American Diabetes Association
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Emotional distress predicts reduced type 2 diabetes treatment adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness (GRADE) Study

posted on 2024-01-16, 20:51 authored by Claire J. Hoogendoorn, Heidi Krause-Steinrauf, Diane Uschner, Hui Wen, Caroline A Presley, Elizabeth A Legowski, Aanand D. Naik, Sherita Hill Golden, Valerie L Arends, Janet Brown-Friday, Jonathan A Krakoff, Colleen E Suratt, Andrea H Waltje, Andrea L Cherrington, Jeffrey S. Gonzalez

We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in the GRADE study, a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM). Research Design and Methods: The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, self-efficacy, and perceived control were evaluated as mediators of longitudinal associations. Results: At baseline, participants (56% White, 17% Hispanic/Latino, 18% Black, 66% male) had a mean (SD) age of 58.0±10.2 years, diabetes duration of 4.2±2.8 years, HbA1c of 7.5±0.5%, and medication adherence of 89.9%±11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (p<0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (p<0.0001), but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9-15.5%) of the longitudinal link between emotional distress and adherence. Conclusions: Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.


The GRADE Study is supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health under Award Number U01DK098246. The planning of GRADE was supported by a U34 planning grant from the NIDDK (U34-DK-088043). The American Diabetes Association supported the initial planning meeting for the U34 proposal. The National Heart, Lung, and Blood Institute and the Centers for Disease Control and Prevention also provided funding support. The Department of Veterans Affairs provided resources and facilities. Additional support was provided by grant numbers P30 DK017047, P30 DK020541-44, P30 DK020572, P30 DK072476, P30 DK079626, P30 DK092926, U54 GM104940, UL1 TR000439, UL1 TR000445, UL1 TR001108, UL1 TR001409, UL1 TR001449, UL1 TR002243, UL1 TR002345, UL1 TR002378, UL1 TR002489, UL1 TR002529, UL1 TR002535, UL1 TR002537, and UL1 TR002548. Educational materials have been provided by the National Diabetes Education Program. Material support in the form of donated medications and supplies has been provided by Becton, Dickinson and Company, Bristol-Myers Squibb, Merck, NovoNordisk, Roche Diagnostics, and Sanofi. The Emotional Distress Substudy was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health under Award Number R01 DK104845. Additional support was provided by grant number P30 DK111022. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The GRADE Study Research Group is deeply grateful to our participants whose loyal dedication made GRADE possible.


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