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      Association of diabetes-related distress, depression, medication adherence, and health-related quality of life with glycated hemoglobin, blood pressure, and lipids in adult patients with type 2 diabetes: a cross-sectional study

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          This study examined the associations of diabetes-related distress (DRD), depressive symptoms, health-related quality of life (HRQoL), and medication adherence with glycemia, blood pressure (BP), and lipid biomarkers in adults with type 2 diabetes mellitus (T2D). This cross-sectional study was conducted in three Malaysian public health clinics in 2012–2013, recruited adult patients (aged ≥30 years) with T2D who had been diagnosed for more than one year, were on active follow-up, and had recent blood test results. Univariable and multivariable analyses were performed to identify significant associated factors for glycated hemoglobin (HbA 1c) BP, and lipids. The response rate was 93.1% (700/752). The majority were females (52.8%), Malay (52.4%), and married (78.7%). DRD correlated with systolic BP ( r= −0.16); depressive symptoms correlated with low-density lipoprotein cholesterol ( r=0.12) and total cholesterol ( r=0.13); medication adherence correlated with HbA 1c ( r= −0.14) and low-density lipoprotein cholesterol ( r= −0.11); and HRQoL correlated with casual blood glucose ( r= −0.11), high-density lipoprotein cholesterol ( r= −0.13), and total cholesterol ( r= −0.08). Multivariable analyses showed that HRQoL was significantly associated with casual blood glucose (adjusted B= −0.06, P=0.024); DRD was associated with systolic BP (adjusted B= −0.08, P=0.066); depressive symptoms were associated with low-density lipoprotein cholesterol (adjusted B=0.02, P=0.061), and medication adherence was associated with HbA 1c (adjusted B= −0.11, P=0.082) and total cholesterol (adjusted B= −0.06, P=0.086). There were significant and distinctive associations of DRD, depressive symptoms, HRQoL, and medication adherence with glycemia, BP, and lipid biomarkers. Unexpected beneficial therapeutic effects of DRD on BP require further study. A multidisciplinary approach may be needed for risk management in adults with T2D at the primary care level.

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          Assessing psychosocial distress in diabetes: development of the diabetes distress scale.

          The purpose of this study was to describe the development of the Diabetes Distress Scale (DDS), a new instrument for the assessment of diabetes-related emotional distress, based on four independent patient samples. In consultation with patients and professionals from multiple disciplines, a preliminary scale of 28 items was developed, based a priori on four distress-related domains: emotional burden subscale, physician-related distress subscale, regimen-related distress subscale, and diabetes-related interpersonal distress. The new instrument was included in a larger battery of questionnaires used in diabetes studies at four diverse sites: waiting room at a primary care clinic (n = 200), waiting room at a diabetes specialty clinic (n = 179), a diabetes management study program (n = 167), and an ongoing diabetes management program (n = 158). Exploratory factor analyses revealed four factors consistent across sites (involving 17 of the 28 items) that matched the critical content domains identified earlier. The correlation between the 28-item and 17-item scales was very high (r = 0.99). The mean correlation between the 17-item total score (DDS) and the four subscales was high (r = 0.82), but the pattern of interscale correlations suggested that the subscales, although not totally independent, tapped into relatively different areas of diabetes-related distress. Internal reliability of the DDS and the four subscales was adequate (alpha > 0.87), and validity coefficients yielded significant linkages with the Center for Epidemiological Studies Depression Scale, meal planning, exercise, and total cholesterol. Insulin users evidenced the highest mean DDS total scores, whereas diet-controlled subjects displayed the lowest scores (P < 0.001). The DDS has a consistent, generalizable factor structure and good internal reliability and validity across four different clinical sites. The new instrument may serve as a valuable measure of diabetes-related emotional distress for use in research and clinical practice.
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            Assessment of diabetes-related distress.

            To describe a new measure of psychosocial adjustment specific to diabetes, the Problem Areas in Diabetes Survey (PAID), and to present initial information on its reliability and validity. Before their routine clinic appointments, 451 female patients with type I and type II diabetes, all of whom required insulin, completed a self-report survey. Included in the survey was the PAID, a 20-item questionnaire in which each item represents a unique area of diabetes-related psychosocial distress. Each item is rated on a six-point Likert scale, reflecting the degree to which the item is perceived as currently problematic. A total scale score, hypothesized to reflect the overall level of diabetes-related emotional distress, is computed by summing the total item responses. To examine the concurrent validity of the PAID, the survey also included a series of standardized questionnaires assessing psychosocial functioning (general emotional distress, fear of hypoglycemia, and disordered eating), attitudes toward diabetes, and self-care behaviors. All subjects were assessed for HbA1, within 30 days of survey completion and again approximately 1-2 years later. Finally, long-term diabetic complications were determined through chart review. Internal reliability of the PAID was high, with good item-to-total correlations. Approximately 60% of the subject sample reported at least one serious diabetes-related concern. As expected, the PAID was positively associated with relevant psychosocial measures of distress, including general emotional distress, disordered eating, and fear of hypoglycemia, short- and long-term diabetic complications, and HbA1, and negatively associated with reported self-care behaviors. The PAID accounted for approximately 9% of the variance in HbA1. Diabetes-related emotional distress, as measured by the PAID, was found to be a unique contributor to adherence to self-care behaviors after adjustment for age, diabetes duration, and general emotional distress. In addition, the PAID was associated with HbA1 even after adjustment for age, diabetes duration, general emotional distress, and adherence to self-care behaviors. These findings suggest that the PAID, a brief, easy-to-administer instrument, may be valuable in assessing psychosocial adjustment to diabetes. In addition to high internal reliability, the consistent pattern of correlational findings indicates that the PAID is tapping into relevant aspects of emotional distress and that its particular feature, the measurement of diabetes-related emotional distress, is uniquely associated with diabetes-relevant outcomes. These data are also consistent with the hypothesis that diabetes-related emotional distress, separate from general emotional distress, is an independent and major contributor to poor adherence. Given that the study was limited to female patients using insulin, further examination of the clinical usefulness of the PAID will need to focus on more heterogeneous samples.
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              A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with Type 2 diabetes.

              To report the prevalence and correlates of affective and anxiety disorders, depressive affect and diabetes distress over time. In a non-interventional study, 506 patients with Type 2 diabetes were assessed three times over 18 months (9-month intervals) for: major depressive disorder (MDD), general anxiety disorder (GAD), panic disorder (PANIC), dysthymia (DYS) (Composite International Diagnostic Interview); depressive affect [Center for Epidemiological Studies-Depression (CES-D)]; Diabetes Distress Scale (DDS); HbA(1c); and demographic data. Diabetic patients displayed high rates of affective and anxiety disorders over time, relative to community adults: 60% higher for MDD, 123% for GAD, 85% for PANIC, 7% for DYS. The prevalence of depressive affect and distress was 60-737% higher than of affective and anxiety disorders. The prevalence of individual patients with an affective and anxiety disorder over 18 months was double the rate assessed at any single wave. The increase for CES-D and DDS was about 60%. Persistence of CES-D and DDS disorders over time was significantly greater than persistence of affective and anxiety disorders, which tended to be episodic. Younger age, female gender and high comorbidities were related to persistence of all conditions over time. HbA(1c) was positively related to CES-D and DDS, but not to affective and anxiety disorders over time. The high prevalence of comorbid disorders and the persistence of depressive affect and diabetes distress over time highlight the need for both repeated mental health and diabetes distress screening at each patient contact, not just periodically, particularly for younger adults, women and those with complications/comorbidities.

                Author and article information

                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                29 April 2015
                : 11
                : 669-681
                [1 ]Department of Family Medicine, Universiti Putra Malaysia, Serdang, Malaysia
                [2 ]Department of Psychiatry, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
                [3 ]Klinik Kesihatan Dengkil, Jalan Dengkil, Malaysia
                Author notes
                Correspondence: Boon-How Chew, Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia, Tel +60 3 8947 2520, Fax +60 3 8947 2328, Email chewboonhow@ 123456gmail.com
                © 2015 Chew et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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