Boon How Chew
Handling emotional distress in Malaysian adults with type 2 diabetes
Type 2 diabetes mellitus (T2DM) has negative impacts on many aspects of life and living of people suffering from it, a challenge in good self-care, a continuous struggle to be adherent to medical treatments and demands regular readjustment in life routines according to clinical outcomes. It is recognized that psychological health such as diabetes-related distress (DD) and depressive symptoms in people with T2DM affects treatment effectiveness, disease control, complications, quality of life, and thus needs more attention. This thesis was conducted in Asian population in Malaysia, examining the prevalence of and factors associated with DD and depressive symptoms. The endeavour of this thesis includes examining the current literature for psychological interventions and conceptual framework that work for DD, developing a relatively short and culturally appropriate intervention programme to reduce DD, testing the programme effectiveness, translating and validating a Malay version of the Brief Illness Perception Questionnaire for Malay-speaking people with T2DM. DD and depression were common in Asian adults with T2DM at the primary care level in Malaysia. Having a Chinese origin or being young was associated with having DD. Being divorced or separated and having microvascular complications was associated with depression in individuals with T2DM. These types of patients require extra clinical attention for a better identification of emotional problems and efficient management of resources. The three different DD scales, namely the DDS-17, the DDS-2 and the PAID-5, showed differential associations with the patient-reported outcomes. Only DD measured with DDS-2 showed significant independent associations with SBP, DBP and BP target < 140/90 mmHg; while the PAID-5 questionnaire with medication adherence (MMAS, continuous and categorical forms) and self-care activities (SDSCA, categorical form). Low DD may predispose to more depressive symptoms some years later, and no or only a few depressive symptoms do not prevent a higher DD level at a later stage. These longitudinal relations signify significant opposite changes in DD and depressive symptoms at the personal level rather than a status quo. Therefore, higher degrees of these feelings and symptoms should not a priori be considered as negative, as the names of these constructs imply because they could be manifestations of initial coping behaviours. Nevertheless, vigilant monitoring of DD and depressive symptoms and additional support if necessary seem reasonable approaches in clinical care. For effective screening and monitoring of DD, DD should be diagnosed with the short DDS-2 or PAID-5 questionnaires. These short questionnaires may identify patients who are distressed, which offers an opportunity to engage the person with T2DM in the formulation of an individualised diabetes management plan. With regard to psychological support or intervention for patients with DD, a general discussion of diabetes-related health issues is equally effective in reducing DD compared to the VEMOFIT programme at six months follow-up. Both interventions decreased DD significantly. For such a ‘general discussion of diabetes-related health issues’ to be effective, at least two group-based meetings on top of usual standard diabetes care are necessary. This could be implemented quicker and easier compared to the VEMOFIT programme.