REVIEW JOURNAL 1

Title Psychological aspects of diabetes care: Effecting behavioral change in patients.

Edition World J Diabetes 2014 December 15; 5(6): 796-808 ISSN 1948-9358

Boon-How Chew, Sazlina Shariff-Ghazali, Aaron Fernandez

Background Patients with diabetes mellitus (DM) need psychological support throughout
their life span from the time of diagnosis.

The psychological make-up of the patients with DM play a central role in self-
management behaviors. Without patient’s adherence to the effective therapies,
there would be persistent sub-optimal control of diseases, increase diabetes-
related complications, causing deterioration in quality of life, resulting in
increased healthcare utilization and burden on healthcare systems.

However, provision of psychosocial support is

generally inadequate due to its challenging nature of needs and demands on the
healthcare systems

Objective This review article examines patient’s psychological aspects in general,

elaborates in particular about emotion effects on health, and emotion in
relation to other psychological domains such as cognition, self-regulation, self-
efficacy and behavior.

Some descriptions are also provided on willpower, resilience, illness

perception and proactive coping in relating execution of new behaviors, coping
with future-oriented thinking and influences of illness perception on health-
related behaviors

Main Point An international survey, the Diabetes Attitudes, Wishes and Needs second
study (DAWN2), included over 16000 individuals (comprising patients, family
members and healthcare providers) in 17 countries across four continents,
reported that the proportion of the people with DM who were likely to have
depression and diabetes-related distress (DRD) was 13.8% and 44.6%,
respectively, with overall poor quality of life at 12.2%[8].

DM had a negative impact on many aspects of life, ranging from 20.5% on

relationship with family or friends to 62.2% on physical health. About 40%
(18.6%-64.9%) of these patients reported their medication interfered with their
ability to live a normal life[8]. Furthermore, these patients often use negative
coping strategies and more frequently perceive that diabetes would negatively
affect their future[4,7]. Untreated psychosocial disorders in DM, may lead to
more physical symptoms[9], cardiovascular complications[10] and
depression[11,12]. Depression may lead to cognitive decline and further
 aggravate thevicious cycles of self-care ability.

Illness Perception
Illness perceptions involve beliefs, cognitive and emotional representations or
understandings that patients have about their illness[93]. These perceptions
have been found to be associated with health behaviors and clinical outcomes,
such as treatment adherence and functional Recovery.

Negative Psychological Effects On Diabetes Mellitus

In adults, children and adolescents with DM, depression was related to poorer
glycemic control, a range of diabetes complications, increased health care
costs, worsened functional disability, re-hospitalization and early mortality[
101]. Those with psychological distress at the time of diagnosis had a higher
risk of cardiovascular events (1.7-fold) and death (1.8-fold) than those without
psychological distress[102].

Psychological Intervention In Diabetes Care

The psychosocial supports through caring and compassionate family, friends,
health care professionals, and even other patients with DM could instill a
positive outlook, sense of resilience and wellbeing in patients with DM.
Screening, evaluation and management of psychological disorders such as
depression and DRD in people with DM in primary care are feasible.

Indeed, positive psychosocial factors are important mediators or independent

predictors of clinical outcomes in chronic diabetes care and positively related
to self-care behaviors[124

Conclusion Understanding the nature of the psychological aspects that are pertinent in
patients with DM, and the links between the emotional disorders (stress,
distress, anxiety, DRD and depression) and inflammation has provided a
mechanistic insight into the relationships between psychological domains and
poor physical health[34].

Positive emotional health may sustain long-term coping efforts and protect
patients from the negative consequences of prolonged emotional
disorders[143], illness perception and thus facilitating diabetes self-
management behaviors and better physical health.
 REVIEW JOURNAL 2

Title Prevalence and correlates of psychological distress among diabetes mellitus

adults in the Jilin province in China: a cross- sectional study

Edition PEER J, 2017

Shuang Qiu1,*, Xuan Hong Sun1,*, Wen Ya Liu1, Joseph Sam Kanu1, Ri Li1,
Qin Ya Yu1, Feng Xu Huang2, Bo Li1 and Yang Xiang Zhang3

Background Psychological disorders are common in diabetes mellitus (DM) patients.

Objective aim of this study was to estimate the prevalence of psychological distress and
to determine the influence factors associated with psychological distress
among DM patients in the Jilin province of China.

Methods Multistage, stratified cluster sampling was used in this cross- sectional study.
The 12-item General Health Questionnaire (GHQ-12) was used to assess
psychological status with the total score of ≥ 4 as the threshold for
psychological distress.

Results A total of 1,956 subjects with DM were included in the study. Out of this total
diabetic participants, 524 (26.8%) had psychological distress. Multiple logistic
regression analysis showed that low educational level, divorce or separation
from one's spouse, low family average monthly income, short sleep duration,
being aware of DM status, and multiple co-morbidities are positively
associated with psychological distress (all P <0:05).

Conclusion This study revealed a high rate of psychological distress among DM population
in Jilin province. Low educational level, divorce or separation from one's
spouse, low family average monthly income, short sleep duration, awareness of
DM status, and multiple co-morbidities are all associated with psychological
distress among our study subjects. Interventions to control these factors are
needed to address the psychological problems among diabetics in Jilin
Province.

Main Point Psychological disorders of DM patients are significantly associated with non-
adherence to healthy lifestyle guidelines, thus increasing the risk for serious
complications that may decrease patients' quality of life and result in premature
death.
 REVIEW JOURNAL 3

Title Comparative study of the influence of diabetes distress and depression on

treatment adherence in Chinese patients with type 2 diabetes: a cross-sectional
survey in the People’s Republic of China

Edition Neuropsychiatric Disease and Treatment

Jie Zhang et all, 30 August 2013

Objective The purpose of this study was to explore diabetes-related distress and
depression and their influence on treatment adherence in Chinese patients with
type 2 diabetes.

Methods We surveyed 200 type 2 diabetic patients from two public hospitals using the
Diabetes Distress Scale (DDS), Zung Self-rating Depression Scale, and
Revised Treatment Adherence in Diabetes Questionnaire (RADQ). A multiple
regression model was used to explore the relationship between diabetes
distress, depression, and treatment adherence
Results In the 200 eligible patients, the incidence of depression and diabetes distress
was approximately 24% and 64%, respectively. The mean score on the RADQ
was 23.0 ± 6.0. Multiple regression analysis showed that DDS scores (β =
5.34, P = 0.000), age (β = 0.15, P = 0.014), and family history (β = 3.2, P =
0.016) had a positive correlation with depression. DDS scores (β = −2.30, P =
0.000) and treatment methods (β = −0.93, P = 0.012) were risk factors for poor
treatment adherence, whereas age (β = 0.089, P = 0.000) and cohabitation (β =
0.93, P = 0.012) increased treatment adherence. The independent-samples t-
test showed that depression also affected treatment adherence (t = 2.53, P ,
0.05).
Conclusion These findings suggest that the DDS is a predictor of depression and that dia-
betes distress plays a more important part than depression in treatment
adherence. Screening for diabetes distress may be useful for primary
prevention of psychologic problems; however, some form of specialized
psychologic intervention should be incorporated to promote patient adherence
with treatment.
Main Point Depression has been shown to affect diabetes treatment outcomes and patient
self-management behaviors. However, there is some evidence showing that the
negative influence of depression on diabetes could also be explained by
diabetes distress.3
Diabetes distress is defined as patient concern about disease management,
support, emotional burden, and access to care,4 and has been considered as
part of a more global approach to the psychologic issues associated with
diabetes
 REVIEW JOURNAL 4

Title Diabetes-Related Distress, Depression and Distress-Depression among Adults

with Type 2 Diabetes Mellitus in Malaysia

Edition PLOS ONE | DOI:10.1371/journal.pone.0152095 March 22, 2016

Boon-How Chew1,2*, Rimke Vos2, Sherina Mohd-Sidik3, Guy E. H. M.

Rutten2

Background Type 2 diabetes mellitus (T2DM) brings about an increasing psychosocial

problem in adult patients. Prevalence data on and associated factors of diabetes
related distress (DRD) and depression have been lacking in Asia.

Objective This study aimed to examine the prevalence of DRD and depression, and their
associated factors in Asian adult T2DM patients

Methods This study was conducted in three public health clinics measuring DRD
(Diabetes Distress Scale, DDS), and depression (Patient Health Questionnaire,
PHQ). Patients who were at least 30 years of age, had T2DM for more than
one year, with regular follow-up and recent laboratory results (< 3 months)
were consecutively recruited. Associations between DRD, depression and the
combination DRD-depression with demographic and clinical characteristics
were analysed using generalized linear models

Results From 752 invited people, 700 participated (mean age 56.9 years, 52.8%
female, 52.9% Malay, 79.1%married). Prevalence of DRD and depression
were 49.2%and 41.7%, respectively.

Conclusion DRD and depression were common and correlated in Asian adults with T2DM
at primary care level. Socio-demographic more than clinical characteristics
were related to DRD and depression.

Main Point  Type 2 diabetes mellitus (T2DM) brings about an increasing psychosocial
problem in adult Patients.
 The most common psychological disorders experienced by adult T2DM
patients are diabetes related distress (DRD) and depressive disorders [14–17].
 A study in the United States (US) showed that over 18 months, T2DM
patients who ever experienced major depressive disorder (MDD) and DRD
were about 20% and 30%, respectively [16].
 Also in the United Kingdom, adults with T2DM were, after controlling for
age, gender, ethnicity, and socioeconomic status, more likely to suffer from
these common mental disorders [14].
 Reported prevalence of DRD in Europe and the US is between 15% and 20%
[18–20].
 DRD and depression in adult T2DM patients have been associated with
somatic symptoms [21], smoking behaviours [22] and disease control.
 A larger study with longer follow up demonstrated an association between
decreased quality of life with either DRD or depression[25].
 Also, diabetes-related complications and mortality are associated with DRD
and depression [26, 27].
 Other risk factors for DRD and/or depression in T2DM patients include
adherence to the complex therapeutic requirement [28], insulin initiation
[29]; the quality of social support [30] and inter-personal relationships with
others including spouses [31, 32].
 REVIEW JOURNAL 5

Title Distress and Diabetes Treatment Adherence: A Mediating Role for Perceived
Control

Edition Health Psychol. Author manuscript; available in PMC 2016 May 01.

Jeffrey S. Gonzalez1,2, Erica Shreck1, Christina Psaros3, and Steven A. Safren

Objective To understand independent pathways linking emotional distress, medication

adherence and glycemic control in adults with type 2 diabetes, as well as the
potential mediating effects of perceived control over illness and self-efficacy.

Methods Adults with type 2 diabetes (N = 142) were recruited for an intervention study
evaluating cognitive behavioral therapy for adherence and depression.
Depressive symptom severity was assessed via semi-structured interview.
Validated self-reports assessed diabetes-related distress, perceived control over
diabetes (perceived control), self-efficacy for diabetes self-management and
medication adherence. Glycemic control was evaluated by hemoglobin A1c
(A1C). Only baseline data were included in correlational and linear regression
analyses.

Diabetes-related Distress—Emotional distress related to the burdens of

diabetes and its treatment was evaluated with the Diabetes Distress Scale (DDS)
(Polonsky et al., 2005).

Results Perceived control was an important mediator for both medication adherence and
A1C outcomes. Specifically, regression analyses demonstrated that diabetes
distress, but not depression severity, was significantly related to medication
adherence and A1C.

Conclusion Results demonstrate that diabetes-related emotional distress is associated with

poorer treatment adherence and glycemic control among adults with type 2
diabetes; these relationships were partially mediated through perceived control
over diabetes.
 REVIEW JOURNAL 6

Title Testing the effectiveness of a mindfulness-based intervention to reduce

emotional distress in outpatients with diabetes (DiaMind): design of a
randomized controlled trial

Edition van Son et al. BMC Public Health 2011, 11:131

http://www.biomedcentral.com/1471-2458/11/131

Background Approximately 20-40% of outpatients with diabetes experience elevated levels

of emotional distress, varying from disease-specific distress to general
symptoms of anxiety and depression. The patient’s emotional wellbeing is
related to other unfavorable outcomes, like reduced quality of life, sub-optimal
self-care, impaired glycemic control, higher risk of complications, and
increased mortality rates.

Objective The purpose of this study is to test the effectiveness of a new diabetes-specific,
mindfulness-based psychological intervention. First, with regard to reducing
emotional distress; second, with respect to improving quality of life,
dispositional mindfulness, and self esteem of patients with diabetes; third, with
regard to self-care and clinical outcomes; finally, a potential effect
modification by clinical and personality characteristics will be explored.

Methods The Diabetes and Mindfulness study (DiaMind) is a randomized controlled

trial. Patients with diabetes with low levels of emotional well-being will be
recruited from outpatient diabetes clinics. Eligible patients will be randomized
to an intervention group or a wait-list control group. The intervention group
will receive the mindfulness program immediately, while the control group
will receive the program eight months later. The
primary outcome is emotional distress (anxiety, stress, depressive symptoms),
for which data will be collected at baseline, four weeks, post intervention, and
after six months follow-up. In addition, self-report data will be collected on
quality of life, dispositional mindfulness, self-esteem, self-care, and
personality, while complications and glycemic control will be assessed from
medical files and blood pressure will be measured. Group differences will be
analyzed with repeated measures analysis of covariance.

Results It is hypothesized that emotional well-being, quality of life, dispositional

mindfulness, self-esteem, selfcare, and blood pressure will improve
significantly more in the mindfulness group compared to the control group.
Results of this study can contribute to a better care for patients with diabetes
with lowered levels of emotional well-being. It is expected that the first results
will become available in 2012.
 REVIEW JOURNAL 7

Title Illness perception, religiosity and mental health of diabetic patients in Ghana

Edition American Journal of Applied Psychology

2014; 3(1): 12-20

Background
Objective This study examines the influence of diabetic patients’ perception of their
illness and their levels of religiosity on their mental health problems.

Introduction The experience of diabetes presents challenges to the patients and as such
several psychosocial factors have been noted to influence the health outcomes
of the patients. Some of these factors include personal religiosity, illness
perception, coping strategies, social support as well as some demographic
characteristics.
Methods A sample of 194 diabetic patients was drawn from two major hospitals (Korle-
Bu Teaching and Tema General Hospitals) in the Greater Accra Region of
Ghana. The cross-sectional survey method was used as the study design.
Results Results from Pearson correlation show that the diabetic patients’ level of
religiosity did not significantly correlate with their mental health problems.
However, illness perception correlates significantly and positively with their
general mental health problem (GSI) and specific ones such as somatization,
obsessive-compulsion, depression, anxiety and psychoticism. Multiple
regression analyses show that level of general mental health problem (GSI)
was significantly predicted by perception of illness Coherence followed by
perceptions Symptoms and Concern. Similarly, perception of coherence was
the most significant predictor of both depression and anxiety among diabetic
patients. The implications of the findings are discussed

Conclusion illness perception by patients was shown to be a significant predictor of overall

mental health problems as well as the level of depression and anxiety
experienced by diabetic patients. On the whole, the perception of illness
coherence was found to be the most significant predictive component and as
such informs healthcare professionals for the need for Psychoeducation on
chronic illness to reduce the level of distress among patients
 REVIEW JOURNAL 8

Title Illness Perception and Depressive Symptoms among Persons with Type 2
Diabetes Mellitus: An Analytical Cross-Sectional Study in Clinical Settings in
Nepal

Edition Hindawi Publishing Corporation Journal of Diabetes Research Volume 2015,

Article ID 908374, 9 pages, http://dx.doi.org/10.1155/2015/908374

Objective This study aimed to assess the relationship between illness perception and
depressive symptoms among persons with diabetes

Introduction Illness representation or perception reflects the patients’ own views about the
cause (beliefs about how the disease occurred), illness identity (beliefs about
how the disease should look like, by relating to the symptoms), illness
consequences (impact of the disease on quality of life, relationships, and
work), timeline (whether the disease is of
long or short duration or has cyclical onset of symptoms), and cure or control
(whether the illness can be controlled by patient’s behavior or treatment
module).

Methods This was an analytical cross-sectional study conducted among 379 type 2
diabetic patients from three major clinical settings of Kathmandu, Nepal.

Results The prevalence of depressive symptoms was 44.1% (95% CI: 39.1, 49.1).
Females
(𝑝 < 0.01), homemakers (𝑝 < 0.01), 61–70 age group (𝑝 = 0.01), those without
formal education (𝑝 < 0.01), and people with lower social status (𝑝 < 0.01) had
significantly higher proportion of depressive symptoms than the others.
Multivariable analysis identified age (𝛽 = 0.036, 𝑝 = 0.016), mode of treatment
(𝛽 = 0.9, 𝑝 = 0.047), no formal educational level (𝛽 = 1.959, 𝑝 = 0.01),
emotional representation (𝛽 = 0.214, 𝑝 < 0.001), identity (𝛽 = 0.196, 𝑝 <
0.001), illness coherence (𝛽 = −0.109, 𝑝 = 0.007), and consequences (𝛽 =
0.093, 𝑝 = 0.049) as significant predictors of depressive symptoms
Conclusion Our study demonstrated a strong relationship between illness perception and
depressive symptoms among diabetic patients. Study finding indicated that
persons living with diabetes in Nepal need comprehensive diabetes education
programfor changing poor illness perception, which ultimately helps to prevent
development of depressive symptoms.
 REVIEW JOURNAL 9

Title Using the Common Sense Model of illness selfregulation to understand

diabetes-related distress: The importance of being able to ‘make sense’ of
diabetes

Edition
Understanding Diabetes-related Distress, New Zealand Journal of Psychology
Vol. 39, No. 1, 2010 . C.A.M Paddison, University of Cambridge et al.

Background
Objective This study examines the relationships between illness perceptions and illness-
related distress among adults with type 2 diabetes.

Introduction The CSM predicts that illness perceptions (e.g., perceived control of diabetes,
or severity of illness consequences) will influence emotional outcomes such as
illness-related distress (Hagger & Orbell, 2003).

Methods Research participants (N = 615) were randomly selected from a primary care
database in New Zealand. Data were collected through a mailed questionnaire
survey and review of medical records. The primary outcome was diabetes-
related psychological distress measured using the Problem Areas in Diabetes
(PAID) scale.

Results Multiple regression analyses controlling for age, clinical characteristics, and
mental health showed that illness perceptions accounted for 15% of differences
in distress about diabetes (F change (4,462) = 35.37, p < .001). Poor mental
health and illness severity alone do not explain differences in diabetes-related
emotional adjustment. Results suggest that ‘making sense’ of diabetes may be
central to successfully managing the emotional consequences of diabetes.

Limitations This study focused on adults with type 2 diabetes living in New Zealand.
and Examining the relationships between illness representations and emotional
directions distress in other populations including adolescents with type 1 diabetes is
for future recommended.
research
The modest response rate (62%) could be improved, and our study was limited
by the self-reported diagnosis of depression and diabetes complications.
Prospective cohort studies are recommended in future research as the cross-
sectional design of this study precludes interpretation of causal relationships.
In particular, we encourage research that explores the associations between
illness representations, diabetes-related distress, and glycaemic control over
time
 REVIEW JOURNAL 10

Title Illness perceptions of Libyans with T2DM and their influence on medication
adherence: a study in a diabetes center in Tripoli

Edition Libyan Journal of Medicine

Sana Taher Ashur1*, Shamsul Azhar Shah1, Soad Bosseri2,

Donald E. Morisky3 and Khadijah Shamsuddin1

Received: 17 September 2015; Revised: 23 November 2015; Accepted: 30

November 2015; Published: 28 December 2015

Objective The surrounding environment influences the constitution of illness perceptions.

Therefore, local research is needed to examine how Libyan diabetes patients
perceive diabetes and how their perceptions influence their medication
adherence

Methods A cross-sectional study was conducted at the National Centre for Diabetes and
Endocrinology in Tripoli, Libya, between October and December 2013. A total
of 523 patients with type 2 diabetes participated in this study. A self-
administered questionnaire was used for data collection; this included the
Revised Illness Perception Questionnaire and the eight-item Morisky
Medication Adherence Scale

Results The respondents showed moderately high personal control and treatment
control perceptions and a moderate consequences perception. They reported a
high perception of diabetes timeline as chronic and a
moderate perception of the diabetes course as unstable. The most commonly
perceived cause of diabetes was Allah’s will. The prevalence of low
medication adherence was 36.1%. The identified significant predictors of low
medication adherence were the low treatment control perception (p_0.044),
high diabetes identity perception (p_0.008), being male (p_0.026), and
employed (p_0.008).

Table 3 shows the descriptive statistics on the perceptions of the cause of

diabetes. The five most commonly indicated causes out of the 19 listed items
as causes for diabetes were ‘Allah’s will/fate’ (86.6%), ‘hereditary _ it runs in
my family’ (53.0%), ‘my emotional state’ (44.4%), ‘family problems or
worries’ (40.0%), and ‘diet or eating habits’ (35.6%).

Conclusion Diabetes illness perceptions of type 2 diabetic Libyans play a role in guiding
the medication adherence and could be considered in the development of
medication adherence promotion plans.
 REVIEW JOURNAL 11

Title Diabetes-Related Distress and Depressive Symptoms Are Not Merely

Negative over a 3-Year Period in Malaysian Adults with Type 2 Diabetes
Mellitus Receiving Regular Primary Diabetes Care

Edition Front. Psychol. 8:1834. doi: 10.3389/fpsyg. 2017.01834

Boon-How Chew1, 2*, Rimke C. Vos 2, Rebecca K. Stellato2 and Guy E. H.

M. Rutten2

BackGround For people with type 2 diabetes mellitus (T2DM) the daily maintenance of
physical and psychological health is challenging. However, the
interrelatedness of these two health domains, and of diabetes-related distress
(DRD) and depressive symptoms, in the Asian population is still poorly
understood. DRD and depressive symptoms have important but distinct
influences on diabetes self-care and disease control. Furthermore, the question
of whether changes in DRD or depressive symptoms follow a more or less
natural course or depend on disease and therapy-related factors is yet to be
answered
Objective The aim of this study was to identify the factors influencing changes in DRD
or depressive symptoms, at a 3-year follow-up point, in Malaysian adults with
T2DM who received regular primary diabetes care.

Methods Baseline data included age, sex, ethnicity, marital status, educational level,
employment status, health-related quality of life (WHOQOL-BREF), insulin
use, diabetes-related complications and HbA1c. DRD was assessed both at
baseline and after 3 years using a 17-item Diabetes Distress Scale (DDS-17),
while depressive symptoms were assessed using the Patient Health
Questionnaire (PHQ-9). Linear mixed models were used to examine the
relationship between baseline variables and change scores in DDS-17 and
PHQ-9.

Results Almost half (336) of 700 participants completed both measurements. At

follow-up, their mean (SD) age and diabetes duration were 60.6 (10.1) years
and 9.8 (5.9) years, respectively, and 54.8% were women. More symptoms of
depression at baseline was the only significant and independent predictor of
improved DRD at 3 years (adjusted b = −0.06, p = 0.002).

Similarly, worse DRD at baseline was the only significant and independent
predictor of fewer depressive symptoms 3 years later (adjusted b = −0.98, p =
0.005). Thus, more “negative feelings” at baseline could be a manifestation of
initial coping behaviors or a facilitator of a better psychological coaching by
physicians or nurses that might be beneficial in the long term. We therefore
conclude that initial negative feelings should not be seen as a necessarily
adverse factor in diabetes care.

Conclusion In conclusion, among Malaysian adults with T2DM who returned regularly to
health clinics and received continuous healthcare treatment, initial depressive
symptoms were correlated with a reduced DRD at 3 years.

Similarly, initial DRD (interpersonal distress) was associated with fewer or

improved depressive symptoms. These observations require a
reconceptualization of DRD and depressive symptoms, at least in Malaysian
people with T2DM. Evidently, such feelings and symptoms should not be
considered as merely negative factors. Nonetheless, vigilant monitoring for
DRD and depressive symptoms, combined with psychological support for
those without emotional distress, seems a reasonable approach in diabetes care