Restriction lift date: 2025-09-30
Recognising emotional aspects of diabetes; understanding detection of diabetes distress and depression among people with type 2 diabetes mellitus in community settings
University College Cork
Background: Diabetes distress and depression are important to address among people with type 2 diabetes (T2DM), who increasingly receive T2DM care in the community. Detection is a pre-requisite for appropriate management, but evidence indicates low detection rates among people with T2DM. Diabetes distress and depression screening have been recommended in contemporary T2DM management guidelines as a strategy to detect these issues. Little is known about detection among people with T2DM in high-income countries or about factors influencing detection at the health system and heath professional (HCP) levels in this population. Moreover, implementation of diabetes distress and depression screening of people with T2DM in the community remains poorly understood. Aim: To improve understanding of diabetes distress and depression detection and the implementation of screening among people with T2DM in community settings. Methods: This PhD thesis employed a mixed methods approach, using a convergent design. Three studies were conducted. First, a cross-sectional comparative analysis estimated the prevalence of depression detection outcomes (undiagnosed, symptomatic and diagnosed and asymptomatic and diagnosed) and using multivariable logistic regression, modelled the association between diabetes and undiagnosed (versus diagnosed) depression in three high income countries with different health systems. Second, a qualitative evidence synthesis (QES) following the best-fit framework method employed behaviour change theory, the theoretical domains framework (TDF), to identify HCP perceived barriers and enablers to diabetes distress and depression screening of people with T2DM in community settings, based on HCPs’ experiences of implementing screening. Finally, a primary qualitative study using the TDF as a data collection and analytic framework and drawing on principles of chart stimulated recall, was conducted with HCPs working in the community setting in Ireland to understand current diabetes distress and depression detection practices and prospectively identify determinants of screening implementation in the Irish context. Results: Undiagnosed depression was more prevalent in people with diabetes than without diabetes in each country with absolute rates varying by country; [Ireland: diabetes 10.1%(95%CI:7.5-12.8) vs no diabetes 7.5%(95%CI:6.8-8.2), England: diabetes 19.3%(95%CI:16.5-22.2) vs no diabetes 11.8%(95%CI:11.0-12.6), USA: diabetes 7.4%(95%CI:6.4-8.4) vs no diabetes 6.1%(95%CI:5.7-6.6)]. There was no clear pattern of association between diabetes status and undiagnosed depression across countries; Ireland: OR=0.82(95%CI:0.5-1.3), England: OR=1.47(95%CI:1.0-2.1), USA: OR=0.80(95%CI:0.7-1.0). Ten articles (9 studies) were synthesised in the QES. All articles related to depression screening and one to diabetes distress screening. Articles included GP (n=7) and nurse (practice and nurse specialist; n=9) perspectives. Fifteen factors comprising 11 barriers, 3 enablers and 1 factor which was both a barrier and enabler, in 8 TDF domains: knowledge, skills, professional role and social identity, beliefs about consequences, reinforcement, environmental context and resources, memory, attention and decision process, emotion, and 1 new domain: people with T2DM factors, were identified as influencing screening implementation. Three barriers; underestimation of depression severity, skills needed to screen, and discomfort screening were predominantly discussed by nurses. One barrier; culture and language issues and 1 enabler; availability of appropriate reimbursement, were only discussed by GP participants. Twenty-eight HCPs across Ireland: 7 GPs, 9 practice nurses, 8 diabetes nurse specialists and 4 dieticians participated in semi-structured telephone interviews. Current practice involved people with T2DM or third parties (e.g. their family members) alerting HCPs to possible mental health issues among people with T2DM, or by HCPs asking people with T2DM about mental health as a response to implicit cues by people with T2DM. Some participants had administered screening tools albeit not systematically or necessarily part of T2DM care. Fifteen factors, comprising 7 barriers, 6 enablers and 2 factors which could inhibit or enable screening were identified. These related to 8 TDF domains; knowledge, skills, beliefs about consequences, environmental context and resources, memory, attention and decision process, emotion, social influences and 1 other domain; person with T2DM factors. Lack of knowledge about which tool(s) to use by HCPs with experience of screening and lack of awareness of diabetes distress, and, limited focus on psychosocial aspects in general practice due to under-resourcing of T2DM were only discussed by GPs and practice nurses. Conclusion: Detection of diabetes distress and depression in people with T2DM is a challenge across health systems and the extent of detection as a challenge varies across countries. Screening implementation strategies should include educational materials, meetings and/or outreach activities, local opinion leaders, reminders and tailored interventions to address HCP specific determinants.
Diabetes , Primary care , Mental health , Depression , Diabetes distress , Guideline implementation
McGrath, N. M. 2021. Recognising emotional aspects of diabetes; understanding detection of diabetes distress and depression among people with type 2 diabetes mellitus in community settings. PhD Thesis, University College Cork.