Diabetes Self-Management Blog

Depression was a big topic at the ADA’s Scientific Sessions last month. It might be an issue for you, too.

Why so much attention? Depression is three to four times more common in people with diabetes than in those without, depending on the study and the country. Depression is known to worsen glucose control and make self-management harder. It leads to higher mortality rates and lower quality of life.

Even people who don’t have major clinical depression can have a lower level of depression that interferes with their life and self-management. People with diabetes who maintain self-confidence and a sense of well-being do much better, so some providers and scientists are working on how they can help.

Edwin B. Fisher, PhD, presented evidence that much of the depression comes from the diabetes itself. This is called “diabetes distress” and is often measured with a 20-question scale called PAID (Problem Areas in Diabetes).

If true, this is important. Instead of looking at other causes of depression, and how depression might cause diabetes, we would do better to focus on improving diabetes care and control. The fears and stresses of diabetes can depress people in a big way.

PAID was used as part of the DAWN (Diabetes Awareness, Wishes, and Needs) study, sponsored by the drug company Novo Nordisk. You might be interested in evaluating yourself with their survey.

PAID lists 20 possible problems that can be part of living with diabetes. For each one, you rate it as not a problem (0), minor problem (1), moderate problem (2), somewhat serious problem (3), or serious problem (4).

You add up your total score and multiply the result by 1.25 to get a number between 0 and 100. According to DAWN, “Patients scoring 40 or higher may be at the level of ‘emotional burnout’ and warrant special attention.”

The potential problems include, “feeling discouraged with your diabetes treatment plan” and “not having clear and concrete goals for your diabetes care.” Most of them are about feelings: “feeling scared when you think about living with diabetes,” “feeling depressed when you think about living with diabetes,” “feeling overwhelmed by your diabetes,” “worrying,” “anxious,” “concerned.” No wonder a high PAID score shows a high risk for depression!

You can see the whole scale and evaluate yourself here. It takes about five minutes.

But you might want to start with this five-item version of PAID. These five seem to do as well for screening as the whole scale.

They are:

1. Feeling scared when you think about living with diabetes?
0 1 2 3 4

2. Feeling depressed when you think about living with diabetes?
0 1 2 3 4

3. Worrying about the future and the possibility of serious complications?
0 1 2 3 4

4. Feeling that diabetes is taking up too much of your mental and physical energy?
0 1 2 3 4

5. Coping with complications of diabetes?
0 1 2 3 4

Add up your answers, then multiply by 1.25. If your score is over 8, you are likely at least moderately distressed and should consider asking for help or making some changes.

It’s useful to combine a PAID survey with its opposite, a test of emotional well-being called WHO-5.

WHO-5 was created as part of a 1982 European multicenter trial of two different insulin delivery methods and is available to anyone on the Internet. These five questions are rated on a scale from 0 to 5, but this time higher numbers are good.

A high WHO-5 score means you are not in danger of depression and are more likely to have good diabetes management. Here’s the screen:

For each of these statements, report how often you have felt this way.
5 = all the time 4 = most of the time, 3 = more than half of the time 2 = less than half of the time 1 = some of the time 0 = at no time.

1. I have felt cheerful and in good spirits
5 4 3 2 1 0

2. I have felt calm and relaxed
5 4 3 2 1 0

3. I have felt active and vigorous
5 4 3 2 1 0

4. I woke up feeling fresh and rested
5 4 3 2 1 0

5. My daily life has been filled with things that interest me
5 4 3 2 1 0

Add up your scores and multiply by 4 to get a score from 0 to 100. According to DAWN, “Evidence suggests a score of 50 or below indicates low mood, though not necessarily depression. A score of 28 or below indicates likely depression.”

Low scores on WHO-5 and high scores on PAID tend to go together. They may indicate both unhappiness and poor health, so we should get help with them. If you have such scores, perhaps you can discuss them with your doctor, diabetes educator, or another advisor.

I think having a chronic illness such as diabetes means it is normal to feel down some of the time. But happier is better, and it’s healthier. The PAID research shows that feeling more confident about diabetes is likely to make you happier and more confident in the rest of your life.

It’s a good idea to take these screens at least once a year. A change in numbers of more than 10% either way is thought to be significant for your health and quality of life. Hope yours improve!

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