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      Letter to the Editor: Mental Health and Psychological Distress in People with Diabetes during COVID-19

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          Abstract

          Dear Sir, Since diabetes is a chronic condition, heightened concern in people with diabetes and their families is understandable. As early as the 17th century, a doctor hypothesized a link between diabetes and low mood and since then researches have suggested that people with diabetes have higher morbidity, prevalence of getting infected and mental health conditions. People with diabetes, if infected, would be harder to manage because of fluctuation of glucose level. COVID-19 has positively affected the diabetes supplies and medications including insulin. Physicians are not available and refills through prescriptions are difficult adding a stressor for people with diabetes. Currently there is insubstantial research on the correlation of diabetes and COVID-19. Nonetheless, high risk or not of coronavirus, the impact of COVID-19 on the mental health of these individuals is highly significant. Additionally, research has shown a higher relationship between diabetes and variety of mental health issue which could easily be exacerbated in stressful environment. Particular diabetes related psychological distress (negative emotions and burden of self-management), and psychological insulin resistance (refusal to initiate insulin therapy under certain conditions) could aggravate during the psychological stress in the wake of COVID-19 and related behavior-modification suggestions [1] [2]. Presence of diabetes-specific psychosocial issues, psychological distress and stressful environment could decrease quality of life and thus self-management which could lead to un-adherence to quarantine recommendations which resultantly compromise mental health of people with diabetes [2]. Psychological distress could increase depressive symptoms and could cause adverse diabetes outcomes [3]. New psychological distress as a product of COVID-19 with connection of diabetes-specific psychological distress could further augment: a) emotional distress of dependence on self-management (including self-care, medication, COVID-19 behavior modification and hygiene practices), and b) psychosocial difficulties at personal and interpersonal level (new demand of maintaining social-distancing and self-isolation). Diabetes-specific distress is associated with higher glycated hemoglobin (A1C levels), higher diastolic blood pressure (BP) and increased low-density lipoprotein cholesterol (LDL-C) levels; and risk factors of are higher body mass index, lower self-efficacy, low social support, poorer diet quality, living alone (incidentally present in COVID-19 lockdown outcome) [4] [5]. Psychological insulin resistance is a common reaction in individuals who report anxiety and fear of health-related concerns [6]. Perceived health anxiety and perceived fear of an illness could have impact on ability to self-manage. Consequently, stress, deficient social support and negative emotions towards any new change in life can impact on glycemic control [7]. COVID-19 related psychological issues in individuals with diabetes require addressing the psychosocial factors, and mental health factors that impact on individuals and their families. Adverse life experience and trauma in these individuals increases the risk as the author developed diabetes after being exposed to a negative life event. Posttraumatic stress symptoms and sub-syndromal traumatic stress can increase the developing diabetes 40% and 20% respectively (as author speak from experience as well) [8]. Individuals with diabetes have higher anxiety (one-third), depressive symptoms, panic attacks, and impaired functioning especially when another stressor is added [9]. Clinical features such as sweating, anxiety, tachycardia and confusion are similar in both hypoglycemic episodes and anxiety induced by a stressful life event. And as up to 45% case of mental health issues and diabetes-related psychological distress in individuals with diabetes goes undetected so the management of their mental health and physical health amidst of COVID-19 pandemic outbreak is even more needed [10] [11]. It is suggested that people with diabetes stay hydrated, and constantly check BGs and check for ketones in the event of high BGs. Above all, sound mental health, psychosocial functioning and emotional wellbeing is necessary for individuals with diabetes during COVID-19 pandemic outbreak. Declaration of Competing Interest None.

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          Depression in Diabetes: Have We Been Missing Something Important?

          An extensive literature has developed to suggest that depression is more common in patients with diabetes than in the general population (1) and is associated with chronic hyperglycemia (2), risk for diabetes complications (3), and mortality (4). Although the causal linkages among these relationships have not been demonstrated, their consistency has led to calls for intensive efforts to identify and treat clinical depression in patients with diabetes, with the reasonable presumption that this will contribute to better diabetes outcomes. Recent studies, however, suggest a more complicated picture and cast doubt on this presumption. Although research has suggested that the prevalence of clinical depression, or major depressive disorder (MDD), among adults with diabetes may be two to three times greater than among community adults (1), recent studies—which have used structured clinical interviews, the gold standard in the diagnosis of MDD—suggest that it is only about 60% more common (5). More importantly, diabetes-related distress, or significant negative emotional reactions to the diagnosis of diabetes, threat of complications, self-management demands, unresponsive providers, and/or unsupportive interpersonal relationships, has been found to be far more common, more chronic, and more closely related to diabetes self-care and glycemic control than MDD (5 –7). Symptoms of depression, such as depressed mood, diminished interest, loss of energy, and concentration difficulties, that are elevated but do not meet severity criteria for MDD (referred to here as depressive symptoms) are also quite common among patients with diabetes and are associated with poor self-care (8). Furthermore, increased risk of complications and early mortality is not limited to those with MDD but also extends to those with elevated depressive symptoms, even when these elevations are quite modest (4). This suggests an incremental relationship between the severity of depressive symptoms and poorer diabetes outcomes rather than an effect of MDD per se. There is minimal evidence for a longitudinal relationship between MDD and hyperglycemia over time, and changes in one over time do not appear to be associated with changes in the other (7). Numerous treatment studies have shown positive effects for the improvement of MDD in diabetic patients, but evidence for resulting glycemic benefit is, at best, weak (9). The current commentary seeks to shed light on the discontinuity among these findings. First, we suggest that there has been considerable confusion among MDD, diabetes-related distress, and depressive symptoms. We argue that this confusion has been exacerbated by measurement problems that stem from the lack of a clear distinction between MDD and nonpsychiatric emotional distress. Second, we suggest that this has led to a narrow focus on potential intervention approaches, originally developed for MDD, that may be limited in their ability to address diabetes-related distress and depressive symptoms. Although we do not deny the importance of true psychiatric presentations of MDD among those with diabetes, traditional approaches to MDD treatment may be unlikely to improve diabetes outcomes unless they also incorporate strategies to address important relationships between MDD and chronic illness (rev. in 10). Finally, we suggest an alternative approach to understanding the common experience of emotional distress in diabetes that emphasizes the demanding experience of diabetes and requires diabetes-specific measurement and treatment approaches. Have we been using the wrong assessment approach? There is a recurrent disconnect in the diabetes literature between the conceptual basis of emotional distress and the measurement methods we use. The predominant conceptual model that underlies the current understanding of emotional distress in diabetes, whether explicit or implicit, is the psychiatric diagnosis of MDD. However, the vast majority of studies rely on self-report questionnaires that assess symptoms of distress that are often only loosely associated with the diagnostic criteria for MDD. These self-report measures have been shown to be more reflective of general emotional distress than MDD (11). Furthermore, they may fully capture but inappropriately pathologize diabetes distress and depressive symptoms. The physical symptoms associated with diabetes further complicate distress assessment because they may be mistaken for symptoms of MDD. Even though many self-report measures have been developed with acceptable psychometric properties for detecting MDD, they often achieve a satisfactory level of sensitivity at the expense of yielding a high percentage of false-positives (12). Thus, diabetic patients experiencing depressive symptoms and/or diabetes distress may be misclassified as having MDD, especially when self-report measures are used. Studies that have used both self-report questionnaires for depressive symptoms and structured interviews based on MDD diagnostic criteria suggest that these measures tap into different constructs that have independent associations with diabetes. For example, 70% of diabetic patients with elevated self-reported depressive symptom scores did not meet diagnostic criteria for MDD on the basis of a structured clinical interview (6). More importantly, depressive symptoms and diabetes distress, which shared only 23% of their variance, were each associated with problematic diabetes self-management, whereas MDD was not (6). A subsequent study further demonstrated that diabetes distress covaried with hyperglycemia over time, but depressive symptoms and MDD did not (7). Thus, it appears that MDD, depressive symptoms, and diabetes distress are distinct constructs with independent relationships to diabetes. We believe that much of the overapplication of the MDD conceptual model to the problem of distress in diabetes is linked to the fact that the contemporary diagnostic system for MDD is based only on symptom assessment (number, duration, and degree of impairment) and ignores the life context in which these symptoms occur. As Horowitz and Wakefield (13) compellingly argue, this represents a departure from a long-standing history of thought, from Hippocrates to Kraepelin, that emphasizes the importance of situational context in the diagnosis of clinical depression. Evaluating symptoms only, regardless of their derivation (e.g., diabetes, job loss, divorce), may improve the reliability of diagnosis, but it sacrifices validity and obfuscates the great heterogeneity of presentations that are, in our view, often misclassified as MDD (leading inexorably, as we discuss below, to inappropriate treatments). This symptom-based and context-neutral approach to conceptualizing and assessing MDD is particularly problematic for patients with diabetes, leading to both an overpathologizing of patients and an underappreciation of the role of chronic illness in explaining emotional symptoms. For example, in a well-defined sample of patients with diabetic peripheral neuropathy, investigators showed that objective indicators of neuropathy severity, neuropathy-related symptoms, impairment in daily activities due to neuropathy and neuropathy-related changes in important roles were predictive of increases in depressive symptoms over time (14). Thus, a cascade of disease-related factors, from objective indicators of severity to subjective ratings of functional impairment, contributed to the development of depressive symptoms in these patients. Applying the label of MDD to the outcome of these studies would not only inaccurately pathologize the observed level of depressive symptoms, it would also ignore the disease-associated factors that explain them. The importance of disease-associated functional impairment, in particular, as a contributor to distress in chronic illness has strong empirical support. For example, disease-related physical limitations predict changes in subsequent depressive symptoms over time, but depressive symptoms do not predict corresponding changes in physical limitations (15). Furthermore, although epidemiological data consistently link MDD and physical illness, the strength of this association diminishes with age; impairments at young ages of adulthood are more strongly associated with MDD than those occurring at advanced ages, when some loss in functioning is normative and expected (16). The link between chronic illness and depressive symptoms similarly diminishes with age, as does the association between functional disability and depressive symptoms (17). Thus, life context (e.g., expectations of functioning in important roles) is crucial for explaining the link between disease and significant emotional distress. The current MDD-focused model ignores this context and when applied to patients with diabetes leads to an underappreciation of the impact of demanding treatment regimens, ongoing threats of serious complications, and associated functional impairment that may contribute to the experience of distress. Have we been using the wrong treatment approach? The implications of this argument go far beyond questions of semantics; the over-application of the MDD-model to the problem of distress in people with diabetes has also led to a narrow focus on treatments for clinical depression that may not be appropriate for the majority of distressed patients. For example, meta-analysis has demonstrated that antidepressants, though widely prescribed as a treatment for MDD, may be no more effective than placebo for mild to moderate levels of symptom severity; clinically significant benefits are only observed at “very severe” levels of impairment (18). Thus, exporting existing treatments for MDD to the greater population of diabetic patients experiencing disease-related distress or depressive symptoms may be ill advised. Interventions that have attempted this among those with diabetes have focused rather narrowly on reducing the severity of MDD with antidepressants or psychotherapy and, for the most part, have not attended to the co-occurring, linked problems of living with and managing the stress of diabetes. Moreover, they have failed to show compelling evidence that amelioration of MDD leads to improved diabetes management or glycemic control (9). Newer intervention approaches reflect an evolution in MDD-focused treatment by concurrently addressing co-occurring problems with diabetes management. These include interventions that integrate psychological treatments with exercise training (20), nurse-led self-management support (21), and nurse-, dietitian-, and mental health-specialist–delivered self-management interventions (22). In contrast to previous intervention studies that focused solely on the amelioration of MDD, these studies also address the behavioral barriers to successful diabetes treatment and, therefore, may be more successful in improving diabetes health outcomes. Novel approaches to the emotional aspects of diabetes management are clearly needed for the far larger population of patients struggling with diabetes-related distress and/or depressive symptoms but who are not clinically depressed. Although very few intervention studies have targeted diabetes distress directly, several trials have attempted to integrate behavioral and distress-related changes into a single, comprehensive intervention. For example, a small trial of cognitive behavioral therapy adapted to address diabetes-relevant behavior change improved both glycemic control and diabetes distress in adults with poorly controlled type 1 diabetes, compared with a control condition, with benefits maintained over 1 year of follow-up (23). Similar benefits were seen from a peer-delivered self-management intervention in Spanish-speaking type 2 diabetic patients: both glycemic control and diabetes-related distress improved relative to control subjects, and improvements were maintained over 18 months (24). These studies suggest that co-occurring improvements in disease management and diabetes distress can be achieved through interventions that target both of these linked problems. Recommendations for clinical practice: toward a new model of care It is time to recognize that the marked emotional distress commonly seen in patients with diabetes may not be a traditional depressive disorder, no matter the elevated score on a self-reported depression questionnaire nor the presentation of recognizable MDD symptoms. A new treatment model to understand and address the emotional concomitants of diabetes is needed. Diabetes-related distress and depressive symptoms are clearly associated with problems of poor diabetes self-management and clinical outcomes and, therefore, should be recognized as important indicators of diabetes self-management. This is consistent with dominant theories on the functional implications of emotion, which argue that emotions, both positive and negative, serve to indicate how well a behavior is leading to a desired outcome or goal (25). Conceptualizing emotional distress within the context of the self-regulation of diabetes management supports intervention approaches that target problems with self-management, including addressing dysfunctional beliefs about diabetes and reducing the tendency to disengage from the pursuit of goals when experiencing emotional distress, rather than treatments that focus exclusively on reducing symptoms of distress disconnected from the diabetes-relevant issues that prompt them (10). This comprehensive approach to the management of diabetes and nonpsychiatric emotional distress (including depressive symptoms and diabetes-related distress) requires several changes to how we deliver care to patients with diabetes. First, emotional distress should be considered a common component of the experience of diabetes; it falls within the spectrum of diabetes management and is not a comorbid disorder. Second, because of the reciprocal influences between emotional distress and diabetes self-management, distress can indicate increased risk for poor treatment outcomes; interventions that focus on addressing both distress and diabetes management are likely to have stronger effects than those that focus on either in isolation (21). Understanding the diabetes-related factors that drive the experience of distress is crucial to the development of appropriate interventions. Third, levels of distress can vary considerably over time, following or preceding changes in diabetes status, and should be evaluated regularly as part of ongoing, comprehensive diabetes care. Fourth, there are major advantages to treating the large number of distressed patients within the diabetes practice environment rather than referring them to other health care providers: comprehensive approaches to care that recognize the bidirectional relationship between distress and diabetes management are likely to have maximal effects. Although validated and easy-to-use screening instruments for diabetes-related distress are presently available (25,26), an ongoing clinical conversation about distress may be the most effective and time-sensitive clinical approach. It avoids false-positives and over-pathologizing common nonpsychiatric distress that can occur with many screening instruments designed to detect MDD and allows for the evaluation of the context that might explain any distress that is reported. The results of a brief conversation can also guide the selection of appropriate intervention. Patients reporting distress secondary to frustration about chronic hyperglycemia or fear of complications (i.e., diabetes-related distress) will likely need different interventions than patients who report being distressed because of life circumstances unrelated to diabetes. Although antidepressants are unlikely to be effective in most presentations of distress (18), physical activity, psychotherapeutic approaches, and discussions with diabetes team members can be effective. Patients are often relieved when health care providers initiate discussions about their distress. Even brief conversations that label feelings, link them to difficulties with self-management and normalize emotional reactions to diabetes issues can be re-assuring; indeed, even the patient's verbalization and expression of emotional experiences of diabetes can be therapeutic. While this comprehensive approach to the assessment and management of distress in diabetes has clear advantages over the current fragmented model of care in the U.S., it may conflict with the existing realities of treatment delivery. The time pressures of clinical care may leave practitioners unwilling to add tasks to an already densely packed clinical encounter. Furthermore, many diabetes team members may be uncomfortable addressing the emotional components of diabetes care, and may be concerned about opening a Pandora's Box that they fear will be difficult to close. We believe that addressing the emotional aspects of living with diabetes does not require extensive mental health training, although some patients, especially those who are experiencing MDD or profound and longstanding depressive symptoms or diabetes distress, may require a referral for specialized care. Rather, all team members should be skilled in attentive and empathic listening, sensitive verbal inquiry, and use of thoughtful and reflective comments—skills that are the hallmarks of good clinical care. Documentation of the content and level of distress that include summaries of discussions among team members as part of clinical care requires only a small shift in perspective. A comprehensive approach that distinguishes clinical depression from disease-related distress and that offers support for the management of emotional distress as an integral part of providing support for the behavioral management of diabetes will have the greatest likelihood of clinical benefit for the vast majority of patients with diabetes.
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            Diabetes Distress Among Adolescents with Type 1 Diabetes: a Systematic Review.

            Diabetes distress (DD) refers to the negative emotions arising from living with diabetes and the burden of self-management. Among adults, the prevalence and significance of DD are well established, but this is not the case among adolescents. This systematic review investigated among adolescents with type 1 diabetes: the prevalence of DD; demographic, clinical, behavioral and psychosocial correlates of DD and interventions that reduce DD. Consistent with adult studies, around one third of adolescents experience elevated DD and this is frequently associated with suboptimal glycemic control, low self-efficacy and reduced self-care. Three measures of DD have been developed specifically for adolescents, as those designed for adults may not be sufficiently sensitive to adolescent concerns. Interventions reducing DD in the short term include strategies such as cognitive restructuring, goal setting and problem solving. Further work is needed to investigate sustainability of effect. Rigorous research is needed to progress this field among adolescents.
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              Are patients with type 2 diabetes reluctant to start insulin therapy? An examination of the scope and underpinnings of psychological insulin resistance in a large, international population.

              To examine the scope and underpinnings of psychological insulin resistance (PIR) across eight Western nations, with special attention to the potential influence of beliefs about insulin and broader patient beliefs regarding medications and diabetes. A total of 1400 subjects with insulin-naïve, type 2 diabetes across eight nations completed an online survey. The survey assessed willingness to start insulin, beliefs about insulin and current medications, and diabetes-related emotional distress. The majority of respondents were male (59.3%), mean age was 51.6 years and mean diabetes duration was 6.1 years. A total of 17.2% reported they would be unwilling to start insulin (the PIR group), while 34.7% were ambivalent and 48.1% indicated they would be willing to do so. Marked differences by country were apparent, with PIR ranging from 5.9% (Spain) to 37.3% (Italy). Both unwilling and ambivalent patients reported significantly more negative (p < 0.001; p < 0.05) and fewer positive beliefs (p < 0.001; p < 0.01) about starting insulin, more negative feelings about their current medications (p < 0.01, p < 0.001), and more diabetes-related distress (p < 0.001; p < 0.05) than willing patients. Unwilling patients also reported significantly more negative (p < 0.05) and fewer positive beliefs (p < 0.001) about starting insulin than ambivalent patients. These are the first data demonstrating the prevalence of PIR across Western nations. PIR is strongly linked to positive and negative insulin beliefs, and may also reflect a broader discomfort with medications and with diabetes in general. Of note, however, PIR is a marker of behavioral intent only; it is not known whether this predicts actual behavior at the time when insulin is prescribed. When addressing patients who are reluctant to initiate insulin therapy, clinicians may find it valuable to inquire about their beliefs about insulin and their current medications.
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                Author and article information

                Contributors
                Role: Counselling Psychologist
                Journal
                Metabolism
                Metab. Clin. Exp
                Metabolism
                Elsevier Inc.
                0026-0495
                1532-8600
                23 April 2020
                July 2020
                23 April 2020
                : 108
                : 154248
                Affiliations
                [a ]University of Management and Technology, Lahore, Pakistan
                [b ]Independent Researcher, Lahore, Pakistan
                Author notes
                [* ]Corresponding author. sonia.mukhtar12@ 123456gmail.com
                Article
                S0026-0495(20)30112-8 154248
                10.1016/j.metabol.2020.154248
                7252044
                32335075
                © 2020 Elsevier Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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