Objective
The 5‐item World Health Organization well‐being index is a commonly used measure of emotional well‐being, but research on psychometric properties in outpatients with diabetes is scarce. We ...examined psychometric and screening properties for depression of this index in a large sample of Dutch outpatients with diabetes.
Methods
Patients with Type 1 (n = 384) and Type 2 (n = 549) diabetes from three outpatient clinics completed the WHO‐5 index, the nine‐item Patient Health Questionnaire, the Problem Areas in Diabetes survey and the Short Form‐12 health survey. Internal consistency of the WHO‐5 index was determined by Cronbach's alpha. The factor structure was tested by confirmatory factor analysis. Concurrent validity was assessed by correlations with the Patient Health Questionnaire, Problem Areas in Diabetes and the Short Form‐12 mental component scores. Sensitivity and specificity of the WHO‐5 index as depression screener were tested against two existing Patient Health Questionnaire cut‐off scores for depression using receiver operating characteristic curves.
Results
A one‐factor structure of the WHO‐5 index was verified by confirmatory factor analysis for patients with Type 1 and Type 2 diabetes. Moderate to strong correlations were observed between the WHO‐5 index and the Patient Health Questionnaire scores, the Problem Areas in Diabetes scores and the Short Form‐12 mental component scores (r = 0.55–0.69, P < 0.001). Receiver operating characteristic curves showed that a WHO‐5 index cut‐off of < 50 performed best as an indication for likely depression, with sensitivity compared with a Patient Health Questionnaire score ≥ 10 and ≥ 12 of 79% and 88%, respectively, and specificity of 88% and 76%, respectively.
Conclusions
The WHO‐5 index is a short, psychometrically sound measure of emotional well‐being that appears suitable for use as screening test for likely depression in outpatients with Type 1 and Type 2 diabetes.
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.
Aims
Depression is common in people with diabetes, and related to higher HbA1c levels. Depression, however, is a heterogeneous construct that involves a variety of symptoms. As little is known about ...the associations of individual depressive symptoms with HbA1c, we explored these associations in outpatients with diabetes.
Methods
The study was conducted in three tertiary diabetes clinics in the Netherlands. At baseline, the presence of the nine depressive symptoms that are listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was assessed with the nine‐item Patient Health Questionnaire (PHQ‐9). At baseline and after a 1‐year follow‐up, HbA1c was derived from the medical charts.
Results
A total of 288 out of 646 subjects with diabetes (45%) reported one or more depressive symptom(s). Depressed mood (β = 0.11, P = 0.005), sleeping difficulties (β = 0.16, P < 0.001), appetite problems (β = 0.15, P < 0.001) and suicidal ideation (β = 0.14, P = 0.001) were significantly related to higher baseline HbA1c values. Furthermore, depressed mood (β = 0.09, P = 0.03) sleeping difficulties (β = 0.12, P = 0.004), appetite problems (β = 0.11, P = 0.01) and psychomotor agitation/retardation (β = 0.09, P = 0.04) were significantly related to higher HbA1c values at 1‐year follow‐up. Associations were more pronounced in Type 1 diabetes than in Type 2 diabetes. None of the depressive symptoms were related to change in HbA1c over time, except suicidal ideation.
Conclusion
In people with diabetes, several individual depressive symptoms were related to higher HbA1c levels. These associations persisted over time. More research is needed to investigate potential mechanistic pathways.
Aims
To compare levels of diabetes distress in people with Type 2 diabetes treated in primary and secondary care and to examine demographic and clinical correlates that may explain potential ...differences in levels of distress between care settings.
Methods
People with Type 2 diabetes from 24 primary care practices (n = 774) and three secondary care clinics (n = 526) completed the Problem Areas In Diabetes questionnaire. Data on HbA1c levels and diabetes complications were derived from medical charts. Hierarchical ordinal regression analysis was used to investigate which correlates could explain the potential differences in level of diabetes distress between care settings.
Results
Diabetes distress levels and the prevalence of elevated diabetes distress were considerably lower in the participants treated in primary care (mean (sd) total diabetes distress score 8 (11); 4% of participants with a Problem Areas In Diabetes score ≥ 40) than in secondary care (mean (sd) total diabetes distress score 23 (21); 19% of participants with a Problem Areas In Diabetes score ≥ 40, P < 0.001). In addition to care setting, the following variables were also independently related to diabetes distress: younger age, ethnic minority status, using insulin, having a higher HbA1c level, having a higher BMI and the presence of neuropathy. Other diabetes complications were not independently associated with diabetes distress.
Conclusions
In primary care, lower levels of diabetes distress were reported than in secondary care. The difference in diabetes distress between care settings can be largely, but not fully, explained by specific demographic and clinical characteristics. These results need to be interpreted with caution as they are based on two separate studies, but do call into question the need to screen for diabetes distress in people with Type 2 diabetes in primary care.
What's new?
This study shows that considerably lower levels of diabetes distress are experienced by people with Type 2 diabetes treated in primary care compared with those treated in secondary care.
These differences may be largely, but not fully, explained by demographic and clinical factors such as ethnicity and glycaemic control. Interestingly, having complications was barely related to diabetes distress.
The low prevalence of diabetes distress in primary care calls into question the need to screen for emotional distress in all people with Type 2 diabetes in primary care.
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.
Aim: Continuous intraperitoneal insulin infusion (CIPII) with the DiaPort system using regular insulin was compared to continuous subcutaneous insulin infusion (CSII) using insulin Lispro, to ...investigate the frequency of hypoglycemia, blood glucose control, quality of life, and safety.
Methods: In this open, randomized, controlled, cross‐over, multinational, 12‐month study, 60 type 1 diabetic patients with frequent hypoglycemia and/or HbA1c > 7.0% with CSII were randomized to CIPII or CSII. The aim was to obtain the best possible blood glucose while avoiding hypoglycemia.
Results: The frequency of any hypoglycemia was similar (CIPII 118.2 (SD 82.6) events / patient year, CSII 115.8 (SD 75.7) p = 0.910). The incidence of severe hypoglycemia with CSII was more than twice the one with CIPII (CIPII 34.8 events / 100 patient years, CSII 86.1, p = 0.013). HbA1c, mean blood glucose, and glucose fluctuations were not statistically different. Treatment‐related severe complications occurred mainly during CIPII: port infections (0.47 events / patient year), abdominal pain (0.21 events / patient year), insulin underdelivery (0.14 events / patient year). Weight gain was greater with CSII (+ 1.5 kg vs. − 0.1 kg, p = 0.013), quality of life better with CIPII.
Conclusions: In type 1 diabetes CIPII with DiaPort reduces the number of severe episodes of hypoglycemia and improves quality of life with no weight gain. Because of complications, indications for CIPII must be strictly controlled. CIPII with DiaPort is an alternative therapy when CSII is not fully successful and provides an easy method of intraperitoneal therapy.
STUDY QUESTION
Is type 1 diabetes a determinant of advanced ovarian ageing, resulting in an early age at natural menopause?
SUMMARY ANSWER
No clear evidence was provided that type 1 diabetes is a ...determinant of accelerated ovarian ageing resulting in an early menopause.
WHAT IS KNOWN ALREADY
The association between type 1 diabetes and early menopause has been examined previously with inconsistent results.
STUDY DESIGN, SIZE, DURATION
A cross-sectional study was performed in 140 post-menopausal women with, and 5426 post-menopausal women without, diabetes.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Both women with and without diabetes had experienced natural menopause. Study participants filled out a standardized questionnaire including report of their age at last menstrual period. Differences in menopausal age were analysed using linear regression analyses, with adjustment for possible confounders.
MAIN RESULTS AND THE ROLE OF CHANCE
Mean age at natural menopause was 49.8 ± 4.7 years in women with type 1 diabetes and 49.8 ± 4.1 in women without diabetes. Linear regression analyses showed that type 1 diabetes was not associated with an earlier menopause compared with the reference group without diabetes, after adjustment for age, smoking history and parity (difference in age at menopause between women with type 1 diabetes and reference group 0.34 years, 95% confidence interval −0.34, 1.01).
LIMITATIONS, REASON FOR CAUTION
Age at menopause was self-reported and assessed retrospectively. We had no information regarding microvascular complications therefore a possible association between vascular health and menopausal age could not be investigated.
WIDER IMPLICATIONS OF THE FINDINGS
It has been hypothesized that the possible mechanism behind an accelerated ovarian ageing process in type 1 diabetes is prolonged poor glycaemic control and subsequent effects on vascular health. The improved glycaemic control during the last decades may have prevented vascular damage from occurring to an extent that would affect organ function. Nevertheless, the present findings are reassuring for reproductive health prospects in women with type 1 diabetes.
STUDY FUNDING/ COMPETING INTEREST(S)
The EPIC-NL study was funded by the ‘Europe against Cancer’ Program of the European Commission (SANCO), the Dutch Ministry of Public Health, Welfare and Sports, the Dutch Cancer Society, the Netherlands Organisation for Health research and Development (ZonMW), and World Cancer Research Fund (WCRF). F.J.M.B. has received fees and grant support from the following companies: Ferring, Gedeon Richter, Merck Serono, Medical Specialties Distributors, and Roche.
TRIAL REGISTRATION NUMBER
Not applicable.
The efficacy and safety of oral pamidronate was examined in a double‐blind, placebo‐controlled trial in women and men with established osteoporosis. Seventy‐eight postmenopausal women and 23 men with ...at least one prevalent vertebral fracture were randomized separately to 150 mg/day of pamidronate or placebo for 3 years followed by 150 mg/day of pamidronate for an additional 2 years. In addition, all patients received 400 U/day of cholecalciferol and 500 mg/day of elemental calcium. Pamidronate increased significantly bone mineral density of the lumbar spine (LS‐BMD) and of the femoral neck (FN‐BMD). The total increase in BMD of the spine after 5 years of treatment was 14.3%. Lateral spine radiographs were obtained at baseline and after 3 years of treatment. Fractures of previously normal vertebrae occurred in 15 of 45 patients treated with placebo (33.3%) and in 5 of 46 patients treated with pamidronate (11%). The relative risk was 0.33 (95% CI, 0.14‐0.77). Treatment was well tolerated and there was no difference in gastrointestinal toxicity between pamidronate and placebo‐treated patients. One hundred fifty milligrams daily of pamidronate is an effective and safe treatment of women and men with established osteoporosis.
Aims/hypothesis
Several publications suggest an association between certain types of insulin and cancer, but with conflicting results. We investigated whether insulin glargine (A21Gly,B31Arg,B32Arg ...human insulin) is associated with an increased risk of cancer in a large population-based cohort study.
Methods
Data for this study were obtained from dispensing records from community pharmacies individually linked to hospital discharge records from 2.5 million individuals in the Netherlands. In a cohort of incident users of insulin, the association between insulin glargine and other insulin analogues, respectively, and cancer was analysed in comparison with human insulin using Cox proportional hazard models with cumulative duration of drug use as a time-varying determinant. The first hospital admission with a primary diagnosis of cancer was considered as the main outcome; secondary analyses were performed with specific cancers as outcomes.
Results
Of the 19,337 incident insulin users enrolled, 878 developed cancer. Use of insulin glargine was associated with a lower risk of malignancies in general in comparison with human insulin (HR 0.75, 95% CI 0.71, 0.80). In contrast, an increased risk was found for breast cancer (HR 1.58, 95% CI 1.22, 2.05). Dose–response relationships could not be identified.
Conclusion/interpretation
Users of insulin glargine and users of other insulin analogues had a lower risk of cancer in general than those using human insulin. Both associations might be a consequence of residual confounding, lack of adherence or competing risk. However, as in previous studies, we demonstrated an increased risk of breast cancer in users of insulin glargine in comparison with users of human insulin.
PDF
