The Role of Thought Believability in the Relationship Between Depression, Diabetes, and Stress.

1. The Role of Thought Believability in the Relationship Between Depression, Diabetes, and Stress. Eric Schmidt, Kate Ward, Jennifer Gregg, Jesse Tarango, and Tommy VanVeghel San José State University

2. The Diabetes Epidemic • In U.S. alone, 24+ million (CDC, 2007/2008) • Diagnosable diabetes > 8% of U.S. population • Another 57 million with pre-diabetes • 250+ million worldwide (WHO, 2009) • 7 million/year increase in cases • Causes 5% of deaths globally • Number of deaths to double by 2030 • Still uncertain etiology in Type 2 Diabetes • Population rates related to obesity

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19. Depression and Diabetes • People with Diabetes at 1.6-2.0x risk for Depression (Anderson et al., 2001; Ali et al., 2006) • No difference has been reported (Téllez-Zenteno et al., 2002) Those with comorbid Diabetes and Depression • Show less adherence to prescription regimen • Tend to partake in fewer self-management activities • Are at increased risk for undesirable and preventable medical outcomes and mortality (Gonzalez et al., 2007; Ciechanowski et al., 2000; Lin et al., 2004; Kalsekar et al., 2006; Katon et al., 2005; Katon et al., 2009) • People with Depression at 23-37%increased risk for developing Diabetes (Knol et al., 2006; Brown et al., 2005)

20. Depression, Stress, & Diabetes • Stress • “Perceived Stress” • Acute stressors and Allostatic Load • Depression and Stress correlated • Stress also important in chronic disease • Self-Management & Adherence linked with blood sugar control • Blood sugar control linked with medical outcomes and mortality in diabetes

21. Cortisol, Diabetes, & Depression • Stress biomedically related to diabetes in a way we don’t often see with psychological disorders • Affects behavior (self-management, etc.) • But *also* matters biologically • Cortisol related to “Fight or Flight” • Related to both Stress and Depression • Activation of HPA Axis, inhibits insulin action • Increased blood sugar levels • Increased risk for undesirable medical outcomes

22. Previous Research Sacco et al. (2005, 2007) • Self-Efficacy mediates adherence and depression Adherence Depression Self-Efficacy 0.74* 0.74* -0.41* -0.38* -0.35* -0.38* * p < .01 †p = n.s. 2005 2007 †† Adherence Depression • Doesn’t give us a way to intervene within the model • “…enhancing adherence in people with diabetes should enhance their physical and mental health by reducing depressive symptoms.” • Recommend emphasis on diet and exercise adherence

23. But From an ACT Perspective Sacco et al. (2005, 2007) • Self-Efficacy mediates adherence and depression Adherence Depression Self-Efficacy 0.74* 0.74* -0.41* -0.38* -0.35* -0.38* * p < .01 †p = n.s. 2005 2007 †† Adherence Depression • Doesn’t give us a way to intervene within the model • “…enhancing adherence in people with diabetes should enhance their physical and mental health by reducing depressive symptoms.” • Recommend emphasis on diet and exercise adherence

24. But From an ACT Perspective Sacco et al. (2005, 2007) • Self-Efficacy mediates adherence and depression ? Adherence Depression Adherence Depression Believability ? ? Adherence Depression • Doesn’t give us a way to intervene within the model • Adherence is still the problem!! • We already know that adherence efforts don’t work consistently

25. BelievabilityAn Intervention for Adherence • Varied levels of depression symptoms related to high levels of non-adherence (Fisher et al., 2007; Gonzalez et al., 2007) • Some patients “distressed,” not depressed • Conflicting support for Depression as predictor in mediation, and relationship remains complicated (McKellar et al., 2004; Gregg et al., 2010) • Insulin vs. medication adherence (Aikens et al., 2008) • Gender differences (Nau et al., 2007) Need interventions that provide patients with behavioral tools delivered within the diabetes self-management and depression relationship.

26. Research Questions • Does Believability of Negative Thoughts mediate relationship between Adherence to diabetes self-management and Depression? • Does Believability of Negative Thoughts mediate the relationship between Adherence to diabetes self-management and Stress?

27. Methods • Cross-sectional internet-based survey • Participants with Type 2 Diabetes Mellitus (N=171) • Diabetes-specific discussion boards, websites, and forums • $5 Amazon.com gift card • Depression, Stress, Diabetes Self-Care • Exclusions: Duplicate IP address, International, Entries not referring to Diabetes, Pregnant, Eating Disorder (N=34)

28. Methods - Measures • Automatic Thoughts Questionnaire (ATQ-B) • “Believability” or Cognitive Fusion • Beck Depression Inventory (BDI) • Perceived Stress Scale (PSS) • Summary of Diabetes Self-Care Activities • “Adherence” • Diet and exercise focus • E.g., “On how many of the last 7 days did you eat your recommended number of vegetables?”

29. Methods: Mediation Analysis • Adherence predicts Stress • Believability predicts Stress • Adherence predicts Believability • Statistically significant reduction of the predictive power of Adherence on Stress when Believability is controlled Proposed Model Believability Adherence Stress

30. Research Question 1 Depression Model • Believability of Negative Thoughts mediates Adherence and Depression (Gregg et al., 2010) • Model not significant with Depression as predictor Believability Adherence Depression -0.24** 0.48*** -0.37*** * p < .01 ** p < .001

31. Research Question 1 Depression Model • Believability of Negative Thoughts mediates Adherence and Depression (Gregg et al., 2010) • Model not significant with Depression as predictor Believability Believability Adherence Adherence Depression Depression -0.24** -0.24** 0.48*** 0.42*** -0.37*** -0.27** * p < .01 ** p < .001

32. Research Question 1 Depression Model • Believability of Negative Thoughts mediates Adherence and Depression (Gregg et al., 2010) • Model not significant with Depression as predictor Believability Believability Adherence Adherence Depression Depression -0.24** -0.24** 0.48*** 0.42*** β = −.270, t (121) = -3.428, p < .01 Sobel = 2.43, p = .015 -0.37*** -0.27** * p < .01 ** p < .001

33. Results: Stress Model β = −.240, t (119) = -2.711, p = .008 AdherenceBelievability AdherenceStress β = −.279, t (119) = -3.182, p = .002 Believability BelievabilityStress β = .306, t (119) = 3.574, p = .001 Adherence Stress Depression Stress r = .219 p = .01 Proposed Model Measures Stress: Perceived Stress Scale Believability: Automatic Thoughts Questionnaire - B Adherence: Summary of Diabetes Self-Care Activities Depression: Beck Depression Inventory

34. Results: Stress Model • Believability of Negative Thoughts mediated Adherence and Perceived Stress • Partial mediation with Believability for Stress, Depression, and Adherence Believability Adherence Stress -0.24** 0.31*** -0.28** *p<.05 **p<.01 ***p<.001

35. Results: Stress Model • Believability of Negative Thoughts mediated Adherence and Perceived Stress • Partial mediation with Believability for Stress, Depression, and Adherence Believability Believability Adherence Adherence Stress Stress -0.24** -0.24** 0.31*** 0.33*** -0.28** -0.20* *p<.05 **p<.01 ***p<.001

36. Results: Stress Model • Believability of Negative Thoughts mediated Adherence and Perceived Stress • Partial mediation with Believability for Stress, Depression, and Adherence Believability Believability Adherence Stress Adherence Stress -0.24** -0.24** 0.31*** 0.33*** β = −.200, t (119) = -2.337, p = .021 Sobel = 2.184, p = .029 -0.28** -0.20* *p<.05 **p<.01 ***p<.001

37. Discussion • Depression and Stress related to Adherence • Believability mediated both relationships • Adherence → Depression • Adherence → Stress • Depression and Stress correlated • Contributes to the viability of Believability as a clinical target in this population • ACT for Clinically Depressed patients with Diabetes • Principles of ACT incorporated into Diabetes Education • Gregg et al. (2007) reported more desirable blood sugar and self-management at 3 months in group receiving 1-day ACT with Diabetes Education

38. Future Research • Limitations • Cross-Sectional Data • Internet-Based (benefit?) • Self-Report • Strength of Relationships • Future Research • Are these models bi-directional? Causation? • Do these models represent distinct sub-populations? • Can ACT principles lead to benefits in Diabetes self-management at various stages of diabetes and psychological flexibility? ATQ-Frequency ATQ-Believability r = .569*** For more information, contact Eric Schmidt at eric.schmidt@stanford.edu

39. References Ali, S., Stone, M.A., Peters, J.L., Davies, M.J., & Kunti, K. (2006). The prevalence of co-morbid depression in adults with Type 2 diabetes: A systematic review and meta-analysis. Diabetic Medicine, 23, 1165-1173. Anderson, R.J., Feedland, K.E., Clouse, R.E., & Lustman, P.J. (2001). The prevalence of comorbid depression in adults with diabetes. Diabetes Care, 24, 1069-1078. Brown, L.C., Majumdar, S.R., Newman, S.C., & Johnson, J.A. (2005). History of depression increases risk of type 2 diabetes in younger adults. Diabetes Care, 28, 1063-1067. Centers for Disease Control and Prevention (2007). National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008. Ciechanowski, P.S., Katon, W.J., & Russo, J.E. (2000). Depression and diabetes: Impact of depressive symptoms on adherence, function, and costs. Archives of Internal Medicine, 160, 3278-3285. Fisher, L., Skaff, M.M., Mullan, J.T., Arean, P., Mohr, D., Masharani, U., et al. (2007). Clinical depression versus distress among patients with type 2 diabetes. Not just a question of semantics. Diabetes Care, 30, 542-548. Gonzalez, J.S., Safren, S.A., Cagliero, E., Wexler, D.J., Delahanty, L., Wittenberg, E. et al. (2007). Depression, self-care, and medication adherence in type 2 diabetes. Diabetes Care, 30, 2222-2227. For more information, contact Eric Schmidt at eric.schmidt@stanford.edu

40. References Gregg, J.A., Callaghan, G.M., Hayes, S.C., & Glenn-Lawson, J.L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75, 336-343. Gregg, J.A., Schmidt, E.S., Ward, K.C., Almada, P., & Knezevich, P. (2010). An alternative model for understanding the diabetes-depression relationship: The mediational role of thought believability. Journal of Behavioral Health and Medicine, 1 (1), 15-23. Kalsekar, I.D., Madhavan, S.S., Amonkar, M.M., Makela, E.H., Scott, V.G., Douglas, S.M., et al. (2006). Depression in patients with type 2 diabetes: Impact on adherence to oral hypoglycemic agents. The Annals of Pharmacotherapy, 40, 605-611. Katon, W.J., Rutter, C., Simon, G., Lin, E.H.B., Ludman, E., Ciechanowski, P. et al. (2005). The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care, 28, 2668-2672. Katon, W., Russo, J., Lin, E.H.G., Heckbert, S.R., Karter, A.J., Williams, L.H., et al. (2009). Diabetes and poor disease control: Is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosomatic Medicine, 71, 965-972. Knol, M.J., Twisk, J.W.R, Beekman, A.T.F., Heine, R.J. Snoek, F.J., & Pouwer, F. (2006). Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis. Diabetologia, 49, 837-845. For more information, contact Eric Schmidt at eric.schmidt@stanford.edu

41. References Lin, E.H.B., Katon, W., Von Korff, M., Rutter, C., Simon, G.E., Oliver, M., et al. (2004). Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care, 27, 2154-2160. Nau, D.P., Aikens, J.E., & Pacholski, A.M. (2007). Effects of gender and depression on oral medication adherence in persons with type 2 diabetes mellitus. Gender Medicine, 4, 205-213. Sacco, W.P., Wells, K.J., Vaughan, C.A., Friedman, A., Perez, S., & Matthew, R. (2005). Depression in adults with type 2 diabetes: The role of adherence, body mass index, and self-efficacy. Health Psychology, 24, 630-634. Sacco, W.P., Wells, K.J., Friedman, A., Matthew, R., Perez, S., & Vaughan, C.A. (2007). Adherence, body mass index, and depression in type 2 diabetes: The mediational role of diabetes symptoms and self-efficacy. Health Psychology, 26, 693-700. Téllez-Zenteno, J.F., & Cardiel, M.H. (2002). Risk factors associated with depression in patients with type 2 diabetes mellitus. Archives of Medical Research, 33 (1), 53-60. World Health Organization (2009). Diabetes fact sheet. No 312. WHO Statistical Information System, Global Burden of Disease Project. Available at http://www.who.int/diabetes/facts/en/index.html, downloaded May 15, 2010. For more information, contact Eric Schmidt at eric.schmidt@stanford.edu

42. References Ali, S., Stone, M.A., Peters, J.L., Davies, M.J., & Kunti, K. (2006). The prevalence of co-morbid depression in adults with Type 2 diabetes: A systematic review and meta-analysis. Diabetic Medicine, 23, 1165-1173. Anderson, R.J., Feedland, K.E., Clouse, R.E., & Lustman, P.J. (2001). The prevalence of comorbid depression in adults with diabetes. Diabetes Care, 24, 1069-1078. Brown, L.C., Majumdar, S.R., Newman, S.C., & Johnson, J.A. (2005). History of depression increases risk of type 2 diabetes in younger adults. Diabetes Care, 28, 1063-1067. Centers for Disease Control and Prevention (2007). National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008. Ciechanowski, P.S., Katon, W.J., & Russo, J.E. (2000). Depression and diabetes: Impact of depressive symptoms on adherence, function, and costs. Archives of Internal Medicine, 160, 3278-3285. Fisher, L., Skaff, M.M., Mullan, J.T., Arean, P., Mohr, D., Masharani, U., et al. (2007). Clinical depression versus distress among patients with type 2 diabetes. Not just a question of semantics. Diabetes Care, 30, 542-548. Gonzalez, J.S., Safren, S.A., Cagliero, E., Wexler, D.J., Delahanty, L., Wittenberg, E. et al. (2007). Depression, self-care, and medication adherence in type 2 diabetes. Diabetes Care, 30, 2222-2227. For more information, contact Eric Schmidt at eric.schmidt@stanford.edu

43. References Gregg, J.A., Callaghan, G.M., Hayes, S.C., & Glenn-Lawson, J.L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75, 336-343. Gregg, J.A., Schmidt, E.S., Ward, K.C., Almada, P., & Knezevich, P. (2010). An alternative model for understanding the diabetes-depression relationship: The mediational role of thought believability. Journal of Behavioral Health and Medicine, 1 (1), 15-23. Kalsekar, I.D., Madhavan, S.S., Amonkar, M.M., Makela, E.H., Scott, V.G., Douglas, S.M., et al. (2006). Depression in patients with type 2 diabetes: Impact on adherence to oral hypoglycemic agents. The Annals of Pharmacotherapy, 40, 605-611. Katon, W.J., Rutter, C., Simon, G., Lin, E.H.B., Ludman, E., Ciechanowski, P. et al. (2005). The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care, 28, 2668-2672. Katon, W., Russo, J., Lin, E.H.G., Heckbert, S.R., Karter, A.J., Williams, L.H., et al. (2009). Diabetes and poor disease control: Is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosomatic Medicine, 71, 965-972. Knol, M.J., Twisk, J.W.R, Beekman, A.T.F., Heine, R.J. Snoek, F.J., & Pouwer, F. (2006). Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis. Diabetologia, 49, 837-845. For more information, contact Eric Schmidt at eric.schmidt@stanford.edu

44. References Lin, E.H.B., Katon, W., Von Korff, M., Rutter, C., Simon, G.E., Oliver, M., et al. (2004). Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care, 27, 2154-2160. Nau, D.P., Aikens, J.E., & Pacholski, A.M. (2007). Effects of gender and depression on oral medication adherence in persons with type 2 diabetes mellitus. Gender Medicine, 4, 205-213. Sacco, W.P., Wells, K.J., Vaughan, C.A., Friedman, A., Perez, S., & Matthew, R. (2005). Depression in adults with type 2 diabetes: The role of adherence, body mass index, and self-efficacy. Health Psychology, 24, 630-634. Sacco, W.P., Wells, K.J., Friedman, A., Matthew, R., Perez, S., & Vaughan, C.A. (2007). Adherence, body mass index, and depression in type 2 diabetes: The mediational role of diabetes symptoms and self-efficacy. Health Psychology, 26, 693-700. Téllez-Zenteno, J.F., & Cardiel, M.H. (2002). Risk factors associated with depression in patients with type 2 diabetes mellitus. Archives of Medical Research, 33 (1), 53-60. World Health Organization (2009). Diabetes fact sheet. No 312. WHO Statistical Information System, Global Burden of Disease Project. Available at http://www.who.int/diabetes/facts/en/index.html, downloaded May 15, 2010. For more information, contact Eric Schmidt at eric.schmidt@stanford.edu