The Relationship of Type 2 Diabetes and Depression

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Table of Contents

Abstract
Introduction
Literature Review
Methodology
References

Abstract

Type 2 diabetes is generally recognized as an imbalance between insulin sensitivity and beta cell function

We have chosen a rural area in Wisconsin where we can focus our study and select a group of participants to answer the questionnaires. The entire detail of the study will be provided in the Methodology Section.

Diabetics feel depressed, one reason they are not so functional or efficient in any activity. They also have poor management behavior and have more comorbidities. There are some findings however, that these are diabetes-specific distress and not depression.

From what we have gathered, some studies seem to point to a relationship between depression and glycemic control. This is the finding of several important studies that should be given credence in the study of depression and type 2 diabetes. Further, this finding will be given more attention during the qualitative research or experimental research in a rural area of Northern Wisconsin.

Introduction

Every research begins with a problem. How this has to be dealt with requires some enigmatic, perplexing, or troubling condition, as what Polit and Beck (2008) would say.

Our research problem is: What is the relationship between Type 2 Diabetes and depression among men and women aged 45-65 residing in a rural area in Northern Wisconsin? This will be researched with a qualitative and quantitative approach.

Diabetes is plaguing the nation and the world. In the research for statistics, we were not stunned of the realities of the times, for there is a growing percent of the population that is succumbing to this disease. All the stakes are in favor of its growth, and we have to prepare for its next attack.

Nevertheless, we are also focusing our attention and concern on a rural area of Northern Wisconsin where we can concentrate our research. Wisconsin is a place where the government and the people have joined hands to fight diabetes and the many effects of the disease to the well being of its inhabitants.

The problem is to address whether there is a link between diabetes and depression. Though there are many points to this relationship, we have to provide a scholarly report with evidence so that the right people in government and the private and the public sector can address the issue on hand.

We have to build some parameters in order to arrive at a point to start with. It has to be started with this researcher and some colleagues. A straight and evidence-full narrative of the background on the subject has to be provided.

Diabetes occurs when an individual develops a dysfunction in insulin production and/or insulin action, which induces an inability to metabolize blood glucose. Insulin is a hormone produced by beta cells within the pancreas. Type II diabetes, also called adult-onset diabetes, begins with the development of insulin resistance. The cells do not properly utilize the available insulin thereby increasing the demand for insulin production as the pancreas eventually fails to produce sufficient insulin (Boyer, 2008).

In 2003-2006, the percent of population with diabetes, for 40-59 years of age, was 8.3, and 16.9 for persons 60 years and over (U.S. Department of Health and Human Services, 2009).

There are 12.2 million persons aged 60 plus years who have diabetes mellitus and thus over half of all diabetics are aged 60 plus years. Currently, over half a million new cases of diabetes mellitus are diagnosed each year in persons aged over 60 years with the mean age of onset of the condition being 51.9 years (Morley, 2009).

This is staggering. But the real problem is this is growing – the disease will spread in such a phenomenal speed that if we don’t all join hands in addressing the issue, it might be too late. To make matters worse, diabetes is a complex disease with many underlying symptoms and complications.

There are the frequent neuropathic complications which have been causing the greatest morbidity and contributing to the greatest mortality in diabetes. Some other complications are renal disease leading to admission to a renal transplant unit, and eye disease which is the third leading cause of blindness in the world.

In the case of the elderly, there is the hypoglycaemia, which is the most serious and disruptive side effect of the treatment of diabetes. While it is a recognized clinical consequence of the use of insulin and sulphonylureas in all age groups requiring such therapy, the frequency of hypoglycaemia is underestimated in elderly people with diabetes. The clinical manifestations are unrecognized or are wrong attributed to other pathological conditions such as cerebral ischaemia or degenerative disorders. (McAulay and Frier, 2009)

Our initial hypothesis that there is a connection between depression and Type 2 diabetes might be proved: there is some evidence that this is occurring. There is a significant correlation between depression and glycemic control. We will explain this further.

Conceptual Framework

We conceptualized on the vast literature on the particular diabetes and the various studies and researches conducted, including the numerous meta-analyses done on the subject, and the qualitative research that we will conduct in a rural area in Northern Wisconsin.

The issue on the relationship of depression and Type 2 diabetes has been the subject of concern since decades ago. But this has not been properly addressed. There is still a lack of appropriate and straightforward study and recommendation to address the issue.

Wisconsin Turning Point Transformation Team for the Wisconsin Department of Health and Family Services and Wisconsin’s Public Health System Partners created a blueprint known as “A Partnership Plan to Improve the Health of the Public” to enjoin all sectors concerned, public health partners, to help protect and promote health for all of their people. This is one step. But as its implementers are saying, what is most important is the action that should result from the plan.

We have chosen a rural area in Wisconsin where we can focus a study and select a group of participants to answer questionnaires. The entire detail of the study will be provided in the Methodology Section.

Relevance of the Study

This study is relevant in the Nursing profession because it involves research and care of patients for a particular growing disease. Diabetes is a kind of illness that needs particular attention and patience on the part of the caregiver.

Research is very important in the Nursing profession. This can provide more insights and fresh ideas on how to address the disease squarely and care for diabetic patients who are suffering or in distress.

Nurses must continue to learn and acquire knowledge about caring and loving patients. They must be as anxious and excited as the researchers in looking for solutions to problems of incurable diseases. Nurses should also immerse themselves in this global village, searching for answers, living as lifelong learners, “capable of reflecting on, evaluating, and modifying their clinical practice based on new knowledge” (Polit and Beck, 2008).

Scope of the Problem

Diabetes is an enormous burden on patients, families, and the health care system today. The epidemic increase in the number of people with diagnosed diabetes forecast year after year for the next half century coupled with its enormous burden of cost, both fiscal and physical, threatens not only the health of tens of millions of individuals in our society but also the health of our society itself (Fonseca, 2006).

To study the disease is to know the causes; causes which are not too complex to understand, but are manageable. To state it simply, it is a way of life. Diabetic or non-diabetic should understand how to live a simple life free of disease.

The statistics of American diabetics reveal how big the problem is.

Lifestyles throughout the world have changed. This includes reductions in physical activity, increases in dietary intake, and the aging of the population. There is also the westernization of diet and of other aspects of lifestyles in developing countries. All these contribute to the dramatic increase in the prevalence of type 2 diabetes. (Shaw and Sicree, 2008)

Risk factors linked with the modern lifestyle, including inactivity and obesity, are associated with insulin resistance, lipid disorders, hypertension, and vascular disease (Blaum, 2007).

The paper submitted by the Wisconsin Turning Point Transformation Team stated some of the causes of Type 2 Diabetes Mellitus, like overweight and obesity which are said to be increasing nationally in Wisconsin. Statistics reveal that one in two adults in the United States is obese. This is increasing steadily “from 23 percent in 1989 to 34 percent in 1998” (Wisconsin Department of Health and Family Services, Bureau of Health Information, 1998, qtd. in the Transformation Plan).

The American Medical Association considers one overweight when he/she has a body mass index (BMI) of 25 to 29.9; obesity is divided into mild (BMI of 30 to 34.9), moderate (BMI of 35 to 39.9), and severe / extreme (BMI ≥ 40) classifications (Kushner, 2003, qtd. in Paharia and Kase, 2008).

People with a weight control problem have a real and identifiable physiological and medical condition (Ezrin and Kowalski, 1999). Does this apply to 1 in 2 adult Americans?

Moreover, concern has been growing over the increasing incidence of type 2 diabetes in childhood and among teenagers, attributed to inactivity and increasing obesity levels in childhood. Early appearance of type 2 diabetes appears to be a growing problem, particularly among minority groups in the United States, including Hispanic Americans, African Americans, and Native Americans (Blaum, 2007).

Literature Review

Depression and Diabetes

Literature reviews can serve a number of important functions in the research process – as well as important functions for nurses seeking to develop an evidence-based practice. Likewise, acquaintance with relevant research literature can help with identification of research questions or hypotheses (Polit and Beck, 2004).

Type 2 diabetes is generally recognized as an imbalance between insulin sensitivity and beta cell function (Chiu and Martinez, 2002). Type 1 diabetes is known as an autoimmune disease due primarily to beta cell failure. In type 2 diabetes, there is the failure of beta cells to compensate for prevailing insulin resistance.

The initial phase of Type 2 diabetes is said to be asymptomatic. There is a long period of asymptomatic hyperglycemia that may last for years. This is known as the prediabetic state wherein postprandial or postglucose levels are mildly elevated, and fasting blood glucose can usually be maintained within the near-normal range.

According to Laakso (2008), the elevation of postglucose levels is used for the definition of impaired glucose tolerance (IGT), a nonspecific reversible stage. About 30% of these subjects progress to overt diabetes within 10 years, and elevation of fasting glucose is used for the definition of impaired fasting glucose (IFG).

Statistically, the prevalence of Type 2 diabetes mellitus is now higher in the United States. There is the heterogeneity of type 2 diabetes due in part to a variable interplay between genetic and environmental factors. The diagnosis rests on documentation of hyperglycemia, but it is also important to appreciate the other metabolic abnormalities such as the disturbances of lipid metabolism which are present and may precede the emergence of hyperglycemia (Kruszynska, 2002).

Over 95% of people with diabetes have type 2 diabetes. In 2004, the Centers for Disease Control (CDC) estimated that nearly 17% of the population of the United States aged 65 to 74 had diabetes, with a slightly lower prevalence among those 75 years and older (Blaum, 2007).

The CDC also estimates that up to one-third of adults with diabetes mellitus are unaware of their condition, presumably because diabetes is often asymptomatic for several years.

According to Blaum (2007), ‘Despite the early asymptomatic period, diabetes mellitus is a serious condition associated with significant morbidity and a shortened survival’.

The comorbidity of diabetes and depression has received enough empirical investigation and several meta-analytic studies. Some findings revealed that depressed adults are 37% more likely than those without depression to develop Type II diabetes mellitus (DM), and depression is more common among individuals who have diabetes than those without diabetes (Boyer, 2008).

Can depression be diagnosed?

Depressive symptoms and feelings of unhappiness often occur as a transient mood state experienced by all individuals. When these depressive symptoms extend across and affect cognition, psychomotor activity and neurovegetative domains, such as appetite, ability to sleep and sex drive, or interfere with normal functioning, they are considered pathological, and the individual can be diagnosed as under depression (Nouwen and Oyebode, 2009).

Diabetics feel tired and are not so efficient in any activity. There are recent findings however, that these are diabetes-specific distress and not depression. (Fisher et al., 2008)

Studies on the Relationship of Depression to Type 2 Diabetes

Findings of previous researches and studies that we want to analyze here are enumerated. Some findings reveal significant correlations but some are conflicting, while others state that these are not clinically significant.

Fisher (2008) and colleagues assessed a major depressive disorder by a standardized clinical interview through a written questionnaire in a sample of 506 type 2 diabetes patients, and found that more than 70% of the patients who scored above the cut-point for depressive affect on the CES-D were not clinically depressed or did not have major depressive disorder.

Major depressive disorder and diabetes distress are two different things. So that when a diabetic is in distress, it does not mean he/she is under depressive state.

This further means that the patient is distressed about his/her diabetes and its management, and not clinically depressed as a result of diabetes. Some say the diabetes regimen is distressing but not the diabetes itself.

According to Landel-Graham, Yount, and Rudnicki (2003), studies by Lustman, Griffith, & Cluse (1988) reveal that depression is three to four times more prevalent among adults with diabetes than among the general population, affecting one in every five patients.

There is also evidence that in both types of diabetes depressive episodes tend to last longer in comparison to individuals without diabetes (Talbot &Nouwen, 2000, qtd. in Landel-Graham et al., 2008).

A research study revealed that depression is six times higher among those with diabetes (Lustman, Griffith, Clouse, & Cryer, 1986, qtd. in Boyer, 2008).

Furthermore, a meta-analysis of 42 studies indicated an odd ratio of 2:1, citing depression to be twice the prevalence among those with diabetes compared to those without diabetes (Anderson, Freedland, Clouse, & Lustman, 2001, qtd. in Boyer, 2008).

When testing the association between depression and control of blood glucose, some studies have compared depressed versus nondepressed populations, whereas others have correlated depressed symptomatology with glycemic control. The former type of study has more frequently reported associations between depression and glycemic control than the latter (Van Tilburg et al., 2008).

Studies assessing the relationship of depressive symptoms and glycemic control have also reported mixed results, but overall no clear association has been demonstrated.

For example, there were studies which showed no significant correlation between depression scores and HbA1c. But studies by Van der Does and Eaton et al. suggested that there were significant correlations between depressive symptoms and glycemic control but that these were not clinically relevant (Van Tilburg et al., 2008).

Meta-analysis followed the observations that included 24 studies and found much smaller effect sizes for studies using self-report questionnaires compared with studies using standardized interviews or diagnostic criteria.

Only a few of these studies accounted for the potential confounding effect of psychopharmacological treatment on metabolic control by excluding patients who were taking antidepressants. In a study of 16 clinically depressed patients who showed improvement in glycemic control, 13 patients were taking antidepressant medications. Antidepressants may impact blood glucose independent of their effect on depression (Van Tilburg et al, 2008).

Because a large number of depressed patients can be expected to take antidepressant medications, the reported associations between depression and glycemic control may have been mediated by antidepressive medications (Van Tilburg et al., 2008).

Another consideration in interpreting studies of depression and glycemic control is the difference that may occur between patients with type 1 and type 2 diabetes. Some investigators have demonstrated a relationship between depression and metabolic control only for patients with type 1 diabetes.

Further studies by Van Tilburg et al (2008) revealed mixed findings, or with undecided results. There was no correlation in 34 type 2 patients between BDI scores and HbA1c (r = 0.06), but there was a good correlation in 30 type 1 patients (r = 0.44).

These results have been confirmed in larger samples in a study of 805 type 2 patients. There was no relationship between depression and HbA1c, whereas, in another study, a significant relationship was noted between depression and HbA1c in 276 type 1 patients (Van Tilburg et al., 2008).

Depression seems to be more clearly related to deterioration of glycemic control in patients with type 1 diabetes. However, the type of diabetes might not be the most important dividing aspect between patients who are and who are not at risk for a negative impact of mood in glycemia because some patients with diabetes are severely insulin deficient, and thus intrinsically more unstable (Van Tilburg et al., 2008).

According to McLeod (2005), there is laboratory evidence that proved that there is a link between depression and impaired glucose metabolism.

An experiment was conducted by Dr. I.G. Pryce by administering glucose to nineteen depressed patients through their veins and found that in depressed patients the speed of movement of glucose from the bloodstream into cells is slower than normal (McLeod, 2005).

This was followed by another study by Dr. Peter Mueller and colleagues of the Department of Psychiatry at Yale University School of Medicine. These researchers measured insulin levels and blood sugar levels in patients with endogenous depression, a type of chronic depression. Endogenous depression is in contrast to reactive depression in which a recent stress can be identified. The study confirmed that glucose burned slowly. The conclusion was that the amount of insulin in the depressed patients’ blood was elevated (McLeod, 2005).

Other studies found that depressed patients whose body movements were slowed had impaired glucose tolerance; lethargic depressed patients were those most likely to have impaired glucose metabolism; and endogenous depression was associated with insulin resistance in that the response of patients to insulin was “blunted”, or the bodies of the patients were resistant to the action of their own insulin (McLeod, 2005).

In another meta-analysis of 42 eligible studies, it was found that overall the odds of depression in patients with diabetes were double those of non-diabetic controls, and when diagnostic criteria were used, the pooled point prevalence of depressive disorders was estimated at about 10%. There were also high levels of subthreshold, clinically significant psychological distress in diabetes populations (Nouwen and Oyebode, 2009).

According to Nouwen and Oyebode (2009), the finding of an increase in the point prevalence of depression diabetes has been reported not only from Western countries but also from various non-Western regions. But the level of depression may vary from country to country, although this is of high level with people with diabetes.

Another study by Nouwen and Oyebode (2009) revealed that from a sample of 245 patients with diabetes, depressive symptoms were assessed at the beginning and end of a comprehensive outpatient diabetes education programme, and at a 6-month follow-up. The rate of depression at follow-up was 10% for those without depressive symptoms at either of the earlier time points.

Studies on the relationship of type II diabetes and depression were analyzed in the meta-analysis of Lee et al (2008, p. 215):

Studies of multiple researchers reveal that depression leads to poorer outcomes and increased risk of complications because of peripheral glucose deregulation (Lustman et al., 1997a; Lustman, Griffith, Freedland, & Clouse, 1997b; Lustman, Griffith, Clouse, & Cryer, 1986; Hendrickx, McEwen, & Ouderaa, 2005; Okamura et al., 1999, qtd. in Lee et al, 2008).
Other researches by multiple researchers/experimenters state that depression leads to poorer outcomes and increased risk of complications as a result of lower adherence to glucose monitoring, exercise, diet, and medical regimens (Anda et al., 1990; Callahan, Hui, Nienaber, Musick, & Tierney, 1994; Carney, Freedland, Eisen, Rich, & Jaffe, 1995; qtd. in Lee et al, 2008).
Due to poor control of diabetes, individuals with depression report poor quality of life more frequently than do those without depression (Ciechanowski et al., 2000; Kaholokula, Haynes, Grandinetti, & Chang, 2003; Paschalides et al., 2004, qtd. in Lee et al, 2008).
Severe depression is the cause of more deaths for U.S. adults with diabetes, some 54% (Zhang et al., 2005, qtd. in Lee et al).
Diabetes and depression share common pathophysiological mechanisms (Burton & Smith, 1997; Musselman, Betan, Larsen, & Phillips, 2003, qtd. in Lee et al).
Theoretically, there is a reciprocal relationship between the disregulation of the hypothalamic-pituitary axis in depression and in diabetes (Musselman et al., qtd. in Lee et al).
Several studies showed a significant correlation between depression and glycemic control (A1C) in individuals with type 1 diabetes, suggesting that the more severe the depression, the worse the glycemic control (Ciechanowski, Katon, Russo, & Hirsch, 2003; Lustman, Clouse, Ciechanowski, Hirsch, & Freedland, 2005; Pouwer & Snoek, 2001; Van Tilburg et al., 2001 qtd. in Lee et al, 2008).

However, Lee et al (2008) also found a contradicting evidence suggesting that research has not established a clear underlying mechanism or direct causal relationship between type 2 diabetes and depression (Burton & Smith; Musselman et al).

Moreover, Hermanns and Kulzer (2010) argue that depression and poor quality of life are common in diabetic patients. Since subthreshold disorders, clinical depression, and distress all have a negative impact on the quality of life as well as on the course of diabetes, depressive symptoms deserve attention in clinical care.

The comorbidity of depression and diabetes can have substantial and debilitating effects on patients’ health. This may occur either directly via physiological routes or indirectly through alterations in self-care (Landel-Graham et al, 2003).

Lustman, Griffith, and Clouse (1997, qtd. in Landel-Graham, 2003) developed an empirically based model in which depression is directly associated with obesity, physical inactivity, and treatment noncompliance, which all lead to diabetes and complications.

According to Hermanns and Kulzer (2010), a meta-analysis was conducted demonstrating that 31.0% of diabetic patients described themselves as having elevated depressive symptoms, compared with 14% of nondiabetic subjects. Moreover, depression was detected based on the diagnosis of mental health specialists; this occurred in 11.4% compared with 5.0% of nondiabetics.

Out of 100 unselected diabetic patients, approximately 10 to 12 meet the diagnostic criteria for clinical depression and a further 20 suffer from mild or subthreshold depression (Hermanns and Kulzer, 2010).

Another meta-analysis was reported by Hermanns and Kulzer (2010) revealing a significant association between depression and glycemic control. A subanalysis was conducted which showed this relationship was even stronger if the only patients who were analyzed were those who fully met the diagnostic criteria for depression.

Clinical depression and depressive symptoms (including subsyndromal depression) are also associated with higher diabetes-related distress. In a clinical survey, only 14.7% of patients with low or no depression reported a high amount of diabetes-related distress, but 56.3% of patients with subthreshold depression and 73.6% with clinical depression suffered from diabetes-related stress.

Fisher and colleagues (2008, also qtd. in Hermanns and Kulzer, 2010) found a strong association between the presence of subthreshold depression, a high amount of diabetes-related distress, and metabolic as well as behavioral risk factors.

As cited by McLeod (2005), there were several experiments conducted in 1988 by Dr. Andrew Winokur and colleagues in the Department of Psychiatry at the University of Pennsylvania School of Medicine that enrolled twenty-eight patients (12 men and 16 women) who had major depression, and control subjects who did not have depression, diabetes, or a family history of diabetes.

In the experiment, the patients drank a solution containing glucose (sugar), and every thirty minutes for five hours, their blood was tested for both glucose and insulin. One hour after drinking the glucose solution, glucose and insulin levels rose in both depressed and non-depressed subjects, indicating that the pancreas in both groups was capable of secreting insulin.

In the control group of non-depressed persons who did not have a family history of diabetes, insulin and glucose levels began to fall after an hour, an indication of sensitivity in the body of insulin receptors to insulin, or insulin sensitivity. However, insulin and glucose levels remained elevated for the group of depressed patients who were not diabetic. Graphs of the glucose and insulin responses for the depressed group resembled that found in type 2 diabetes. The experiment concluded that non-depressed patients were sensitive to the action of insulin, but the depressed patients were not. It was concluded that depression and type 2 diabetes caused by insulin resistance are linked. (McLeod, 2005)

McLeod (2005) revealed in his discreet studies of the literature that there was extensive evidence that impaired glucose metabolism caused depression in some people, and that depression could be an early sign of type 2 diabetes.

Dr. William Eaton and his colleagues at the School of Public Health at Johns Hopkins University studied 3,481 people diagnosed with serious (major) depression, who then after a span of thirteen years, dwindled down to 1,897. From the group, eighty-nine had developed type 2 diabetes. This was more than twice the incidence expected in the general population. This meant that the study suggested that the people who had been seriously depressed are at increased risk of developing type 2 diabetes. (McLeod, 2005)

Another study by Dr. Norito Kawakami and colleagues in Japan on 2,380 depressed male employees of an electrical company for eight years found that forty-one of them developed type 2 diabetes. Statistical analysis revealed that people with moderate to severe depression have 2.3 times higher risk of developing diabetes than did non-depressed people. (McLeod, 2005)

Health as a whole involves several aspects in an individual. Health does not only mean physical, but involves biological, psychological, and social realms – all these interact and integrate as health. When one factor is affected, health as a whole is also affected.

According to Lee et al (2008), ‘acute and chronic shifts in each real affect health status and health status affects biological, social, and psychological factors.’

Psychosocial factors have a great effect on the health of an individual: it can either moderate pathological process or enhance the disease. Psychological factors can cause anxiety and depression and can make us sick. But social support can ease suffering or make people feel better. (Lee et al, 2008)

Diabetes in the Elderly

There are several lines of evidence which suggest that there is a strong genetic component to diabetes in the elderly, although the specific genes responsible have to be defined (Meneilly, 2009).

Meneilly (2009) has these facts on diabetes:

If you have a family history of type 2 diabetes, you are much more likely to develop the disease as you age.
Diabetes is much more common in the elderly in certain ethnic groups.

From what we have gathered, the literature review seems to point to a relationship between depression and glycemic control. This is the finding of several important studies that should be given credence in the study of depression and type 2 diabetes. Further, this finding will be given more attention during the qualitative research or experimental research in a rural area of Northern Wisconsin.

Additionally, there are some contradictions in the findings of the studies which state that there is no significant correlation, or no relationship, between depression and type 2 diabetes. What the participants felt in the study was a form of distress as a result of the diabetes regimen. They must found some of those activities laborious on their part, or that they needed more assistance and guidance from caregivers in the course of the diabetes regimen.

These discrepancies, inconsistencies or contradictions in the different studies of the relationship between depression and type 2 diabetes can only be corrected with more researches, both qualitative and quantitative, to prove more points in the study of the relationship of depression and type 2 diabetes.

Methodology

Quantitative research is also known as experimental research wherein researchers actively introduce an intervention or treatment. In nonexperimental research, researchers collect data without making changes or introducing treatments (Polit and Beck, 2008).

Moreover, experimental research is the only type of research that directly attempts to influence a particular variable, and when properly applied, it is the best type for testing hypotheses about cause-and-effect relationships. In an experimental research study, researchers look at the effect(s) of at least one independent variable on one or more dependent variables. The independent variable is also referred to as the experimental variable, or treatment variable. The dependent variable is also known as the outcome variable and refers to the results or outcomes of the study. (Fraenkel and Wallen)

Clinicians use survey to help in treating diabetes. Polonsky and his colleagues developed the PAID questionnaire to tap emotional responses to diabetes. The survey can help clinicians understand a patient’s level of diabetes-related emotional distress and how it may be linked to specific aspects of life with the disease.

The PAID is a 2—item questionnaire wherein each item asks about a specific source of diabetes-related distress, including feeling deprived regarding food and meals, feeling alone with diabetes, and feeling burned out by the constant effort to manage diabetes (Rubin, 2006).

In our study, we’ll use quantitative research on participants aged 45-65 years old residing in a rural area in Wisconsin. The participants will be recruited from a community-based diabetes and education center in the area. Patients will be eligible if they are 45-65 years old, residents of the area, and could speak and read English fluently. They must not have been diagnosed of dementia or psychosis and with no severe diabetes complications.

A number of fifty to sixty patients is sufficient to provide qualitative research on the relationship of depression and type 2 diabetes among 45-65 years of age male and female residents of a rural area in Northern Wisconsin.

A rural area is defined as being resided by low-income residents in marginal farm land, with the young mostly in out-migration, and there is a disproportion in the number of the aged and the very young population. This can be found in Northern Wisconsin.

Our choice of a rural area of Northern Wisconsin is quite appropriate, and dramatic, to say the least. This rural community that we have chosen is suitable to the study of the relationship of depression and type 2 diabetes of people aged 45-65 years of age. As we have observed, the community is populated by mostly older people, and most of the young population have out-migrated or gone somewhere for more challenges in life.

Patients will be personally interviewed and informed that their participation in the study is absolutely voluntary. They will be given an introductory letter and provided the details of study participation, along with a packet of questionnaires to review while they wait to see their care providers. The participants are also asked to sign a consent form, and grant permission to the researchers to review their medical records and fill up their demographic profile. No incentives will be offered to the participants. Their level of depression will be recorded and if this indicates a significant level, their healthcare providers will be informed.

Those who are willing to participate will be asked to provide blood and urine specimens that will be collected at the community laboratory. All appropriate procedures to safeguard the rights of the participants will be afforded.

To be included in the participants’ demographic information will be the age, gender, ethnic group, marital status, and educational level.

Medical records will include when the onset of diabetes was obtained, recent A1C, current medications, diabetes-related comorbidities, height, and weight.

The study will be reviewed by the Internal Review Board, and designed to minimize risks and maximize benefits to participants.

Instruments to be used will be the Beck Depression Inventory-II (BDI-II) and the Inventory of Depressive Symptomatology-Self Report (IDS-SR), to measure depression.

The BDI-II, the most widely used tool for self-assessment of depression in clinical research, will be used to assess the severity of depression symptoms. Each item is rated on a Likert (0–3) scale. Higher scores indicate increased depressive symptoms (Beck, Steer, & Brown, 1996, qtd. in Lee, 2008).

A1C will be used to evaluate each participant’s degree of diabetes control; diabetes is considered controlled if A1C is 7.0% or lower (American Diabetes Association, 2007, qtd. in Lee, 2008).

The screening performance of questionnaires is evaluated according to their sensitivity and specificity. These depend on the selection of a cutoff score defining a positive screening result. For clinical practice, the positive (PPV) and negative (NPV) predictive values are also of considerable interest, since the PPV informs the healthcare professional about the relationship between patients who screen positive and truly depressed patients. A rather low PPV is associated with high rate of false positives. (Hermanns and Kulzer, 2010).

Qualitative study will be using the Diabetes Distress Scale (DDS-17) which lists 17 items for the participants to choose from in a scale of 1 (no distress) to 6 (serious distress). The researchers will explain carefully to the participants how to answer the questions, e.g. encircle or rate their feelings about certain symptoms. These are actually problems that diabetics feel which range from different feelings about the disease, other emotions like anger or depression in having the disease, and other psycho-social feelings.

Coefficient alpha will be assessed to determine internal consistency.

Moreover, the participants’ intake of average kilocalories, saturated fat, and fruit and vegetable servings consumed will be measured using the Block 2000 Brief Food Frequency Questionnaire (Fisher et al., 2008).

The results will be analyzed to determine the relationship of depression and type 2 diabetes. The data gathered from the participants will be inputted in the SPSS software, and an analysis of the results will be provided.

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Kruszynska, Y. (2002). V. Diabetes syndrome: Chapter 2: Type 2 diabetes mellitus: etiology, pathogenesis and clinical manifestations. In L. Poretsky (Ed.), Principles of Diabetes Mellitus. Massachusetts, USA: Kluwer Academic Publishers. pp. 179-180.

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