Background Due to the aging of the population and the increasing prevalence of overweight and obesity, the global prevalence of diabetes had been steadily rising. The onset of depression among this diabetes population is a public health issue because of the negative impact on diabetes self-care, treatment adherence and increases in healthcare costs. Three previous meta-analyses have showed that diabetes patients are at an increased risk of developing depression when compared to their non-diabetes counterparts. However, none of these meta-analyses have included primary studies that consisted of primarily Chinese subjects or have considered studies published in Chinese. Thus, there is a knowledge gap for a meta-analysis to study the onset of depression among both Chinese and non-Chinese diabetes subjects. Methods Studies will be selected based on the pre-specified inclusion and exclusion criteria. Studies that are ambiguous to this study criterion will not be selected. Studies are retrieved from three electronic databases, PUBMED, Cochrane library and Wanfang databases. Keywords of “diabet*” and “depress*” where “*” indicated a truncated term were used to identify articles related to diabetes and depression. Only longitudinal studies are selected. Chinese and English articles that are published on or before 31 July 2013 are considered. Besides data collection, quality assessment are also performed based on a tool developed with reference to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement. Results 12 longitudinal studies are identified after the quality assessment procedures, with one study being a Chinese study from Taiwan. In this meta-analysis, the pooled unadjusted odds ratio was 1.26 [95% confidence interval: 1.09, 1.45]. The pooled adjusted hazards ratio is 1.26 [95% confidence interval: 1.12, 1.41]. Since both pooled unadjusted odds ratio and pooled adjusted hazards ratio estimates did not include 1, it may imply that the increases in risk of depression onset among diabetes subjects are significant, whether controlled for confounding factors or not. Conclusion This meta-analysis showed a significant increase in the risk of depression onset among Chinese and non-Chinese diabetes subjects, when compared to their non-diabetes counterparts. There are possible public health implications for depression screening needs for the diabetes population in Hong Kong. / published_or_final_version / Public Health / Master / Master of Public Health

abstract / Anatomy / Doctoral / Doctor of Philosophy

Major depressive disorder (MDD) is a prevalent and disabling disorder worldwide and in Hong Kong. It can occur alone or as a psychiatric sequelae of stroke known as post stroke depression (PSD). Our recent randomized controlled trial (RCT) found that additional dense cranial electroacupuncture stimulation (DCEAS) produced significantly greater improvement on depressive symptoms in patients with MDD compared to conventional antidepressants alone. However, the effectiveness of DCEAS on PSD and the underlying neural mechanism of its antidepressant effects remain unclear and need further investigation. This thesis consisted of three studies aimed to evaluate the efficacy of DCEAS as an additional therapy in PSD and to explore the neuroimaging correlates of DCEAS in MDD using PET and fMRI modalities. The purpose of Study 1 was to examine whether additional DCEAS was effective in treating PSD. A single blind RCT was conducted in 43 PSD patients treated with antidepressants and same body acupuncture combined with sham or active DCEAS with 3 acupuncture sessions per week for 4 weeks. Clinical outcomes included the Hamilton Depression Rating Scale 17-Item (HAMD-17), Clinical Global Impression - Severity Scale (CGI-S), and Barthel Index (BI).The results showed that DCEAS significantly reduced HAMD-17 at week 1, CGI-S at week 1 and endpoint whereas BI was more significantly decreased in control group. A combination of DCEAS and body acupuncture can be considered as an augmenting treatment for PSD. Study 2 aimed to explore the potential effects of DCEAS in regulating abnormal glucose metabolism in patients with MDD using 18F-FDG PET/CT. A single blind RCT was conducted in 25 MDD patients treated with antidepressants combined with sham or active DCEAS with 3 acupuncture sessions per week for 6 weeks. Clinical outcomes were measured using the HAMD-17, Zung Self-Rating Depression Scale (SDS), CGI-S and Insomnia Severity Index (ISI). There was a significant difference on the slope in SDS in linear mixed model analysis, indicating a faster improvement in subjective depressive symptoms by DCEAS. While the increased 18F-FDG signals in the cerebellum were normalized in both groups, the reversion of the reduced 18F-FDG signals in the left prefrontal cortex was only observed in DCEAS-treated patients, suggesting that additional DCEAS could more vigorously improve abnormal brain glucose metabolism in MDD. The purpose of Study 3 was to further investigate the neuropsychological and functional neuroimaging correlates of the antidepressant effects of DCEAS in the same pool of MDD subjects in Study 2 using fMRI with sad-face paradigm. The sad-face stimulation increased BOLD signals in an extensive neural network of the brain, including the frontal, temporal, parietal, limbic system and cerebellum. Additional DCEAS extensively suppressed the abnormal BOLD signals in these brain regions, more apparently in left caudate and cingulate, whereas sham treatment had slightly suppressive effects in fewer brain regions, suggesting that additional DCEAS could more robustly alter the biases towards sadness in MDD. In conclusion, DCEAS additional treatment is more effective in reducing depressive symptoms in patients with PSD, improving brain glucose metabolism and normalizing the abnormal neural activation due to biases towards sadness in patients with MDD. / published_or_final_version / Chinese Medicine / Doctoral / Doctor of Philosophy

Depression research demonstrates that self-focused processing, such as rumination, causes and maintains depressive disorders (Pyszczynski & Greenberg, 1987; Kuhl & Helle, 1986; Nolen-Hoeksema, 1987), while emotional processing literature shows beneficial effects to self-focus under some circumstances (Rachman, 1980; Foa & Kozak, 1986; Pennebaker, 1989). Therefore, it seems that self-focus is not inherently detrimental; rather, the way a person self-focuses could differentiate between unhealthy rumination and healthy emotional processing. Rude, Maestas, and Neff (2006) demonstrated that when the wording of a well-known rumination measure was altered to reduce judgment, the measure no longer correlated with depression. Mindfulness approaches that emphasize a non-judgmental acceptance of one's experience have produced beneficial outcomes (Baer, 2003), thus corroborating this finding. This dissertation investigated the role of acceptance in emotional recovery from a distressing event. It was hypothesized that encouraging participants to process emotions in an accepting manner would help them recover from a dysphoric mood more quickly than participants not given acceptance instructions or those given instructions to evaluate and change their emotions. Recovery was defined as return to baseline on measures of heart rate, skin conductance, skin temperature, self-reported positive and negative affect, and rumination (cognitive priming). In addition, the study investigated whether differences in the effects of emotional processing condition would be greatest for participants with low trait acceptance of emotions or high trait rumination. As predicted, Acceptance participants reported less negative affect than Control participants at the end of the study. There were no significant differences on negative affect between Acceptance and Evaluation conditions, however. Hypothesized differences in recovery as measured by heart rate, skin conductance, skin temperature, positive affect, and rumination were not found. As predicted, trait rumination and emotional acceptance interacted with processing condition for negative mood and heart rate: Acceptance and Evaluation conditions reduced negative mood more than the Control group for participants low in trait Emotional Acceptance, and the Acceptance condition reduced heart rate for high ruminators more than the Control group. Interestingly, and contrary to prediction, Acceptance participants showed evidence of greater priming of failure-related words than the other two groups on the reaction time measure. / text

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Given the pervasive, debilitating nature of major depressive disorder, a large body of clinical research has evaluated the efficacy of short-term treatments for depression. Researchers have attempted to understand the complex mechanism of therapeutic change by examining treatment response, which is typically defined as the extent of symptom change between the intake and termination sessions. However, this approach fails to recognize that therapy is a non-linear, dynamic longitudinal process. An alternative approach involves analysis of longitudinal repeated measures process and outcome indicators in order to examine change both during treatment as well as following treatment. In order to evaluate dynamic, longitudinal hypotheses, it is necessary to use an appropriate analytical framework. A structural modelling technique termed Latent Difference Score Analysis (LDS) is well suited for this purpose, allowing for evaluation of longitudinal growth within a time series, while also considering multivariate relationships and determinants. / The purpose of this research was to evaluate established theories of depression vulnerability as well as theories of psychotherapy process, both during and following depression treatment. The research described in Chapter 2 examined several theories of the longitudinal relationship between depression and perfectionism during depression treatment, while considering the role of the therapeutic alliance. Longitudinal LDS analyses supported a "personality vulnerability" model of depression, in which perfectionism predicted the subsequent rate of depression change throughout treatment. Results indicate that patients with high levels of perfectionism experience less reduction in their depression scores throughout treatment. Furthermore, the strength of the therapeutic alliance significantly predicted the rate of change in personality vulnerability throughout therapy. The research described in Chapter 3 examined several theories of the longitudinal relationship between depression and stress following treatment termination. Results supported a "stress reactivity" model, in which stressful events led to elevations in the rate of depression change following therapy. Multigroup LDS analysis indicated that stress reactivity only occurred for patients who had been treated with medication, and not for those who had received psychotherapy. / These findings have several implications. First, comprehensive analyses of treatment efficacy can move beyond symptom reduction by examining mechanisms underlying treatment response using an appropriate statistical framework. The first paper demonstrates that an efficient route to symptom reduction involves establishing an adequate therapeutic alliance in order to target personality vulnerability. The second paper demonstrates that importance of evaluating treatment efficacy by considering whether a treatment leads to enduring change. Specifically, results indicate that the enduring effects of psychotherapy (in comparison to medication treatments) following treatment termination involves increased resiliency to stressful life events.