychiatric history. This studys findings suggest that psychiatric illness may be a risk factor for development of retinopathy in Type I diabetic patients.

Cultural Relevancy of a Diabetes Prevention Nutrition Program for African American Women

Diabetes among African American women is a pressing health concern, yet there are few evaluated culturally relevant prevention programs for this population. This article describes a case study of the Eat Well Live Well Nutrition Program, a community-based, culturally specific diabetes prevention nutrition program for African American women. The stages of change theory and principles from community organization guided the development of the program. Health education strategies, including participatory development and program delivery by peer educators, were applied to promote cultural relevance. Results indicated that overall participants (90%) believed the program to be culturally relevant and were very satisfied with the program (82%). Cultural relevancy was significantly associated with greater program satisfaction and changes in dietary patterns when controlling for the number of sessions attended. Conclusions suggest that participatory strategies can be effective in designing culturally specific prevention programs for African American women.

Depression and poverty among African-American women at risk for Type 2 diabetes

Poverty is associated with negative health outcomes, including depression. Little is known about the specific elements of poverty that contribute to depression, particularly among African American women at risk for type 2 diabetes. This study examined the relationships of economic and social resources to depression among African American women at high risk for the development of type 2 diabetes (N = 181) using the Conservation of Resources theory as a conceptual framework. Women were assessed at 3 time points in conjunction with a dietary change intervention. At baseline, 40% of women reported clinically significant depression, and 43.3% were below the poverty line. Depressed women reported fewer economic assets and greater economic distress than nondepressed peers. Multivariate logistic regression analyses indicated that nonwork status, lack of home ownership, low appraisal of one’s economic situation, low self-esteem, and increased life events were significantly associated with depression at baseline. Longitudinal multivariate logistic regression models indicated that income, home ownership, future economic appraisal, life events, and self-esteem predicted depression trajectories at Time 3. These results speak to the multifaceted sources of stress in the lives of poor African American women. Interventions that address the economic and social factors associated with depression are needed.