C:/Postscript/05_Papathanasiou_MHFM5_2_D2.3d – 1/12/8 – 13:54 [This page: 85] Mental Health in Family Medicine 2008;5:85–93 # 2008 Radcliffe Publishing Article Reporting distress and quality of life of patients with diabetes mellitus in primary and secondary care in Greece Athanasia Papathanasiou MD Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece; Health Medical Centre of Stylida, Lamia, Greece and Diabetes Center ‘Tzaneio’ General Hospital of Piraeus, Piraeus, Greece Sue Shea Psychologist, Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece Anastasios Koutsovasilis MD Diabetes Centre ‘Tzaneio’ General Hospital of Piraeus, Piraeus, Greece Andreas Melidonis MD PhD Head, Diabetes Centre ‘Tzaneio’ General Hospital of Piraeus, Piraeus, Greece Eustathios Papavasiliou MD PhD Associate Professor, Department of Endocrinology, Diabetes Mellitus and Diseases of Metabolism, University Hospital of Heraklion, Greece Christos Lionis MD PhD Associate Professor and Head, Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece ABSTRACT Background and aim This study constitutes an (PCS) and Mental Component Summary (MCS) initial attempt at elucidating the relationship and six subscales of the SF-36 v2 demonstrated between quality of life (QoL), health status and significant differences between the two partici- psychological distress in patients with diabetes pating centres (P<0.0001). The mean PAID score mellitus (DM) in Greece, by comparing patients was 19.18 (Æ15.58) for patients from the PHCC, with DM registered at a rural primary healthcare versus 40.19 (Æ17.36) for the DOC (P<0.0001). centre (PHCC) and those attending a diabetes Lower scores on the MCS of the SF-36 v2, and outpatient clinic (DOC) at an urban hospital. higher scores on PAID in patients with T2 DM Methods Cross-sectional study. Participants were were related to major co-morbidities, insulin use consecutive, consenting patients with a known and duration of DM. history of type 2 DM (T2 DM), currently registered Conclusions Patients with T2 DM from the ur- at either of the two centres. All patients were ban DOC had significantly higher levels of distress administered the Short Form-36 version 2 (SF-36 and consequently lower levels of QoL compared v2) and the Problem Areas In Diabetes (PAID) with patients from the rural PHCC. The findings questionnaire, and information in relation to from this study may have important implications socio-demographic data and clinical character- with regard to the individualisation of patient istics were also obtained. care in Greece, and encouragement of patient Results Patients with DM had a lower QoL over participation in the treatment process. all domains when compared with general popu- lation normative data. In addition, mean scores Keywords: diabetes mellitus, Greece, mental for the SF-36 v2 Physical Component Summary health, quality of life C:/Postscript/05_Papathanasiou_MHFM5_2_D2.3d – 1/12/8 – 13:54 [This page: 86] 86 A Papathanasiou, S Shea, A Koutsovasilis et al Introduction Methods Diabetes mellitus (DM) is one of the most psycho- logically challenging chronic illnesses, which demands Setting many lifestyle changes, poses life-threatening com- Patients registered at Stylida primary healthcare plications, and requires education, awareness and centre (PHCC) in Greece (rural population) and at constant compliance with treatment on the part of the diabetes outpatient clinic (DOC) of the Diabetes 1,2 the patient. The assessment of health-related Centre of Tzaneio hospital, Piraeus, Greece (urban quality of life (QoL) in patients with DM is an im- population) were invited to participate in the study. portant additional consideration to the traditional The health centre of Stylida is located in the region measures of laboratory values or mortality and mor- of Phthiotida, in central Greece and covers the coastal 2 bidity. As QoL represents the effect of DM, as per- town of Stylida and the neighbouring villages. Tzaneio ceived by the patient, it has also been characterised general hospital operates within the metropolitan 1 as the ultimate goal of all healthcare interventions. area of Athens, in Piraeus, which is the principal port Diabetes-related emotional distress is an import- and the second-largest city of Greece. ant element that may influence adherence to self- The study population consisted of patients with 3 care, glycaemic control and risk of complications. a known history of type 2 DM (T2 DM), at various During recent years there has been increasing ap- disease stages, who were attending the centre of preciation of the need to estimate the degree to their area more than four times per year. DM diag- which DM affects QoL (e.g. mental, physical, social nosis was based on current diagnostic criteria, estab- and occupational functioning) and enhances the lished by the World Health Organization (WHO).14 4,5 psychological distress of the patient, but this The patients were considered eligible for partici- subject has received little attention in Greece. In pation if they were mentally lucid and able to read general, psychosocial determinants of chronic ill- and write Greek. Patients were excluded from the ness have not gained the consideration that they study if they were illiterate, if they had cognitive need in the field of clinical practice and research in disorders and if they had severe disability and mo- general practice/family medicine. Thus, while it is bility problems, to the degree that they were not able recognised that psychosocial factors may have an to complete the patient-assessed questionnaires. impact on QoL, it is still unknown to what extent They were examined by the first author, and given traditional life in rural areas affects the QoL of the questionnaires during an ordinary consultation people with a chronic illness. Several studies focus- at the centres. ing on QoL among patients with DM have been Concerning the PHCC, all patients with T2 DM 6–12 published. The results from these studies differ who met the inclusion criteria and were treated and are difficult to compare, for example due to regularly from December 2006, were consecutively variations in the populations studied and the instru- assessed for inclusion in the study. Similarly, for the ments that were used to measure QoL. DOC centre, all patients with T2 DM who met the In Greece, care of patients with DM is provided inclusion criteria were consecutively evaluated for through primary healthcare settings, and via diabetes participation. For the PHCC a total of 203 patients 13 outpatient clinics or private practices. Modern (95% of those initially enrolled) and for the DOC a primary care and general practice in Greece arose total of 201 (97% of those initially enrolled) met the from the development of the national healthcare criteria and completed the study. system, inaugurated in the 1980s. As such, at the All participants underwent a thorough physical present time it is not as highly developed as Northern examination, and blood samples were collected for European national healthcare systems, with dense the measurement of clinical parameters. An elec- networks of primary care settings, located in rural tronic filing system, using FileMaker Pro Advanced 9 regions. However, the role of general practitioners was created and the following data concerning each in the management of diabetes is essential. Thus, individual patient were recorded: age, sex, body mass understanding this deficit is an important step index (BMI), duration of diabetes, type of current toward implementing interventions that might treatment, metabolic levels (haemoglobin A1c (HbA1c), have the potential to improve the QoL and quality fasting glucose and blood lipids) and diabetic com- 13 of care for patients with DM in everyday practice. plications. We also recorded general disease data The current study reports on the psychological such as hypertension, cardiovascular and non-vascu- burden of distress caused by DM in primary and lar co-morbidity and pharmacological treatment. secondary care patient populations in Greece, and The follow-up of the patients was performed accord- discusses factors that affect the QoL of patients with ing to American Diabetes Association (ADA) guide- DM in this part of the Mediterranean. lines for diabetes.15 C:/Postscript/05_Papathanasiou_MHFM5_2_D2.3d – 1/12/8 – 13:54 [This page: 87] Distress and quality of life of patients with diabetes mellitus in Greece 87 Patient-reported measures one-way analysis of variance (ANOVA), with Bonferroni’s test for post hoc analysis of multiple All participants with T2 DM completed two validated comparisons, or with Kruskal–Wallis one-way analysis questionnaires: the generic instrument Short Form- of variance for non-normally distributed continuous 36 version 2 (SF-36 v2), and the disease-specific variables. Problem Areas In Diabetes (PAID) scale. No data To answer the research question, contributing were missing. factors for the explanation of QoL were explored, The SF-36 v2 consists of 36 questions assessing based on a linear regression analysis. To this end, eight conceptual domains: physical functioning, role we used three models of linear regression analysis, limitations due to physical health, bodily pain, gen- where the dependent variables in the first two re- eral health perceptions, vitality, social functioning, gression models were the two summary measures of role limitations due to emotional problems and SF-36