Comparison of Quality of Life, Depression and Anxiety According to the Type of Treatment in Type 2 Diabetes

Abstract

The aim of this study was to compare the quality of life (QoL) and the prevalence of depression and anxiety in patients with type 2 diabetes mellitus according to the type of treatment: insulin, oral therapy or both therapies. A cross-sectional study that included adults with diabetes mellitus type 2 was conducted at Hassan II University Hospital in Fez, Morocco. Patients are divided into 3 groups: the anti-diabetic agents’ group, the insulin therapy group and the combined therapy group. The Hospital Anxiety and Depression Scale (HADS) was used to measure depression and anxiety. A 12-Item Short-Form Health Survey questionnaire (SF-12) was employed to assess QoL. All statistical analyses were conducted using SPSS Version 26. A total of 176 diabetics with type 2 were included in the study: (61.9%) in the hypoglycemic drug group; (14.2%) in the insulin group and (23.9%) in both therapy groups. The mean age of the patients was 54.36 ± 10.18 years with a female predominance (60.8%). Our study showed a significant association between the scores of QoL (p < 0.05), the prevalence of depression (p = 0.03) and the type of therapy. A high prevalence of depression and poor QoL have been observed in patients on insulin therapy. Patients on insulin therapy have a high prevalence of depression and a more significant impairment of QoL. In fact, their evaluation must be integrated into the management of type 2 diabetics on insulin.

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Benmaamar, S., Salhi, H., El Harch, I., Lazar, N., Diagne, B.J., Maiouak, M., Berraho, M., Tachfouti, N., El Ouahabi, H. and El Fakir, S. (2023) Comparison of Quality of Life, Depression and Anxiety According to the Type of Treatment in Type 2 Diabetes. Open Access Library Journal, 10, 1-9. doi: 10.4236/oalib.1110062.

1. Introduction

Diabetes mellitus is a major public health problem. Its prevalence is increasing, from 285 million in 2009 to 463 million in 2019 [1] . Type 2 diabetes accounts for 90% of all diabetes worldwide [2] . In 2017, approximately 6.28% of the world’s population were affected by type 2 diabetes corresponding to a prevalence rate of 6059 cases per 100.000 [2] . In Morocco, the prevalence of diabetes is also high. Consequently, it represents an important socio-economic burden [3] [4] .

Type 2 diabetes can cause significant psychological difficulties for the patient and family members and may affect the quality of life (QoL). The data in the literature have shown that diabetes patients have high rates of depression and anxiety [5] [6] . Numerous studies [7] have been conducted to explore QoL in people with type 2 diabetes and its associated factors. Socio-demographic factors (age, gender, socio-economic level), level of glycemic control, duration of diabetes, type of treatment, therapeutic compliance, complications, mental health, and presence of other comorbidities are the factors influencing the QoL of these patients [7] [8] [9] [10] .

The management of diabetes is based on different therapies to achieve good metabolic control: changes in lifestyle (diet, physical activity), oral agents and insulin therapy [11] . Factors related to the treatment and its properties such as effectiveness, risk of hypoglycemia, ability to reduce diabetes complications, effect on body weight and side effects may have an effect on the QoL and mental health of patients.

The meta-analysis by de Bai et al. [12] and the study by Šurkienė G et al. [13] have investigated the relationship between depression and the type of treatment, but this association remains controversial. Results of studies, that examined the impact of treatment on QoL, have been mixed, with the type of therapy showing decreased, enhanced, or no impact on QoL [14] . In Morocco, mental health promotion is one of the priorities of the National Multisectoral Strategy for the Prevention and Control of Non-transmissible Diseases 2019-2029 [15] . However, QoL and psychological disorders, especially in diabetic patients, are not sufficiently studied. The aim of the present study was to compare the QoL and prevalence of depression and anxiety in patients with type 2 diabetes mellitus according to the type of treatment: insulin, oral therapy or both therapies.

2. Methods

2.1. Study and Population

A cross-sectional study, including adult patients with a confirmed diagnosis of type 2 diabetes who use oral medications, insulin or both therapies, was carried out at Hassan II University-Hospital of Fes, Morocco. We excluded type 1 diabetics, pregnant women and patients with impairment from auditory, mental and cognitive conditions.

2.2. Data Collection and Scoring

An anonymous face-to-face questionnaire was used to collect data. It included:

The socio-demographic and socio-economic variables: age, gender, residence, marital status, employment status and monthly income.

Clinical variables: type of treatment used (oral therapy, insulin or both therapies), duration of disease, and presence of comorbidities.

2.3. Measure of Depression and Anxiety

The study utilized the Hospital Anxiety and Depression Scale (HADS) [16] to evaluate the levels of anxiety and depression. This is a self-assessment tool that contains 14 items, seven of which pertain to anxiety and the other seven relate to depression. Respondents indicate the intensity of their symptoms over the past week by scoring each item from 0 to 3. The scores range from 0 to 21 for each subscale, with higher scores indicating more severe symptoms. The HADS also provides threshold values for each subscale: scores ranging from 0 to 7 are considered normal, while scores above 7 indicate symptoms of anxiety or depression [16] .

2.4. Measure of Quality of Life

For assessment of quality of life, a 12-Item Short-Form Health Survey (SF-12) in its translated and validated Moroccan version was used [17] . The SF-12 is an instrument for evaluating health-related quality of life that employs twelve questions to gauge physical and mental well-being across eight health domains. Physical health domains include General Health (GH), Physical Functioning (PF), Role Physical (RP), and Body Pain (BP). Meanwhile, mental health domains include Vitality (VT), Social Functioning (SF), Role Emotional (RE), and Mental Health (MH). Each quality of life domain is scored from 0 to 100, where a higher score indicates a better quality of life [18] .

2.5. Statistical Analysis

The participants are divided into 3 groups: the oral medication group, the insulin group and the combined therapy group. The Chi2 and Fisher tests were used to test associations between socio-demographic and clinical variables, depression and anxiety, and the treatment groups. The ANOVA test was used to compare scores of quality of life between groups of treatments. In all the analyses, the level of significance was kept at 0.05. Statistical analyses were performed using SPSS Version 26 software.

2.6. Ethics Statement

Ethical approval was obtained from the Ethics Committee of Hassan II University Hospital, Fez, Morocco (N 26/18). All participants provided their informed consent after being made aware of the conditions related to the study.

3. Results

3.1. Baseline Characteristics of Participants

A total of 176 diabetes type 2 patients were included in the study. The mean age of the patients was 54.36 ± 10.18 years with a female predominance (60.8%). More than two-thirds (61.9%) of the participants were unemployed or housewives; 83.3% were from urban areas; and 53.4% had comorbidities.

Depending on the type of treatment, 61.9% were taking hypoglycemic drugs, 14.2% were taking insulin and 23.9% were taking both. There was no statistically significant difference between the three groups in terms of socio-demographic, socio-economic and clinical parameters.

Table 1 shows the baseline characteristics of the participants.

Table 1. Baseline characteristics of participants (n = 176).

SD: standard deviation; % percentage.

3.2. Depression and Anxiety

Our results showed a significant difference in the prevalence of depression between the different groups (p = 0.03). The prevalence of depression was higher in patients on insulin (32.0%), followed by patients on oral therapy (21.1%) and patients who received both therapies (7.1%).

There was no significant difference in the prevalence of anxiety between the different groups (p = 0.88). The prevalence was 28.4%, 24.0%, and 26.2% in patients receiving oral therapy, insulin therapy, or both therapies, respectively.

Figure 1 shows the prevalence of depression and anxiety between the treatment groups.

3.3. Quality of Life

Our study showed a significant association between the scores of QoL (physical or mental) and type of treatment (p < 0.05) except for general health. In all domains, QoL was most impaired in patient insulin treated patients.

Table 2 and Table 3 show the results of physical and mental QoL between the treatment groups.

Figure 1. Prevalence of depression and anxiety in type 2 diabetics according to type of treatment.

Table 2. Physical quality of life in type 2 diabetics according to type of treatment.

General Health (GH); Physical Functioning (PF); Role Physical (RP); Body Pain (BP); Physical Score (PCS).

Table 3. Mental quality of life in type 2 diabetics according to type of treatment.

Vitality (VT); Social Functioning (SF); Role Emotional (RE); Mental Health (MH); Mental Score (MCS).

4. Discussion

Our study aimed to compare QoL and the prevalence of depression and anxiety between the groups of treatment: the anti-diabetics agents group, the insulin group and both therapy groups in diabetic type 2 patients.

The prevalence of depression was higher in patients on insulin compared to those on oral anti-diabetics or both treatments. This result is consistent with the literature [12] [13] . On the other hand, other studies [9] [19] have not found a significant difference between the prevalence of depression and the type of treatment.

The high risk of depression in patients on insulin may be explained by psychological resistance to insulin (PIR). The international research study by Polonsky et al. [20] showed a 17.2% prevalence of PIR in patients with type 2 diabetes. PIR is mainly due to negative beliefs about insulin: the technical aspect, the risk of weight gain and hypoglycemia, feelings of dependence, guilt or injustice and the severity of diabetes [21] .

Besides, insulin therapy is usually prescribed after the failure of oral therapy. Therefore, its use is a symbol of advanced diabetes. According to the results of the DESMOND trial [22] , depressive symptoms in diabetes do not manifest until at least 1 year after diagnosis. This may also explain the high prevalence of depression in patients on insulin.

In this study, we have not found any significant association between the type of treatment and anxiety. The same result was observed by Palizger et al. [23] and Trento et al. [24] . But researches [13] have shown a high prevalence of anxiety in patients on insulin.

Physical and mental QoL were more impaired in patients on insulin therapy. This result is in line with other studies [10] [25] [26] . The alteration of the QoL in our research may be related to the type of insulin therapy used. A prospective cohort study [27] , of patients with insulin-dependent diabetes, that intensive insulin therapy with pens and pumps improves QoL more than traditional insulin therapy. However, other studies [28] found that insulin was associated with significantly greater improvements in QoL among patients with type 2 diabetes mellitus. These studies conclude that insulin therapy can indirectly contribute to good QoL by improving glycemic control and thus the prevention of diabetes complications. The results from the UKPDS [29] showed that a switch to insulin therapy probably does not impact QoL. The differences in the results concerning the impact of treatment on QoL are due to the use of different measurement scales and the cultural variations of the populations.

This study is the first to our knowledge that investigated psychiatric disorders and quality of life according to type of the treatment in type 2 diabetics in Morocco. However, it has some limitations: First, because the study was conducted in a single hospital, the results may not be generalizable to all diabetics. Secondly, the study did not include diabetics followed in primary health care facilities, these patients may have different socio-demographic, economic and clinical characteristics than patients followed in the university center, which may affect the assessment of QoL and depression and anxiety.

5. Conclusion

In conclusion, patients with T2DM on insulin were associated with a high prevalence of depression and altered QoL. For insulin users, careful monitoring of depressive symptoms and continuous assessment of QoL should be incorporated into the management of the disease. After insulin initiation, communication with patients about their beliefs about insulin is necessary to overcome psychological resistance to insulin.

Declaration of Interests

The authors declare that they have no competing interest.

References

  1. 1. Saeedi, P., Petersohn, I., Salpea, P., et al. (2019) Global and Regional Diabetes Prevalence Estimates for 2019 and Projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th Edition. Diabetes Research and Clinical Practice, 157, Article ID: 107843. https://doi.org/10.1016/j.diabres.2019.107843

  2. 2. Khan, M.A.B., Hashim, M.J., King, J.K., Govender, R.D., Mustafa, H. and Al Kaabi, J. (2019) Epidemiology of Type 2 Diabetes—Global Burden of Disease and Forecasted Trends. Journal of Epidemiology and Global Health, 10, 107-111. https://doi.org/10.2991/jegh.k.191028.001

  3. 3. Rapport Annuel Global de l’AMO 2018. https://anam.ma/anam/wp-content/uploads/2021/07/RAG2018-VF.pdf

  4. 4. Rapport de l’enquête nationale sur les facteurs de risque des maladies non transmissibles 2017-2018.

  5. 5. Bickett, A. and Tapp, H. (2016) Anxiety and Diabetes: Innovative Approaches to Management in Primary Care. Experimental Biology and Medicine (Maywood), 241, 1724-1731. https://doi.org/10.1177/1535370216657613

  6. 6. Roy, T. and Lloyd, C.E. (2012) Epidemiology of Depression and Diabetes: A Systematic Review. Journal of Affective Disorders, 142, S8-S21. https://doi.org/10.1016/S0165-0327(12)70004-6

  7. 7. Jing, X., Chen, J., Dong, Y., et al. (2018) Related Factors of Quality of Life of Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis. Health and Quality of Life Outcomes, 16, 189. https://doi.org/10.1186/s12955-018-1021-9

  8. 8. Shetty, A., Afroz, A., Ali, L., Siddiquea, B.N., Sumanta, M. and Billah, B. (2021) Health-Related Quality of Life among People with Type 2 Diabetes Mellitus—A Multicentre Study in Bangladesh. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 15, Article ID: 102255. https://doi.org/10.1016/j.dsx.2021.102255

  9. 9. Chung, J.O., Cho, D.H., Chung, D.J. and Chung, M.Y. (2013) Assessment of Factors Associated with the Quality of Life in Korean Type 2 Diabetic Patients. Internal Medicine, 52, 179-185. https://doi.org/10.2169/internalmedicine.52.7513

  10. 10. Cong, J.-Y., Zhao, Y., Xu, Q.-Y., et al. (2012) Health-Related Quality of Life among Tianjin Chinese Patients with Type 2 Diabetes: A Cross-Sectional Survey. Nursing & Health Sciences, 14, 528-534. https://doi.org/10.1111/j.1442-2018.2012.00734.x

  11. 11. Marín-Peñalver, J.J., Martín-Timón, I., Sevillano-Collantes, C. and Cañizo-Gómez, F.J. (2016) Del: Update on the Treatment of Type 2 Diabetes Mellitus. World Journal of Diabetes, 7, 354. https://doi.org/10.4239/wjd.v7.i17.354

  12. 12. Bai, X., Liu, Z., Li, Z. and Yan, D. (2018) The Association between Insulin Therapy and Depression in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis. BMJ Open, 8, e020062. https://doi.org/10.1136/bmjopen-2017-020062

  13. 13. Surkiene, G. (2014) Prevalence and Determinants of Anxiety and Depression Symptoms in Patients with Type 2 Diabetes in Lithuania. Medical Science Monitor, 20, 182-190. https://doi.org/10.12659/MSM.890019

  14. 14. Pouwer, F. and Hermanns, N. (2009) Insulin Therapy and Quality of Life. A Review. Diabetes/Metabolism Research and Reviews, 25, S4-S10. https://doi.org/10.1002/dmrr.981

  15. 15. Stratégie Nationale Multisectorielle de Prévention et de Contrôle des Maladies Non Transmissibles 2019-2029.

  16. 16. Zigmond, A.S. and Snaith, R.P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

  17. 17. Obtel, M., El Rhazi, K., Elhold, S., Benjelloune, M., Gnatiuc, L. and Nejjari, C. (2013) Cross-Cultural Adaptation of the 12-Item Short-Form Survey Instrument in a Moroccan Representative Survey. Southern African Journal of Epidemiology and Infection, 28, 166-171. https://doi.org/10.1080/10158782.2013.11441540

  18. 18. Ware, J.E., Kosinski, M. and Keller, S.D. (1996) A 12-Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity. Medical Care, 34, 220-233. https://doi.org/10.1097/00005650-199603000-00003

  19. 19. Bensbaa, S., Agerd, L., Boujraf, S., et al. (2014) Clinical Assessment of Depression and Type 2 Diabetes in Morocco: Economical and Social Components. Journal of Neurosciences in Rural Practice, 5, 250-253. https://doi.org/10.4103/0976-3147.133576

  20. 20. Polonsky, W.H., Hajos, T.R.S., Dain, M.-P. and Snoek, F.J. (2011) Are Patients with Type 2 Diabetes Reluctant to Start Insulin Therapy? An Examination of the Scope and Underpinnings of Psychological Insulin Resistance in a Large, International Population. Current Medical Research and Opinion, 27, 1169-1174. https://doi.org/10.1185/03007995.2011.573623

  21. 21. Réticences à l’insulinothérapie du patient diabétique de type 2: Croyances du soigné et du soignant. https://www.realites-cardiologiques.com/wp-content/uploads/sites/2/2011/10/Ciangura.pdf

  22. 22. Skinner, T.C., Carey, M.E., Cradock, S., et al. (2010) Depressive Symptoms in the First Year from Diagnosis of Type 2 Diabetes: Results from the Desmond Trial. Diabetic Medicine, 27, 965-967. https://doi.org/10.1111/j.1464-5491.2010.03028.x

  23. 23. Palizgir, M., Bakhtiari, M. and Esteghamati, A. (2013) Association of Depression and Anxiety with Diabetes Mellitus Type 2 Concerning Some Sociological Factors. Iranian Red Crescent Medical Journal, 15, 644-648. https://doi.org/10.5812/ircmj.12107

  24. 24. Trento, M., Raballo, M., Trevisan, M., et al. (2012) A Cross-Sectional Survey of Depression, Anxiety, and Cognitive Function in Patients with Type 2 Diabetes. Acta Diabetologica, 49, 199-203. https://doi.org/10.1007/s00592-011-0275-z

  25. 25. Reis, A.C., Cunha, M.V., Bianchin, M.A., Freitas, M.T.R., Castiglioni, L., et al. (2020) Comparison of Quality of Life and Functionality in Type 2 Diabetics with and without Insulin. Revista da Associacao Medica Brasileira, 65, 1464-1469. https://doi.org/10.1590/1806-9282.65.12.1464

  26. 26. Redekop, W.K., Koopmanschap, M.A., Stolk, R.P., et al. (2002) Health-Related Quality of Life and Treatment Satisfaction in Dutch Patients with Type 2 Diabetes. Diabetes Care, 25, 458-463. https://doi.org/10.2337/diacare.25.3.458

  27. 27. Chantelau, E., Schiffers, T., Schütze, J. and Hansen, B. (1997) Effect of Patient-Selected Intensive Insulin Therapy on Quality of Life. Patient Education and Counseling, 30, 167-173. https://doi.org/10.1016/S0738-3991(96)00964-0

  28. 28. Funnell, M.M. (2008) Quality of Life and Insulin Therapy in Type 2 Diabetes Mellitus. Insulin, 3, 31-36. https://doi.org/10.1016/S1557-0843(08)80009-7

  29. 29. U.K. Prospective Diabetes Study Group (1999) Quality of Life in Type 2 Diabetic Patients Is Affected by Complications but Not by Intensive Policies to Improve Blood Glucose or Blood Pressure Control (UKPDS 37). Diabetes Care, 22, 1125-1136. https://doi.org/10.2337/diacare.22.7.1125

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1] Saeedi, P., Petersohn, I., Salpea, P., et al. (2019) Global and Regional Diabetes Prevalence Estimates for 2019 and Projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th Edition. Diabetes Research and Clinical Practice, 157, Article ID: 107843. https://doi.org/10.1016/j.diabres.2019.107843
[2] Khan, M.A.B., Hashim, M.J., King, J.K., Govender, R.D., Mustafa, H. and Al Kaabi, J. (2019) Epidemiology of Type 2 Diabetes—Global Burden of Disease and Forecasted Trends. Journal of Epidemiology and Global Health, 10, 107-111. https://doi.org/10.2991/jegh.k.191028.001
[3] Rapport Annuel Global de l’AMO 2018. https://anam.ma/anam/wp-content/uploads/2021/07/RAG2018-VF.pdf
[4] Rapport de l’enquête nationale sur les facteurs de risque des maladies non transmissibles 2017-2018.
[5] Bickett, A. and Tapp, H. (2016) Anxiety and Diabetes: Innovative Approaches to Management in Primary Care. Experimental Biology and Medicine (Maywood), 241, 1724-1731. https://doi.org/10.1177/1535370216657613
[6] Roy, T. and Lloyd, C.E. (2012) Epidemiology of Depression and Diabetes: A Systematic Review. Journal of Affective Disorders, 142, S8-S21. https://doi.org/10.1016/S0165-0327(12)70004-6
[7] Jing, X., Chen, J., Dong, Y., et al. (2018) Related Factors of Quality of Life of Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis. Health and Quality of Life Outcomes, 16, 189. https://doi.org/10.1186/s12955-018-1021-9
[8] Shetty, A., Afroz, A., Ali, L., Siddiquea, B.N., Sumanta, M. and Billah, B. (2021) Health-Related Quality of Life among People with Type 2 Diabetes Mellitus—A Multicentre Study in Bangladesh. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 15, Article ID: 102255. https://doi.org/10.1016/j.dsx.2021.102255
[9] Chung, J.O., Cho, D.H., Chung, D.J. and Chung, M.Y. (2013) Assessment of Factors Associated with the Quality of Life in Korean Type 2 Diabetic Patients. Internal Medicine, 52, 179-185. https://doi.org/10.2169/internalmedicine.52.7513
[10] Cong, J.-Y., Zhao, Y., Xu, Q.-Y., et al. (2012) Health-Related Quality of Life among Tianjin Chinese Patients with Type 2 Diabetes: A Cross-Sectional Survey. Nursing & Health Sciences, 14, 528-534. https://doi.org/10.1111/j.1442-2018.2012.00734.x
[11] Marín-Peñalver, J.J., Martín-Timón, I., Sevillano-Collantes, C. and Cañizo-Gómez, F.J. (2016) Del: Update on the Treatment of Type 2 Diabetes Mellitus. World Journal of Diabetes, 7, 354. https://doi.org/10.4239/wjd.v7.i17.354
[12] Bai, X., Liu, Z., Li, Z. and Yan, D. (2018) The Association between Insulin Therapy and Depression in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis. BMJ Open, 8, e020062. https://doi.org/10.1136/bmjopen-2017-020062
[13] Surkiene, G. (2014) Prevalence and Determinants of Anxiety and Depression Symptoms in Patients with Type 2 Diabetes in Lithuania. Medical Science Monitor, 20, 182-190. https://doi.org/10.12659/MSM.890019
[14] Pouwer, F. and Hermanns, N. (2009) Insulin Therapy and Quality of Life. A Review. Diabetes/Metabolism Research and Reviews, 25, S4-S10. https://doi.org/10.1002/dmrr.981
[15] Stratégie Nationale Multisectorielle de Prévention et de Contrôle des Maladies Non Transmissibles 2019-2029.
[16] Zigmond, A.S. and Snaith, R.P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
[17] Obtel, M., El Rhazi, K., Elhold, S., Benjelloune, M., Gnatiuc, L. and Nejjari, C. (2013) Cross-Cultural Adaptation of the 12-Item Short-Form Survey Instrument in a Moroccan Representative Survey. Southern African Journal of Epidemiology and Infection, 28, 166-171. https://doi.org/10.1080/10158782.2013.11441540
[18] Ware, J.E., Kosinski, M. and Keller, S.D. (1996) A 12-Item Short-Form Health Survey: Construction of Scales and Preliminary Tests of Reliability and Validity. Medical Care, 34, 220-233. https://doi.org/10.1097/00005650-199603000-00003
[19] Bensbaa, S., Agerd, L., Boujraf, S., et al. (2014) Clinical Assessment of Depression and Type 2 Diabetes in Morocco: Economical and Social Components. Journal of Neurosciences in Rural Practice, 5, 250-253. https://doi.org/10.4103/0976-3147.133576
[20] Polonsky, W.H., Hajos, T.R.S., Dain, M.-P. and Snoek, F.J. (2011) Are Patients with Type 2 Diabetes Reluctant to Start Insulin Therapy? An Examination of the Scope and Underpinnings of Psychological Insulin Resistance in a Large, International Population. Current Medical Research and Opinion, 27, 1169-1174. https://doi.org/10.1185/03007995.2011.573623
[21] Réticences à l’insulinothérapie du patient diabétique de type 2: Croyances du soigné et du soignant. https://www.realites-cardiologiques.com/wp-content/uploads/sites/2/2011/10/Ciangura.pdf
[22] Skinner, T.C., Carey, M.E., Cradock, S., et al. (2010) Depressive Symptoms in the First Year from Diagnosis of Type 2 Diabetes: Results from the Desmond Trial. Diabetic Medicine, 27, 965-967. https://doi.org/10.1111/j.1464-5491.2010.03028.x
[23] Palizgir, M., Bakhtiari, M. and Esteghamati, A. (2013) Association of Depression and Anxiety with Diabetes Mellitus Type 2 Concerning Some Sociological Factors. Iranian Red Crescent Medical Journal, 15, 644-648. https://doi.org/10.5812/ircmj.12107
[24] Trento, M., Raballo, M., Trevisan, M., et al. (2012) A Cross-Sectional Survey of Depression, Anxiety, and Cognitive Function in Patients with Type 2 Diabetes. Acta Diabetologica, 49, 199-203. https://doi.org/10.1007/s00592-011-0275-z
[25] Reis, A.C., Cunha, M.V., Bianchin, M.A., Freitas, M.T.R., Castiglioni, L., et al. (2020) Comparison of Quality of Life and Functionality in Type 2 Diabetics with and without Insulin. Revista da Associacao Medica Brasileira, 65, 1464-1469. https://doi.org/10.1590/1806-9282.65.12.1464
[26] Redekop, W.K., Koopmanschap, M.A., Stolk, R.P., et al. (2002) Health-Related Quality of Life and Treatment Satisfaction in Dutch Patients with Type 2 Diabetes. Diabetes Care, 25, 458-463. https://doi.org/10.2337/diacare.25.3.458
[27] Chantelau, E., Schiffers, T., Schütze, J. and Hansen, B. (1997) Effect of Patient-Selected Intensive Insulin Therapy on Quality of Life. Patient Education and Counseling, 30, 167-173. https://doi.org/10.1016/S0738-3991(96)00964-0
[28] Funnell, M.M. (2008) Quality of Life and Insulin Therapy in Type 2 Diabetes Mellitus. Insulin, 3, 31-36. https://doi.org/10.1016/S1557-0843(08)80009-7
[29] U.K. Prospective Diabetes Study Group (1999) Quality of Life in Type 2 Diabetic Patients Is Affected by Complications but Not by Intensive Policies to Improve Blood Glucose or Blood Pressure Control (UKPDS 37). Diabetes Care, 22, 1125-1136. https://doi.org/10.2337/diacare.22.7.1125

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