Treatment of subclinical depression with a CBT program (DIAMOS): Results of a prospective randomized, controlled study
- Depression without meeting the criteria of a major depression. However,
elevated depressive symptoms are associated with a reduced quality of
life, lower self-care activities, and a higher mortality. To target this large
group of people, a diabetes-specific treatment program (DIAMOS) was
developed and evaluated in a randomized controlled trial with a 12-month
DIAMOS is a group program based on cognitive-behavioral-therapy
(CBT). It consists of 5 group sessions which lasts for 90 minutes each. 214
inpatients with subclinical depression were randomized either to DIAMOS
or to a control group receiving diabetes education. Depression, diabetesrelated
distress, and quality of life were assessed via questionnaires (CES-D,
PAID, WHO-5 respectively). HbA1c was analyzed in a central laboratory.
181 patients (age: 45±14 yrs.; 57% female; 63% Type 1 DM; diabetes
duration 15±11 yrs.; 95% with insulin; 51% with late complications; HbA1c
8.8±1.7%; CES-D 23.3±8.1; PAID 39.5±18.4; WHO-5 8.9±4.5) were available
at the 12-month follow-up (drop-out rate: 15%). Compared to the control
group, patients treated with DIAMOS showed a significantly greater reduction of depressive symptoms (- 7.4 ± 11.4 vs. - 2.7 ± 11.7; p < .01), and
diabetes-related distress (- 13.0 ± 18.9 vs. - 4.2 ± 16.9; p < .01), as well as a
significantly greater improvement of quality of life (+ 4.5 ± 6.1 vs. + 2.5 ± 6.3;
p = .03). HbA1c improvement was comparable in both groups.
The results demonstrate that DIAMOS is an effective tool for the
treatment of subclinical depression in people with diabetes. In addition,
DIAMOS positively affects diabetes-related distress and quality of life.
Interestingly, the reduction of depressive symptoms and distress was not
associated with an improvement of glycemic control. DIAMOS proofs to be
an innovative tool for routine care to improve the situation of people with
diabetes and subclinical depression.
The effect of a diabetes-specific cognitive behavioural treatment programme (DIAMOS) for people with diabetes and subthreshold depression
- Background and aims: Subthreshold depression is one of the most frequent
mental comorbidities in people with diabetes and is associated with a poorer
long-term prognosis. Since specific intervention concepts are missing a new
self-management oriented group programme (DIAMOS) was developed for
this patient group and evaluated in a randomised trial.
Materials and methods: The active control group (CG) received diabetes education.
DIAMOS consisted of cognitive behavioural interventions aiming at
the reduction of diabetes distress. Patients completed several questionnaires
at baseline and follow-up: The Center of Epidemiological Studies-Depression
Scale (CES-D), the Patient Health Questionnaire (PHQ 9), the Problem Areas
in Diabetes Questionnaire (PAID) and the Diabetes Distress Scale (DDS).
Primary outcome was the reduction of depressive symptoms. Secondary outcomes
were diabetes distress, well-being, self-care behaviour, diabetes acceptance,
diabetes treatment satisfaction, HbA1c and inflammatory markers. 214
participants were randomised.
Results: Baseline characteristics (age 43.3 ±13.3 yrs., female gender 56.5%,
diabetes duration 14.2 ±10.5 yrs., type 2 diabetes 34.1%, BMI 28.7 ±71 kg/m²)
were comparable between both interventions groups except BMI and diabetes
type. At 12-month follow-up there was a significant greater reduction
of the CESD- and PHQ 9-scores in DIAMOS compared to the CG (Δ -3.7,
95%-CI 0.57 to 6.85 p=.021 respectively Δ -1.49, 95%-CI 0.08 to 2.90; p=.039
). The risk of incident major depression was reduced (OR 0.63, 95%-CI 0.42
to 0.96, p=.028) Also PAID-scores (Δ -8.3 95%-CI 3.33 to 12.72, p=.001) and
DDS-scores (Δ -0.22 95%-CI 0.02 to 0.42, p=.042) were significantly reduced.
C-reactive protein was significantly more lowered (Δ -0.25 95%-CI 0.02 to
0.48 p=.035). No effect of the intervention was observed in other inflammatory
markers (IL1RA, IL6 and adiponectin).
Conclusion: DIAMOS is more effective in lowering depressive symptoms
and diabetes related distress in diabetic patients with subthreshold depression.
DIAMOS also has a preventive effect regarding the incidence of major
The Diabetes Self-Management Questionnaire (DSMQ) can detect inadequate self-care behaviour and help identify patients at risk of a negative diabetes prognosis
- Background and aims: Existing psychometric instruments to assess diabetes
self-management often reveal weak or inconsistent associations with ‚hard
data‘ such as medical outcomes and HbA1c. To fill this gap, the Diabetes SelfManagement
Questionnaire (DSMQ) was developed, focussing on self-care
activities which directly impact medical diabetes outcomes. This study evaluates
the questionnaire’s practical utility in detecting high-risk patients at a
tertiary diabetes centre.
Materials and methods: 226 people with diabetes (age 43 ± 15 y.; 55% female;
BMI 29 ± 7; 70% type 1 diabetes; illness duration 15 ± 10 y.; 92% treated
with insulin; HbA1c 8.9 ± 1.6%) were assessed with the DSMQ and further
questionnaires regarding diabetes acceptance (AADQ), coping with illness
(FQCI), treatment satisfaction (DTSQ), diabetes distress (PAID), and depressive
symptoms (CES-D); additional data (demographic variables, self-monitoring
of blood glucose, HbA1c, and long-term complications) were gained
from electronic patient records. People were then categorized by a median
split of the DSMQ total score into groups performing ‘adequate’ (n = 107)
versus ‘inadequate’ diabetes self-care (n = 119); the groups were compared
regarding relevant outcomes using multivariate ANOVA (subsequently presented
data are M ± SD, F statistic, and effect size Cohen’s d).
Results: After adjusting for sex, age, BMI, diabetes type, diabetes duration,
and type of treatment, people performing ‘inadequate self-care’ compared to
those with ‘adequate self-care’ showed stronger diabetes non-acceptance (31
± 8 vs. 22 ± 6, F = 90.5, d = 1.24), less active coping with diabetes (2.7 ± 0.9
vs. 3.4 ± 0.8, F = 18.1, d = 0.82), lower diabetes treatment satisfaction (20 ± 7
vs. 24 ± 6, F = 21.3, d = 0.60), higher diabetes distress (43 ± 21 vs. 33 ± 19, F
= 17.0, d = 0.85), and more depressive symptoms (24 ± 11 vs. 20 ± 11, F = 4.8,
d = 0.36). Moreover, they performed fewer blood glucose self-tests (3.3 ± 3.5
vs. 5.6 ± 2.4 times per day, F = 24.7, d = 0.74), consulted their diabetologist
less often (1.9 ± 1.8 vs. 2.6 ± 2.3 times per half-year, F = 6.6, d = 0.34), had a
higher HbA1c value (9.5 ± 1.5 vs. 8.2 ± 1.4%, F = 34.6, d = 0.87), and showed
a higher prevalence of retinopathy (28% vs. 14%, F = 6.0, d = 0.35).
Conclusion: The DSMQ yields excellent distinction between people with
diabetes performing adequate versus insufficient diabetes self-care, thus enabling
detection of people at high risk of a negative diabetes prognosis. The
16-item questionnaire is an efficient tool which may be used for screening
and diagnostic purposes or clinical diabetes research.
A new assessment tool to measure the ability of Bolus Calculation and Carbohydrate Estimation (SMART) in people with diabetes performing an intensive insulin therapy
- Background and aims: Intensive insulin therapy relies on correct prandial
insulin dose adaptation dependent from current glucose level, amount of
planned carbohydrate intake and the consideration of other situational factors
like physical activity or circadian fluctuation of insulin sensitivity. People
with diabetes and intensive insulin therapy should be able to estimate carbohydrates
and calculate insulin bolus correctly, while regarding the factors
mentioned above. An assessment tool for the measurement of the ability of
carbohydrate estimation and bolus calculation is missing. The objective of
this study was the development and psychometric evaluation of an assessment
tool for carbohydrate estimation and bolus calculation (“aSsessMent of
the Ability of Bolus Calculation and CaRbohydrate esTimation” SMART). Of
special interest were the associations of both abilities with glycaemic control.
Materials and methods: The SMART consisted of one scale for the assessment
of bolus calculation (BOLUS) with 10 items and a scale for carbohydrate
estimation (CARB) with 12 items. People with type 1 or type 2 diabetes
on an intensive insulin regimen were invited to participate. HbA1c and stored
data of blood glucose meters were used to determine glycaemic control.
Results: 411 patients participated (age 42.9 ±15.7, 58% female, HbA1c 8.6
±1.8%, 28% with CSII-treatment) and approx. 56,000 blood glucose meter
readings could be obtained. The reliability of both scales was sufficient (Cron-bachs alpha for BOLUS r= 0.78 and the CARB r = 0.67). Better bolus calculation
was associated with a higher level of education (r = 0.24, p<.05), lower
HbA1c (r = -0.27, p<.05), lower mean blood glucose (r = -0.29, p<.05), and
a lower standard deviation of blood glucose values (r = -0.43, p<.05). Better
carbohydrate estimation was associated with a lower body mass index (r =
-0.2, p<.05), lower mean blood glucose (r = -0.3, p<.05), a lower frequency of
hyperglycaemia (r = -0.27, p<.05), and a higher frequency of euglycaemia (r
= 0.26, p<.05). Patients with an insulin pump were better on both scales than
patients with multiple daily insulin injections (BOLUS: 7.2 ± 2.4 vs. 6.4 ± 2.7,
p<.01; CARB: 7.8 ± 2.1 vs. 7.1 ± 2.6, p<.01). Patients with previous diabetes
education performed significantly better on both scales (BOLUS: 6.8 ± 2.5 vs.
5.7 ± 2.8, p<.01; CARB: 7.4 ± 2.4 vs. 6.5 ± 2.6, p<.01).
Conclusion: SMART provides a reliable and valid assessment of the ability to
estimate the correct amount of carbohydrates and to calculate the appropriate
prandial insulin dose. SMART is also sensitive to depict effects of diabetes
education and of CSII treatment in comparison to multiple daily insulin
injections. In summary SMART can assist the identification of people with
diabetes on an intensive insulin regimen, who are in need for improvements
in carbohydrate estimation and/or calculation of prandial insulin dose
The Influence of Diabetes-related Distress on Depression
- Depressive disorders in diabetic patients are nearly twice as likely
compared to the non-diabetic population. There is evidence that patients’
perception of diabetes is a decisive aspect of this association. Therefore this
study prospectively investigates the role of patients’ perceived diabetesrelated
distress on incidence depression and recovery.
343 patients with type 1 diabetes completed the CES-D and the Problem
Areas in Diabetes Scale (PAID) at baseline and at the 6-month follow-up. A
CES-D score of ≥16 indicated elevated depressive symptoms. A PAID score
of ≥30 indicated elevated diabetes-related distress. Logistic regression
analyses were performed with recovery from and incidence of depressive
symptoms as dependent variables. Independent variable was diabetesrelated
distress adjusted for possible demographic (age, gender, BMI) and
medical confounders (diabetes duration, HbA1c, insulin pump therapy, and
At baseline 130 patients (37.9%) reported elevated depressive symptoms
and 40 of these patients (30.8%) recovered 6 months later. Of the 213 patients
without elevated depressive symptoms, 27 (12.7%) had elevated depressive
symptoms 6 months later. Diabetes-related distress at baseline diminished
the chance to recover from elevated depressive symptoms by 64% (OR =
0.36, p<.05). In addition, the chance for incident depressive symptoms if
diabetes-related distress was present at baseline is 2.5 times more likely in
contrast to no diabetes-related distress at baseline (OR=2.5; p<.05). In both
analyses, no other variables reached a signifi cant infl uence.
It could be demonstrated that preventing diabetes-related distress is a
protective factor regarding the incidence of elevated depressive symptoms.
Furthermore, preventing diabetes-related distress supports the recovery
from already elevated depressive symptoms. This supports the notion that
diabetes per se is not a risk factor for depressive disorders but the perceived
emotional distress is.
Phonological determinants of grammatical variation in English: Chomsky’s worst possible case
Constraints on the attributive use of 'predicative only' adjectives : A reassessment
Early Modern English: Phonology
- In the Early Modern English period, English underwent a number of substantial
changes in all phonological subsystems, which transformed the Middle English
system into a distinctly modern one. The present chapter highlights in turn changes in
lexical stress patterns, the reduction of unstressed syllables, changes in the
distribution of certain consonants and their allophones (in particular /h/, [ç], [x], /r/),
the reduction of consonant clusters (including the emergence of the novel /ʒ/ and /ŋ/
phonemes) and changes in the vowel system. A large part of the chapter is devoted to
the important shifts undergone by the latter category of sounds in the Early Modern
era; yet it excludes the massive turnover known as the Great Vowel Shift (which is
treated in a separate chapter of the present handbook). The vowel changes are, for
expository purposes, subdivided into unconditioned and conditioned changes; the
subsystems of long vowels, diphthongs and short vowels are treated separately. The
chapter describes the most important qualitative changes in long vowels (beyond the
Great Vowel Shift), the monophthongization of many ME diphthongs, the
development of some of the short vowels, and the interfering effect of certain
consonantal environments, partly leading to phonemic splits.
Low arousing positive affect broadens visual attention and alters the thought-action repertoire while broadened visual attention does not
- The Broaden-and-Build Theory states that positive emotions broaden cognition and
therefore build personal resources. However, missing theoretical precision regarding the
interaction of the cognitive processes involved offers a variety of possible explanations
for the mechanisms of broadening and building. In Experiment 1 we tested the causality
assumption which states that positive emotions first broaden visual attention which in
turn leads to broadened cognition. We examined the effects of a broadened, narrowed
or neutral attentional scope of 72 subjects (30 men) on their momentary thought-action
repertoire. Results showed that there were no significant differences between groups
regarding the breadth or the content of the thought-action repertoire. In Experiment 2 we
studied the non-causality hypothesis which assumes a non-causal relationship between
cognitive processes. We did so by investigating the effects of negative, neutral, and
positive affect on the visual attentional scope of 85 subjects (41 men) in Experiment 2a,
as well as on the thought-action repertoire of 85 participants (42 men) in Experiment 2b.
Results revealed an attentional broadening effect in Experiment 2a but no differences
between groups concerning the breadth of the thought-action repertoire in Experiment
2b. However, a theory driven content analysis showed that positive affect promoted
social actions. Thus, our results favor the non-causality assumption. Moreover, results
indicate that positive emotions do not target personal resources in general but rather
resources associated with social behavior. In conclusion, we argue that the Broadenand-
Build Theory should be refined.
Magnetometry of neolithic sites in the Mil Plain of Azerbaijan
- Ergebnisse geophysikalischer Prospektionen in der Milsteppe in Aserbaidschan