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.
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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