Whom should we target? A brief report on a prospective study to identify predictors of mental health and self-care worsening in patients with diabetes mellitus during the COVID-19 pandemic

ABSTRACT

Objective

To identify predictors of mental health disorders and self-care worsening in patients with diabetes through 15 months of COVID-19 pandemic.

Subjects and methods

Prospective study following patients with type 1 and type 2 diabetes during the COVID-19 pandemic in Southern Brazil. Participants were evaluated through phone calls in two moments: first three months of the outbreak, and 15 months later. The outcomes were the assessment of worsening in mental health disorders (increase ≥ 10% in the total score of the Self-Report Questionnaire), the assessment of emotional distress related to diabetes (increase ≥ 10% in the total score of the Brazilian version of the Problem Areas in Diabetes), and worsening in self-care parameters (reduction ≥ 3 points in the Self-Care Inventory-Revised). Logistic regression models were used to determine the odds ratio (OR) and their respective confidence intervals. Point-biserial correlation coefficients (r^pb) were used to measure the relationship between the variation in scores and patient characteristics.

Results

In total, 150 adults were enrolled (54.6 ± 13.9 years old, 58.7% female, 85.9% white), out of which 118 remained during follow up. After 18 months, 34,7% of them (52.2 ± 14.8 years old, 53.7% female, 87.5% white) worsened mental health scores. An increase in mental health disorders was experienced by patients with lower middle-income [OR 4.2 (1.2-15.0)], and those who reported greater difficulty managing diabetes [OR 3.2 (1.4-7.1); r^pb 0.32, P < 0.01]. In contrast, those who perceived an improvement in diabetes control showed a reduction in their mental health scores [OR 0.3 (0.1-0.8)]. For self-care, there was a score worsening in patients with longer duration of diabetes [OR 1.1 (1.0-1.1)] and in those using insulin [OR 8.3 (1.7-41.4); r^pb 0.23, P = 0.01]. Conversely, those who followed the social distancing guidance had an improvement in self-care [OR 0.4 (0.1-0.9); r^pb 0.18, P = 0.05].

Conclusion

Some clinical and socioeconomic characteristics may be suitable for identifying patients at higher risk of mental health and self-care worsening, signaling who needs to be monitored more closely during crisis situations.

Depression; anxiety; outbreak; health care; diabetes

INTRODUCTION

Diabetes mellitus is a long-term progressive disease that can pose emotional, social, and economic challenges. Studies have shown that people with diabetes are up to four times more likely to be affected by depression and anxiety compared to their peers without diabetes (¹). Numerically, mental health disorders are about as prevalent as direct complications from diabetes, highlighting the significance of incorporating emotional assessments into standard diabetes care (²).

The coronavirus 2019 (COVID-19) pandemic has had huge impact for individuals with chronic diseases, including diabetes. The disruption of medical appointments, associated with the changes in lifestyle routines that accompanied the pandemic, negatively impacted the emotional well-being, self-care and adherence to treatment (³,⁴). Furthermore, the experienced stressogenic environment represented a risk factor for the exacerbation of preexisting psychiatric disorders, which is corroborated by the alarming finding that one in ten patients with diabetes had suicidal thoughts after one year of the COVID-19 pandemic (⁵).

Studies indicate that the COVID-19 pandemic has resulted in a range of emotional issues in individuals with diabetes (³). However, who are those who would benefit most from protective measures to prevent a decline in mental health and self-care? Our study aimed to identify factors predicting the deterioration of mental health and self-care among patients with diabetes over the 15 months of the COVID-19 pandemic.

METHODS

This is a prospective study focused on patients with diabetes mellitus during the COVID-19 pandemic in Southern Brazil. We identified adults previously diagnosed with either type 1 or type 2 diabetes from electronic medical records. The patients were regularly monitored at one of two public tertiary care hospitals in Southern Brazil. Inclusion criteria were being aged 18 years or older, having an updated phone number in their medical records and a recent HbA1c assessment. Eligible patients were contacted in April 2020 to invite them to take part in the study, submit their informed consent, and their initial assessment was carried out. Then, in July 2021 – 15 months after their inclusion – participants were contacted again for a reassessment.

Electronic medical records were used to assess demographics and clinical characteristics, presence of diabetes complications, and previous laboratory tests. Directive questions were used to access about psychosocial aspects, use of medication, and lifestyle habits. For the evaluation of outcomes related to mental health and adherence to treatment, specific questionnaires validated for the Brazilian population were used. For the assessment of mental health disorders, the Self-Report Questionnaire (SRQ 20) was used, which consisted of 20 questions with “yes and no” answer options. For the assessment of emotional distress related to diabetes, the Brazilian version of the Problem Areas in Diabetes (B-PAID) was used. This is a 20-item questionnaire on a 4-point response scale, with responses ranging from 0 (“it is not a problem”) to 4 (“it is a serious problem”). For self-care and treatment adherence evaluation, the Self-Care Inventory-Revised (SCI-R) was used, a 14-question survey that reflects how patients with diabetes have adhered to treatment recommendations. Higher scores indicate better adherence.

The study outcomes were the assessment of predictors of: (¹) worsening in mental health disorders, defined as an increase ≥ 10% in the total score of the SRQ-20 questionnaire; (²) worsening in emotional distress related to diabetes, defined as an increase ≥ 10% in the total score of the BPAID; (³) worsening in self-care parameters, defined as reduction ≥ 3 points in the SCI-R. To increase the specificity of our analysis, we pre-specified a 10% margin of tolerance in the total scores in order to consider only clinically relevant changes. The 10% margin was defined arbitrarily before the analysis, and it is equivalent to approximately 3 points in the SCI-R score.

Baseline characteristics are presented as mean ± standard deviation (SD) and percentages, and groups were compared using the chi-square (χ²) test for categorical variables and Student’s t-test for continuous variables. Clinical parameters and social aspects potentially modified during the pandemic were tested to identify its association with worsening in mental health, emotional distress and self-care parameters. Logistic regression models were used to determine the odds ratio (OR) and their respective 95% confidence intervals (CI). Sensitivity analysis included a model with correction for sex, age and duration of diabetes. Lastly, point-biserial correlation coefficients (r^pb) were used to measure the relationship between the variation in total scores of the questionnaires and patient characteristics. An α level of ≤ 0.05 was used to determine statistical significance.

RESULTS

In total, 150 adults were enrolled (54.6 ± 13.9 years old, 58.7% female, 85.9% white), out of which 118 remained during follow up (Figure 1). The characteristics of participants are described in Table 1. After 15 months, 34,7% of them (52.2 ± 14.8 years old, 53.7% female, 87.5% white) worsened mental health scores; compared to those who did not worsen, both groups had similar age, sex, skin color, duration of diabetes and HbA1c at baseline.

Figure 1
Flowchart of participant selection and baseline characteristics of the study participants.

Table 1
Demographics and clinical characteristics of study participants

	Total (n = 118)	Type 1 diabetes (n = 58)	Type 2 diabetes (n = 60)
Age (years)	54.2 ± 14.0	53.6 ± 13.1	54.7 ± 14.8
Sex (% female)	56.8%	60.3%	53.3%
Self-reported skin color (% white)	89.3%	89.5%	89.1%
Diabetes duration (years)	22.1 ± 10.7	20.9 ± 11.4	23.2 ± 9.9
HbA1c (%)	8.7 ± 1.5	8.8 ± 1.6	8.7 ± 1.5
Diabetes complications
Retinopathy	47.5%	50.0%	45.0%
Neuropathy	29.9%	22.8%	36.7%
Nephropathy	42.4%	31.0%	53.3%
Insulin use	92.5%	100%	86.8%
Metformin use	46.7%	-	46.7%
Glibenclamide use	10.0%	-	10.7%
Systemic arterial hypertension	59.3%	58.6%	60.0%
Coronary artery disease	18.6%	20.7%	16.7%
ACE inhibitors use	40.2%	49.1%	31.7%
ARB use	25.6%	21.1%	30.0%

• Data are mean ± standard deviation or %. An α ≤ 0.05 indicates significant difference. HbA1c: hemoglobin A1c. ACE: Angiotensin-converting enzyme; ARB: angiotensin receptor blockers.

For mental health evaluation (SRQ-20), a worsening in mental health scores was experienced by patients with lower middle-income [OR 4.1 (1.2-15.0)], and those who reported greater difficulty in managing diabetes [OR 3.2 (1.4-7.1); r 0.32, P < 0.01]. In contrast, those who perceived an improvement in diabetes control showed a reduction in their mental health scores [OR 0.3 (0.1-0.8)]. Sensitivity analysis showed that these associations remained similar when the model was corrected for age, sex, and duration of diabetes (Table 2).

Table 2
Assessment of predictors of mental health, emotional distress and self-care worsening in patients with diabetes mellitus during the 15 months of follow up

	Worsening in mental health score (SRQ 20)	Worsening in emotional distress related to diabetes (BPAID)	Worsening in self-care (SCI-R)
Type 1 diabetes	0.8 (0.4-1.8)	1.1 (0.5-2.3)	1.0 (0.5-2.2)
Type 2 diabetes	1.2 (0.6-2.5)	0.9 (0.4-1.9)	0.9 (0.6-2.1)
Duration of diabetes	1.0 (0.9-1.0)	1.0 (0.9-1.1)	1.1 ( 1.0-1.1)
Baseline HbA1c	0.9 (0.7-1.1)	1.0 (0.8-1.3)	0.9 (0.7-1.2)
Family income	4.1 (1.2-15.0)	0.6 (0.2-2.3)	1.2 (0.4-3.7)
Insulin use	1.3 (0.3-4.8)	5.5 (0.7-45.1)	8.3 (1.7-41.4)
Followed the social distancing guidance	1.0 (0.4-2.3)	0.7 (0.3-1.8)	0.4 (0.1-0.9)
COVID-19 infection	1.1 (0.2-6.4)	1.8 (0.3-12.3)	1.4 (0.2-8.7)
Loss of a loved one	1.6 (0.7-3.7)	1.4 (0.6-3.2)	1.2 (0.5-2.8)
Job loss	1.5 (0.5-4.5)	1.5 (0.5-4.3)	1.4 (0.5-4.1)
Perceived difficulty managing diabetes	3.2 (1.4-7.1)	1.8 (0.8-4.0)	0.8 (0.3-1.7)
Perceived improvement in glycemic control	0.3 (0.1-0.8)	0.5 (0.2-1.2)	0.7 (0.4-2.7)

• Data are odds ratio (OR) and 95% confidence interval (CI). HbA1c: glycated hemoglobin.

The assessment of emotional distress related to diabetes (BPAID) was not associated with any of the clinical and social parameters evaluated. Furthermore, type of diabetes, HbA1c value, having had COVID-19 infection, dealing with the loss of a loved one, or job loss during the pandemic were not associated with any of the outcomes assessed (Table 2).

For self-care assessment (SCI-R), there was a score worsening in patients with longer duration of diabetes [OR 1.1 (1.0-1.1)] and in those using insulin [OR 8.3 (1.7-41.4); r 0.23, P = 0.01]. Conversely, those who followed the social distancing guidance had an improvement in self-care [OR 0.4 (0.1-0.9); r 0.18, P = 0.05]. These associations remained similar in the corrected model (Table 2).

DISCUSSION

This study aimed to identify predictors of mental health disorders, emotional distress, and worsening self-care habits in individuals with diabetes during the COVID-19 pandemic. Our findings show that patients of low-to-middle-income status and those struggling with diabetes management are most susceptible to declining mental health scores during crises. Regarding self-care, patients with a longer history of diabetes, especially those using insulin, appear most at risk of worsening self-care habits. These individuals could greatly benefit from protective measures aimed at mental health and self-care in similar situations in the future.

The association between family income and deteriorated mental health in individuals without diabetes has been long established (⁶). This linkage is primarily explained by two mechanisms: the social causation hypothesis and the health selection hypothesis. The first suggests that stress, social adversity, and reduced coping capacity associated with low income escalate the risk of emotional disorder development. The second theory posits that individuals with mental disorders might be predisposed to reduced educational attainment and lower income (⁶,⁷). Additionally to these mechanisms, the economic crisis that accompanied the COVID-19 pandemic was a trigger for the reduction of family income worldwide. A previous study showed that COVID-19 had a significantly greater negative impact among the low-income patients on family income/employment, access to food, access to mental health treatment, and family conflicts (⁸). For patients with diabetes mellitus, the pandemic represented an additional challenge, making it difficult to access medical care and supplies for diabetes treatment, conditions that may have contributed to individuals in greater economic vulnerability being more affected by mental health disorders.

Routine changes that accompanied the COVID-19 pandemic directly interfered with diabetes and health care, as supported by several studies. Barone and cols. showed that among patients with diabetes living in Brazil more than 59% experienced a high variability in glucose levels during the pandemic, 38.4% postponed their medical appointments, and 59.5% reduced their physical activity (⁹). In our study, individuals who had greater difficulty managing diabetes were more likely to experience worsening mental health scores during the pandemic. In the opposite, those who perceived an improvement in diabetes control had a lower chance of worsening in this parameter. Our findings also reflect the impact of perceptions regarding diabetes care in mental health status of these individuals, as previously described by Lange and Piette (¹⁰). This result is alarming as other Brazilian studies have also demonstrated a significant worsening of mental health parameters in patients with diabetes. Alessi and cols. showed that almost 43% of patients with diabetes showed evidence of significant psychological distress during the pandemic, with a greater tendency in those with type 2 diabetes (³). Another Brazilian study found that psychological symptoms were experienced by almost 61% of patients with type 1 diabetes (¹¹).

In this scenario of lifestyle changes and suspension of elective care, having a longer duration of diabetes and using insulin were associated with worsening in self-care scores, which may reflect a profile of patients who would probably benefit most from maintaining medical care in crisis situations. Finally, in our study those patients who followed the social distancing recommendation had a lower risk of self-care deterioration, which may be explained by the convenience of managing diabetes at home during quarantine, and a greater motivation to optimize diabetes care during critical times.

Despite potential limitations, such as using screening-focused questionnaires and a predominantly female sample, our study broadens our understanding of mental health decline predictors in diabetes mellitus patients. It also indicates that certain clinical and socioeconomic characteristics could be beneficial in identifying patients at an increased risk of worsening mental health and self-care, indicating who may require more thorough monitoring in crises.

Acknowledgments

JA is the guarantor of this study. She has full access to all the data and assumes responsibility for the integrity and accuracy of the data.

REFERENCES

• ¹
  Buchberger B, Huppertz H, Krabbe L, Lux B, Mattivi JT, Siafarikas A. Symptoms of depression and anxiety in youth with type 1 diabetes: A systematic review and meta-analysis. Psychoneuroendocrinology. 2016;70:70-84. doi: 10.1016/j.psyneuen.2016.04.019.
  » https://doi.org/10.1016/j.psyneuen.2016.04.019
• ²
  Holt RI, Mitchell AJ. Diabetes mellitus and severe mental illness: mechanisms and clinical implications. Nat Rev Endocrinol. 2015;11(2):79-89. doi: 10.1038/nrendo.2014.203.
  » https://doi.org/10.1038/nrendo.2014.203
• ³
  Alessi J, de Oliveira GB, Franco DW, do Amaral B B, Becker AS, Knijnik CP, et al. Mental health in the era of COVID-19: prevalence of psychiatric disorders in a cohort of patients with type 1 and type 2 diabetes during the social distancing. Diabetol Metab Syndr. 2020;12:76. doi: 10.1186/s13098-020-00584-6.
  » https://doi.org/10.1186/s13098-020-00584-6
• ⁴
  Franco DW, Alessi J, Becker AS, do Amaral BB, de Oliveira GB, Schaan BD, et al. Medical adherence in the time of social distancing: a brief report on the impact of the COVID-19 pandemic on adherence to treatment in patients with diabetes. Arch Endocrinol Metab. 2021;65(4):517-21. doi: 10.20945/2359-3997000000362.
  » https://doi.org/10.20945/2359-3997000000362
• ⁵
  Alessi J, Scherer GDL, Erthal IN, Teixeira JB, de Oliveira GB, Jaeger EH, et al. One in ten patients with diabetes have suicidal thoughts after 1 year of the COVID-19 pandemic: We need to talk about diabetes and mental health not only during Suicide Prevention Awareness Month. Acta Diabetol. 2022;59(1):143-5. doi: 10.1007/s00592-021-01807-6.
  » https://doi.org/10.1007/s00592-021-01807-6
• ⁶
  Dohrenwend BP, Levav I, Shrout PE, Schwartz S, Naveh G, Link BG, et al. Socioeconomic status and psychiatric disorders: the causation-selection issue. Science. 1992;255(5047):946-52. doi: 10.1126/science.1546291.
  » https://doi.org/10.1126/science.1546291
• ⁷
  Sareen J, Afifi TO, McMillan KA, Asmundson GJ. Relationship between household income and mental disorders: findings from a population-based longitudinal study. Arch Gen Psychiatry. 2011;68(4):419-27. doi: 10.1001/archgenpsychiatry.2011.15.
  » https://doi.org/10.1001/archgenpsychiatry.2011.15
• ⁸
  Hall LR, Sanchez K, da Graca B, Bennett MM, Powers M, Warren AM. Income Differences and COVID-19: Impact on Daily Life and Mental Health. Popul Health Manag. 2022;25(3):384-91. doi: 10.1089/pop.2021.0214.
  » https://doi.org/10.1089/pop.2021.0214
• ⁹
  Barone MTU, Harnik SB, de Luca PV, Lima BLS, Wieselberg RJP, Ngongo B, et al. The impact of COVID-19 on people with diabetes in Brazil. Diabetes Res Clin Pract. 2020 Aug;166:108304. doi: 10.1016/j.diabres.2020.108304.
  » https://doi.org/10.1016/j.diabres.2020.108304
• ¹⁰
  Lange LJ, Piette JD. Perceived health status and perceived diabetes control: psychological indicators and accuracy. J Psychosom Res. 2005;58(2):129-37. doi: 10.1016/j.jpsychores.2004.08.004.
  » https://doi.org/10.1016/j.jpsychores.2004.08.004
• ¹¹
  de Mattos Matheus AS, Cabizuca CA, Tannus LRM, Passos AC, Schmidt AC, de Gouveia AT, et al. Telemonitoring type 1 diabetes patients during the COVID-19 pandemic in Brazil: was it useful? Arch Endocrinol Metab. 2021;65(1):105-11. doi: 10.20945/2359-3997000000309.
  » https://doi.org/10.20945/2359-3997000000309

• Ethics approval and consent to participate: the study was conducted in accordance with the Helsinki Declaration, 2004, performed following all relevant guidelines and regulations and approved by the National Research Ethics Committee (no. 4.903.365). All authors signed the confidentiality document for data use, and participants provided informed consent through electronic recording (audio recording or text messaging).
• Availability of data and materials: the data collected for the study will be available upon justified request to the email address of the main researcher.

• Funding: this study was conducted with support from Research Incentive Fund (FIPE/HCPA), Postgraduate Program in Endocrinology at the Universidade Federal do Rio Grande do Sul, School of Medical Sciences at the Pontifícia Universidade Católica do Rio Grande do Sul and Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul. This study was funded in part by the Coordination for the improvement of Higher Education Personnel – Brazil (Capes) – Finance Code 001.

Data availability

Availability of data and materials: the data collected for the study will be available upon justified request to the email address of the main researcher.

Publication Dates

• Publication in this collection
  23 Aug 2024
• Date of issue
  2024

History

• Received
  21 Feb 2023
• Accepted
  23 Feb 2024