Search

Type 2 diabetes is a chronic, progressive disease, and its management results in a high emotional burden on patients. Eventually many patients require and can benefit from the use of insulin. This article reports results of a survey of patients and health care providers regarding their experiences of and challenges with the use of basal insulin. Health care providers can play a key role in helping people with type 2 diabetes overcome the challenges associated with the use of basal insulin, including connecting with their emotional needs and understanding the stressors associated with managing diabetes. [ABSTRACT FROM AUTHOR]

OBJECTIVE To test cognitive behavioral therapy for adherence and depression (CBT-AD) in type 2 diabetes. We hypothesized that CBT-AD would improve adherence; depression; and, secondarily, hemoglobin A1c (A1C). RESEARCH DESIGN AND METHODS Eighty-seven adults with unipolar depression and uncontrolled type 2 diabetes received enhanced treatment as usual (ETAU), including medication adherence, self-monitoring of blood glucose (SMBG), and lifestyle counseling; a provider letter documented psychiatric diagnoses. Those randomized to the intervention arm also received 9-11 sessions of CBT-AD. RESULTS Immediately after acute treatment (4months), adjusting for baseline, CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap (95% CI - 231.14 to -10.22, P = 0.000); 30.2 percentage points greater SMBG adherence through glucometer downloads (95% CI -42.95 to -17.37, P = 0.000); 6.44 points lower depression scores on the Montgomery-Asberg Depression Rating Scale (95% CI 2.33-10.56, P = 0.002); 0.74 points lower on the Clinical Global Impression (95% CI 0.16-1.32, P = 0.01); and 0.72 units lower A1C (95% CI 0.29-1.15, P = 0.001) relative to ETAU. Analyses of 4-, 8-, and 12-month follow-up time points indicated that CBT-AD maintained 24.3 percentage points higher medication adherence (95% CI-38.2 to -10.3, P = 0.001); 16.9 percentage points greater SMBG adherence (95% CI-33.3 to -20.5, P = 0.043); and 0.63 units lower A1C (95% CI 0.06-1.2, P = 0.03) after acute treatment ended. For depression, there was some evidence of continued improvement posttreatment, but no between-group differences. CONCLUSIONS CBT-AD is an effective intervention for adherence, depression, and glycemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- Depression is common in patients with diabetes and is associated with worse treatment outcomes. Its relationship to treatment adherence, however, has not been systematically reviewed. We used meta-analysis to examine the relationship between depression and treatment nonadherence in patients with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS -- We searched MEDLINE and PsycINFO databases for all studies published by June 2007 and reviewed references of published articles. Meta-analytic procedures were used to estimate the effect size r in a random effects model. Significance values, weighted effect sizes, 95% CIs, and tests of homogeneity of variance were calculated. RESULTS -- Results from 47 independent samples showed that depression was significantly associated with nonadherence to the diabetes treatment regimen (z = 9.97, P < 0.0001). The weighted effect size was near the medium range (r = 0.21, 95% CI 0.17-0.25). Moderator analyses showed that the effect was significantly larger in studies that measured self-care as a continuous versus categorical variable (P = 0.001). Effect sizes were largest for missed medical appointments and composite measures of self-care (r values = 0.31, 0.29). Moderation analyses suggest that effects for most other types of self-care are also near the medium range, especially in studies with stronger methodologies. CONCLUSIONS-- These findings demonstrate a significant association between depression and treatment nonadherence in patients with diabetes. Studies that used stronger methodologies had larger effects. Treatment nonadherence may represent an important pathway between depression and worse diabetes clinical outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- We examined the association between depression, measured as either a continuous symptom severity score or a clinical disorder variable, with self-care behaviors in type 2 diabetes. RESEARCH DESIGN AND METHODS -- We surveyed 879 type 2 diabetic patients from two primary care clinics using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS), the Summary of Diabetes Self-Care Activities, and self-reported medication adherence. RESULTS -- Of the patients, 19% met the criteria for probable major depression (HANDS score ±9), and an additional 66.5% reported at least some depressive symptoms. After controlling for covariates, patients with probable major depression reported significantly fewer days' adherent to diet, exercise, and glucose self-monitoring regimens (P < 0.01) and 2.3-fold increased odds of missing medication doses in the previous week (95% CI 1.5-3.6, P < 0.001) compared with all other respondents. Continuous depressive symptom severity scores were better predictors of nonadherence to diet, exercise, and medications than categorically defined probable major depression. Major depression was a better predictor of glucose monitoring. Among the two-thirds of patients not meeting the criteria for major depression (HANDS score < 9, n = 709), increasing HANDS scores were incrementally associated with poorer self-care behaviors (P < 0.01). CONCLUSIONS -- These findings challenge the conceptualization of depression as a categorical risk factor for nonadherence and suggest that even low levels of depressive symptomatology are associated with nonadherence to important aspects of diabetes self-care. Interventions aimed at alleviating depressive symptoms, which are quite common, could result in significant improvements in diabetes self-care. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- Using the common-sense model of illness behavior, we developed and validated a self-report instrument for assessment of patients' cognitive and emotional representations of diabetic peripheral neuropathy (DPN) influencing foot self-care. RESEARCH DESIGN AND METHODS -- The Patient Interpretation of Neuropathy (PIN) questionnaire, generated from discussions with clinicians and interviews with patients with DPN, was administered to patients with DPN attending U.K. (n = 325) and U.S. (n = 170) diabetes centers. Psychometric tests of the PIN questionnaire comprised factor analysis, internal consistency, and test-retest reliability. Partial correlations and multivariate regressions established construct and criterion-related validity. The associations of PIN scales to past foot ulceration and foot self-care behaviors were compared with those using a generic measure of illness perception and emotion, the Revised Illness Perception Questionnaire (IPQ-R), which was adapted to neuropathy. RESULTS -- Factor analysis of the PIN questionnaire produced 11 scales, which explained 69% of item variance. Nine factors measured patients' common-sense beliefs about DPN and their levels of understanding of DPN-related medical information. Two factors assessed the emotions of worry about potential consequences and anger at practitioners. Most scales demonstrated adequate internal (Cronbach's α = 0.62-0.90) and test-retest reliability (Pearson's rp = 0.51-0.64). Partial correlations between the PIN and IPQ-R scales in corresponding domains were significant but modest (rp = 0.15-0.26). Finally, PIN scales showed significant associations with past foot ulceration and foot self-care behaviors, thereby confirming criterion validity. CONCLUSIONS -- The 39-item PIN questionnaire is a reliable and valid measure of patients' cognitive and emotional representations of neuropathy affecting foot self-care. [ABSTRACT FROM AUTHOR]

A large body of research suggests that self-rated health (SRH) is a robust and consistent predictor of morbidity and mortality in various community and chronic illness populations, including patients with diabetes. Even when controlling for potential confounds, respondents rating their health as "poor" have been found to have a 6-fold increased risk of death due to diabetes as compared to respondents who rate their health as "excellent." The aim of the current study was to address the lack of information about the determinants of SRH in patients with diabetes by examining factors predictive of SRH in a sample of 295 patients with diabetic peripheral neuropathy (DPN) using a longitudinal design. Patients (mean age = 62 y; 70% male) rated SRH using a single item from the SF-12. They completed the NeuroQoL to assess neuropathic symptoms of pain, unsteadiness, and reduced feeling and limitations in daily activities due to DPN. The Hospital Anxiety and Depression Scale assessed symptoms of depression and the Big Five Inventory assessed neuroticism. DPN was diagnosed by the Neuropathy Disability Score (NDS; mean = 7.4). Measures were completed at baseline and 18-months. Hierarchical linear regression analyses controlling for demographic variables showed that more medical comorbidities and complications of diabetes at baseline each significantly predicted lower SRH at 18-months (p̠ < .01). Higher NDS scores also significantly predicted lower SRH at follow-up (p̠ < .01). This relationship was mediated by associated increases in symptoms of unsteadiness, which independently predicted lower SRH at follow-up (p̠ < .001). Higher levels of neuroticism, more limitations in daily activities, and more symptoms of depression were each independently predictive of lower SRH at follow-up (all p̠s < .05). The full model of baseline variables accounted for 34% of the variance in SRH 18 months later. These results identify independent predictors of SRH and suggest that objective neuropathy severity influences SRH through the experience of unsteadiness in patients with DPN. ADA-Funded Research [ABSTRACT FROM AUTHOR]

Depressive symptoms are prevalent among people with type 2 diabetes (T2D) and, even at low severity levels, are associated with worse diabetes outcomes. Carbohydrate restriction is an effective treatment for T2D but its long-term impacts on depressive symptoms are unclear. In the current study we explored changes in depressive symptoms over 2 years among 262 primarily non-depressed T2D patients participating in a continuous remote care intervention emphasizing carbohydrate restriction. Subclinical depressive symptoms decreased over the first 10 weeks and reductions were maintained out to 2 years. Increased frequency of blood ketone levels indicative of adherence to low carbohydrate eating predicted decreases in depressive symptoms. Concerns have been raised with recommending restrictive diets due to potential negative impacts on quality-of-life factors such as mood; however, results of the current study support positive rather than negative long-term impacts of closely monitored carbohydrate restriction on depressive symptoms. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- We examined the association between severity of diabetic peripheral neuropathy and depressive symptoms and investigated the potential mediators of this association. RESEARCH DESIGN AND METHODS -- The Hospital Anxiety and Depression Scale (HADS) was used to assess depressive symptoms in 494 patients (mean age 62 years; 70% male; 72% type 2 diabetic) with diabetic neuropathy diagnosed by the Neuropathy Disability Score (NDS) and the Vibration Perception Threshold (VPT). Diabetic neuropathy symptoms, activities of daily living (ADLs), and social self-perception were measured by the neuropathy and foot ulcer-specific quality-of-life instrument, NeuroQoL; perceptions of diabetic neuropathy symptom unpredictability and the lack of effective treatment were assessed by the revised Illness Perception Questionnaire. RESULTS -- Both the NDS and VPT were significantly associated with the HADS after controlling for demographic and disease variables. Although diabetic neuropathy symptoms mediated this association, with unsteadiness being most strongly associated with HADS, the relationship between foot ulceration and depression was nonsignificant. The association between diabetic neuropathy symptoms and HADS was partially mediated by two sets of psychosocial variables: 1) perceptions of diabetic neuropathy symptom unpredictability and the lack of treatment control and 2) restrictions in ADLs and changes in social self-perception. CONCLUSIONS -- These findings establish the association between diabetic neuropathy and depressive symptoms and identify potential targets for interventions to alleviate depressive symptoms in persons affected by diabetic peripheral neuropathy. [ABSTRACT FROM AUTHOR]

The article presents the position statement of the American Diabetes Association on psychosocial care for people with diabetes. Topics discussed include the general considerations in psychosocial care, situations that warrant referral of a person with diabetes to a mental health provide for evaluation and treatment, and selected measures for the evaluation of psychosocial constructs in the clinical setting.

This study examined responsiveness (change in scores: baseline (T1) - 18 months) of the NeuroQoL to both baseline levels (lagged effects) and change in clinical indicators of neuropathy severity (baseline (T1) - 9 months). Severity of diabetic peripheral neuropathy (DPN) was defined by the Neuropathy Disability Score (NDS; T1 mean=7.4) and Vibration Perception Threshold (VPT; T1 mean=41 volts). Three NeuroQoL scales measured DPN symptoms (pain, diffuse sensorimotor and reduced feeling in the feet), two assessed psychosocial dysfunction (restrictions in activities of daily living (ADL) and interpersonal-emotional burden) and two single-item scores represented DPN-specific and overall QoL judgments. Two sets of multivariate regression analyses, controlling for T1 outcome values and demographic/disease variables, were performed separately for each NeuroQoL scale, each using as predictors both T1 and change in either NDS or VPT scores. 295 adult DPN patients in the US and UK completed the study (mean age 60 y; 71% male). Change in NeuroQoL diffuse sensorimotor symptoms was sensitive to both T1 and change in both NDS and VPT (NDS: T1 coefficient beta (β)=. 16; p=.001; change β=.11; p=.011; VPT: T1 β=. 16; p=.001; change β=.11; p=.011). Change in NeuroQoL symptoms of reduced feeling was sensitive only to T1 NDS and VPT scores (β=.18; p<.001; β=.16; p=.002). Change in NeuroQoL pain scores was not sensitive to either NDS or VPT. Changes in NeuroQoL ADL and interpersonal-emotional burden were sensitive to T1 levels of NDS (β=.18; p=.001; β=.12; p=.006) and VPT (β=.12; p=.036; β=.097; p=.028). Finally, while changes in NeuroQoL DPN-specific and overall QoL judgments were sensitive to both T1 NDS (β.286; p<.001; β=-. 13; p=.005) and change in NDS (β= -.17; p=.002; β=-.11; p=.012), for VPT only T1 levels predicted changes in these QoL judgrnents (β-.19; p<.001; β=-. 17; p=.001). This study provides further support for the validity of NeuroQoL by demonstrating its sensitivity to both lagged effects of and change in DPN severity. ADA-Funded Research [ABSTRACT FROM AUTHOR]

A correction to the article “Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association." that was published in a 2016 issue is presented.