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      Depression and Diabetes Treatment Nonadherence: A Meta-Analysis

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          Abstract

          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.

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          Most cited references36

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          On the use of beta coefficients in meta-analysis.

          This research reports an investigation of the use of standardized regression (beta) coefficients in meta-analyses that use correlation coefficients as the effect-size metric. The investigation consisted of analyzing more than 1,700 corresponding beta coefficients and correlation coefficients harvested from published studies. Results indicate that, under certain conditions, using knowledge of corresponding beta coefficients to input missing correlations (effect sizes) generally produces relatively accurate and precise population effect-size estimates. Potential benefits from applying this knowledge include smaller sampling errors because of increased numbers of effect sizes and smaller non-sampling errors because of the inclusion of a broader array of research designs.
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            Depression and poor glycemic control: a meta-analytic review of the literature.

            Depression is common among patients with diabetes, but its relationship to glycemic control has not been systematically reviewed. Our objective was to determine whether depression is associated with poor glycemic control. Medline and PsycINFO databases and published reference lists were used to identify studies that measured the association of depression with glycemic control. Meta-analytic procedures were used to convert the findings to a common metric, calculate effect sizes (ESs), and statistically analyze the collective data. A total of 24 studies satisfied the inclusion and exclusion criteria for the meta-analysis. Depression was significantly associated with hyperglycemia (Z = 5.4, P < 0.0001). The standardized ES was in the small-to-moderate range (0.17) and was consistent, as the 95% CI was narrow (0.13-0.21). The ES was similar in studies of either type 1 or type 2 diabetes (ES 0.19 vs. 0.16) and larger when standardized interviews and diagnostic criteria rather than self-report questionnaires were used to assess depression (ES 0.28 vs. 0.15). Depression is associated with hyperglycemia in patients with type 1 or type 2 diabetes. Additional studies are needed to establish the directional nature of this relationship and to determine the effects of depression treatment on glycemic control and the long-term course of diabetes.
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              Association of depression and diabetes complications: a meta-analysis.

              The objective of this study was to examine the strength and consistency of the relationship between depression and diabetes complications in studies of type 1 and type 2 adult patients with diabetes. MEDLINE and PsycINFO databases were searched for articles examining depression and diabetes complications in type 1 and type 2 diabetes samples published between 1975 and 1999. Meta-analytic procedures were used. Studies were reviewed for diabetes type, sample size, statistical tests, and measures of diabetes complications and depression. Significance values, weighted effect sizes r, 95% confidence intervals (CI), and tests of homogeneity of variance were calculated for the overall sample (k = 27) and for subsets of interest. A total of 27 studies (total combined N = 5374) met the inclusion criteria. A significant association was found between depression and complications of diabetes (p < .00001, z = 5.94). A moderate and significant weighted effect size (r = 0.25; 95% CI: 0.22-0.28) was calculated for all studies reporting sufficient data (k = 22). Depression was significantly associated with a variety of diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction). Effect sizes were in the small to moderate range (r = 0.17 to 0.32). These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.
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                Author and article information

                Journal
                Diabetes Care
                diacare
                Diabetes Care
                American Diabetes Association
                0149-5992
                1935-5548
                December 2008
                : 31
                : 12
                : 2398-2403
                Affiliations
                [1 ]Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital Boston, Boston, Massachusetts
                [2 ]Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
                [3 ]Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
                [4 ]Department of Sociology, Loyola College, Baltimore, Maryland
                Author notes

                Corresponding author: Jeffrey S. Gonzalez, jsgonzalez@ 123456partners.org

                Article
                31122398
                10.2337/dc08-1341
                2584202
                19033420
                37776b78-ca31-4829-9290-35a88e99321b
                Copyright © 2008, American Diabetes Association

                Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

                History
                : 24 July 2008
                : 29 August 2008
                Categories
                Reviews/Commentaries/ADA Statements

                Endocrinology & Diabetes
                Endocrinology & Diabetes

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