Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis

Aims. To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi- directional association between depression and diabetes macrovascular and microvascular complications. Methods. Embase, Medline, and PsycINFO databases were searched from inception through 27th November 2017. A total of 4,592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Results. 22 studies were included in the systematic review. 16 studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over 1 million participants were suitable for meta-analysis. Depression was associated with an increased risk for incident macrovascular (Hazard Ratio HR=1.38; 95%CI: 1.30-1.47) and microvascular disease (HR=1.33; 95%CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR=1.14; 95%CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Conclusions. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research

Comment on the consensus report on the management of hyperglycaemia in Type 2 diabetes by the American Diabetes Association and the European Association for the Study of Diabetes

Letter to the edito

Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis

Aims. To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi- directional association between depression and diabetes macrovascular and microvascular complications. Methods. Embase, Medline, and PsycINFO databases were searched from inception through 27th November 2017. A total of 4,592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Results. 22 studies were included in the systematic review. 16 studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over 1 million participants were suitable for meta-analysis. Depression was associated with an increased risk for incident macrovascular (Hazard Ratio HR=1.38; 95%CI: 1.30-1.47) and microvascular disease (HR=1.33; 95%CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR=1.14; 95%CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Conclusions. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research

Diabetes Self-Management Decrements Mediate the Relation of Stressful Life Events and Hemoglobin A1c-Differences by Race/Ethnicity in Adolescents

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Hypoglycaemia induces emotional disruption

This study investigated how hypoglycaemia affects mood, and whether psychological characteristics mediate an emotional disturbance during hypoglycaemia. Ten IDDM patients (1 female) were studied, aged [mean (range)] 28 (20-37) years, body mass index (BMI) 23.4 (19.6-25.7) kg/m2 diabetes duration 11 (7-15) years, HbA1c 7.5 (6.0-8.7)%. Patients underwent a standardized stepwise, hypoglycaemic, hyperinsulinaemic clamp, performed in steps of 0.5 mmol/l from 4.0 mmol/1 to a glucose nadir of 2.0 mmol/l. At euglycaemia, the Symptom Checklist-90 (SCL-90) was administered. The Profile of Mood States (POMS) was completed at 4.0 and 2.5 mmol/l, while the feelings chart of the COOP/WONCA was filled out at euglycaemia and all hypoglycaemic steps. Results: The t-test for the POMS demonstrated a significant increase for anger (P < 0.05). COOP/WONCA scores displayed a progressive negative change in mood for each hypoglycaemic step, albeit with a large interindividual variability. Hostility (SCLr90) significantly interacted with anger (POMS) at 2.5 mmol/l (P < 0.05). Conclusions: Progression of hypoglycaemia negatively alters the overall mood state. IDDM patients characterised by high scores on hostility (SCL-90) apparently are more prone to experience an increase in anger (POMS) during hypoglycaemia

Examining the Behaviour subscale of the Hypoglycaemia Fear Survey: an international study

The Hypoglycemia Fear Survey (HFS)-II Behaviour and Worry subscales were developed to measure behaviours and anxiety related to hypoglycaemia in diabetes. However, previous studies found lower reliability in the HFS Behaviour subscale and inconsistent relationships with glucose control. The purpose of this study was to conduct extensive analyses of the internal structure of the HFS Behaviour subscale's internal structure and its relationships with diabetes outcomes, including HbA1c and episodes of severe hypoglycaemia. HFS-II survey data from 1460 adults with Type 1 diabetes were collected from five countries. This aggregated sample underwent exploratory factor analysis and item analysis to determine the internal structure of the survey and subscales. A three-factor solution showed the best fit for the HFS, with two subscales emerging from the HFS Behaviour representing tendencies towards (1) maintenance of high blood glucose and (2) avoidance of hypoglycaemic risks by other behaviours, and a third single HFS Worry subscale. Subscale item analysis showed excellent fit, separation and good point-measure correlations. All subscales demonstrated acceptable (0.75) to excellent (0.94) internal reliability. HbA(1c) correlated with Maintain High Blood Glucose subscale scores, r = 0.14, P < 0.001, and severe hypoglycaemia frequency correlated with all subscales. The HFS Worry subscale measures one construct of anxiety about various aspects of hypoglycaemia. In contrast, the HFS Behaviour subscale appears to measure two distinct aspects of behavioural avoidance to prevent hypoglycaemia, actions which maintain high blood glucose and other behaviours to avoid hypoglycaemic risk. These results demonstrate the clinical importance of the HFS Behaviour subscales and their differential relationships with measures of diabetes outcome such as HbA1

Substitution of night-time continuous subcutaneous insulin infusion therapy for bedtime NPH insulin in a multiple injection regimen improves counterregulatory hormonal responses and warning symptoms of hypoglycaemia in IDDM

In patients with insulin-dependent diabetes mellitus (IDDM) good glycaemic control confers an enhanced risk of hypoglycaemia. Nocturnal hypoglycaemia occurs frequently and contributes to the syndrome of hypoglycaemia unawareness. In order to avoid nocturnal hypoglycaemia we substituted night-time continuous subcutaneous insulin infusion (CSII) therapy in 14 patients with well-controlled IDDM using a multiple injection regimen for the more variable bedtime NPH insulin. During a stepwise hypoglycaemic clamp we studied the effect of this regimen on counterregulatory hormonal responses, warning symptoms and cognitive function. In addition, we investigated the incidence of daytime hypoglycaemia and the acceptability of night-time CSII treatment. CSII was associated with a lower frequency of hypoglycaemia (mean ± SEM): 16.1 ± 3.1 vs 23.6 ± 3.3) episodes during the last 6 weeks of treatment, p = 0.03 (CSII vs NPH)) with maintenance of good glycaemic control (HbA(1c) 7.2 ± 0.2 vs 7.1 ± 0.2%, p = 0.2). Hypoglycaemic thresholds for the growth hormone response and for autonomic symptoms were lower for CSII treatment than for NPH treatment. Of 14 patients 6 decided to continue with the nocturnal CSII treatment. In conclusion, nocturnal CSII improves warning symptoms and counterregulatory hormonal responses to hypoglycaemia and is an acceptable treatment strategy for patients suffering from hypoglycaemia unawareness, as demonstrated in this acute feasibility study

Longitudinal associations between depression and diabetes complications: A systematic review and meta-analysis

To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi-directional association between depression and diabetes macrovascular and microvascular complications. Embase, Medline and PsycINFO databases were searched from inception through 27 November 2017. A total of 4592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Twenty-two studies were included in the systematic review. Sixteen studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over one million participants were suitable for meta-analysis. Depression was associated with an increased risk of incident macrovascular (HR = 1.38; 95% CI: 1.30-1.47) and microvascular disease (HR = 1.33; 95% CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two studies involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR = 1.14; 95% CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research

Comment on the consensus report on the management of hyperglycaemia in Type 2 diabetes by the American Diabetes Association and the European Association for the Study of Diabetes

We read with interest the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) joint consensus report on the management of hyperglycaemia in Type 2 diabetes. Following publication of the report, discussions of the content among networks of behavioural and educational researchers prompted us to write this letter