Molly L. Tanenbaum

“Does That Make Me A Woman?” Breast Cancer, Mastectomy, and Breast Reconstruction Decisions Among Sexual Minority Women

Feminist scholars and activists writing about breast cancer care among women have highlighted the sexist and heterosexist assumptions often embedded in the medical management of breast cancer, and of mastectomy in particular. Despite these contributions, and some speculation that sexual minority women may be less interested in breast reconstruction, limited research explores sexual minority women’s lived experience of mastectomy and decision making about reconstruction. Thirteen lesbian and/or bisexual women who had undergone mastectomy for treatment of breast cancer participated in individual qualitative interviews exploring decisions to have, or not have, breast reconstruction. Reasons for/against reconstruction reflected themes identified in prior studies among heterosexual women. Although participants described sexual, gender, and political identities and orientations as influences on their decision making, for most participants, experiences with physicians who encouraged reconstruction and concerns about stigmatization of illness in romantic, professional, and social contexts were also central. Findings are interpreted through feminist dis/ability, medicalization, and existential frameworks.

Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets

OBJECTIVE Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target. RESEARCH DESIGN AND METHODS We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices. RESULTS Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one’s body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6–26.0 vs. 21.4–24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18–25 years) had the lowest CGM (26% vs. 40–48%) and insulin pump (64% vs. 69–77%) uptake, highest diabetes distress (2.2 vs. 1.8–2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2–7.4% [55–57 mmol/mol]). CONCLUSIONS Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.

Disentangling Clinical Depression from Diabetes-Specific Distress: Making Sense of the Mess We’ve Made

This chapter examines conceptual and applied issues regarding the screening of depression and diabetes-specific distress in adults with diabetes. We explore the conceptualization of depression as a frequently comorbid condition of diabetes and the importance of diabetes-specific distress and subthreshold depressive symptoms in regard to the emotional, behavioral, and health outcomes of living with diabetes. Overviews of the constructs of major depressive disorder (MDD) and diabetes-specific distress and challenges to an operational approach to negative emotion in the context of chronic illness are also presented in light of the meaningful overlap between diagnostic criteria of MDD and symptoms of diabetes and distress related to the burden of living with diabetes. Assessment of both depression and diabetes-specific distress are considered, including methodological issues and the strengths and weakness of leading self-report and semi-structured interview tools. Finally, suggestions for valid and clinically meaningful assessment of depressive symptoms and diabetes-specific distress in medical settings are discussed.

Successful self‐management among non‐insulin‐treated adults with Type 2 diabetes: a self‐regulation perspective

To clarify the role of self‐monitoring of blood glucose (SMBG) in the self‐management of Type 2 diabetes from the patients perspective, using in‐depth interviews with non‐insulin‐treated adults to investigate how they learned to manage their diabetes effectively and whether SMBG played a significant role in this process.

The Influence of Diabetes on a Clinician-Rated Assessment of Depression in Adults With Type 1 Diabetes

Purpose The purpose of the study was to examine the role of diabetes and diabetes-related distress within clinician-administered depression interviews of adults with type 1 diabetes. Methods This mixed-methods study coded responses to a structured clinical interview of depressive symptom severity administered to adults with type 1 diabetes (n = 34; 65% female; 56% white, 38% African American, 27% Hispanic). Pearson correlations and t tests assessed relationships between interview-based and self-reported ratings of diabetes-related distress and depression. Results Among participants endorsing depressive symptoms in the interview, 73% mentioned diabetes as a contributing factor. Themes emerged relating to (1) a link between diabetes symptoms and distress, including problems with appetite, sleep, concentration, and social relationships; (2) overlapping symptoms between diabetes and depression; and (3) the perceived interconnectedness of mood and blood glucose levels. Clinician-assessed depression ratings were strongly associated with self-reported ratings of depression and self-reported diabetes-related distress. Interview-based diabetes-related distress was significantly associated with self-reported diabetes-related distress. Those with a diagnosis of major depressive disorder (44%) reported more diabetes-related distress. Conclusions Results suggest that diabetes may influence the evaluation of depression, even in standardized clinical interviews administered by trained professionals, the gold standard of assessment. Findings highlight a need for improved conceptualization and measurement of distress in individuals with diabetes to distinguish between symptoms caused by illness burden and those indicating a psychiatric disorder.

Expectations and Attitudes of Individuals With Type 1 Diabetes After Using a Hybrid Closed Loop System

Purpose The first hybrid closed loop (HCL) system, which automates insulin delivery but requires user inputs, was approved for treatment of type 1 diabetes (T1D) by the US Food and Drug Administration in September 2016. The purpose of this study was to explore the benefits, expectations, and attitudes of individuals with T1D following a clinical trial of an HCL system. Methods Thirty-two individuals with T1D (17 adults, 15 adolescents) participated in focus groups after 4 to 5 days of system use. Content analysis generated themes regarding perceived benefits, hassles, and limitations. Results Some participants felt misled by terms such as “closed loop” and “artificial pancreas,” which seemed to imply a more “hands-off” experience. Perceived benefits were improved glycemic control, anticipated reduction of long-term complications, better quality of life, and reduced mental burden of diabetes. Hassles and limitations included unexpected tasks for the user, difficulties wearing the system, concerns about controlling highs, and being reminded of diabetes. Conclusion Users are willing to accept some hassles and limitations if they also perceive health and quality-of-life benefits beyond current self-management. It is important for clinicians to provide a balanced view of positives and negatives to help manage expectations.

Diabetes Technology Uptake, Outcomes, Barriers, and the Intersection With Distress

Patients managing type 1 diabetes have access to new technologies to assist in management. This manuscript has two aims: 1) to briefly review the literature on diabetes technology use and how this relates to psychological factors and 2) to present an example of human factors research using our data to examine psychological factors associated with technology use. Device/technology uptake and use has increased over the years and at present day is a common clinical practice. There are mixed results in terms of health and psychosocial outcomes, with specific subgroups doing better than others with technology. Our data demonstrated that patients have moderately elevated diabetes distress across differing types of technology used, from low-tech to high-tech options, possibly meaning that technology does not add or take away distress. In addition, users on multiple daily injections compared to all other technology groups have less positive attitudes about technology. Finally, we discuss implications for clinical practice and future research.

Probing for depression and finding diabetes: a mixed-methods analysis of depression interviews with adults treated for type 2 diabetes

BACKGROUND Depression has increased prevalence and consistently predicts poor health outcomes among patients with diabetes. The impact of stressors related to diabetes and its treatment on depression assessment is infrequently considered. METHODS We used mixed methods to evaluate depressive symptoms in adults with type 2 diabetes. We categorized responses related to diabetes and its treatment during interviews (n=70) using the Montgomery-Åsberg Depression Rating Scale (MADRS) and administered questionnaires to measure diabetes-related distress and depressive symptoms. RESULTS Participants (M age=56, SD=7; 67% female; 64% Black; 21% Latino) had mild depression on average (MADRS M=10, SD=9). Half of those with symptoms spontaneously mentioned diabetes context; 61% said diabetes contributed to their symptoms when questioned directly. Qualitative themes included: overlapping symptoms of diabetes and depression; burden of diabetes treatment; emotional impact of diabetes; and the bidirectional influence of depression and diabetes. Diabetes was mentioned more often at higher levels of depression severity (r=.38, p=.001). Higher HbA1c was associated with mentioning diabetes as a context for depressive symptoms (r=.32, p=.007). Insulin-users mentioned diabetes more often than those on oral medications only (p=.005). LIMITATIONS MADRS is not a traditional qualitative interview so themes may not provide an exhaustive view of the role of diabetes context in depression assessment. CONCLUSIONS AND CLINICAL IMPLICATIONS The burden of type 2 diabetes and its treatment often provide an explanatory context for depressive symptoms assessed by structured clinical interviews, the gold standard of depression assessment. Diabetes context may influence accuracy of assessment and should inform intervention planning for those needing treatment.

Diabetes distress from the patient's perspective: Qualitative themes and treatment regimen differences among adults with type 2 diabetes.

AIMS To explore diabetes distress in a sample of adults with type 2 diabetes, treated and not treated with insulin. METHODS Six focus groups were conducted with 32 adults with type 2 diabetes, divided by treatment regimen (insulin-treated N=15; 67% female; 60% black; 46% Hispanic; M age 54; M HbA1c 73mmol/mol (8.8%); non-insulin-treated N=17; 53% female; 65% black; 13% Hispanic; M age 58; M HbA1c 55mmol/mol (7.2%)). A coding team transcribed and analyzed interviews to describe themes. Themes were then compared between groups and with existing diabetes distress measures. RESULTS Participants in both groups described a range of sources of diabetes distress, including lack of support/understanding from others, difficulties communicating with providers, and distress from the burden of lifestyle changes. Insulin-treated participants described significant emotional distress related to the burden of their insulin regimen. They were more likely to report physical burden related to diabetes; to describe feeling depressed as a result of diabetes; and to express distress related to challenges with glycemic control. Non-insulin-treated participants were more likely to discuss the burden of comorbid medical illnesses. CONCLUSIONS Our data generate hypotheses for further study into the emotional burdens of diabetes for insulin-treated adults with type 2 diabetes and are in line with quantitative research documenting increased diabetes-related distress among insulin-treated individuals. Data describe needs, currently unmet by most models of care, for comprehensive assessment and tailored management of diabetes-related distress.

The self-management experience of patients with type 2 diabetes and chronic kidney disease: A qualitative study

Background The purpose of this study was to explore views related to the self-management of type 2 diabetes and chronic kidney disease. Methods We conducted three semi-structured focus groups in participants with type 2 diabetes and chronic kidney disease. Interviews were transcribed, coded, and analyzed using thematic analysis. Credibility was supported through triangulation of data sources and the use of multiple investigators from different disciplines. Results Twenty-three adults participated. Three major themes were identified: emotional reactions to health state, the impact of family dynamics on self-management, and the burden of self-management regimens. Family dynamics were found to be a barrier and support to self-management, while complicated self-management regimens were found to be a barrier. Additionally, participants expressed several emotional reactions related to their CKD status, including regret related to having developed CKD and distress related both to their treatment regimens and the future possibility of dialysis. Conclusions This exploratory study of patients with type 2 diabetes and chronic kidney disease describes barriers and supports to self-management and emotional reactions to chronic kidney disease status. Future research should confirm these findings in a larger population and should include family members and/or health care providers to help further define problems with self-management in patients with type 2 diabetes and chronic kidney disease.