Publications by authors named "Khalida Ismail"

98 Publications

Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years.

BMJ Open Diabetes Res Care 2021 Sep;9(1)

Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK.

Introduction: Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme.

Research Design And Methods: Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models.

Results: Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels.

Conclusions: Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.
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http://dx.doi.org/10.1136/bmjdrc-2021-002118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8438718PMC
September 2021

Protocol for a qualitative study exploring the perception of need, importance and acceptability of a digital diabetes prevention intervention for women with gestational diabetes mellitus during and after pregnancy in Malaysia (Explore-MYGODDESS).

BMJ Open 2021 08 26;11(8):e044878. Epub 2021 Aug 26.

Institute of Psychiatry, King's College London, London, UK.

Introduction: Women who develop gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes, and to reduce this risk the women have to adopt healthy behaviour changes. Although previous studies have explored the challenges and facilitators to initiate behaviour change among women with GDM, there is limited data from Malaysian women. Thus, this study will explore the factors affecting the uptake of healthy behaviour changes and the use of digital technology among women and their healthcare providers (HCPs) to support healthy behaviour changes in women with GDM.

Methods And Analysis: The study will be modelled according to the Capability, Opportunity, Motivation and Behaviour and Behaviour Change Wheel techniques, and use the DoTTI framework to identify needs, solutions and testing of a preliminary mobile app, respectively. In phase 1 (design and development), a focus group discussion (FGDs) of 5-8 individuals will be conducted with an estimated 60 women with GDM and 40 HCPs (doctors, dietitians and nurses). Synthesised data from the FGDs will then be combined with content from an expert committee to inform the development of the mobile app. In phase 2 (testing of early iterations), a preview of the mobile app will undergo alpha testing among the team members and the app developers, and beta testing among 30 women with GDM or with a history of GDM, and 15 HCPs using semi-structured interviews. The outcome will enable us to optimise an intervention using the mobile app as a diabetes prevention intervention which will then be evaluated in a randomised controlled trial.

Ethics And Dissemination: The project has been approved by the Malaysia Research Ethics Committee. Informed consent will be obtained from all participants. Outcomes will be presented at both local and international conferences and submitted for publications in peer-reviewed journals.
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http://dx.doi.org/10.1136/bmjopen-2020-044878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8395347PMC
August 2021

Dietary intake, physical activity and sedentary behaviour patterns in a sample with established psychosis and associations with mental health symptomatology.

Psychol Med 2021 Aug 23:1-11. Epub 2021 Aug 23.

Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, London, UK.

Background: People with psychosis experience cardiometabolic comorbidities, including metabolic syndrome, coronary heart disease and diabetes. These physical comorbidities have been linked to diet, inactivity and the effects of the illness itself, including disorganisation, impairments in global function and amotivation associated with negative symptoms of schizophrenia or co-morbid depression.

Methods: We aimed to describe the dietary intake, physical activity (PA) and sedentary behaviour patterns of a sample of patients with established psychosis participating in the Improving Physical Health and Reducing Substance Use in Severe Mental Illness (IMPaCT) randomised controlled trial, and to explore the relationship between these lifestyle factors and mental health symptomatology.

Results: A majority of participants had poor dietary quality, low in fruit and vegetables and high in discretionary foods. Only 29.3% completed ⩾150 min of moderate and/or vigorous activity per week and 72.2% spent ⩾6 h per day sitting. Cross-sectional associations between negative symptoms, global function, and PA and sedentary behaviour were observed. Additionally, those with more negative symptoms receiving IMPaCT therapy had fewer positive changes in PA from baseline to 12-month follow-up than those with fewer negative symptoms at baseline.

Conclusion: These results highlight the need for the development of multidisciplinary lifestyle and exercise interventions to target eating habits, PA and sedentary behaviour, and the need for further research on how to adapt lifestyle interventions to baseline mental status. Negative symptoms in particular may reduce patient's responses to lifestyle interventions.
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http://dx.doi.org/10.1017/S0033291721003147DOI Listing
August 2021

SITAgliptin for Depressive Symptoms (SITADS) in type 2 diabetes: a feasibility randomized controlled trial.

Psychosom Med 2021 Jul 21. Epub 2021 Jul 21.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RJ, UK Division of Diabetes and Nutritional Sciences, Faculty of Life Sciences and Medicine, King's College London, London SE1 1UL and SE5 9RJ, UK Department of Biostatistics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK.

Objective: We tested the feasibility of using sitagliptin - a dipeptidyl peptidase-IV inhibitor - for depressive symptoms in type 2 diabetes (T2D).

Methods: In a feasibility, double-blind, randomised controlled trial, we recruited people aged 18-75 with T2D (HbA1c ≥53 and ≤ 86 mmol/mol prescribed oral hypoglycaemic therapy) and comorbid depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥ 10) from family practices in South London. Eligible patients were randomised to sitagliptin 100 mg per day or matched placebo for 12 weeks. The primary feasibility outcomes were participation rates, attrition rates and adverse events. The primary clinical outcomes were depressive symptoms (PHQ-9 and Quick Inventory of Depressive Symptomatology [QIDS-SR-16] scores) at 12 weeks as assessed using ANCOVA analyses. Ranges of treatment effects were estimated using Cohen's d and associated 95% confidence intervals, where negative values favoured sitagliptin over placebo.

Results: Of 153 people screened across 32 practices, 44 were randomised (22 to each arm). The mean age was 58.8 (SD = 8.3) years, 46% were female and 52% of non-white ethnicity. Of those treated, 1 patient (4.5%) in each arm withdrew and there were no group differences in adverse events. Despite improving 12-week HbA1c (d = -1.19 [95% CI -1.90, -0.48]), improvement in 12-week QIDS-SR-16 score with sitagliptin was inferior to placebo across the range of estimated treatment effects (d = 0.71 [0.13, 1.30]). Effects of sitagliptin on inflammation were inconsistent (d = -0.32 [-0.81, 0.17] for hs-CRP).

Conclusions: Repositioning of oral hypoglycaemic therapy for depressive symptoms in T2D is feasible. However, in this under-powered feasibility study, we did not detect evidence of superiority of sitagliptin over placebo. The results are cautioned by the small sample size and limited treatment duration.Trial RegistrationEudraCT: 2015-004527-32.
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http://dx.doi.org/10.1097/PSY.0000000000000985DOI Listing
July 2021

A framework for handling missing accelerometer outcome data in trials.

Trials 2021 Jun 5;22(1):379. Epub 2021 Jun 5.

Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK.

Accelerometers and other wearable devices are increasingly being used in clinical trials to provide an objective measure of the impact of an intervention on physical activity. Missing data are ubiquitous in this setting, typically for one of two reasons: patients may not wear the device as per protocol, and/or the device may fail to collect data (e.g. flat battery, water damage). However, it is not always possible to distinguish whether the participant stopped wearing the device, or if the participant is wearing the device but staying still. Further, a lack of consensus in the literature on how to aggregate the data before analysis (hourly, daily, weekly) leads to a lack of consensus in how to define a "missing" outcome. Different trials have adopted different definitions (ranging from having insufficient step counts in a day, through to missing a certain number of days in a week). We propose an analysis framework that uses wear time to define missingness on the epoch and day level, and propose a multiple imputation approach, at the day level, which treats partially observed daily step counts as right censored. This flexible approach allows the inclusion of auxiliary variables, and is consistent with almost all the primary analysis models described in the literature, and readily allows sensitivity analysis (to the missing at random assumption) to be performed. Having presented our framework, we illustrate its application to the analysis of the 2019 MOVE-IT trial of motivational interviewing to increase exercise.
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http://dx.doi.org/10.1186/s13063-021-05284-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178870PMC
June 2021

A cognitive behavioural model of the bidirectional relationship between disordered eating and diabetes self care in people with type 1 diabetes mellitus.

Diabet Med 2021 Jul 6;38(7):e14578. Epub 2021 May 6.

Diabetes Research Group, Weston Education Centre, King's College London, London, UK.

Aims: This qualitative study aimed to develop the first cognitive behavioural therapy model outlining the development and maintenance of disordered eating in type 1 diabetes and report on recovery strategies and resilience factors to improve previous theoretical models of type 1 diabetes and disordered eating.

Methods: Twenty-three women (n = 9 with type 1 diabetes and disordered eating, n = 5 with type 1 diabetes recovering from disordered eating, and n = 9 with type 1 diabetes without disordered eating) participated in semi-structured interviews. Data were analysed using grounded theory and individual cognitive-behavioural formulations were developed for each participant to inform the development/maintenance and resilience models.

Results: The development/maintenance model summarises commonly experienced vicious cycles of thoughts, feelings and behaviours in type 1 diabetes and disordered eating. The resilience model summarises strategies and knowledge acquired by those with type 1 diabetes in recovery from disordered eating and individuals with type 1 diabetes who did not develop disordered eating. Early adverse life events, past psychiatric history, perfectionist personality traits, difficult experiences around type 1 diabetes diagnosis and its relentless daily management sensitise individuals to eating, weight and shape cues. Alongside physical symptoms/complications, unhelpful interpersonal reactions and inadequate healthcare, vicious cycles of thoughts, feelings and behaviours develop. 'Good enough' psychological adaptation to type 1 diabetes, integrating type 1 diabetes into one's identity, self care and compassion around eating, weight and shape were key protective/post-traumatic resilience factors.

Conclusions: This first cognitive behavioural therapy model of type 1 diabetes and disordered eating informed by personal experience will inform an intervention for type 1 diabetes and disordered eating.
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http://dx.doi.org/10.1111/dme.14578DOI Listing
July 2021

Understanding developmental psychopathology in Type 1 diabetes through attachment, mentalisation and diabetes distress.

Clin Child Psychol Psychiatry 2021 Jul 24;26(3):682-694. Epub 2021 Feb 24.

Division of Psychology and Language Sciences, University College London, UK.

This article examines the combined roles of attachment mentalisation and diabetes distress in the psychological development of young people with Type 1 diabetes (T1D). We use these ideas to unify the evidence for psychological variables affecting young people and their families and suggest how diabetes distress and mentalisation might be part of the pathways for development of psychiatric diagnoses.Attachment theory's central hypothesis is that a secure relationship with a care-giver in the early life of a child is essential to normal emotional and relational development, whilst diabetes distress is a well recognised phenomena of burden experienced by both child and parent in relation to the condition.We extend the ideas of attachment, into the psychological adaptation processes for young people at the time of diagnosis of T1D with emphasis on the function of the parent/caregiver in mentalising the experience of the child. We also connect our current understanding of diabetes distress to the associated increased risk for disorders of eating and personality in T1D.Using principles learnt in other areas of psychotherapeutic practice we end by suggesting interventions that could impact mental health and diabetes outcomes using the mentalisation model.
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http://dx.doi.org/10.1177/1359104521994640DOI Listing
July 2021

Feasibility study of real-time online text-based CBT to support self-management for people with type 1 diabetes: the Diabetes On-line Therapy (DOT) Study.

BMJ Open Diabetes Res Care 2021 01;9(1)

Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

Introduction: This study examines the feasibility of conducting diabetes-focused cognitive-behavioral therapy (CBT) via a secure online real-time instant messaging system intervention to support self-management and improve glycemic control in people with type 1 diabetes.

Research Design And Methods: We used a pre-post uncontrolled intervention design over 12 months. We recruited adults with type 1 diabetes and suboptimal glycemic control (HbA1c ≥69 mmol/mol (DCCT 8.5%) for 12 months) across four hospitals in London. The intervention comprised 10 sessions of diabetes-focused CBT delivered by diabetes specialist nurses. The primary outcomes were number of eligible patients, rates of recruitment and follow-up, number of sessions completed and SD of the main outcome measure, change in HbA1c over 12 months. We measured the feasibility of collecting secondary outcomes, that is, depression measured using Patient Health Questionnaire-9 (PHQ-9), anxiety measured Generalised Anxiety Disorder (GAD) and the Diabetes Distress Scale (DDS).

Results: We screened 3177 patients, of whom 638 were potentially eligible, from whom 71 (11.1%) were recruited. The mean age was 28.1 (13.1) years, and the mean HbA1c was 84.6 mmol/mol (17.8), DCCT 9.9%. Forty-six (65%) patients had at least 1 session and 29 (41%) completed all sessions. There was a significant reduction in HbA1c over 12 months (mean difference -6.2 (2.3) mmol/mol, DCCT 0.6%, p=0.038). The change scores in PHQ-9, GAD and DDS also improved.

Conclusions: It would be feasible to conduct a full-scale text-based synchronized real-time diabetes-focused CBT as an efficacy randomized controlled trial.
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http://dx.doi.org/10.1136/bmjdrc-2020-001934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813360PMC
January 2021

Mental health symptoms in a cohort of hospital healthcare workers following the first peak of the COVID-19 pandemic in the UK.

BJPsych Open 2020 Dec 29;7(1):e24. Epub 2020 Dec 29.

University Hospitals Birmingham NHS Foundation Trust, UK.

Background: The coronavirus disease 2019 (COVID-19) pandemic is likely to lead to a significant increase in mental health disorders among healthcare workers (HCW).

Aims: We evaluated the rates of anxiety, depressive and post-traumatic stress disorder (PTSD) symptoms in a population of HCW in the UK.

Method: An electronic survey was conducted between the 5 June 2020 and 31 July 2020 of all hospital HCW in the West Midlands, UK using clinically validated questionnaires: the 4-item Patient Health Questionnaire(PHQ-4) and the Impact of Event Scale-Revised (IES-R). Univariate analyses and adjusted logistic regression analyses were performed to estimate the strengths in associations between 24 independent variables and anxiety, depressive or PTSD symptoms.

Results: There were 2638 eligible participants who completed the survey (female: 79.5%, median age: 42 years, interquartile range: 32-51). The rates of clinically significant symptoms of anxiety, depression and PTSD were 34.3%, 31.2% and 24.5%, respectively. In adjusted analysis a history of mental health conditions was associated with clinically significant symptoms of anxiety (odds ratio (OR) = 2.3, 95% CI 1.9-2.7, P < 0.001), depression (OR = 2.5, 95% CI 2.1-3.0, P < 0.001) and PTSD (OR = 2.1, 95% CI 1.7-2.5, P < 0.001). The availability of adequate personal protective equipment (PPE), well-being support and lower exposure to moral dilemmas at work demonstrated significant negative associations with these symptoms (P ≤ 0.001).

Conclusions: We report higher rates of clinically significant mental health symptoms among hospital HCW following the initial COVID-19 pandemic peak in the UK. Those with a history of mental health conditions were most at risk. Adequate PPE availability, access to well-being support and reduced exposure to moral dilemmas may protect hospital HCW from mental health symptoms.
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http://dx.doi.org/10.1192/bjo.2020.150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844153PMC
December 2020

The psychopathology of recurrent diabetic ketoacidosis: A case-control study.

Diabet Med 2021 Jul 8;38(7):e14505. Epub 2021 Jan 8.

Diabetes, Psychiatry and Psychology Research Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Despite its poor prognosis, the psychological factors associated with recurrent diabetic ketoacidosis are poorly understood. In people with type 1 diabetes, we assessed for psychopathology in those with and without recurrent diabetic ketoacidosis (DKA).

Method: The design was a case-control study. Cases were defined as people with two or more DKA episodes in a 12-month period (recurrent DKA). Cases and controls were matched for gender and age. We compared groups for scores on Beck's Anxiety Inventory (BAI), Beck's Depression Inventory II, Difficulty in Emotion Regulation Scale (DERS), Experiences in Close Relationships-Revised, Standardised Assessment of Personality-Abbreviated Scale (SAPAS), Interpersonal Problem Inventory, Eating Disorder Examination Questionnaire and Problem Areas in Diabetes (PAID) using unpaired t-tests or Mann-Whitney U tests for parametric and non-parametric data, respectively. Correction was made for multiple testing.

Results: In all, 23 cases and 23 controls were recruited with mean age 31.0 (11.4) years and 65.2% were men. Cases had higher HbA levels than controls (101.1 (23.2) vs. 85.7 (21.7) mmol/mol, (p = 0.02)). Compared to controls, people with recurrent DKA had higher scores on the BAI (p = 0.004), PAID (p = 0.004), DERS (p = 0.001) and SAPAS (p < 0.001). Sixteen of 23 (69.6%) cases screened positive for a personality disorder compared to 6 of 23 (26.1%) controls.

Conclusions: People with recurrent DKA have elevated levels of anxiety and diabetes distress, greater difficulty with emotion regulation and personality dysfunction compared to matched controls.
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http://dx.doi.org/10.1111/dme.14505DOI Listing
July 2021

Disordered eating in women with type 1 diabetes: Continuous glucose monitoring reveals the complex interactions of glycaemia, self-care behaviour and emotion.

Diabet Med 2021 02 23;38(2):e14446. Epub 2020 Nov 23.

Diabetes Research Group, King's College London, Weston Education Centre, London, UK.

Objectives: Glycaemia in people with type 1 diabetes and disordered eating is not well characterised. We explored the glycaemia, self-care behaviour and emotional state of women with type 1 diabetes and disordered eating.

Research Design And Methods: In all, 13 women with and 10 without disordered eating and type 1 diabetes participated in this case-control study. We used a mixed-methods approach with a 7-day blinded continuous glucose monitoring and real-time record of non-prompted capillary glucose (CG), emotion, activity and physical symptoms on a diabetes diary using a smartphone application (mySugr®). We compared groups using Mann-Whitney U test or Fisher's exact test. We conducted thematic analyses of free-text diary entries (NVivo®) and quantitative analysis of emotion/symptom tags.

Results: People with type 1 diabetes and disordered eating spent longer time above range in level 2 hyperglycaemia (>13.9 mmol/L, Median [interquartile range]: 21% [16,60] vs 5% [2,17], p = 0.015). They had lower time in range and similar time below range compared to those without disordered eating. The standard deviation of CG was significantly higher in the disordered eating group (4.7 mmol/L [4.5, 6.1] vs 3 [2.8, 3.2], p = 0.018). The median of the percentage of rising sensor glucose trends was three times higher in the disordered eating group. They also had higher negative emotional and physical symptoms associated with high blood glucose (>15 mmol/L).

Conclusions: Disordered eating has a significant impact on the glycaemia and emotion of a person with type 1 diabetes.
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http://dx.doi.org/10.1111/dme.14446DOI Listing
February 2021

Is there an association between anxiety and depression prior to and during pregnancy and gestational diabetes? An analysis of the Born in Bradford cohort.

J Affect Disord 2020 11 18;276:345-350. Epub 2020 Jul 18.

Section of Women's Mental Health, King's College London and South London and Maudsley NHS Foundation Trust, PO31 King's College London, De Crespigny Park, London, SE5 8AF, UK.

Background: anxiety and depression are common in women with gestational diabetes but it is not clear whether they are more likely to precede the onset of gestational diabetes or to co-occur with it. Our aims were to compare the strength of association between common mental disorders of anxiety and depression (i) before pregnancy and (ii) during pregnancy in women with and without gestational diabetes.

Methods: the sample comprised 12,239 women with 13,539 pregnancies from the UK's Born in Bradford cohort. Gestational diabetes was diagnosed by oral glucose tolerance test (OGTT). Indicators of common mental disorders were obtained from linked primary care records. Multivariable robust Poisson and logistic regression were employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education and obstetric complications. Analyses of common mental disorders during pregnancy were additionally adjusted for maternal smoking, pre-pregnancy BMI, multiple pregnancy and common mental disorders prior to pregnancy.

Results: there was no evidence for an association between common mental disorders prior to pregnancy and gestational diabetes (adjusted RR 0.96; 95% CI 0.80,1.15) or between gestational diabetes and common mental disorders during pregnancy (adjusted OR 0.91; 95% CI 0.73,1.12).

Limitations: high levels of deprivation and multi-ethnic composition of the cohort may limit generalisability of these findings to other populations.

Conclusions: routine primary care records did not identify an increased risk of gestational diabetes in women with common mental disorders prior to pregnancy or of gestational diabetes in women with common mental disorders during pregnancy.
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http://dx.doi.org/10.1016/j.jad.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477491PMC
November 2020

Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review.

Health Technol Assess 2020 06;24(28):1-232

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: For people with diabetes mellitus to achieve optimal glycaemic control, motivation to perform self-management is important. The research team wanted to determine whether or not psychological interventions are clinically effective and cost-effective in increasing self-management and improving glycaemic control.

Objectives: The first objective was to determine the clinical effectiveness of psychological interventions for people with type 1 diabetes mellitus and people with type 2 diabetes mellitus so that they have improved (1) glycated haemoglobin levels, (2) diabetes self-management and (3) quality of life, and fewer depressive symptoms. The second objective was to determine the cost-effectiveness of psychological interventions.

Data Sources: The following databases were accessed (searches took place between 2003 and 2016): MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO, EMBASE, Cochrane Controlled Trials Register, Web of Science, and Dissertation Abstracts International. Diabetes conference abstracts, reference lists of included studies and Clinicaltrials.gov trial registry were also searched.

Review Methods: Systematic review, aggregate meta-analysis, network meta-analysis, individual patient data meta-analysis and cost-effectiveness modelling were all used. Risk of bias of randomised and non-randomised controlled trials was assessed using the Cochrane Handbook (Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. 2011;:d5928).

Design: Systematic review, meta-analysis, cost-effectiveness analysis and patient and public consultation were all used.

Setting: Settings in primary or secondary care were included.

Participants: Adolescents and children with type 1 diabetes mellitus and adults with types 1 and 2 diabetes mellitus were included.

Interventions: The interventions used were psychological treatments, including and not restricted to cognitive-behavioural therapy, counselling, family therapy and psychotherapy.

Main Outcome Measures: Glycated haemoglobin levels, self-management behaviours, body mass index, blood pressure levels, depressive symptoms and quality of life were all used as outcome measures.

Results: A total of 96 studies were included in the systematic review ( = 18,659 participants). In random-effects meta-analysis, data on glycated haemoglobin levels were available for seven studies conducted in adults with type 1 diabetes mellitus ( = 851 participants) that demonstrated a pooled mean difference of -0.13 (95% confidence interval -0.33 to 0.07), a non-significant decrease in favour of psychological treatment; 18 studies conducted in adolescents/children with type 1 diabetes mellitus ( = 2583 participants) that demonstrated a pooled mean difference of 0.00 (95% confidence interval -0.18 to 0.18), indicating no change; and 49 studies conducted in adults with type 2 diabetes mellitus ( = 12,009 participants) that demonstrated a pooled mean difference of -0.21 (95% confidence interval -0.31 to -0.10), equivalent to reduction in glycated haemoglobin levels of -0.33% or ≈3.5 mmol/mol. For type 2 diabetes mellitus, there was evidence that psychological interventions improved dietary behaviour and quality of life but not blood pressure, body mass index or depressive symptoms. The results of the network meta-analysis, which considers direct and indirect effects of multiple treatment comparisons, suggest that, for adults with type 1 diabetes mellitus (7 studies; 968 participants), attention control and cognitive-behavioural therapy are clinically effective and cognitive-behavioural therapy is cost-effective. For adults with type 2 diabetes mellitus (49 studies; 12,409 participants), cognitive-behavioural therapy and counselling are effective and cognitive-behavioural therapy is potentially cost-effective. The results of the individual patient data meta-analysis for adolescents/children with type 1 diabetes mellitus (9 studies; 1392 participants) suggest that there were main effects for age and diabetes duration. For adults with type 2 diabetes mellitus (19 studies; 3639 participants), baseline glycated haemoglobin levels moderated treatment outcome.

Limitations: Aggregate meta-analysis was limited to glycaemic control for type 1 diabetes mellitus. It was not possible to model cost-effectiveness for adolescents/children with type 1 diabetes mellitus and modelling for type 2 diabetes mellitus involved substantial uncertainty. The individual patient data meta-analysis included only 40-50% of studies.

Conclusions: This review suggests that psychological treatments offer minimal clinical benefit in improving glycated haemoglobin levels for adults with type 2 diabetes mellitus. However, there was no evidence of benefit compared with control interventions in improving glycated haemoglobin levels for people with type 1 diabetes mellitus.

Future Work: Future work should consider the competency of the interventionists delivering a therapy and psychological approaches that are matched to a person and their life course.

Study Registration: This study is registered as PROSPERO CRD42016033619.

Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 24, No. 28. See the NIHR Journals Library website for further project information.
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http://dx.doi.org/10.3310/hta24280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336224PMC
June 2020

The Epidemiology of Depression and Diabetes Distress in Type 2 Diabetes in Kuwait.

J Diabetes Res 2020 1;2020:7414050. Epub 2020 Jun 1.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

This study is aimed at describing the prevalence of and risk factors for depression and diabetes distress in people with type 2 diabetes and whether depression and distress are independently associated with worse biomedical outcomes. The study was of cross-sectional design. The setting was the Dasman Diabetes Institute, Kuwait. The Patient Health Questionnaire-9 (PHQ-9) was used to measure the prevalence of depression, defined as a score ≥ 10 (depression caseness). The Problem Areas in Diabetes (PAID) was used to measure diabetes-related distress. Data on biomedical outcomes, lifestyle factors, and sociodemographic information were collected. The prevalence of depression and diabetes distress caseness was 29% and 14%, respectively. Depression caseness patients were more likely to be female (60%; = 0.001), have Kuwaiti nationality (68%, = 0.121), were on insulin (67%, = 0.001), have higher body mass index ( = 0.047), were less physically active (78%; = 0.034), have a higher PAID score ( < 0.001), and have hypertension (74%, = 0.047). After adjustment of sociodemographics (age, gender, and marital status) and body mass index, the prevalence of depression was associated with higher HbA1c ( = 0.04, 95% confidence interval 0.01 to 0.60), while diabetes distress had a weak association with HbA1c ( = 0.13, 95% confidence interval 0.04 to 0.22). In conclusion, people with type 2 diabetes in Kuwait have a high prevalence of depression but lower diabetes distress and this was associated with worse glycaemic control.
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http://dx.doi.org/10.1155/2020/7414050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288194PMC
April 2021

Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression: Systematic Review and Meta-analysis.

JAMA 2020 06;323(22):2290-2300

Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Québec, Canada.

Importance: The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9.

Objective: To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression.

Data Sources: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018).

Study Selection: Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview.

Data Extraction And Synthesis: Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27.

Results: Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%).

Conclusions And Relevance: In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.
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http://dx.doi.org/10.1001/jama.2020.6504DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284301PMC
June 2020

A Wearable Technology Delivering a Web-Based Diabetes Prevention Program to People at High Risk of Type 2 Diabetes: Randomized Controlled Trial.

JMIR Mhealth Uhealth 2020 07 15;8(7):e15448. Epub 2020 Jul 15.

Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, United Kingdom.

Background: Intensive lifestyle interventions are effective in reducing the risk of type 2 diabetes, but the implementation of learnings from landmark studies is expensive and time consuming. The availability of digital lifestyle interventions is increasing, but evidence of their effectiveness is limited.

Objective: This randomized controlled trial (RCT) aimed to test the feasibility of a web-based diabetes prevention program (DPP) with step-dependent feedback messages versus a standard web-based DPP in people with prediabetes.

Methods: We employed a two-arm, parallel, single-blind RCT for people at high risk of developing diabetes. Patients with a hemoglobin A (HbA) level of 39-47 mmol/mol were recruited from 21 general practices in London. The intervention integrated a smartphone app delivering a web-based DPP course with SMS texts incorporating motivational interviewing techniques and step-dependent feedback messages delivered via a wearable device over 12 months. The control group received the wearable technology and access to the web-based DDP but not the SMS texts. As this was a feasibility study, the primary aim was to estimate potential sample size at different stages of the study, including the size of the target study population and the proportion of participants who consented, were randomized, and completed follow-up. We also measured the main outcomes for a full-scale RCT, namely, change in weight and physical activity at 6- and 12-month follow-ups, and secondary outcomes, including changes in the HbA level, blood pressure, waist circumference, waist-to-hip ratio, and lipid levels.

Results: We enrolled 200 participants: 98 were randomized to the intervention and 102 were randomized to the control group. The follow-up rate was higher in the control group (87/102, 85.3%) than in the intervention group (69/98, 70%) at 12 months. There was no treatment effect on weight at 6 months (mean difference 0.15; 95% CI -0.93 to 1.23) or 12 months (mean difference 0.07 kg; 95% CI -1.29 to 1.44) or for physical activity levels at 6 months (mean difference -382.90 steps; 95% CI -860.65 to 94.85) or 12 months (mean difference 92.64 steps; 95% CI -380.92 to 566.20). We did not observe a treatment effect on the secondary outcomes measured at the 6-month or 12-month follow-up. For the intervention group, the mean weight was 92.33 (SD 15.67) kg at baseline, 91.34 (SD 16.04) kg at 6 months, and 89.41 (SD 14.93) kg at 12 months. For the control group, the mean weight was 92.59 (SD 17.43) kg at baseline, 91.71 (SD 16.48) kg at 6 months, and 91.10 (SD 15.82) kg at 12 months. In the intervention group, the mean physical activity was 7308.40 (SD 4911.93) steps at baseline, 5008.76 (SD 2733.22) steps at 6 months, and 4814.66 (SD 3419.65) steps at 12 months. In the control group, the mean physical activity was 7599.28 (SD 3881.04) steps at baseline, 6148.83 (SD 3433.77) steps at 6 months, and 5006.30 (SD 3681.1) steps at 12 months.

Conclusions: This study demonstrates that it is feasible to successfully recruit and retain patients in an RCT of a web-based DPP.

Trial Registration: ClinicalTrials.gov NCT02919397; http://clinicaltrials.gov/ct2/show/NCT02919397.
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http://dx.doi.org/10.2196/15448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7391669PMC
July 2020

Psychological interventions to improve glycemic control in adults with type 2 diabetes: a systematic review and meta-analysis.

BMJ Open Diabetes Res Care 2020 04;8(1)

Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.

The quality of evidence that psychological interventions are effective in improving glycemic control in adults with type 2 diabetes (T2D) is weak.We conducted a systematic review and meta-analysis of psychological interventions in T2D to assess whether their effectiveness in improving glycemic levels has improved over the past 30 years. We applied the protocol of a systematic review and aggregate meta-analysis conducted to January 2003. We added network meta-analysis (NMA) to compare intervention and control group type against usual care. MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, EMBASE, Cochrane Controlled Trials Database, Web of Science, and Dissertation Abstracts International were searched from January 2003 to July 2018. Only randomized controlled trials (RCT) of psychological interventions for adults with T2D reported in any language were included. The primary outcome was change in glycemic control (glycated hemoglobin (HbA1c) in mmol/mol). Data were extracted from study reports and authors were contacted for missing data.94 RCTs were eligible for inclusion in the systematic review since the last review. In 70 RCTs (n=14 796 participants) the pooled mean difference in HbA1c in those randomized to psychological intervention compared with control group was -0.19 (95% CI -0.25 to -0.12), equivalent to a reduction in HbA1c of 3.7 mmol/mol, with moderate heterogeneity across studies (I=64.7%, p<0.001). NMA suggested the probability of intervention effectiveness is highest for self-help materials, cognitive-behavioral therapy, and counseling, compared with usual care. Limitations of this study include that there is a possibility that some studies may have been missed if diabetes did not appear in the title or abstract.The effectiveness of psychological interventions for adults with T2D have minimal clinical benefit in improving glycemic control. PROSPERO REGISTRATION NUMBER: CRD42016033619.
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http://dx.doi.org/10.1136/bmjdrc-2019-001150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254106PMC
April 2020

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis.

J Clin Epidemiol 2020 06 24;122:115-128.e1. Epub 2020 Feb 24.

Centre for Rural Health, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa; Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.

Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

Study Design And Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

Conclusion: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.
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http://dx.doi.org/10.1016/j.jclinepi.2020.02.002DOI Listing
June 2020

Forgotten: mental health interventions in type 1 diabetes.

Lancet 2020 01;395(10218):115

Department of Psychological Medicine, Weston Education Centre, King's College London, London, UK.

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http://dx.doi.org/10.1016/S0140-6736(19)32688-1DOI Listing
January 2020

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT.

Health Technol Assess 2019 12;23(69):1-144

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Background: Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor.

Objectives: The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested.

Design: This was a three-arm, single-blind, parallel randomised controlled trial.

Setting: A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited.

Participants: A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised.

Interventions: The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC.

Randomisation: Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation.

Main Outcome Measures: The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score.

Results: The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective.

Conclusions: Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care.

Trial Registration: Current Controlled Trials ISRCTN84864870.

Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London.
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http://dx.doi.org/10.3310/hta23690DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6943381PMC
December 2019

Reducing weight and increasing physical activity in people at high risk of cardiovascular disease: a randomised controlled trial comparing the effectiveness of enhanced motivational interviewing intervention with usual care.

Heart 2020 03 12;106(6):447-454. Epub 2019 Dec 12.

Department of Biostatistics and Health Informatics, Institute of Psychiatry, King's College London, London, UK.

Objective: The epidemic of obesity is contributing to the increasing prevalence of people at high risk of cardiovascular disease (CVD), negating the medical advances in reducing CVD mortality. We compared the clinical and cost-effectiveness of an intensive lifestyle intervention consisting of enhanced motivational interviewing in reducing weight and increasing physical activity for patients at high risk of CVD.

Methods: A three-arm, single-blind, parallel-group randomised controlled trial was conducted in consenting primary care centres in south London. We recruited patients aged 40-74 years with a QRisk2 score ≥20.0%, which indicates the probability of having a CVD event in the next 10 years. The intervention was enhanced motivational interviewing which included additional behaviour change techniques and was delivered by health trainers in 10 sessions over 1 year, in either group (n=697) or individual (n=523) format. The third arm received usual care (UC; n=522). The primary outcomes were physical activity (mean steps/day) and weight (kg). Secondary outcomes were changes in low-density lipoprotein cholesterol and CVD risk score. We estimated the relative cost-effectiveness of each intervention.

Results: At 24 months, the group and individual interventions were not more effective than UC in increasing physical activity (mean difference=70.05 steps, 95% CI -288.00 to 147.90 and mean difference=7.24 steps, 95% CI -224.01 to 238.50, respectively), reducing weight (mean difference=-0.03 kg, 95% CI -0.49 to 0.44 and mean difference=-0.42 kg, 95% CI -0.93 to 0.09, respectively) or improving any secondary outcomes. The group and individual interventions were not cost-effective at conventional thresholds.

Conclusions: Enhancing motivational interviewing with additional behaviour change techniques was not effective in reducing weight or increasing physical activity in those at high CVD risk.
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http://dx.doi.org/10.1136/heartjnl-2019-315656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057797PMC
March 2020

Genetic Overlap Between Type 2 Diabetes and Depression in a Sri Lankan Population Twin Sample.

Psychosom Med 2020 Feb/Mar;82(2):247-253

From the Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (Kan, Hotopf, Ismail), King's College London, London, United Kingdom; Institute for Research and Development (Jayaweera, Adikari, Sumathipala), Colombo; Department of Medicine, University of Rajarata (Siribaddana), Mihintale, Sri Lanka; Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience (Zavos), King's College London, London, United Kingdom; Department of Public Health Sciences (Aschan), Karolinska Institutet, Solna, Sweden; Research Institute for Primary Care and Health Science (Sumathipala), Keele University, Newcastle, United Kingdom; and Social Genetic and Developmental Research Centre, Institute of Psychiatry, Psychology and Neuroscience (Rijsdijk), King's College London, London, United Kingdom.

Objective: Results from twin studies examining the genetic overlap between type 2 diabetes and depression are currently inconclusive. This question has not been addressed in non-Western populations. We aimed to examine whether there are common genetic factors between type 2 diabetes and depression in a Sri Lankan population using genetic model-fitting analysis.

Method: The Colombo Twin and Singleton Study-Phase 2 consists of 2019 singletons, and 842 monozygotic and 578 dizygotic twin pairs. The primary outcomes were self-reported type 2 diabetes diagnosis and Beck Depression Inventory scores. Standard bivariate twin models were fitted to estimate the genetic and environmental (co)variance of type 2 diabetes and depression.

Results: In the best-fitting model, the phenotypic correlation between type 2 diabetes and depression was significant in female individuals only (r = 0.15 [0.08-0.21]). This association was primarily attributed to a significant genetic correlation between the traits (rA = 0.53 [0.19-0.98]).

Conclusions: In female individuals, but not male individuals, we found a significant genetic overlap between type 2 diabetes and depression in the context of a modest phenotypic correlation.
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http://dx.doi.org/10.1097/PSY.0000000000000771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012333PMC
January 2021

Exploring healthcare professionals' perspectives of barriers and facilitators to supporting people with severe mental illness and Type 2 diabetes mellitus.

Health Soc Care Community 2020 03 27;28(2):690-697. Epub 2019 Nov 27.

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.

Individuals with comorbid severe mental illness (SMI) and diabetes experience an average mortality gap of 20 years compared to individuals without these conditions. There has been some recognition by policies that there is a gap between mental healthcare and physical healthcare for SMI patients. Despite this, there are still no defined care pathways for individuals with SMI and diabetes. The aim of this study was to explore healthcare professionals' (HCPs) perspectives of barriers and solutions to supporting people with SMI and diabetes. HCPs in areas of South London were invited to attend a workshop event to discuss their views of SMI and diabetes pathways. Fifty participants were recruited using the Local Care Network. HCPs included GPs, mental health nurses, psychiatrists, diabetologists and care co-ordinators. The main themes were as follows: (a) poor coordination of care and care planning between services; (b) key techniques to improve integrated care; (c) perceived difficulties achieving better care and (d) supporting patient empowerment. The findings and recommendations from this workshop may provide some insight into key factors in providing and improving integrated SMI and diabetes care for patients in South East London and further afield.
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http://dx.doi.org/10.1111/hsc.12903DOI Listing
March 2020

Experiences of Attending Group Education to Support Insulin Initiation in Type 2 Diabetes: A Qualitative Study.

Diabetes Ther 2020 Jan 15;11(1):119-132. Epub 2019 Nov 15.

Florence Nightingale Faculty of Nursing and Midwifery and Palliative Care, King's College London, London, UK.

Introduction: Type 2 diabetes is a progressive condition and many people require insulin therapy 5-10 years post diagnosis. Considering the global increase in type 2 diabetes, group education programmes to initiate insulin are beneficial as they are cost-effective and provide peer support. However, group education to initiate insulin has not been widely evaluated and there is a need to elicit the views and experience of people with type 2 diabetes who start insulin in groups. The aim of this study was to explore the perspectives of people with type 2 diabetes who receive nurse-led group-based insulin education.

Methods: Qualitative, semi-structured interviews of people with type 2 diabetes in south London, UK, who had attended group education sessions to start insulin. Inductive thematic analysis identified themes within the data.

Results: Fifteen people with type 2 diabetes were interviewed. Three main themes were identified: creating a supportive environment; facilitator skills; and effectiveness of group. Factors which created a supportive environment included peer support, providing reassurance and printed materials. Facilitator skills associated with positive experiences included addressing negative insulin beliefs and managing group dynamics. The effectiveness of the group was determined by ongoing self-management success, need for more peer support, and insulin concerns post insulin education group.

Conclusion: Positive experiences of insulin group education for people with type 2 diabetes were associated with sharing experiences with other people starting insulin, reassurance from healthcare professionals, appropriate supportive materials, and skill of the facilitator to address insulin concerns and manage group dynamics. People with type 2 diabetes may benefit more from education if healthcare professionals are skilled in psychological techniques to facilitate group education aimed at addressing concerns around insulin therapy. Further research needs to assess the effectiveness of structured insulin group education for people with type 2 diabetes.
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http://dx.doi.org/10.1007/s13300-019-00727-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6965558PMC
January 2020

A systematic review of diabetes self-management education interventions for people with type 2 diabetes mellitus in the Asian Western Pacific (AWP) region.

Nurs Open 2019 Oct 3;6(4):1424-1437. Epub 2019 Sep 3.

Florence Nightingale Faculty of Nursing Midwifery & Palliative Care King's College London London UK.

Aims And Objectives: To assess the effectiveness of educational and/or psychological diabetes self-management education (DSME) intervention for people with type 2 diabetes (T2DM) in the Asian Western Pacific (AWP) region.

Background: Translational research indicates that DSME is effective; therefore, it is important to look at the AWP region to see what has been implemented and what the potential barriers are for the low integration of DSME. The need for DSME is present, and programmes are being developed. Therefore, focusing a systematic review of DSME research in the AWP region would give a better understanding of which intervention approaches are associated with better clinical outcomes and are culturally acceptable.

Design: A systematic review.

Methods: A review of randomized controlled trials (RCTs) and comparative studies to evaluate the effectiveness of face-to-face delivery reporting educational and/or psychological interventions for people with T2DM was implemented. We conducted searches using MEDLINE, EMBASE, CINAHL, PubMed and ASSIA databases between January 1990-June 2018. Studies published in English and non-English were included. Two reviewers independently extracted data on participant and intervention characteristics. The quality of evidence was rated on predetermined criteria. Main outcomes included glycaemic control (reduction in HbA1c level).

Results: We included 21 DSME programmes (17 RCTs), while 15 were group-based approaches. Twelve studies (60%) were categorized as high quality. Three studies (25%) had a moderate (good) effect. Eight trials were effective in improving glycaemic control and reported statistically significant improvements in HbA1c levels. 50% of these were high-intensity group-based programmes.
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http://dx.doi.org/10.1002/nop2.340DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6805261PMC
October 2019

The Accuracy of the Patient Health Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis.

Psychother Psychosom 2020 8;89(1):25-37. Epub 2019 Oct 8.

Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.

Background: Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results.

Objective: To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of ≥10.

Methods: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview.

Results: Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of ≥10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88).

Conclusions: The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression.
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http://dx.doi.org/10.1159/000502294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960351PMC
November 2020

The Prospective Association Between Inflammation and Depressive Symptoms in Type 2 Diabetes Stratified by Sex.

Diabetes Care 2019 10 15;42(10):1865-1872. Epub 2019 Aug 15.

Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, U.K.

Objective: We tested whether inflammation is associated with worsening depressive symptoms in type 2 diabetes and examined whether sex moderated this association.

Research Design And Methods: In a prospective cohort study of people with newly diagnosed type 2 diabetes, we measured depressive symptoms over a 2-year follow-up using the Patient Health Questionnaire-9 (PHQ-9). The independent variable was a composite inflammation burden score at diagnosis of diabetes, derived from hs-CRP, white cell count, interleukin (IL)-1β, IL-1 receptor antagonist, monocyte chemotactic protein-1, and vascular endothelial growth factor concentrations. General linear models assessed ) the association between overall inflammation burden and estimated marginal mean PHQ-9 score (ln transformed) at 2 years and ) whether sex interacted with elevated inflammation burden (above-median score) in predicting change in PHQ-9 score. Models were adjusted for age, ethnicity, BMI, blood pressure, cholesterol, HbA, antidepressants, anti-inflammatory medications, and baseline ln PHQ-9 score.

Results: Of 1,174 people with complete inflammation data, mean (SD) age was 56.7 (11.0) years and 46.1% were of nonwhite ethnicity and 44.1% female. After full adjustment, inflammation burden was not associated with worsening ln PHQ-9 score ( = 0.65). However, female sex interacted with elevated inflammation in predicting higher 2-year ln PHQ-9 score (β = 0.32, = 0.005), showing that the difference by inflammation burden in females was 0.32 larger than in males. In post hoc comparisons, ln PHQ-9 score was higher in females than males with elevated inflammation ( = 0.003) but not with low inflammation ( = 0.34) burden.

Conclusions: In type 2 diabetes, female sex confers specific vulnerability to the effects of inflammation on depressive symptoms.
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http://dx.doi.org/10.2337/dc19-0813DOI Listing
October 2019

Effect of lifestyle, medication and ethnicity on cardiometabolic risk in the year following the first episode of psychosis: prospective cohort study.

Br J Psychiatry 2019 12;215(6):712-719

Professor of Psychiatry and Medicine, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, UK.

Background: The first episode of psychosis is a critical period in the emergence of cardiometabolic risk.

Aims: We set out to explore the influence of individual and lifestyle factors on cardiometabolic outcomes in early psychosis.

Method: This was a prospective cohort study of 293 UK adults presenting with first-episode psychosis investigating the influence of sociodemographics, lifestyle (physical activity, sedentary behaviour, nutrition, smoking, alcohol, substance use) and medication on cardiometabolic outcomes over the following 12 months.

Results: Rates of obesity and glucose dysregulation rose from 17.8% and 12%, respectively, at baseline to 23.7% and 23.7% at 1 year. Little change was seen over time in the 76.8% tobacco smoking rate or the quarter who were sedentary for over 10 h daily. We found no association between lifestyle at baseline or type of antipsychotic medication prescribed with either baseline or 1-year cardiometabolic outcomes. Median haemoglobin A1c (HbA1c) rose by 3.3 mmol/mol in participants from Black and minority ethnic (BME) groups, with little change observed in their White counterparts. At 12 months, one-third of those with BME heritage exceeded the threshold for prediabetes (HbA1c >39 mmol/mol).

Conclusions: Unhealthy lifestyle choices are prevalent in early psychosis and cardiometabolic risk worsens over the next year, creating an important window for prevention. We found no evidence, however, that preventative strategies should be preferentially directed based on lifestyle habits. Further work is needed to determine whether clinical strategies should allow for differential patterns of emergence of cardiometabolic risk in people of different ethnicities.
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http://dx.doi.org/10.1192/bjp.2019.159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557635PMC
December 2019

The Association Between Selective Serotonin Reuptake Inhibitors and Glycemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Psychosom Med 2019 09;81(7):570-583

From the Departments of Psychological Medicine (Tharmaraja, Ismail, Moulton) and Biostatistics and Health Informatics (Stahl), Institute of Psychiatry, Psychology and Neuroscience, King's College London; Psychological Medicine Service (Hopkins), Berkshire Healthcare NHS Foundation Trust, Royal Berkshire Hospital, Reading; and Department of Diabetes (Persaud, Jones), School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, United Kingdom.

Objective: Individual studies have reported conflicting effects of selective serotonin reuptake inhibitors (SSRIs) on glycemia. We systematically reviewed the effects of SSRIs on glycemia and whether metabolic and psychological factors moderated these effects.

Methods: We systematically searched for placebo-controlled randomized controlled trials investigating the effect of SSRIs on glycemia (fasting blood glucose or HbA1c) as a primary or secondary outcome. Random effects meta-analysis was conducted to compute an overall treatment effect. Meta-regression tested whether depression, type 2 diabetes, insulin resistance, treatment duration, and weight loss moderated treatment effects.

Results: Sixteen randomized controlled trials (n = 835) were included and glycemia was usually a secondary outcome. Overall, SSRIs improved glycemia versus placebo (pooled effect size (ES) = -0.34, 95% confidence interval (CI) = -0.48 to -0.21; p < .001, I = 0%). Individually, fluoxetine (ES = -0.29, 95% CI = -0.54 to -0.05; p = .018) and escitalopram/citalopram (ES = -0.33, 95% CI = -0.59 to -0.07; p = .012) outperformed placebo, but paroxetine (ES = -0.19, 95% CI = -0.58 to 0.19; p = .33) did not. Results were similar in populations selected for depression as those not. Across studies, baseline insulin resistance (p = .46), treatment duration (p = .47), diabetes status (p = .41), and weight loss (p = .93) did not moderate changes. Heterogeneity for all analyses was nonsignificant.

Conclusions: SSRIs seem to have an association with improvement in glycemia, which is not moderated by depression status, diabetes status, or change in weight across studies. Future powered trials with longer treatment duration are needed to confirm these findings.

Registration: PROSPERO ID: CRD4201809239.
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http://dx.doi.org/10.1097/PSY.0000000000000707DOI Listing
September 2019
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