close

Вход

Забыли?

вход по аккаунту

?

Burden of illness metabolic control and complications in relation to depressive symptoms in IDDM patients

код для вставкиСкачать
ORIGINAL ARTICLES
Burden of Illness, Metabolic Control,
and Complications in Relation to
Depressive Symptoms in IDDM Patients
B. Karlson*1, C.-D. Agardh2
1
Department of Applied Psychology, Lund University, Lund, Sweden
Department of Internal Medicine, University Hospital, Lund,
Sweden
2
Relationships between demographic-, treatment-, and sickness-related factors, metabolic
control (HbA1c), perceived burden of illness, and degree of depressive symptoms were
examined in a group of 155 insulin-dependent diabetic patients, aged 35.3 ± 8.9 years.
The patients completed a questionnaire measuring depressive symptoms and three aspects
of perceived burden of illness. No gender differences in HbA1c level or occurrence of late
diabetic complications were found. Both men and women showed a modestly elevated
degree of depression compared with norm groups. Self-reported burden of illness was
strongly related to depression but was largely unrelated to objective disease-related
measures. Level of depression was correlated neither with degree of metabolic control
nor with the presence of such late diabetic complications as retinopathy and nephropathy.
Some 44 % of the variance in depression could be explained by worries about complications
in those patients with the lowest HbA1c levels, by perceived restrictions in everyday life
in patients with intermediate metabolic control, and by problems of glycaemic regulation
in patients with poor metabolic control. Degree of depression was largely unrelated to
disease severity, but was found to be related to the perceived daily burden of living with
the disease, the specific worries and concerns associated with a depressed mood varying
with degree of metabolic control.  1997 by John Wiley & Sons, Ltd.
Diabet. Med. 14: 1066–1072 (1997)
No of Figures: 1.
KEY WORDS
No of Tables: 3. No of Refs: 20
psychosocial adaptation; depression; disease perception; type 1 diabetes
mellitus
Received 29 July 1996; revised 9 April 1997; accepted 28 April 1997
Introduction
Whereas patients with chronic disease have been found
generally to have an increased frequency of anxiety,
affective and other psychiatric disorders,1,2 in patients
with diabetes mellitus a depressed affect is more common.
This may range from a depressed mood,3 through a subclinical depressive state, to a genuine clinical depression,
the latter having been reported to be more common
than in the general population.2 The aetiology of
depression in diabetes is not fully understood and
is probably multifactorial.4 The presence of chronic
complications in diabetes has been found to be associated
with depression in some 5 but not all studies,6–9 whereas
diabetes duration does not appear to be related.4 In
some studies, an association between poor metabolic
control and depression has been obtained8,10 but very
strict glycaemic control can also contribute to
depression.4 A causal relationship between diabetes
control and depression is difficult to establish, particularly
*Correspondence to: Björn Karlson, Lund University, Department of
Applied Psychology, Paradisgatan 5, S-223 50 Lund, Sweden.
Sponsors: Malmöhus läns landstings utvecklingsfond
1066
CCC 0742–3071/97/141066–07$17.50
 1997 by John Wiley & Sons, Ltd.
since depression may be primary and be associated with
decreased adherence to therapy, just as poor glycaemic
control and its associated malaise may render the
individual more susceptible to psychiatric illness.2,8
Worries about glycaemic control and diabetic complications may be causally linked to a depressive state.4
Sanders et al.11 found that fear for the future and fear of
severe hypoglycaemia were common sources of anxiety
and depression in diabetic patients. Connell et al.12 also
found the perceived threat of diabetes to be related to
depression. Although in the non-diabetic population
depression is reported to be more common in women,13
this relationship has not always been found in patients
with diabetes.9
The aim of the present study was to examine relationships between self-reported measures of the perceived
burden of illness and the level of depressive symptoms,
as well as relationships of both of these measures to
objective demographic-, treatment-, and sickness-related
factors, in patients with insulin-dependent (Type 1)
diabetes mellitus (IDDM). We also set out to determine
the contribution of these various factors to depressive
symptoms in the patients studied.
DIABETIC MEDICINE, 1997; 14: 1066–1072
ORIGINAL ARTICLES
Patients and Methods
Patients
A sample of 200 patients aged 35.3 ± 8.9 years
(mean ± SD) was selected by drawing every second
patient from a list of patients, sorted by date of birth,
comprising all patients who visited the outpatient diabetes
clinic of the Department of Internal Medicine at the
University Hospital in Lund, Sweden during a 5-month
period. Of the 200 questionnaires, 155 (77.5 %) were
analysable when returned, 43.6 % of the patients in this
final group being women (aged 35.1 ± 8.3 years, with a
diabetes onset at the age of 16.5 ± 9.7 years and a
diabetes duration of 18.9 ± 9.9 years) and 56.4 % being
men (aged 35.6 ± 9.3 years, with a diabetes onset at the
age of 17.6 ± 10.6 years and a diabetes duration of
17.2 ± 11.3 years). HbA1c measures were available for
152 subjects and documentation of late diabetic complications was available from the medical records for 129.
All the patients were insulin-dependent, 87.6 % showing
a diabetes onset prior to age 30 and 12.4 % an onset
beween the ages of 30 and 41. The insulin dosage was
44.3 ± 20.1 IU day−1 and injection regimens varied: one
injection (5.5 %), two injections (28.3 %), three (25.2 %),
four or more (39.4 %), and insulin pump (CSII: 1.6 %).
The study was approved by the ethics committee of
Lund University, subjects giving their informed consent
to participate.
Testing Procedures and Self-reported
Measures
A questionnaire consisting of two parts was mailed to
the patients. The time frame for assessment was the
preceding 2 weeks. The first part was the depression
scale from the Symptom Check List SCL-90,14 for which
a standardized sum score (range 0–4) was computed.
The other part, referred to as the ‘Burden of Illness’ (BI)
questionnaire, consisted of seven questions concerning
three different aspects of BI. Two of these aspects, each
assessed by a separate question, concerned the degree
to which the subject had been distressed by worries
concerning late diabetic complications and by perceived
difficulties in maintaining blood glucose control during
the preceding two weeks. The third aspect was assessed
by five questions that comprised a ‘Restrictions’ scale,
concerning the extent to which the presence of diabetes
was found to be disturbing by the need to be tied to
fixed hours; the need for careful everyday planning; by
restrictions of eating and drinking and on doing things
they wanted to do, and by their daily living being
restricted by hypoglycaemia or the fear of it. The five
items on the scale employed the same type of Likert
scale as the SCL-90 and a standardized sum score similar
to that for the SCL-90 was computed.
The level of depression in the group was compared
with that of two control groups described in the SCL-90
DEPRESSIVE SYMPTOMS IN DIABETES MELLITUS
 1997 by John Wiley & Sons, Ltd.
manual,15 one a group of non-diabetic healthy subjects
and the other a group of psychiatric outpatients, the
mean scores for each gender being transformed separately
into T-scores on the basis of the scores of the two
control groups.
Medical Measures
The patients’ degree of metabolic control was assessed
by measuring glycosylated haemoglobin (HbA1c ) levels
within 6 weeks before or after they answered the
questionnaire. The following diabetic complications were
classified on the basis of the patients’ medical records:
retinopathy (background or proliferative), nephropathy
(incipient nephropathy, i.e. urinary albumin 30–
300 mg l−1; or clinical, i.e. urinary albumin .300 mg l−1
and/or serum creatinine .116 mmol l−1 for men and
.100 mmol l−1 for women). Hypertension was defined
as a diastolic blood pressure of $90 mmHg being
obtained and/or a systolic blood pressure $160 mmHg
and/or antihypertensive treatment being prescribed.
Analytical Techniques
Glycosylated haemoglobin (HbA1c) levels were analysed
by fast liquid chromatography (normal value , 5.3 %).
Urinary albumin concentration was measured by turbidimetry using an automated analyser (Cobras Mira,
Roche), antibodies (rabbit anti-human albumin), and
a technique described by Dakopatts in Copenhagen;
detection limit 5 mg l−1. Serum creatinine concentration
was measured by the kinetic Jaffe technique.
Statistics
Since subjects with different levels of HbA1c may differ
in their perception of and adaptation to their disease,
they were divided in terms of their HbA1c level into
three groups (HbA1c ,6.9 %, 6.9–8.6 %, and .8.6 %,
the first and last of these comprising the lowest and
highest quartiles, respectively).
For analysing differences between these groups and
between insulin regimens, the chi-square test for trend
was employed for the categorical variables, and the
ANOVA test for trend, using linear contrast, for the
continuous data. An ordinary chi-square test was used
for examining gender differences in the case of categorical
variables. Correlations of variables were computed as
Eta coefficients for gender, as Spearman’s correlations
for ordinal data and dummy variables, and otherwise as
Pearson’s product–moment correlations. In order to
reduce the risk for type 1 errors, for the data presented
in Table 1 only group differences with p-values ,0.01
were considered as significant, and for the data presented
in Table 2 only correlations for which p , 0.001, although
p-values ,0.01 are also indicated. A hierarchical multiple
regression analysis was employed for predicting the level
of depression on the basis of certain of the variables. In
1067
Diabet. Med. 14: 1066–1072 (1997)
ORIGINAL ARTICLES
Table 1. Characteristics of the HbA1c subgroups
,6.9
(n = 38)
Total group
(n = 155)
M
Age (years)
Age at diabetes onset (years)
Diabetes duration (years)
Insulin dosage (IU day−1)
HbA1c (%)
35.3
16.9
17.8
44.6
7.8
n
Gender (men/women)
Number of injections day−1
1–2
3
.3 or CSII
Retinopathy
no signs
background
proliferative
Nephropathy
no signs
incipient
clinical signs
Hypertension
yes
no
Antihypertensive treatment
yes
no
.8.8
(n = 39)
6.9 – 8.8
(n = 75)
SD
M
SD
M
SD
M
SD
8.9
10.1
10.6
19.8
1.4
34.2
17.8
15.2
38.5
6.0
8.6
10.2
10.7
15.3
0.7
36.8
16.2
19.6
45.3
7.7
9.3
10.2
11.0
14.3
0.5
33.8
17.7
17.0
47.6
9.6
8.2
10.3
9.2
29.9
0.7
%
n
%
n
%
n
%
88/68 56.4/43.6 20/18 52.6/47.4 44/31 58.7/41.3 20/18 56.4/43.6
43
30
52
34.4
24.0
41.6
9
8
14
29.0
25.8
45.2
19
17
26
30.6
27.4
41.9
15
5
12
46.9
15.6
37.5
48
52
26
38.1
41.3
20.6
14
14
3
45.2
45.2
9.6
21
25
15
34.4
41.0
24.6
11
13
8
34.4
40.6
25.0
93
25
9
73.2
19.7
7.1
26
3
2
83.9
9.7
6.5
42
15
5
67.7
24.2
8.1
23
7
2
71.9
21.9
6.3
21
107
16.4
83.6
1
30
3.2
96.8
10
53
15.9
84.1
10
22
31.3
68.8
19
109
14.8
85.2
1
30
3.2
96.8
10
53
15.9
84.1
8
24
25.0
75.0
P-value
0.78
0.64
0.50
0.03
1.0
0.24
0.17
0.45
0.003
0.02
In the lower part of the table, column percentages are given
p-values refer to comparisons of the subgroups. Continuous data were analysed by a one-way ANOVA test for trend using linear contrast. For
categorical data the chi-square test for trend was employed.
the correlation and regression analyses, retinopathy and
nephropathy were recorded into two dichotomized (0, 1)
dummy variables. For the first of these dummy variables,
1 indicates the lack of retinopathy or of nephropathy,
respectively, in contrast to its presence. For the second
dummy variable, 1 indicates the presence of the most
severe complications (proliferative retinopathy and clinical signs of nephtopathy, respectively), in contrast to
having no complications or less severe ones. The number
of insulin doses was dummy coded in a similar way.
For the first dummy variable, 1 indicates having less
than three injections per day. For the other dummy
variable, 1 indicates either having more than three
injections per day or receiving CSII treatment. The
reliability of the Restrictions scale was computed as
Cronbach’s alpha, based on internal consistency. When
used to test another group of Type 1 diabetic patients
(n = 82), the Restrictions scale had been found to
have satisfactory reliability (Cronbach’s alpha = 0.86,
unpublished data), as was the case in this study as well
(Cronbach’s alpha = 0.85). The demonstration of such
high and quite similar alpha coefficients in two separate
samples of insulin-dependent diabetic patients further
1068
Diabet. Med. 14: 1066–1072 (1997)
supports the reliability of the scale. Since it could be
argued that the Restrictions scale simply measures aspects
of depression, a factor analysis including the SCL-90
items and the seven BI items was conducted, using a
varimax rotation. Three factors with Eigenvalues greater
than 1.0 and explaining 63 % of the total variance were
extracted. The first factor comprised all but one of the
depression items, the second factor comprised the five
Restrictions scale items, and the third factor comprised
the two questions concerning glucose regulation and
worries concerning complications, as well as the
depression scale item of ‘crying easily’ (the Eigenvalues
of the three factors were 9.5, 2.0, and 1.0, respectively).
The factor solution thus supports the cohesiveness and
face validity of the Restrictions scale and its measuring
something different from depressive symptoms. The third
factor included the two BI questions associated with the
medical outcome of the disease and one of the depression
items, its thus not appearing to primarily indicate
depression. The two BI questions belonging to the third
factor were treated as individual variables in order to
take account of the uniqueness of their respective
contents. Calculations were carried out using SPSS
for Windows.
B. KARLSON, C.-D. AGARDH
 1997 by John Wiley & Sons, Ltd.
ORIGINAL ARTICLES
Table 2. Correlations between self-reported and objective data
Depressive
symptoms r
Demographic data
Gender
Age
Diabetes duration
Age at onset
Medical status
HbA1c
Retinopathy
no signs
proliferative
Nephropathy
no signs
clinical signs
Hypertension
Antihypertensive treatment
Insulin regimen
Insulin dosage (IU day−1)
Number of injections day−1
,3
.3 or CSII
Depressive symptoms
Restrictions r Complication
worries
Glycaemic
regulation
problems r
−0.24a
0.07
0.00
0.14
−0.12
0.10
−0.11
0.18
−0.18
0.04
0.00
0.06
−0.23a
0.00
−0.07
0.11
0.15
0.14
0.20a
0.40c
−0.10
−0.03
0.04
−0.12
−0.19
0.06
−0.09
0.03
−0.04
−0.07
−0.03
−0.02
0.03
−0.18
0.01
−0.06
0.00
−0.12
0.23a
0.20
0.04
−0.02
0.09
0.06
0.13
0.04
0.08
0.10
0.10
−0.07
0.08
−0.17
0.56b
0.19
−0.14
0.52b
0.03
−0.04
0.56b
Significance testing of Eta coefficient for gender, of Spearman rank correlations for independent variables of
ordinal data level and of Pearson’s product–moment correlation for interval data variables, are two-tailed.
Male = 1; female = 0. a = p , 0.01, b = p , 0.0001.
Results
Group Characteristics
The HbA1c level was 7.8 % ± 1.4 (mean ± SD) for the
entire group, no significant differences being found either
between the insulin regimens or for gender. Background
retinopathy was present in 41.7 %, proliferative retinopathy in 20.5 %, incipient nephropathy in 19.5 %,
and clinical nephropathy in 7.0 % of the patients.
Hypertension was present in 17.3 % of the patients, most
of whom (91 %) were on antihypertensive treatment. No
differences in the occurrence of any of the complications
were found between genders or between the insulin regimens.
The mean scores on the depression scale were
1.1. ± 0.9 for the women and 0.7 ± 0.7 for the men. The
T-score for the entire group was 63 on the basis of the
scores for the non-diabetic healthy control group and
42 on the basis of those for the psychiatric outpatient
group. The mean scores for each of the three HbA1c
subgroups on the depression scale and the Burden of
Illness scales are shown in Figure 1. The groups differed
in worries about complications (p = 0.02) and perceived
glycaemic regulation problems (p , 0.0001). For the
latter, pairwise comparisons showed the low and intermediate HbA1c level subgroups to differ from the high
subgroup. Demographic and medical characteristics of
DEPRESSIVE SYMPTOMS IN DIABETES MELLITUS
 1997 by John Wiley & Sons, Ltd.
Figure 1. Burden of Illness and depressive symptoms in the
HbA1c subgroups
the total group and the HbA1c levels for the subgroups
are shown in Table 1.
Correlations Between Psychological
Variables and Demographic and Medical
Variables
Correlations between all the independent variables and
the three BI subscales (restrictions, complication worries,
1069
Diabet. Med. 14: 1066–1072 (1997)
ORIGINAL ARTICLES
and glycaemic regulation problems) as well as depressive
symptom scores are shown in Table 2.
Depressive symptom scores were found to be significantly correlated with all three BI subscales (p , 0.001)
and showed a weak positive correlation with female
gender (p , 0.01) whereas no correlation was found
with HbA1c, age, age at onset, diabetes duration or the
occurrence of any particular type of diabetic complications.
The three BI subscales correlated positively with each
other (p , 0.0001). The degree of restrictions reported
was not correlated with any of the other variables, and
worries about complication showed only weak positive
correlations with HbA1c level and with hypertension
(p , 0.01 for both). Perceived problems of glycaemic
regulation, however, were positively correlated with
HbA1c level (r = 0.40, p , 0.0001). Thus, there were
almost no zero-order correlations between the objective
data and the self-reported measures, although the latter
were correlated with each other.
The report of perceiving oneself to have problems in
glycaemic regulation was thus related both to depression
(Table 1) and to HbA1c, although depression and HbA1c
were not significantly correlated with each other (r = 0.15,
p = 0.06). When ‘perceived glycaemic regulation problems’ was controlled for, the correlation between HbA1c
and depression was reduced (r = −0.10, p = 0.23), indicating most of the overlap between HbA1c and depression
to be accounted for by these self-reported problems
in regulation.
Interactions
To analyse whether relations between the three aspects
of perceived burden of illness and depression differed
with respect to level of metabolic control, interaction
effects between the BI variables and HbA1c subgroups
in accounting for the degree of depression were tested
by analysis of variance. Interaction effects were found
between HbA1c subgroup membership and the ‘complication worries’ (p , 0.0001) and ‘restrictions’ (p = 0.005)
variables, but not ‘perceived glycaemic regulation problems’ (p = 0.07). This indicates the level of depression
associated with different worries or concerns to differ
between various levels of glycaemic regulation.
Regression Analysis
A multiple regression analysis was conducted to determine the relative contribution to the depressive symptom
scores of variables being entered hierarchically in blocks,
first the demographic variables (gender, age, age at
diabetes onset, and diabetes duration), then those of
treatment regimen (insulin dosage and number of injections or CSII), then the objective disease-related measures
(the complications), and finally the variables of interaction
between the HbA1c subgroups and the three BI aspects.
In a second regression analysis, only those variables
1070
Diabet. Med. 14: 1066–1072 (1997)
shown to contribute significantly in each block were
included, again entered hierarchically in blocks. As
shown in Table 3, the initial contribution of female
gender disappeared when the interaction variables were
entered. Interactions which contributed to the degree of
depression were found between good metabolic control
and ‘complication worries’ (p , 0.0001), between intermediate metabolic control and ‘perceived restrictions’
(p = 0.001), and between poor metabolic control and
‘perceived glycaemic regulation problems’ (p , 0.002).
Altogether, 44.0 % of the variance in depression could
be explained. Thus, the BI variables differed in the levels
of glycaemic regulation at which they contributed most
to the variance in depression.
Discussion
The relative contributions of demographic-, treatmentand sickness-related variables and Burden of Illness to
level of depression in insulin-dependent diabetic patients
was examined by use of multivariate analysis after
certain relationships between the variables assessed had
been explored.
Although the term depression is sometimes used in
this study, this does not refer to clinically diagnosed
depression, but rather to a broad range of depressive
symptoms, measured dimensionally by use of the SCL90. In our study women displayed higher depression
scores than men, in accordance with previous epidemiological studies in the general population.5 The difference
was of the same magnitude as that obtained in the control
groups included in the SCL-90 manual.15 Reference to
the control groups indicated the depression level in the
present group to be above the mean for a group of nondiabetic healthy subjects and below that for a psychiatric
outpatient group, for both the men and the women.
Thus, the elevation in the level of depressive symptoms
was about the same for both genders.
Each of the three separate aspects of BI was shown to
be a dimension which differed from depression but was
related to the level of depressive symptoms. This is in
line with other findings, showing a strong relationship
between threat of illness and depression.12
‘Perceived glycaemic regulation problems’ was also
found to be related to HbA1c and accounted for the
overlap between HbA1c and depression. It can be
conceived as a link between the latter two variables,
although the mechanisms of such an indirect relationship
may be of various kinds. Patients with poor metabolic
control may worry about not being able to regulate their
glycaemia, worries which may result in depression.
Conversely, patients who for any reason are depressed,
and perceive themselves as having problems in regulating
their glucose levels, may be more likely to have poor
metabolic control, due either to ineffectiveness in coping
emotionally with stress 16 or to difficulties in adherence
to a regimen. However, the weak correlation between
HbA1c and depression, and the complex causal relationB. KARLSON, C.-D. AGARDH
 1997 by John Wiley & Sons, Ltd.
ORIGINAL ARTICLES
Table 3. Relations of depressive symptom scores in the patients as a whole to demographic, medical, and attitude variables.
Regression analysis was performed hierarchically in blocks
Variables
Values at the end of each block
Slope
SE of slope
Stand. regr.
coeff.
95 % CI
p-value
Overall R2
(%)
Block 1
Gender
−0.39
0.13
−0.24
−0.64–−0.14
0.003
5.8
Block 2
Gender
HbA1c low group × complication worry
HbA1c mid group × restrictions
HbA1c high group × glycaemia
regulation problem
−0.10
0.45
0.37
0.40
0.11
0.10
0.11
0.13
−0.06
0.53
0.40
0.55
−0.31–0.11
0.26–0.64
0.15–0.58
0.15–0.65
0.36
,0.0001
0.001
0.002
44.0
Male = 1; female = 0. The last three variables of block 2 are interaction terms between the BI variables and the low, mid and high subgroups
of HbA1c, defined as HbA1c ,6.9, 6.9–8.8, and .8.8 %, respectively.
ship between the two,8 call for caution in interpreting
the results.
Complication worries and perceived glycaemic regulation problems, but not perceived lifestyle restrictions
and depression, increased from the lowest to the highest
HbA1c level subgroup. People in different levels of
metabolic control differed in the major worries and
concerns connected with their depression. Although
those with good metabolic control were characterized
by the lowest degree of worry of the three groups
regarding complications, a high degree of depression
was found to be associated with that worry rather than
with the other aspects of burden of illness. One can
speculate that their good metabolic control may have
been the result of their aims of preventing complications,
worry about this making them feel depressed, whereas
perceived restrictions did not have this effect, these
patients possibly finding them to be worthwhile. Low
emotional well-being in metabolically well-regulated
patients has been suggested previously to be due to
over-ambitious aims and to feelings of failure.17 In
contrast, for those with an intermediate level of metabolic
control a depressed mood was mainly associated with
perceived restrictions. Such patients may be thought to
have adopted a less tight metabolic control in order to
cope with their major concerns. The depressed mood in
the most poorly regulated patients was associated, in
particular, with their experiencing problems of glycaemic
regulation, which may indicate feelings of failure to cope
were dominating.
Degree of depression was not found to be related to
any of the chronic complications. This failed to lend
support to the assumption that depression is directly
related to the severity of the disease. The Burden of
Illness variables were likewise not related to the presence
of these chronic complications. The absence of such
direct relationships may be due to most patients adapting
to the development or worsening of late diabetic
complications, and to the depressed mood elicited by
DEPRESSIVE SYMPTOMS IN DIABETES MELLITUS
 1997 by John Wiley & Sons, Ltd.
such somatic changes, this being part of a transient crisis
reaction. It should be noted, however, that data were
not available regarding all the complications, for example
macrovascular disease and neuropathy, both of which
have been reported to be associated with a decreased
quality of life. 18
Depression was found to be related more to daily
concerns or worries regarding glycaemic regulation,
restrictions in activities, and anticipated complications,
the impact of these different worries on mood varying
with glycaemic control level. The relations found between
depression and burden of illness are open to various
interpretations. The increase in the prevalence of
depression that has been reported in diabetes2 may result
from perceived burden of illness, in line with previous
findings showing threat of illness to be strongly related
to depression.12 Another interpretation is that depression
in diabetic patients, whatever its basis may be, negatively
affects the experiencing of the disease. Such reported
perceptions and depressive symptoms may be a function,
in turn, of dimensions not measured in the present study,
such as personality traits, adaptive strategies, or the state
or trait of negative affectivity that has been described
as a general tendency toward distress and negative
reporting.19–20 Clinically, one should be sensitive to the
fact that diabetic patients’ depressive feelings may be
largely unrelated to the severity of the disease per se,
being related instead to their perceptions of the daily
burdens of living with their condition. The specific
worries and concerns of patients with depressed mood
varies with degree of metabolic control.
Acknowledgements
We thank A. Sternerup-Hansson, Lund University Computing Centre, and M. Hagnell and P.-E. Isberg, Department of Statistics, Lund University, for statistical advice.
The study was supported by grants from Malmöhus läns
lanstings utvecklingsfond.
1071
Diabet. Med. 14: 1066–1072 (1997)
ORIGINAL ARTICLES
References
1. Klerman GL. Depression in the medically ill. Psychiatr
Clin North Amer 1981; 4: 301–317.
2. Gavard JA, Lustman PJ, Clouse RE. Prevalence of
depression in adults with diabetes. An epidemiological
evaluation. Diabetes Care 1993; 16: 1167–1178.
3. Surridge DHC, Williams Erdahl DL, Lawson JS, Donald
MW, Monga TN, Bird CE, Letemendia FJJ. Psychiatric
aspects of diabetes mellitus. Br J Psychiatry 1984; 145:
269–276.
4. Lustman PJ, Griffith LS, Gavard JA, Clouse RE. Depression
in adults with diabetes. Diabetes Care 1992; 15: 1631–
1639.
5. Haire-Joshu D, Heady S, Thomas L, Schechtman K, Fisher
EB Jr. Depressive symptomatology and smoking among
persons with diabetes. Res Nurs Health 1994; 17: 273–282.
6. Robinson N, Fuller JH, Elmeades SP. Depression and
diabetes. Diabetic Med 1988; 5: 268–274.
7. Leedom L, Meehan WP, Procci W, Zeidler A. Symptoms
of depression in patients with type II diabetes mellitus.
Psychosomatics 1991; 32: 280–286.
8. Lustman PJ, Griffith LS, Clouse RE, Cryer PE. Psychiatric
illness in diabetes mellitus. J Nerv Ment Dis 1986; 174:
736–742.
9. Popkin MK, Callies AL, Lentz RD, Colon EA, Sutherland
DE. Prevalence of major depression, simple phobia and
other psychiatric disorders in patients with long-standing
type I diabetes mellitus. Arch Gen Psychiatry 1988; 45:
64–68.
10. Mazze RS, Lucido D, Shamoon H. Psychological and
social correlates of glycemic control. Diabetes Care 1984;
7: 360–366.
1072
Diabet. Med. 14: 1066–1072 (1997)
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Sanders K, Mills J, Martin FIR, Horne DJDeL. Emotional
attitudes in adult insulin-dependent diabetics. J Psychosom
Res 1975; 19: 241–246.
Connell CM, Wayne KD, Gallant MP, Sharpe PA. Impact
of social support, social cognitive variables, and perceived
threat on depression among adults with Diabetes. Health
Psychol 1994; 13: 263–273.
Hagnell O, Essen-Möller E, Lanke J, Öjesjö L, Rorsman
B. The Incidence of Metal Illness over a Quarter of a
Century. Stockholm: Almqvist & Wiksell International,
1990.
Derogatis LR, Lipman RS, Covi L. SCL-90: An outpatient
psychiatric rating scale-preliminary report. Psychopharmacol Bull 1973; 9: 13–28.
Derogatis LR. SCL-90-R. Administration, Scoring and
Procedures. Manual II. Towson: Clinical Psychometric
Research Inc., 1992.
Peyrot MF, McMurray JF Jr. Stress buffering and glycaemic
control. The role of coping styles. Diabetes Care 1992;
15: 842–846.
Lundman B, Asplund K, Norberg A. Tedium among
patients with insulin-dependent diabetes mellitus. J Adv
Nurs 1988; 13: 23–31.
Lloyd CE, Matthews KA, Wing RR, Orchard TJ. Psychosocial factors and complications of IDDM. The Pittsburgh
Epidemiology of Diabetes Complications Study. VIII.
Diabetes Care 1992; 15: 166–172.
Costa PT, McCrae RM. Neuroticism, somatic complaints,
and disease: Is the bark worse than the bite? J Pers 1987;
55: 299–316.
Watson D, Pennebaker JW. Health complaints, stress,
and distress: exploring the central role of negative
affectivity. Psychol Rev 1989; 96: 234–254.
B. KARLSON, C.-D. AGARDH
 1997 by John Wiley & Sons, Ltd.
Документ
Категория
Без категории
Просмотров
3
Размер файла
91 Кб
Теги
illness, burden, patients, metabolico, relations, symptom, complications, depression, control, iddm
1/--страниц
Пожаловаться на содержимое документа