Differentiating symptoms of depression from diabetes-specific distress: relationships with self-care in type 2 diabetes
Open accessAbstract
Aims/hypothesisThe aim of this study was to examine the relationship between depressive symptoms and diabetes-specific distress and the independent relationships of each of these factors with diabetes self-care. We expected that symptoms of depression would be associated with poorer diabetes self-care, independent of diabetes-specific distress.MethodsWe surveyed 848 primary care patients with type 2 diabetes using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS), Problem Areas in Diabetes scale (PAID), Summary of Diabetes Self-Care Activities, and self-reported medication adherence.ResultsThe PAID and HANDS scores were positively correlated in the overall sample (r=0.54, p<0.0001), among those who did not meet diagnostic criteria for major depressive disorder (MDD) based on the HANDS screening result (n=685; r=0.36, p<0.001) and in patients who did meet the screening criteria for MDD (n=163; r=0.36, p<0.001). Higher PAID scores significantly predicted lower levels of diet, exercise and medication adherence (all p values <0.05). However, once depression symptom scores were entered into these models, most relationships were reduced to non-significance, while the HANDS score retained significant relationships with most indices of diabetes self-care. The same pattern of results was found in the subset of patients who did not screen positive for MDD.Conclusions/interpretationThese results suggest that specific symptoms of depression have a greater negative relationship with diabetes self-care than diabetes-specific distress, even among those patients who do not meet screening criteria for MDD. Interventions that focus on improving the management of specific symptoms of depression may be more effective in improving self-care than those that focus on reducing distress.
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0 of 9 cited sources checked · 0 supported · 0 flagged
- Findingown data
In models with PAID alone, higher PAID scores were significantly associated with less frequent exercise.
“while higher PAID scores were significantly associated with poorer adherence to general dietary recommendations, less spacing of carbohydrates, less frequent exercise, and non-adherence to prescribed medication (when each subscale was examined individually)”
Quote in the paperSubstantial claim - Findingown data
HANDS score did not reduce the relationship between PAID and high-fat food consumption.
“HANDS score, which was unrelated to high-fat food consumption, did not reduce this relationship.”
Quote in the paperSubstantial claim - Findingown data
Among patients who did not meet HANDS criteria for MDD (n=685), PAID and HANDS scores were positively correlated (r=0.36, p<0.001).
“among those who did not meet diagnostic criteria for major depressive disorder (MDD) based on the HANDS screening result (n=685; r=0.36, p<0.001)”
- Also stated in: § Results · plain
“in those patients who did not meet HANDS criteria for MDD (n=685; r=0.36, p<0.001)”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
HANDS score was unrelated to high-fat food consumption.
“HANDS score, which was unrelated to high-fat food consumption”
Quote in the paperNot a substantial claim - Findingown data
In models with PAID alone, higher PAID scores were significantly associated with less spacing of carbohydrates.
“while higher PAID scores were significantly associated with poorer adherence to general dietary recommendations, less spacing of carbohydrates, less frequent exercise, and non-adherence to prescribed medication (when each subscale was examined individually)”
Quote in the paperSubstantial claim
- Findingown data
Higher PAID scores were significantly related to more high-fat food consumption.
“Higher PAID scores were significantly related to more high-fat food consumption”
Quote in the paperSubstantial claim - Findingown data
In the full sample of 848 primary care patients with type 2 diabetes, scores on the PAID and HANDS were positively correlated (r=0.54, p<0.001).
“The PAID and HANDS scores were positively correlated in the overall sample (r=0.54, p<0.0001)”
- Also stated in: § Results · plain
“The PAID and HANDS were completed by 848 respondents and scores were positively correlated (r=0.54, p<0.001) in the overall sample”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
When HANDS score was added to the models, the relationships between PAID and general diet, carbohydrate spacing, exercise, and medication adherence were reduced to non-significance.
“these relationships were reduced to non-significance when HANDS score was added to the model.”
- Also stated in: § Results · plain
“once depression symptom scores were entered into these models, most relationships were reduced to non-significance”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
In models with PAID alone, higher PAID scores were significantly associated with non-adherence to prescribed medication.
“while higher PAID scores were significantly associated with poorer adherence to general dietary recommendations, less spacing of carbohydrates, less frequent exercise, and non-adherence to prescribed medication (when each subscale was examined individually)”
Quote in the paperSubstantial claim - Findingown data
Among patients who met HANDS screening criteria for MDD (n=163), PAID and HANDS scores were positively correlated (r=0.36, p<0.001).
“and in patients who did meet the screening criteria for MDD (n=163; r=0.36, p<0.001)”
- Also stated in: § Results · plain
“and among those who did meet screening criteria for MDD (n=163; r=0.36, p<0.001)”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
In models with PAID alone, higher PAID scores were significantly associated with poorer adherence to general dietary recommendations.
“while higher PAID scores were significantly associated with poorer adherence to general dietary recommendations”
Quote in the paperSubstantial claim - Findingown data
Neither HANDS nor PAID scores were associated with foot care.
“Neither HANDS nor PAID scores were associated with foot care.”
Quote in the paperNot a substantial claim - Premisecitation
Higher diabetes-specific distress is associated with poorer self-care.
“We have also observed that higher diabetes-specific distress is associated with poorer self-care [4].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [4] Delahanty LM, Grant RW, Wittenberg E et al (2007) Association of diabetes-related emotional distress with diabetes treatment in primary care patients with type 2 diabetes. Diabet Med 24:48–54 source
Not checked in the free run.
- Interpretationown data
Depressive symptoms are more consistently and strongly related to worse diabetes self-care than diabetes-specific distress, even among patients unlikely to meet MDD criteria.
“Our results also show that symptoms of depression are more consistently related to worse diabetes self-care than diabetes-specific distress.”
- Also stated in: § Discussion · boosted
“Our analysis demonstrates that depressive symptoms are a better predictor of diabetes self-care than diabetes-specific distress, even among those unlikely to meet criteria for MDD.”
- Also stated in: § Discussion · hedged
“our data suggest that depressive symptoms may be more problematic for diabetes self-care than the more general emotional reactions to diabetes captured by the PAID, even among those unlikely to meet criteria for MDD.”
Quote in the paperSubstantial claim - Also stated in: § Discussion · boosted
- Study design and conductown data
Controlling for prescription of antidepressants did not alter the results.
“Controlling for prescription of antidepressants did not alter these results (data not shown).”
Quote in the paperNot a substantial claim
- Classified as probably not a substantial claim. 6
- May combine two claims. 7
Probably not a substantial claim: may not pass S1 (asserted), S4 (based).
Findingown dataIn models including both PAID and HANDS, higher HANDS scores remained significantly associated with each of the diabetes self-care outcomes, independent of PAID score.
“In these models, higher levels of depressive symptoms remained significantly associated with each of the diabetes self-care outcomes, independent of PAID score.”
- Also stated in: § Results · plain
“while the HANDS score retained significant relationships with most indices of diabetes self-care.”
Quote in the paperNot a substantial claim- Also stated in: § Results · plain
May combine two claims.
Findingown dataIn the subsample of patients who did not meet MDD screening criteria, the pattern of relationships between PAID, HANDS and self-care was similar, except HANDS score was negatively related to high-fat food consumption.
“These relationships were paralleled in the subsample of patients who did not meet screening criteria for MDD, except that HANDS score was negatively related to high-fat food consumption (Table 2).”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductnone givenThe HANDS and PAID each had high internal reliability (0.85 and 0.95, respectively).
“Because the HANDS and PAID each had high internal reliability (0.85 and 0.95, respectively)”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationMeasurement inconsistencies complicate the conceptualisation of depression in diabetes and call into question how depression, especially as measured by depressive symptom scales, differs from diabetes-specific distress.
“Measurement inconsistencies complicate the conceptualisation of depression in diabetes and call into question how depression, especially as measured by depressive symptom scales, differs from diabetes-specific distress [1, 2].”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [1] Fisher L, Skaff MM, Mullan JT et al (2007) Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics. Diabetes Care 30:542–548 source
Not checked in the free run.
- cites [2] Hermanns N, Kulzer B, Krichbaum M, Kubiak T, Haak T (2006) How to screen for depression and emotional problems in patients with diabetes: comparison of screening characteristics of depression questionnaires, measurement of diabetes-specific emotional problems and standard clinical assessment. Diabetologia 49:469–477 source
Not checked in the free run.
May combine two claims.
PremisecitationLongitudinal data support the directionality of the relationship and show that baseline symptoms of depression and increases in depressive symptoms over time are each significantly associated with worse diabetes self-care 9 months later, even when baseline levels of self-care are controlled.
“we have recently published longitudinal data that support the directionality of this relationship and show that baseline symptoms of depression and increases in depressive symptoms over time are each significantly associated with worse diabetes self-care 9 months later, even when baseline levels of self-care are controlled [8].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [8] Gonzalez JS, Safren SA, Delahanty LM, et al. Symptoms of depression prospectively predict poorer self-care in patients with type 2 diabetes. Diabetic Medicine doi: 10.1111/j.1464-5491.2008.02535.x source
Not checked in the free run.
May combine two claims.
Interpretationown dataSymptoms of MDD and diabetes-specific distress are related but independent constructs, sharing 29% of variance in the overall sample and 13% among those not meeting MDD screening criteria.
“Our findings suggest that while symptoms of MDD and diabetes-specific distress are related, sharing 29% of their variance in the overall sample and 13% among those who did not meet screening criteria for MDD, they are independent constructs.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductnone givenThe study is limited by use of self-reports for self-care, which may overestimate true levels.
“Our study is limited by our use of self-reports for self-care, which may overestimate true levels.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim.
PremisecitationPreviously, Fisher and colleagues reported that diabetes-specific distress was a better predictor of diabetes self-care than symptoms of depression or a diagnosis of MDD.
“Previously, Fisher and colleagues reported that diabetes-specific distress was a better predictor of diabetes self-care than symptoms of depression or a diagnosis of MDD [1].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [1] Fisher L, Skaff MM, Mullan JT et al (2007) Clinical depression versus distress among patients with type 2 diabetes: not just a question of semantics. Diabetes Care 30:542–548 source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationAll models controlled for the same set of covariates as in the previous report to avoid potential demographic and illness-related confounding of measures of depression/diabetes-specific distress.
“all models controlled for the same set of covariates as in our previous report to avoid potential demographic and illness-related confounding of measures of depression/diabetes-specific distress [3].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [3] Gonzalez JS, Safren SA, Cagliero E et al (2007) Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. Diabetes Care 30:2222–2227 source
Not checked in the free run.
May combine two claims.
PremisecitationThe relationship between symptoms of depression and worse diabetes self-care is linear and extends to patients who do not meet screening criteria for MDD.
“We previously reported that the relationship between symptoms of depression and worse diabetes self-care is linear and extends to patients who do not meet screening criteria for major depressive disorder (MDD) [3].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3] Gonzalez JS, Safren SA, Cagliero E et al (2007) Depression, self-care, and medication adherence in type 2 diabetes: relationships across the full range of symptom severity. Diabetes Care 30:2222–2227 source
Not checked in the free run.
May combine two claims.
Study design and conductown dataCross-sectional data from a relatively ethnically homogeneous sample limit causal inferences.
“Further, these cross-sectional data, from a relatively ethnically homogeneous sample, limit causal inferences.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationThe HANDS screens for MDD by assessing symptoms over the prior 2 weeks.
“The HANDS screens for MDD by assessing symptoms over the prior 2 weeks [5].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [5] Baer L, Jacobs DG, Meszler-Reizes J et al (2000) Development of a brief screening instrument: The HANDS. Psychother Psychosom 69:35–41 source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationThe specific diet subscale was examined at the item level because of poor inter-item correlations.
“The specific diet subscale, which includes fruit and vegetable consumption, high-fat food consumption and spacing of carbohydrates, was examined at the item level because of poor inter-item correlations [6].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [6] Toobert DJ, Hampson SE, Glasgow RE (2000) The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care 23:943–950 source
Not checked in the free run.
The paper relies on this without support.
Before this study, no data existed on the relationship between scores on a diagnostic symptom-based MDD screen and diabetes-specific distress, and the relationship of PAID scores to type 2 diabetes self-care independent of MDD symptoms had not been examined.
“Data on the relationship between scores on a measure of diagnostic symptoms of MDD and diabetes-specific distress have not previously been available, and the relationship of the Problem Areas in Diabetes scale (PAID) scores to type 2 diabetes self-care, independent of MDD symptoms, has not been examined.”
Cites
The summary of diabetes self-care activities measure: results from 7 studies and a revised scale.
Toobert, D. J., Hampson, S. E., & Glasgow, R. E. (2000) · Diabetes Care · doi:10.2337/diacare.23.7.943 · Cited by 2,561 · see citing works
Assessment of Diabetes-Related Distress
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Depression, Self-Care, and Medication Adherence in Type 2 Diabetes
Gonzalez, J. S., Safren, S. A., Cagliero, E., Wexler, D. J., Delahanty, L., Wittenberg, E., Blais, M. A., Meigs, J. B., & Grant, R. W. (2007) · Diabetes Care · doi:10.2337/dc07-0158 · Cited by 579 · see citing works
Self-citationClinical Depression Versus Distress Among Patients With Type 2 Diabetes
Fisher, L., Skaff, M. M., Mullan, J. T., Arean, P., Mohr, D., Masharani, U., Glasgow, R., & Laurencin, G. (2007) · Diabetes Care · doi:10.2337/dc06-1614 · Cited by 465 · see citing works
Hermanns, N., Kulzer, B., Krichbaum, M., Kubiak, T., & Haak, T. (2006) · Diabetologia · doi:10.1007/s00125-005-0094-2 · Cited by 324 · see citing works
Diabetic Peripheral Neuropathy and Depressive Symptoms
Vileikytė, L., Leventhal, H., Gonzalez, J. S., Peyrot, M. F., Rubin, R. R., Ulbrecht, J. S., Garrow, A. P., Waterman, C. G., Cavanagh, P. R., & Boulton, A. J. M. (2005) · Diabetes Care · doi:10.2337/diacare.28.10.2378 · Cited by 286 · see citing works
Self-citationDelahanty, L. M., Grant, R. W., Wittenberg, E., Bosch, J. L., Wexler, D. J., Cagliero, E., & Meigs, J. B. (2007) · Diabetic Medicine · doi:10.1111/j.1464-5491.2007.02028.x · Cited by 248 · see citing works
Self-citationSymptoms of depression prospectively predict poorer self‐care in patients with Type 2 diabetes
Gonzalez, J. S., Safren, S. A., Delahanty, L. M., Cagliero, E., Wexler, D. J., Meigs, J. B., & Grant, R. W. (2008) · Diabetic Medicine · doi:10.1111/j.1464-5491.2008.02535.x · Cited by 192 · see citing works
Self-citationDevelopment of a Brief Screening Instrument: The HANDS
Baer, L., Jacobs, D. G., Meszler-Reizes, J., Blais, M., Fava, M., Kessler, R., Magruder, K., Murphy, J., Kopans, B., Cukor, P., et al. (2000) · Psychotherapy and Psychosomatics · doi:10.1159/000012364 · Cited by 128 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Schmitt, A., Gahr, A., Hermanns, N., Kulzer, B., Huber, J., & Haak, T. (2013) · Health and Quality of Life Outcomes · doi:10.1186/1477-7525-11-138 · Cited by 587 · see citing works
Constructs of depression and distress in diabetes: time for an appraisal
Snoek, F. J., Bremmer, M. A., & Hermanns, N. (2015) · The Lancet Diabetes & Endocrinology · doi:10.1016/s2213-8587(15)00135-7 · Cited by 449 · see citing works
Prospective Associations Between Emotional Distress and Poor Outcomes in Type 2 Diabetes
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Addressing diabetes distress in clinical care: A practical guide
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Strandberg, R. B., Graue, M., Wentzel-Larsen, T., Peyrot, M., & Rokne, B. (2014) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2014.06.015 · Cited by 208 · see citing works
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Gonzalez, J. S., Kane, N. S., Binko, D. H., Shapira, A., & Hoogendoorn, C. J. (2016) · Diabetes Care · doi:10.2337/dc16-1657 · Cited by 80 · see citing works
Self-citationDistress and Type 2 Diabetes Self-Care: Putting the Pieces Together
Hoogendoorn, C. J., Schechter, C. B., Llabre, M. M., Walker, E. A., & Gonzalez, J. S. (2021) · Annals of Behavioral Medicine · doi:10.1093/abm/kaaa070 · Cited by 28 · see citing works
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- Authors
- Gonzalez, J. S., Delahanty, L. M., Safren, S. A., Meigs, J. B., & Grant, R. W.
- Affiliations
- Harvard University (US)
- Corresponding author
- Gonzalez, J. S.
- Venue
- Diabetologia
- Published
- 2008-08-09
- Volume
- 51
- Issue
- 10
- Pages
- 1822-1825
- ISSN
- 0012-186X (ISSN-L)
- 1432-0428
- PMC
- PMC2678064
- OpenAlex
- W2118613065
- Semantic Scholar
- 0e9feb763e8a70109c9256d2a4553f5fcb8e4e88
- Cited by
- 117
- References
- 9
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 5 · 2023: 6 · 2022: 11 · 2021: 1 · 2020: 5 · 2019: 9 · 2018: 4 · 2017: 10 · 2016: 11 · 2015: 14 · 2014: 8 · 2013: 7 · 2012: 8
- FWCI
- 2.89
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Diabetologia (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- American Diabetes Association
- Pfizer
- GlaxoSmithKline
- Sanofi
- Massachusetts General Hospital
- National Institutes of Health (1r01mh078571-01)
- National Institute of Mental Health (1R01MH078571, R01 MH-078571)
- National Institute of Diabetes and Digestive and Kidney Diseases (DK080140, DK067452, K24DK080140, K23DK067452)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Keywords
- depression, type 2 diabetes, diabetes self-care, medication adherence, dietary adherence, exercise adherence, major depressive disorder, primary care patients, Problem Areas in Diabetes scale
- MeSH terms
- Depression, Diabetes Mellitus, Diabetes Mellitus, Type 2, Female, Humans, Male, Patient Compliance, Self Care, Stress, Psychological
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