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Emotional sequelae during and following hospital admission for diabetic ketoacidosis Kirsty Yvonne Matheson Presented to the University of Edinburgh in Partial Fulfilment of the Requirements for the Degree of Doctorate in Clinical Psychology August 2012 Declaration of Own Work v Acknowledgements vi 1. THESIS ABSTRACT 1 2. THESIS OVERVIEW 3 3. SYSTEMATIC REVIEW 4 Abstract 5 3.1 Introduction 6 3.2 Methods 8 3.2.1 Search strategy 9 3.2.2 Study selection 9 3.2.3 Data abstraction 9 3.2.4 Methods of reviewing studies 10 3.3 Results 11 3.3.1 Search results 11 3.3.2 Study characteristics 13 3.3.3 Attrition 18 3.3.4 Outcome measures 20 3.3.5 Missing data 22 3.3.6 Reporting quality of studies included 22 3.4 Discussion 24 3.4.1 Overview 24 3.4.2 Strengths and limitations of review 24 3.4.3 Implications for current practice and future research 27 3.4.4 Conclusions 27 3.5 References 29 4. BRIDGING CHAPTER 33 4.1 Intensive care and psychological outcomes 33 4.2 Diabetes 34 4.2.1 Type 1 diabetes 34 4.2.2 Self-management in Type 1 diabetes 35 4.3.2 Emotional distress and diabetes 35 4.3 Diabetic ketoacidosis 36 4.3.1 Diabetic ketoacidosis 36 4.3.2 Complications of diabetic ketoacidosis 36 4.3.3 Ketones 36 4.3.4 Clinical management of diabetic ketoacidosis 36 4.94 Summary 37 5. METHODOLOGY 38 5.1 Design 38 ii 5.2 Participants 38 5.3 Inclusion and Exclusion criteria 38 5.3.1 Inclusion criteria 38 5.3.2 Exclusion criteria 39 5.4 Procedure 39 5.4.1 Recruitment procedure 39 5.4.2 Assessment procedure 39 5.5 Measures 39 5.5.1 Demographic and pre-existing clinical data 41 5.5.2 Diabetes control 41 5.5.3 The Hospital Anxiety and Depression Scale 42 5.5.4 Impact of Events Scale - Revised 43 5.5.5 Problem Areas in Diabetes 44 5.6 Ethical Considerations 45 5.6.1 Potential distress to participants 45 5.6.2 Informed consent 46 5.6.3 Confidentiality 46 5.6.4 Ethical approval 46 5.6.5 Sample size 47 5.7 Analytic Plan 47 5.7.1 Hypotheses 47 5.7.2 Data screening 47 5.7.3 Analysis 48 6. JOURNAL ARTICLE 51 Abstract 52 6.1 Introduction 53 6.2 Research design and methods 54 6.2.1 Design and methods 54 6.2.2 Comparative data 55 6.2.3 Power 56 6.2.4 Ethics 56 6.2.5 Statistical methods 56 6.3 Results 57 6.3.1 Participant characteristics 57 6.3.2 Comparison of study and non-study DKA admissions 58 6.3.3 Comparison of those recruited who completed the study and 60 those who dropped out 6.3.4 Emotional distress 61 6.3.5 Anxiety 61 6.3.6 Depression 62 6.3.7 PTSD 63 6.3.8 Diabetes related distress 63 6.3.9 Co-morbidity 63 6.3.10 Diabetes control 64 6.4 Conclusions 65 6.4.1 Main outcomes 65 iii 6.4.2 Anxiety 65 6.4.3 Depression 66 6.4.4 Diabetes Control 66 6.4.5 Findings in wider context 66 6.4.6 Limitations 67 6.4.7 Clinical implications and future research 67 6.4.8 Summary 69 6.5 Acknowledgements 70 6.6 References 71 REFERENCES 72 APPENDICES 81 Appendix 1 Guidelines for Journal of Critical Care Appendix 2 Guidelines for Diabetes Care Appendix 3 STROBE guidelines Appendix 4 Systematic review search results Appendix 5 NHS North of Scotland Research Ethics Committee Approval Appendix 6 Participant Information Sheet Appendix 7 Participant Consent Sheet Appendix 8 Letter to GP and diabetes team regarding patient participation Appendix 9 Three month follow-up patient letter if scoring at clinical levels for anxiety/ depression/ PTSD Appendix 10 Three month follow-up letter to GP if patient scoring at clinical levels for anxiety/ depression/ PTSD Appendix 11 Hospital Anxiety and Depression Scale (HADS) Appendix 12 Impact of Events Scale - Revised (IES-R) Appendix 13 Problem Areas in Diabetes (PAID) Appendix 14 System of care should participant score at clinical levels for anxiety/ depression/ PTSD Appendix 15 NHS Grampian Research and Development Approval Word count (excluding references and appendixes) : 17,416 iv D. Clin. Psychol. Declaration of own work I confirm that all this work is my own except where indicated, and that I have: • Read and understood the Plagiarism Rules and Regulations • Composed and undertaken the work myself • Clearly referenced/listed all sources as appropriate • Referenced and put in inverted commas any quoted text of more than three words (from books, web, etc) • Given the sources of all pictures, data etc. that are not my own • Not made undue use of essay(s) of any other student(s) either past or present (or where used, this has been referenced appropriately) • Not sought or used the help of any external professional agencies for the work (or where used, this has been referenced appropriately) • Not submitted the work for any other degree or professional qualification except as specified • Acknowledged in appropriate places any help that I have received from others • (e.g. fellow students, technicians, statisticians, external sources) • Complied with other plagiarism criteria specified in the Programme Handbook • I understand that any false claim for this work will be penalised in accordance with the University regulations Signature ……… Date ……01.08.2012…… v Acknowledgements There are a number of people whom I would like to thank as without their support and guidance completion of thesis would have been so much more challenging. My clinical supervisor, Dr Andrew Keen, helped me focus my ideas for research and I give extended thanks to him for his continued guidance and support. I am truly indebted to him for the time he spent with me sharing his expertise and providing me with the motivation to complete this thesis. In particular, I express my gratitude to him for improving the standard of my work. Dr David Gillanders, academic supervisor, provided me with thoughtful feedback and support over the course of my thesis. Without the support and interest in psychology from Dr Ann Gold, consultant diabetologist, this project would not have been possible. Therefore as special thanks must go to her, as well as Norma Alexander, diabetes specialist nurse, who went that extra mile to ensure recruitment was as smooth as possible. Further thanks go to all the diabetes inpatient team who made me feel welcome on the ward and helped me by alerting me to potential participants. I am incredibly grateful to all the participants who kindly completed the questionnaires and thank them for making the process of data collection simple. My family and friends have supported me during every stage of the last three years as well as providing me with encouragement and food! A special thank you goes to Lucy for helping me with some typing prior to submission following injury. Finally, I would like to thank David for his unconditional support, care and patience. vi 1. THESIS ABSTRACT Increasingly patients are surviving admission to intensive care units (ICUs) with life- threatening, critical illness. This has led to a growing interest in longer-term patient outcomes, including their psychological health. This thesis consists of two discrete sections: 1) a systematic review of research that evaluated emotional outcomes between 3 and 12 months post-ICU discharge, and 2) a longitudinal cohort study of emotional sequelae among adults with Type 1 diabetes during and following admission for diabetic ketoacidosis (DKA). The systematic review identified seven studies that met inclusion criteria, and highlighted weaknesses in the existing literature. From the available evidence there appears to be elevated rates of clinically significant depression (11%), anxiety (15%) and post-traumatic stress disorder (PTSD) symptoms (23%) 3 months after discharge, and these remain high 9 months later (12%; 18%, and 27%, respectively). The prospective study of DKA admissions indicated substantial rates of clinically relevant depression (25%); anxiety (37.5%), and PTSD symptoms (37.5%) prior to discharge. However, 3 months later the rates of depression and PTSD had substantially attenuated (both 8.3%) although rates of anxiety (37.5%) remained higher than that found in the general population (7%) and the local Type 1 diabetes clinical community (11.9%). Those admitted with DKA had significantly poorer HbA 1c compared to the overall Type 1 clinic population (10.9% vs. 8.9%; p < 0.0001), which indicates substantial difficulties in self managing their condition. It appears that psychological problems are elevated over time following ICU discharge. PTSD is notably high and enduring in general ICU survivors, whereas was observed to fall away in the DKA sample.