The aim of this review was to provide an overview of developments, clinical implications and gaps in knowledge regarding the relationship between diabetes and sleep over the past 25 years, with ...special focus on contributions from the behavioural sciences. Multiple prospective observational and experimental studies have shown a link between suboptimal sleep and impaired glucose tolerance, decreased insulin sensitivity and the development of type 2 diabetes. While prevalence rates of suboptimal sleep vary widely according to definition, assessment and sample, suboptimal subjective sleep quality appears to be a common reality for one‐third of people with type 1 diabetes and over half of people with type 2 diabetes. Both physiological and psychosocial factors may impair sleep in these groups. In turn, suboptimal sleep can negatively affect glycaemic outcomes directly or indirectly via suboptimal daytime functioning (energy, mood, cognition) and self‐care behaviours. Technological devices supporting diabetes self‐care may have both negative and positive effects. Diabetes and its treatment also affect the sleep of significant others. Research on the merits of interventions aimed at improving sleep for people with diabetes is in its infancy. Diabetes and sleep appear to be reciprocally related. Discussion of sleep deserves a central place in regular diabetes care. Multi‐day, multi‐method studies may shed more light on the complex relationship between sleep and diabetes at an individual level. Intervention studies are warranted to examine the potential of sleep interventions in improving outcomes for people with diabetes.
What's new?
In 1994, studying suboptimal sleep in people with diabetes was highlighted as a promising new research area.
Since then, a large evidence base has illustrated the myriad of ways in which sleep and diabetes are linked.
Suboptimal sleep is a common reality for many people with diabetes, which may negatively impact glycaemic and psychosocial outcomes.
In turn, physiological and psychosocial factors may impair sleep.
Sleep deserves a more central place in regular diabetes care.
Future studies may focus on clarifying the interactions of sleep and diabetes on the individual level, as well as on evaluating the merits of sleep interventions in this group.
Diabet. Med. 27, 798–803 (2010)
Objectives To investigate whether diabetes‐specific emotional distress mediates the relationship between depression and glycaemic control in patients with Type 1 and ...Type 2 diabetes.
Research design and methods Data were derived from the baseline assessment of a depression in diabetes screening study carried out in three tertiary diabetes clinics in the Netherlands. Most recent glycated haemoglobin (HbA1c) measurement was obtained from medical records. The Centre for Epidemiologic Studies Depression Scale (CES‐D) and Problem Areas in Diabetes scale (PAID) were used to measure depression and diabetes‐specific emotional distress respectively. Linear regression was performed to examine the mediating effect of diabetes–distress.
Results Complete data were available for 627 outpatients with Type 1 (n = 280) and Type 2 (n = 347) diabetes. Analyses showed that diabetes–distress mediated the relation between depression and glycaemic control and not differently for both disease types. Post‐hoc analyses revealed that patients depressed and distressed by their diabetes were in significantly poorer glycaemic control relative to those not depressed nor distressed (HbA1c 8.7 ± 1.7 vs. 7.6 ± 1.2% in those without depressive symptoms, 7.6 ± 1.1% in depressed only and 7.7 ± 1.1% in the distressed only, P < 0.001). Depressed patients without elevated diabetes‐distress did not show a significantly increased risk of elevated HbA1c.
Conclusions In explaining the association between depression and glycaemic control, diabetes‐specific emotional distress appears to be an important mediator. Addressing diabetes‐specific emotional problems as part of depression treatment in diabetes patients may help improve glycaemic outcomes.
Since patient-centered communication is directly connected to clinical performance, it should be integrated with medical knowledge and clinical skills. Therefore, clinical communication skills should ...be trained and assessed as an integral part of the student's clinical performance. We were unable to identify a tool, which helps when assessing patient-centered communication skills as an integrated component of medical history taking ('the integrated medical interview'). Therefore, we decided to design a new tailor-made assessment tool, the BOCC (BeOordeling Communicatie en Consultvoering (Dutch), Assessment of Communication and Consultation (English) to help raters assess students' integrated clinical communication skills with the emphasis on patient-centred communication combined with the correct medical content. This is a first initiative to develop such a tool, and this paper describes the first steps in this process.
We investigated the tool in a group of third-year medical students (n = 672) interviewing simulated patients. Internal structure and internal consistency were assessed. Regression analysis was conducted to investigate the relationship between scores on the instrument and general grading. Applicability to another context was tested in a group of fourth-year medical students (n = 374).
PCA showed five components (Communication skills, Problem clarification, Specific History, Problem influence and Integration Skills) with various Cronbach's alpha scores. The component Problem Clarification made the strongest unique contribution to the grade prediction. Applicability was good when investigated in another context.
The BOCC is designed to help raters assess students' integrated communication skills. It was assessed on internal structure and internal consistency. This tool is the first step in the assessment of the integrated medical interview and a basis for further investigation to reform it into a true measurement instrument on clinical communication skills.
Diabet. Med. 27, 217–224 (2010)
Aims Depression is common in diabetes, but the scope of the problem and associated correlates are not well established in specialist diabetes care. We aimed to ...determine the prevalence of depression among adult outpatients with Type 1 (T1DM) or Type 2 diabetes (T2DM) using both self‐report measures and a diagnostic interview, and to establish demographic and clinical characteristics associated with depressive affect.
Methods A random sample of 2055 diabetes out‐patients from three diabetes clinics was invited to participate. Depressive affect was assessed using the World Health Organization‐5 Well Being Index (WHO‐5), the Centre for Epidemiologic Studies‐Depression scale (CESD) using predefined cut‐off scores, and depressive disorder with the Composite International Diagnostic Interview (CIDI). Associations between depression and patient characteristics were explored using regression analyses.
Results Seven hundred and seventy‐two patients completed the depression questionnaires. About one‐third of T1DM patients and 37–43% of T2DM patients reported depressive affect (WHO‐5). The prevalence of depressive affect (CESD) was 25% and 30% for men and women with T1DM, and 35% and 38% for men and women with T2DM, respectively. Based on the CIDI, 8% of T1DM patients (no gender difference) and 2% of men and 21% of women with T2DM suffered from a depressive disorder. Depressive affect was associated with poor glycaemic control and proliferative retinopathy in T1DM, while non‐Dutch descent, obesity and neuropathy were correlates in T2DM.
Conclusions Depressive symptoms and major depressive disorder constitute a common comorbid problem among Dutch out‐patients with T1DM or T2DM and appear particularly common in migrants and women with T2DM.
Aims/hypothesis The aim of this study was to test the effectiveness of a screening procedure for depression (SCR) vs care as usual (CAU) in outpatients with diabetes. The primary outcome measured was ...depression score and the secondary outcomes were mental healthcare consumption, diabetes-distress and HbA₁c. Materials and methods In a multicentre parallel randomised controlled trial, 223 outpatients with diabetes, who had an elevated depression score, were randomly assigned to SCR (n = 116) or CAU (n = 107), using computer generated numbers. SCR-patients were invited for a Composite International Diagnostic Interview (CIDI) to diagnose depression and/or anxiety (interviewers were not blinded for group assignment). As part of the intervention, patients and their physicians were informed of the outcome of the CIDI in a letter and provided with treatment advice. At baseline and 6 month follow-up, depression and diabetes-distress were measured using the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Problem Areas in Diabetes survey (PAID). HbA₁c levels were obtained from medical charts. Results Mean CES-D depression scores decreased from baseline to 6 months in both groups (24 ± 8 to 21 ± 8 CAU and 26 ± 7 to 22 ± 10 SCR respectively p < 0.001), with no significant differences between groups. Neither diabetes-distress nor HbA₁c changed significantly within and between groups. The percentage of patients receiving mental healthcare increased in the SCR group from 20% to 28%, compared with 15% to 18% in the CAU group. Conclusions/interpretation Depression screening with written feedback to patient and physician does not improve depression scores and has a limited impact on mental healthcare utilisation, compared with CAU. It appears that more intensive depression management is required to improve depression outcomes in patients with diabetes.
Poor glycaemic control is an undesirable, but frequently encountered problem in diabetes. Reasons for not achieving optimal glycaemic control are not yet clear. A common belief is that psychological ...factors contribute importantly. This study compared general psychological problems and diabetes-related distress between patients with persistently poor glycaemic control to patients with optimal glycaemic control.
Patients from an outpatient clinic with type 1 or type 2 diabetes with a mean HbA1c ≥ 86 mmol/mol (≥ 10%) over two consecutive years (poor-control, n = 32) and those with diabetes and a mean HbA1c ≤ 53 mmol/mol (≤ 7%) over two consecutive years (optimal-control, n = 53) were studied. Clinical characteristics were obtained from the medical records. Psychological characteristics were investigated cross-sectionally using questionnaires.
Patients in the poor-control group had a higher BMI compared with the optimal-control group. Self- reported previous anxiety was more prevalent in the poor-control group (34 versus 9%). All other mean test scores and proportions of subjects above cut-off levels were similar in the two groups.
Patients with diabetes and persistently poor glycaemic control have surprisingly few psychological problems and diabetes-related emotional distress. It seems that people with diabetes do not see persistent poor glycaemic control as a problem.
Background: Persistent fatigue among employees, burnout, and chronic fatigue syndrome (CFS) are three fatigue conditions that share some characteristics in theory. However, these conditions have not ...been compared in empirical research, despite conceptual similarities. Methods: This cross sectional study aimed to investigate relations between persistent fatigue, burnout, and CFS by describing the clinical features of a sample of 151 fatigued employees on sick leave. Using validated instruments, subgroups based on research criteria for CFS and burnout within the sample of fatigued employees and a reference group of 97 diagnosed CFS patients were compared. Analyses of covariance were performed. Results: A total of 66 (43.7%) fatigued employees met research criteria for CFS (except symptom criteria) and 76 (50.3%) met research criteria for burnout. “CFS-like employees” (fatigued employees who met CFS criteria) reported stronger somatic attributions than “non-CFS-like employees”. Burnt out CFS-like employees were more depressed and distressed than CFS-like employees who were not burnt out. Burnout cases among the non-CFS-like employees had stronger psychological attributions than fatigued employees who were not burnt out. Compared to diagnosed CFS patients, CFS-like employees merely had a shorter duration of fatigue complaints. Burnt out CFS-like employees had stronger psychological attributions and were more distressed than CFS patients. Conclusions: Fatigued employees shared many important characteristics with CFS patients, regardless of burnout status, and many fatigued employees met CFS criteria and/or burnout criteria. Differences however concerned the causal attributions that were made. This raises questions about the role of causal attributions: are they modified by fatigue complaints or do they determine illness outcome?
Fatigue is a common complaint that may lead to long-term sick leave and work disability.
To assess the efficacy of cognitive-behavioural therapy by general practitioners for unexplained, persistent ...fatigue among employees.
A randomised controlled trial, using a pre-randomisation design in primary care, investigated 151 employees on sick leave with fatigue. Participants in the experimental group were offered five to seven 30 min sessions of cognitive-behavioural therapy by a general practitioner; those in the control group were offered no treatment. Main outcome measures (fatigue severity, self-reported absenteeism, registered absenteeism and clinical recovery) were assessed at 4 months, 8 months and 12 months.
At baseline, 44% of the patients already met research criteria for chronic fatigue syndrome. There was no significant difference between the experimental group and the control group on primary or secondary outcomes at any point.
Cognitive-behavioural therapy by general practitioners for unexplained, persistent fatigue did not prove to be an effective intervention. Since these doctors were unable to deliver this therapy effectively under ideal circumstances, it is unlikely that doctors in routine practice would be more successful in doing so.
This paper describes the assessment of physical activity in chronic fatigue syndrome (CFS) and investigated the following questions: Do patients with CFS have low levels of physical activity; is ...there a relationship between actual level of physical activity and fatigue: can self-report measures adequately assess actual level of physical activity; what is the role of cognitions with respect to physical activity; and are results with respect to physical activity specific to CFS? Three different types of activity measures were used: self-report questionnaires, a 12-day self-observation list, and a motion-sensing device (Actometer) which was used as a reference for actual activity level. Fifty-one patients with CFS, 50 fatigued patients with multiple sclerosis (MS), and 53 healthy subjects participated in this study. Although none of the self-report questionnaires showed high correlations with the Actometer, questionnaires that require simple ratings of specified activities were related to the Actometer and can be used as acceptable substitutes, in contrast to instruments that require general subjective interpretations of activity that had low or non-significant correlations with the Actometer. Actometer results showed that CFS patients and MS patients had similar activity levels and both groups were significantly less active than healthy subjects. Compared to MS patients, CFS patients were more likely to indicate that they had been less active than other persons they knew. Activities which patients expected to result in higher fatigue levels were less frequently performed. Patients with CFS had significantly higher scores on this measure than MS patients and healthy subjects. Low levels of physical activity were related to severe fatigue in CFS but not in MS. In conclusion, although CFS patients have similar low activity levels than MS patients, there are also important differences between both groups: in CFS cognitive factors are more prominently involved in producing the low activity levels than in MS and in CFS patients activity level is related to fatigue but not in MS.
Background: It has been demonstrated that individual cognitive behaviour therapy is an effective treatment for chronic fatigue syndrome (CFS). The aim of the present study was to investigate the ...effectiveness of cognitive behaviour group therapy (CBGT) in an unselected group of CFS patients. Additionally, pretreatment characteristics of CFS patients who improve after CBGT were explored. Methods: In a non-randomised waiting list controlled design, 31 patients were allocated to CBGT and 36 to the waiting list condition. CBGT consisted of 12 two-hour sessions during 6 months. Main outcome measures were fatigue (Checklist Individual Strength) and functional impairment (Sickness Impact Profile). Results: A moderate effect on fatigue in favour of CBGT was found. For functional impairment, the effect was opposite to what was expected. Patients who improved after CBGT had less complaints at baseline compared to patients who did not improve. Conclusions: An explanation for the moderate effect might be that during CBGT, rest and relaxation were too much emphasised. Furthermore, an unselected group of CFS patients and therapists inexperienced in CB(G)T for CFS participated. Suggestions to improve CBGT for future research are given.
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