Preventing diabetes-related depression -
The summation of responses ranges from 0 to 21 for both the depression and anxiety scales; higher numbers are indicative of an increase in the number and severity of symptoms. HADS is widely used within primary care, community, and research settings, and it has been shown to be a valid measure for detecting clinical anxiety and depression 27 , When using a threshold score of 8 to identify individuals with anxiety or depression disorders, sensitivity and specificity values between 0.
For the purposes of this study, the primary analysis was undertaken using depression and anxiety as continuous scores indicating the number and severity of symptoms. This study also reports data on various characteristics collected following the methods reported in the original trials 20 , 22 : age, sex, ethnicity, smoking status, BMI, HbA 1c , and social deprivation Index of Multiple Deprivation.
Antidepressant medication use and previous cardiovascular disease myocardial infarction, stroke, heart failure, angina were captured through interview. All other participant characteristics were measured using the same methods and standard operating procedures.
Data were analyzed by using generalized estimating equations with an exchangeable matrix taking into account potential clustering within recruited family practices general practices did not overlap between studies and repeated follow-up measures over time.
This approach ensures that all data captured for each individual contribute to the analysis, while taking into account that repeated measures have a within-person correlation Change in steps per day was the dependent variable.
Models were adjusted for measurement time point, treatment, sex, ethnicity, age, social deprivation, smoking status, cardiovascular disease, baseline antidepressant medication use, and baseline steps per day. We used treatment × time interaction to assess whether the intervention effect varied by time across 12, 24, and 36 months.
To assess the modifying effect of the number and severity of depressive symptoms, we simultaneously added to the model baseline depressive symptom score and change in depressive symptom score and their interactions with treatment. We used the coefficient for baseline depressive symptom score × treatment to derive the reduction in the intervention effect per unit depressive symptom score, which is referred to here as the decay in the intervention effect for every additional 1-unit-higher depressive symptom score.
Similarly, we used the coefficient for change in depressive symptom score × treatment to derive the change in the intervention effect for each unit change in depressive symptom score from baseline to follow-up.
We used the coefficient for treatment within the model to derive the intervention effect when baseline and change in depressive symptom scores were set to 0.
We used the generated coefficients to model the continuous association of baseline and change in depressive symptom scores with the effectiveness of the intervention at promoting increased steps per day in those with a HADS score in the normal range between 0 and 7.
In addition, we report the intervention effect in those classified with mild to severe depression. To assess whether differences in the rates of those attending the primary initial intervention session or the annual follow-up maintenance sessions could confound interactions for the depressive or anxiety symptom scores, we assessed whether baseline depressive and anxiety symptom scores were associated with intervention attendance.
We also repeated the analysis when restricting the intervention sample to those who 1 attended the initial intervention session or 2 attended the initial intervention session and at least one follow-up maintenance session.
Data were analyzed in SPSS software version This study included 1, individuals who had concurrent steps-per-day and depressive symptom data at both baseline and follow-up, of whom were allocated to the control group and were allocated to the intervention group.
Supplementary Fig. On average, those included were 65 years of age and had a high BMI The numbers of steps per day taken by participants within each study at each time point are shown in Table 1. Within the pooled cohort at baseline, the control group took a mean SD of 6, 3, steps per day and the intervention group took 6, 3, steps per day.
Depressive symptom scores at baseline and follow-up within each study are presented in Supplementary Table 2. Figure 1 shows the modeled reduction in the intervention effect for every additional 1-unit-higher depressive symptom score within the normal range and how this varies if the score decreased or increased by 2 units from baseline to follow-up.
For example, those with a depressive symptom score of 0 at baseline and follow-up would, on average, increase their ambulatory activity by steps per day as a result of taking part in the intervention. For an individual with a depressive symptom score of 3, corresponding to the median level within the population, the mean intervention effect reduced to steps per day; however, this intervention effect could be increased to steps per day if depressive symptoms were reduced by 2 units between baseline and follow-up.
When the baseline depressive symptom score was 7, representing the upper limit of normal, no intervention effect occurred. Influence of depression score at baseline and change in depression score in modifying the effectiveness of the intervention at increasing steps per day.
Data are adjusted for follow-up time period and various patient characteristics, including sex, ethnicity, age, social deprivation, smoking status, previous cardiovascular disease, antidepressant medication use at baseline, and steps per day at baseline.
Ambulatory activity levels steps per day at follow-up in those categorized with mild to severe depression. Anxiety symptom scores at baseline and follow-up within each study are presented in Supplementary Table 3. Furthermore, the pattern of results for the depressive symptom score was maintained when we restricted the intervention group to those who attended the initial intervention session or those who attended the initial intervention session and at least one follow-up session Supplementary Fig.
In a pooled analysis of two randomized controlled diabetes prevention trials with physical activity interventions based on promoting walking, the presence and severity of depressive symptoms was associated with reduced effectiveness at promoting increased steps per day in a dose-response manner, even within normal ranges e.
Those without any depressive symptoms at baseline or follow-up increased their ambulatory activity by steps per day over a 3-year period; however, this intervention effect decayed by 88 steps per day for every additional 1-unit-higher depressive symptom score at baseline and by a further 99 steps per day for every 1-unit increase in the score between baseline and follow-up.
The secondary analysis found that anxiety did not modify the intervention, suggesting that the findings are specific to depression. To our knowledge, this is the first study to assess the impact of depression and anxiety symptom burden on change in physical activity objectively assessed following referral to a pragmatic diabetes prevention program within primary care.
The median symptom scores for depression and anxiety observed among the cohorts within this study are consistent with normative HADS data from primary care in England and are set against a background of an increasing prevalence of common mental health disorders more generally 32 , However, because changes in the depressive symptom score were also associated with the intervention effect, the majority would achieve a clinically meaningful increase in physical activity if depressive symptoms were reduced by at least two, which is potentially achievable through simple cognitive-behavioral interventions 34 — The results of this study contrast with those reported for the DPP, which did not find that baseline depression modified the effectiveness of the intervention at promoting increased physical activity 19 , However, physical activity was assessed by self-report, which is accompanied by substantial measurement error 19 , Depression was, however, found to predict objectively measured weight regain in the DPP 38 , supporting the impact of depression on lasting behavior change.
Our results are consistent with the wider physical activity literature, which has shown that depression or symptoms of depression are associated with a lower likelihood of achieving physical activity goals or engaging with physical activity interventions in older adults or following a coronary event 17 , Given the many benefits of physical activity to both cardiometabolic and mental health 12 — 16 , the potential for depressive symptoms to diminish intervention effectiveness is likely to be reinforced, whereby depression reduces the potential for promoting meaningful changes in physical activity, which in turn leads to a relative worsening of both cardiometabolic and mental health.
This is also consistent with the bidirectional association reported between type 2 diabetes and depression This study has important strengths and limitations.
Strengths include the population with a high risk of type 2 diabetes recruited from primary care and the pragmatic nature of the interventions, making both the population and the intervention reflective of real-world prevention.
In addition, the objective assessment of steps per day and the inclusion of studies that were conducted with the same standard operating procedures and physical activity intervention are strengths.
Finally, the randomized design of the studies included in this analysis strengthens the conclusions, especially for the intervention effect on physical activity. HADS is not an instrument for use in diagnosing depression or anxiety, and our results should therefore be interpreted as relating to the general burden of depressive and anxiety symptoms rather than the presence of a major affective disorder.
However, the modifying effect of depressive symptom scores was maintained within a per-protocol analysis, and the intervention attendance reflects that reported for implemented diabetes prevention services In addition, as the interventions included in this study were not aimed at reducing depression, we cannot assume causation with regard to the modifying effect of depression.
Further research is required to confirm whether introducing strategies to reduce depression will improve the effectiveness of interventions within diabetes prevention programs. In conclusion, this study suggests that the presence of depressive symptoms is associated with a reduction in the effectiveness of diabetes prevention programs at promoting physical activity within primary care.
Therefore, diabetes prevention programs should consider broadening their content to include a focus on depression as a core aim.
Simple tools—like HADS, used in this study—are available to help identify those who would benefit most from such an approach. However, considering the average levels of depressive symptoms observed in this cohort, a general focus on depression within diabetes prevention may benefit the majority of those referred.
Given that the intervention studies used in this analysis were not aimed at reducing depression, the hypotheses generated by this research need to be evaluated in future diabetes prevention trials or ongoing services.
Clinical trial reg. NCT and NCT , clinicaltrials. The authors thank the reviewers of this manuscript, who helped to improve the presentation and interpretation of data. This research was supported by the National Institute for Health Research NIHR Leicester Biomedical Research Centre, which is a partnership between the University Hospitals of Leicester National Health Service Trust, Loughborough University, and the University of Leicester.
Walking Away was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care CLAHRC Leicestershire, Northamptonshire and Rutland and CLAHRC East Midlands. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health.
Duality of Interest. chair , and M. were members of the National Institute for Health and Care Excellence NICE Public Health Guidance PH38 , Type 2 diabetes: prevention in people at high risk.
Author Contributions. analyzed the data and wrote the manuscript. conceived and designed the studies. analyzed and interpreted data, critically revised the manuscript, and approved the final version of the manuscript.
and C. acquired data. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest.
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Article Information. Article Navigation. Impact of Depression and Anxiety on Change to Physical Activity Following a Pragmatic Diabetes Prevention Program Within Primary Care: Pooled Analysis From Two Randomized Controlled Trials Thomas Yates Thomas Yates.
Corresponding author: Thomas Yates, ty20 le. This Site. Google Scholar. Laura J. Gray ; Laura J. Joseph Henson Joseph Henson. Charlotte L. Edwardson ; Charlotte L. Kamlesh Khunti Kamlesh Khunti. Melanie J. Davies Melanie J. Diabetes Care ;42 10 — Article history Received:.
Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. We used the same modeling to assess whether anxiety modified the intervention effect.
Maintenance pharmacotherapy refers to the practice of keeping patients on antidepressant medication beyond the point of depression remission to prevent or delay recurrence. The depression-free interval during follow-up was significantly three to four times longer in the group maintained on sertraline.
Glycemic control improved during open-label treatment and remained so in both treatment groups during the depression-free interval of maintenance. Other approaches to maintenance currently are being investigated. Without alteration in weight or body composition, physical activity improves insulin sensitivity, glycemic control, and compliance and provides useful adjunctive treatment for depression.
Our understanding of optimal treatment for depression in diabetic patients is evolving. At present, it is best understood as a process requiring simultaneous comprehensive care of both medical and psychiatric illness aspects.
We reviewed here evidence in support of a hypothesis that relief of depression may improve the medical prognosis, delaying development or slowing progression of diabetes. We think it important that both patients and providers recognize the implications of the hypothesis for individuals and for society: the genuine possibility that treatment of depression may promote health, even extend life.
At the same time we recognize the limited nature of the evidence presented and the somewhat speculative character of our argument. Apart from its effects on specific diabetes end points, depression remains an important focus of clinical care because of its beneficial effects on mood,functioning, and quality of life.
Williams, MD, is an instructor, and Ray E. Clouse, MD, is a professor in the Departments of Psychiatry and Medicine at Washington University School of Medicine in St. Louis, Mo. Patrick J. Lustman, PhD, is a professor in the Department of Psychiatry at Washington University School of Medicine and a counseling psychologist at the Department of Veterans Affairs Medical Center in St.
Clouse and Dr. Lustman have received research funding from GlaxoSmithKline to study the use of its bupropion hydrochloride extended-release tablet product for the treatment of depression in patients with diabetes. The writing of this article was supported in part by grants DK and DK from the National Institutes of Health, including the Alan A.
and Edith L. Wolff charitable trust fund in support of P50AG, and by a grant from the Sidney R. Baer, Jr. Williams is a recipient of the Alene and Meyer Kopolow award. Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Clinical Diabetes.
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Article Information. Article Navigation. Features April 01 Treating Depression to Prevent Diabetes and Its Complications:Understanding Depression as a Medical Risk Factor Monique M. Williams, MD ; Monique M.
Williams, MD. This Site. Google Scholar. Ray E. Clouse, MD ; Ray E. Clouse, MD. Lustman, PhD Patrick J. Lustman, PhD. Clin Diabetes ;24 2 — Get Permissions.
toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. IN BRIEF Current diabetes practice guidelines emphasize the need to augment conventional diabetes therapy with other evidence-based treatments that support improved diabetes outcomes.
Figure 1. View large Download slide. Figure 2. Table 1. Potential Mediators of Depression Effects on Risk and Progression of Diabetes. View large. View Large. Figure 3. Figure 4. Table 2. Table 3. BDI and PHQ Depression Screening Tools. Diabetes Care. J Clin Psychiatry.
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Thank diabetes-relatde for visiting nature. You diabetes-relayed using Glucose monitoring innovation browser version depreseion limited support for CSS. To obtain the Glucose monitoring innovation experience, we recommend you use Preventiing more up to date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. Depression and antidepressant medications increase risk for type 2 diabetes. Cambodian-Americans have exceedingly high rates of both depression and diabetes.
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