Instructor, Pediatrics - Endocrinology and Diabetes
Fellowship: Stanford University Psychology Postdoctoral Fellowship (2017) CA
Internship: Warren Alpert Medical School Brown University (2015) RI
PhD Training: Yeshiva University (2015) NY
Overcoming Barriers and Obstacles to Adopting Diabetes Devices (ONBOARD) RCT
This study is a comprehensive, multicomponent behavioral intervention package (ONBOARD; OvercomiNg Barriers & Obstacles to Adopting Diabetes Devices). ONBOARD will provide adults with T1D the skills to maximize benefit and minimize daily interference from barriers associated with Continuous Glucose Monitoring (CGM) and increase readiness for closed loop.
Overcoming Barriers and Obstacles to Adopting Diabetes Devices
This study will create a comprehensive, multicomponent behavioral intervention package (ONBOARD; OvercomiNg Barriers & Obstacles to Adopting Diabetes Devices). ONBOARD will provide adults with type 1 diabetes (T1D) the skills to maximize benefit and minimize daily interference from barriers associated with continuous glucose monitoring (CGM) and increase readiness for closed loop.
Stanford is currently not accepting patients for this trial. For more information, please contact Molly Tanenbaum, PhD, 650-725-3955.
Barriers to Prevention and Timely Presentation of Diabetic Foot Ulcers: Perspectives of Patients from a High-risk Urban Population in the United States
JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED
2021; 32 (3): 1554-1565
Diabetic foot amputation is a preventable complication that is increasing in incidence in the United States, with disparities across geography, race, ethnicity, and income. This qualitative study explored the experiences of people in a low-income urban area in the United States in preventing and obtaining care for foot ulcers. Sixteen adults with foot ulcers were identified through purposive sampling based on records of hospital stays and primary care visits. Semi-structured interviews were transcribed and analyzed for key themes. Participants described inadequate understanding of diabetic foot disease: many sought care only after developing advanced symptoms. They identified social and health system factors as barriers to timely access to care. Some participants described a realization of the seriousness of their condition and an ability to improve self-care after developing an ulcer. Patients' experiences can inform the design of amputation-reduction initiatives to achieve more desirable results, including enhanced self-management capabilities, timely access, and attention to social determinants.
View details for Web of Science ID 000686341700040
View details for PubMedID 34421048
USE OF DIABETESWISE.ORG PROMOTES UPTAKE OF DIABETES DEVICES AND SHOWS PRELIMINARY EVIDENCE OF IMPROVED GLYCEMIC OUTCOMES
MARY ANN LIEBERT, INC. 2021: A98-A99
View details for Web of Science ID 000656638700246
PILOT OF A BEHAVIORAL INTERVENTION FOR CGM USERS DECREASES DIABETES DISTRESS AND IMPROVES TIME IN RANGE IN ADULTS WITH TYPE 1 DIABETES (T1D)
MARY ANN LIEBERT, INC. 2021: A62
View details for Web of Science ID 000656638700160
Qualitative Exploration of the Pediatric Heart Failure Experience for Development of a Patient-Reported Outcome Measure
ELSEVIER SCIENCE INC. 2021: S205
View details for Web of Science ID 000631254400468
"IT'S LIKE LEARNING TO DRIVE A MANUAL CAR": EXPERIENCES OF CONTINUOUS GLUCOSE MONITORING ADOPTION IN ADULTS WITH TYPE 1 DIABETES
OXFORD UNIV PRESS INC. 2021: S27
View details for Web of Science ID 000648922700055
"I was ready for it at the beginning": Parent experiences with early introduction of continuous glucose monitoring following their child's Type 1 diabetes diagnosis.
Diabetic medicine : a journal of the British Diabetic Association
To capture the experience of parents of youth with recent onset Type 1 diabetes who initiated use of continuous glucose monitoring (CGM) technology soon after diagnosis, which is a new practice.Focus groups and individual interviews were conducted with parents of youth with Type 1 diabetes who had early initiation of CGM as part of a new clinical protocol. Interviewers used a semi-structured interview guide to elicit feedback and experiences with starting CGM within 30 days of diagnosis, and the benefits and barriers they experienced when adjusting to this technology. Groups and interviews were audio-recorded, transcribed, and analyzed using content analysis.Participants were 16 parents (age 44.13±8.43 years; 75% female; 56.25% non-Hispanic White) of youth (age 12.38±4.15 years; 50% female; 50% non-Hispanic White; diabetes duration 10.35±3.89 months) who initiated CGM 11.31±7.33 days after diabetes diagnosis. Overall, parents reported high levels of satisfaction with starting CGM within a month of diagnosis and described a high level of reliance on the technology to help manage their child's diabetes. All participants recommended early CGM initiation for future families and were committed to continue using the technology for the foreseeable future, provided that insurance covered it.Parents experienced CGM initiation shortly after their child's Type 1 diabetes diagnosis as a highly beneficial and essential part of adjusting to living with diabetes.
View details for DOI 10.1111/dme.14567
View details for PubMedID 33772862
ONBOARD: A feasibility study of a telehealth-based continuous glucose monitoring adoption intervention for adults with type 1 diabetes.
Diabetes technology & therapeutics
Continuous glucose monitoring (CGM) can improve glycemic control for adults with Type 1 diabetes but certain barriers interfere with consistent use including: cost; data overload; alarm fatigue; physical discomfort; and unwanted social attention. This pilot study aimed to examine feasibility and acceptability of a behavioral intervention, ONBOARD (Overcoming Barriers and Obstacles to Adopting Diabetes Devices) to support adults with type 1 diabetes in optimizing CGM use.Adults (18-50) with type 1 diabetes in their first year of CGM use were invited to participate in a tailored, multicomponent telehealth-based intervention delivered over four 60-minute sessions every 2-3 weeks. Participants completed surveys (demographics; diabetes distress, T1-DDS; satisfaction with program) and provided CGM data at baseline and post-intervention (3 months). Data were analyzed using paired t-tests and Wilcoxon signed-rank tests.Twenty-two participants (age=30.95±8.32; 59% female; 91% Non-Hispanic; 86% White, 5% Black, 9% other; 73% pump users) completed the study. ONBOARD demonstrated acceptability and a high rate of retention. Moderate effect sizes were found for reductions in diabetes distress (p=.01, r=-.37) and increases in daytime spent in target range (70-180 mg/dL: p=.03, r=-.35). There were no significant increases in hypoglycemia.Findings show preliminary evidence of feasibility, acceptability, and efficacy of ONBOARD for supporting adults with type 1 diabetes in optimizing CGM use while alleviating diabetes distress. Further research is needed to examine ONBOARD in a larger sample over a longer period.
View details for DOI 10.1089/dia.2021.0198
View details for PubMedID 34270351
Do Youth Want Psychosocial Screenings in Diabetes Clinic? Profiles of Acceptability.
Journal of pediatric psychology
AIMS: Psychosocial screenings are recommended and increasingly common in pediatric subspecialty clinics, though little is known about their acceptability. This study seeks to uncover profiles of acceptability and assess demographic and clinical correlates among adolescents with diabetes.METHODS: A sample of 124 adolescents (57.7% female) ages 12-21years (M=16.2±2.3) completed screenings during routine diabetes appointments. K-means clustering of responses to acceptability items derived profiles; Analysis of Variance (ANOVA) and Chi-square tests assessed correlates.RESULTS: Adolescents with the most common profile (72.6%) placed high importance on medical providers' awareness of their emotions and reported no difficulties/discomfort with the screener. These youth had moderate depressive symptoms, low diabetes distress, and low A1c. Those who fit a less common profile (18.5%) were uncomfortable with the screener and had the highest depressive symptoms and lowest A1c. Youth who fit a smaller profile (6.5%) endorsed technical difficulties and had high depressive symptoms and lowest diabetes distress. The smallest profile (2.4%, N=3) had difficulty understanding and experienced discomfort with the screening and had the lowest depressive symptoms and the highest diabetes distress and A1c. These differences in depressive symptoms (F=3.54, p=.017), A1c values (F=4.03, p=.009), and diabetes distress (F=3.27, p=.036) were significant though differences in age, gender, and diabetes duration were not.CONCLUSIONS: Most youth responded favorably to in-clinic psychosocial screenings. Youth who were less satisfied were at increased risk for psychosocial and medical complications. Findings highlight areas of need, such as enhanced support with and an emphasized rationale for screenings, which may improve patient experience in subspecialty care.
View details for DOI 10.1093/jpepsy/jsaa112
View details for PubMedID 33316061
Barriers to Continuous Glucose Monitoring in People With Type 1 Diabetes: Clinician Perspectives.
Diabetes spectrum : a publication of the American Diabetes Association
2020; 33 (4): 324–30
The purpose of this study was to determine clinician attitudes about the distinct barriers to uptake of continuous glucose monitoring (CGM) among people with diabetes. Survey data were collected measuring individual barriers, prerequisites to CGM, confidence in addressing barriers, and clinic staff resources. Results show that clinicians commonly report barriers to using CGM among people with diabetes in their clinic. Furthermore, clinicians who report a high number of barriers do not feel confident in overcoming the barriers to CGM. Interventions that attempt to empower clinicians to address concerns about CGM among people with diabetes may be warranted because low uptake does not appear to be directly related to available resources or prerequisites to starting CGM.
View details for DOI 10.2337/ds19-0039
View details for PubMedID 33223770
- Early Introduction of Continuous Glucose Monitoring Is Well Accepted by Youth and Parents AMER DIABETES ASSOC. 2020
GETTING ONBOARD (OVERCOMING BARRIERS & OBSTACLES TO ADOPTING DIABETES DEVICES): A PILOT STUDY TO SUPPORT USE OF CONTINUOUS GLUCOSE MONITORING (CGM)
OXFORD UNIV PRESS INC. 2020: S136
View details for Web of Science ID 000546262400281
PRIMARY CARE PATIENTS' PERSPECTIVE IN THE MODERN ERA: DIGITAL TECHNOLOGY, POLICY CHANGES, AND SHIFTING PERSPECTIVES
OXFORD UNIV PRESS INC. 2020: S135
View details for Web of Science ID 000546262400279
DIABETES-RELATED QUALITY OF LIFE: LEARNING FROM PATIENTS MAKING LIFESTYLE CHANGES TOIMPROVE TYPE 2 DIABETES SELF-MANAGEMENT
OXFORD UNIV PRESS INC. 2020: S37
View details for Web of Science ID 000546262400079
Qualitative Exploration of the Pediatric Heart Failure Experience for Development of a Patient-Reported Outcome Measure
ELSEVIER SCIENCE INC. 2020: S452
View details for Web of Science ID 000522637203132
Parental Perspectives: Identifying Profiles of Parental Attitudes and Barriers Related to Diabetes Device Use.
Diabetes technology & therapeutics
BACKGROUND: Despite the demonstrated benefits of diabetes device use, uptake of insulin pumps and continuous glucose monitors (CGMs) remains quite low. The current study aimed to identify profiles of parents of youth with type 1 diabetes based on their attitudes toward diabetes-specific technology and barriers to diabetes technology uptake.METHODS: Online survey data were collected from 471 parents in the T1D Exchange Clinic Network (child's age=12.0±3.2 years; diabetes duration=7.0±2.9 years; A1c=8.4%±1.3; 75% using insulin pump; 27% using CGM).RESULTS: K-means cluster analyses revealed 5 parent profiles: Embracers (50.7%), Burdened (15.7%), Hopeful but Hassled (14.2%), Distrusting (12.7%), and Data Minimalists (6.6%). ANOVAs and Chi-square tests identified differences between groups based on diabetes distress, worry over hypoglycemia, device use, and demographic characteristics.CONCLUSIONS: Providers encouraging device uptake may benefit from tailoring their approaches based on these distinct groups and their corresponding concerns and needs.
View details for DOI 10.1089/dia.2019.0492
View details for PubMedID 31971451
Diabetes-Specific Self-Compassion: A New Measure for Parents of Youth With Type 1 Diabetes.
Journal of pediatric psychology
Given the high daily demands of managing type 1 diabetes (T1D), parents of youth with T1D can experience high levels of emotional distress, burden, and self-criticism, with implications for parent and child well-being and parent self-efficacy for managing diabetes. Diabetes-specific self-compassion (SC), or being kind to oneself when facing challenges related to managing diabetes, may serve as protective for parents. This study aimed to create and assess the psychometric properties of a new tool, the diabetes-specific Self-Compassion Scale (SCS-Dp), to assess diabetes-specific SC in parents of youth with T1D.We adapted a parent diabetes-specific SC measure; surveyed parents (N = 198; parent: 88% female; 95% non-Hispanic White; M age = 44 ± 8.9; child: 46% female; M age = 13 ± 3.4, range 2-18 years; 83% insulin pump users; 40% continuous glucose monitor (CGM) users; HbA1c from clinic data available for 76 participants: M HbA1c = 8.1 ± 1.3%) and conducted confirmatory factor analysis, and reliability and construct validity analyses. Validity measures included diabetes distress, diabetes empowerment, diabetes numeracy, and HbA1c.A bifactor structure provided the best fit, with one general factor and two wording-related group factors (positively and negatively worded items). The final 19-item SCS-Dp demonstrated excellent internal consistency (α =.94; range of item-total correlations: .52-.81) and good construct validity. As predicted, greater SC was associated with lower distress (r = -.68, p < .001) and greater empowerment (r = .43, p < .001) and was not associated with diabetes numeracy (p = .61). Diabetes-specific Self-Compassion Scale was not associated with HbA1c (p = .28).Results provide initial evidence of good reliability and validity of the SCS-Dp to assess diabetes-specific SC in parents.
View details for DOI 10.1093/jpepsy/jsaa011
View details for PubMedID 32196093
Cost, Hassle, and On-Body Experience: Barriers to Diabetes Device Use in Adolescents and Potential Intervention Targets.
Diabetes technology & therapeutics
Adolescents with diabetes have the highest A1cs of all age group. Diabetes devices (insulin pumps and continuous glucose monitors [CGM]) can improve glycemic outcomes, and though uptake of devices have increased, they remain underutilized in this population. This study characterizes adolescent-reported barriers to diabetes device use to determine targets for clinician intervention.We surveyed 411 adolescents with type 1 diabetes (mean age 16.302.25 years) on barriers to diabetes device use, technology use attitudes (general and diabetes-specific), benefits and burdens of CGM, self-efficacy for diabetes care, diabetes distress, family conflict, and depression. We characterize barriers to device uptake; assess demographic and psychosocial differences in device users, discontinuers, and non-users; and determine differences in device use by gender and age.The majority of adolescents used an insulin pump (n=307, 75%) and more than half used CGM (n=225, 55%). Cost/insurance-related concerns were the most commonly endorsed barrier category (61%) followed by wear-related issues (58.6%) which includes hassle of wearing the device (38%), and dislike of device on body (33%). Adolescents who endorsed more barriers also reported more diabetes distress (p=0.003), family conflict (p=0.003), and depressive symptoms (p=0.014). Pump and CGM discontinuers both endorsed more barriers and more negative perceptions of technology than current users, but reported no difference from device users in diabetes distress, family conflict, or depression. Gender was not related to perceptions of devices.Clinicians can proactively assess attitudes toward diabetes technology and perceptions of benefits/burdens to encourage device uptake and potentially prevent device discontinuation among adolescents.
View details for DOI 10.1089/dia.2019.0509
View details for PubMedID 32163719
"It Made Me the Person I Am Today": Survivors of Childhood, Adolescent, and Young Adult Cancer Reflect on Their Experiences.
Journal of adolescent and young adult oncology
Purpose: As survival rates of childhood, adolescent, and young adult (YA) cancers improve, there is a growing population of YA cancer survivors who can provide insight into the lived experience of cancer. The goal of this study was to improve understanding of the cancer experience through interviews with YA-aged survivors. Methods: A convenience sample of survivors (age ≥18; remission ≥5 years) was recruited from an urban pediatric hospital. Participants responded to demographic questions, open-ended questions about cancer experience, and optional verbal interview. Responses to questions (written and verbal) were transcribed and coded using thematic analysis to identify common themes. Results: Participants were 18 cancer survivors (M age=22.17±3.96, 50% male, 33.3% Latino/Hispanic). The main themes reported were as follows: (1) importance of mind-set (reported by 94% of participants); (2) positive transformation (61%); (3) importance of support from medical team (61%); (4) importance of social support (56%); and (5) burden of cancer (44%). Conclusions: Themes of resilience and optimism were pervasive throughout responses. YA-aged survivors were both proponents of adapting a positive mind-set when undergoing treatment, and appeared to maintain this positive mind-set into survivorship by describing cancer as a transformative experience. Cognition, positive change, and social support, are all concepts that could be addressed through targeted screenings and interventions. Fostering a positive lens may help with overall adjustment and mood during treatment, and be protective for physical and mental health.
View details for DOI 10.1089/jayao.2019.0122
View details for PubMedID 31738652
CGM Benefits and Burdens: Two Brief Measures of Continuous Glucose Monitoring.
Journal of diabetes science and technology
BACKGROUND:: Continuous glucose monitors (CGM) are underutilized by individuals with type 1 diabetes (T1D), particularly during the adolescent years. Little is known about perceptions of CGM benefit and burdens, and few tools exist to quantify this information.METHODS:: Two questionnaires were developed and validated-Benefit of CGM (BenCGM) and Burdens of CGM (BurCGM)-in a sample of adolescents ages 12-19 years involved in the T1D Exchange Registry. We chose to start the validation process with adolescents given their low CGM uptake and high risk for suboptimal glycemic outcomes. Exploratory and confirmatory factor analyses were conducted to confirm factor structure and select items. The resultant scales were tested for internal reliability and convergent/divergent validity with critical diabetes and quality of life outcomes: age, depression, diabetes distress, self-efficacy, technology attitudes, and diabetes technology attitudes.RESULTS:: A total of 431 adolescents with T1D completed the questionnaires (51% female, mean age 16.3 ± 2.26, 83% white non-Hispanic, 70% having used CGM). Two single factor scales emerged, and scales were reduced to 8 items each. Those who perceived higher benefit of CGM exhibited lower diabetes distress, higher self-efficacy, and more positive attitudes toward technology. Those who perceived higher burden of CGM exhibited higher diabetes distress, lower self-efficacy, and less positive technology attitudes.CONCLUSION:: The BenCGM and BurCGM questionnaires each comprise 8-items that demonstrate robust psychometric properties for use in adolescents with T1D, and can be used to develop targeted interventions to increase CGM wear to improve diabetes management.
View details for PubMedID 30854886
Depression in Context: Important Considerations for Youth with Type 1 vs Type 2 Diabetes.
Youth with diabetes are at increased risk for depression. However, severity and correlates of depressive symptoms may differ by diabetes type.Associations of depressive symptoms with global health, diabetes duration, and gender were compared between youth with type 1 and type 2 diabetes.A sample of 149 youth ages 12-21 diagnosed with either type 1 (n = 122) or type 2 (n = 27) diabetes were screened during routine clinic appointments. Regression models were constructed to examine differences by diabetes type.Adolescents with type 2 diabetes had significantly higher depressive symptom scores (4.89 vs 2.99, P = 0.025) than those with type 1 diabetes. A significant interaction between global health and diabetes type on depressive symptoms revealed inverse associations between global health and depressive symptoms that was stronger among youth with type 2 diabetes (β = -0.98, P < 0.001) than type 1 (β = -0.48, P < 0.001). Further probing revealed that among youth with better global health, adolescents with type 1 had more depressive symptoms than those with type 2 diabetes (β = 0.33, P = 0.035). Diabetes duration and depressive symptoms were positively associated among individuals with type 2 (β = 0.86, P = 0.043), but not type 1 diabetes. No gender differences were detected.These findings suggest that correlates of depressive symptoms in youth with diabetes differ by diabetes type. Global health appears to be an important correlate among youth with both types, whereas diabetes duration was only a significant factor among those with type 2 diabetes. The current findings can inform future psychosocial intervention efforts within both these populations. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/pedi.12939
View details for PubMedID 31644828
Feasibility Studies of an Insulin-Only Bionic Pancreas in a Home-Use Setting.
Journal of diabetes science and technology
We tested the safety and performance of the "insulin-only" configuration of the bionic pancreas (BP) closed-loop blood-glucose control system in a home-use setting to assess glycemic outcomes using different static and dynamic glucose set-points.This is an open-label non-randomized study with three consecutive intervention periods. Participants had consecutive weeks of usual care followed by the insulin-only BP with (1) an individualized static set-point of 115 or 130 mg/dL and (2) a dynamic set-point that automatically varied within 110 to 130 mg/dL, depending on hypoglycemic risk. Human factors (HF) testing was conducted using validated surveys. The last five days of each study arm were used for data analysis.Thirteen participants were enrolled with a mean age of 28 years, mean A1c of 7.2%, and mean daily insulin dose of 0.6 U/kg (0.4-1.0 U/kg). The usual care arm had an average glucose of 145 ± 20 mg/dL, which increased in the static set-point arm (159 ± 8 mg/dL, P = .004) but not in the dynamic set-point arm (154 ± 10 mg/dL, P = ns). There was no significant difference in time spent in range (70-180 mg/dL) among the three study arms. There was less time <70 mg/dL with both the static (1.8% ± 1.4%, P = .009) and dynamic set-point (2.7±1.5, P = .051) arms compared to the usual-care arm (5.5% ± 4.2%). HF testing demonstrated preliminary user satisfaction and no increased risk of diabetes burden or distress.The insulin-only configuration of the BP using either static or dynamic set-points and initialized only with body weight performed similarly to other published insulin-only systems.
View details for DOI 10.1177/1932296819872225
View details for PubMedID 31470740
- Physical symptom complaints, cognitive emotion regulation strategies, self-compassion and diabetes distress among adults with Type 2 diabetes DIABETIC MEDICINE 2018; 35 (12): 1671–77
- Psychosocial and Human Factors During a Trial of a Hybrid Closed Loop System for Type 1 Diabetes Management DIABETES TECHNOLOGY & THERAPEUTICS 2018; 20 (10): 648–53
From Wary Wearers to d-Embracers: Personas of Readiness to Use Diabetes Devices.
Journal of diabetes science and technology
BACKGROUND: Diabetes devices such as insulin pumps and continuous glucose monitoring (CGM) are associated with improved health and quality of life in adults with type 1 diabetes (T1D). However, uptake remains low. The aim of this study was to develop different "personas" of adults with T1D in relation to readiness to adopt new diabetes technology.METHODS: Participants were 1498 T1D Exchange participants who completed surveys on barriers to uptake, technology attitudes, and other psychosocial variables. HbA1c data was available from the T1D Exchange for 30% of the sample. K-means cluster analyses grouped the sample by device barriers and attitudes. The authors assigned descriptive labels based on cluster characteristics. ANOVAs and chi-square tests assessed group differences by demographic and psychosocial variables (eg, diabetes duration, diabetes distress).RESULTS: Analyses yielded five distinct personas. The d-Embracers (54% of participants) endorsed few barriers to device use and had the highest rates of device use, lowest HbA1c, and were the least distressed. The Free Rangers (23%) had the most negative technology attitudes. The Data Minimalists (10%) used pumps but had lower CGM use and did not want more diabetes information. The Wary Wearers (11%) had lower overall device use, were younger, more distressed, endorsed many barriers, and had higher HbA1c. The High Distress (3%) group members were the youngest, had the shortest diabetes duration, reported the most barriers, and were the most distressed.CONCLUSION: These clinically meaningful personas of device readiness can inform tailored interventions targeting barriers and psychosocial needs to increase device uptake.
View details for PubMedID 30132692
Using Cluster Analysis to Understand Clinician Readiness to Promote Continuous Glucose Monitoring Adoption.
Journal of diabetes science and technology
BACKGROUND: Background:Many people with type 1 diabetes (T1D) report barriers to using continuous glucose monitoring (CGM). Diabetes care providers may have their own barriers to promoting CGM uptake. The goal of this study was to develop clinician "personas" with regard to readiness to promote CGM uptake.METHODS: Diabetes care providers who treat people with T1D (N = 209) completed a survey on perceived patient barriers to device uptake, technology attitudes, and characteristics and barriers specific to their clinical practice. K-means cluster analyses grouped the sample by CGM barriers and attitudes. ANOVAs and chi-square tests assessed group differences on provider and patient characteristics. The authors assigned descriptive names for each persona.RESULTS: Analyses yielded three clinician personas regarding readiness to promote CGM uptake. Ready clinicians (20% of sample; 24% physicians, 38% certified diabetes educators/CDEs) had positive technology attitudes, had clinic time to work with patients using CGM, and found it easy to keep up with technology advances. In comparison, Cautious clinicians (41% of sample; 17% physicians, 53% CDEs) perceived that their patients had many barriers to adopting CGM and had less time than the Ready group to work with patients using CGM data. Not Yet Ready clinicians (40% of sample; 9% physicians; 79% CDEs) had negative technology attitudes and the least clinic time to work with CGM data. They found it difficult to keep up with technology advances.CONCLUSION: Some diabetes clinicians may benefit from tailored interventions and additional time and resources to empower them to help facilitate increased uptake of CGM technology.
View details for PubMedID 29991281
Computerized cognitive training in prostate cancer patients on androgen deprivation therapy: a pilot study
SUPPORTIVE CARE IN CANCER
2018; 26 (6): 1917–26
Prostate cancer patients who have undergone androgen deprivation therapy (ADT) may experience cognitive impairment, yet there is an unmet need for nonpharmacological interventions to address cognitive impairment in this population. This study examines the feasibility, acceptability, and preliminary efficacy of a home-based computerized cognitive training (CCT) program to treat cancer-related cognitive impairment.Sixty men who had received ≥ 3 months of ADT were screened for at least mild cognitive or neurobehavioral impairment and randomized to 8 weeks of CCT or usual care. Follow-up assessments occurred immediately post-intervention or equivalent (T2) and 8 weeks later (T3). The acceptability of CCT was also assessed.Feasibility:A priori feasibility thresholds were partially met (i.e., randomization rate > 50%, retention rate > 70% excluding CCT drop-outs, but < 70% for intent-to-treat). Acceptability: Participants were mostly satisfied with CCT and found it somewhat enjoyable, though barriers to uptake existed. Preliminary efficacy: Linear mixed models indicated significant time by group effects favorable to CCT in reaction time (p = .01), but unfavorable to CCT in verbal and visual memory (ps < .05). Memory was temporarily suppressed in the CCT group at T2, but normalized by T3. There was no effect of CCT on self-reported cognitive functioning, neurobehavioral functioning, nor quality of life.This study provides tentative support for the feasibility and acceptability of CCT to treat mild cognitive impairment in ADT patients. CCT had a beneficial effect on reaction time, but temporarily suppressed memory. CCT's benefits may be limited to a narrow area of functioning. Larger-scale studies are needed.
View details for PubMedID 29282534
Adapting and validating a measure of diabetes-specific self-compassion
JOURNAL OF DIABETES AND ITS COMPLICATIONS
2018; 32 (2): 196–202
Self-compassion (SC), or treating oneself with kindness when dealing with personal challenges, has not been rigorously examined in people with T1D. SC has been shown to buffer against negative emotions and to be linked to improved health outcomes, but diabetes-specific SC has not been studied. This study aimed to adapt the Self-Compassion Scale and validate it for a diabetes-specific population.We developed and validated a diabetes-specific version of the Self-Compassion Scale (Neff, 2003) in a sample of adults with T1D (N=542; 65% female; 97% non-Hispanic White; M age 41, SD=15.7; M A1c=7.3, SD=1; 72% insulin pump users; 50% continuous glucose monitoring [CGM] users). Confirmatory factor analyses (CFA), and reliability and construct validity analyses were conducted. Validity measures included diabetes distress, diabetes empowerment, diabetes numeracy, and A1c.A two-factor bi-factor structure showed best fit, providing support for use of the adapted scale (SCS-D) as a unitary construct. The 19-item unidimensional SCS-D demonstrated excellent internal consistency (ɑ=0.94; range of item-total correlations: 0.52-0.71) and construct validity. As hypothesized, higher SCS-D was associated with less distress, greater empowerment, and lower A1c, and was not associated with numeracy.The SCS-D is a reliable and valid measure of diabetes-specific self-compassion in adults with T1D.
View details for PubMedID 29157869
Diabetes technology: improving care, improving patient-reported outcomes and preventing complications in young people with Type 1 diabetes.
Diabetic medicine : a journal of the British Diabetic Association
With the evolution of diabetes technology, those living with Type 1 diabetes are given a wider arsenal of tools with which to achieve glycaemic control and improve patient-reported outcomes. Furthermore, the use of these technologies may help reduce the risk of acute complications, such as severe hypoglycaemia and diabetic ketoacidosis, as well as long-term macro- and microvascular complications. In addition, diabetes technology can have a beneficial impact on psychosocial health by reducing the burden of diabetes. Unfortunately, diabetes goals are often unmet and people with Type 1 diabetes too frequently experience acute and long-term complications of this condition, in addition to often having less than ideal psychosocial outcomes. Increasing realization of the importance of patient-reported outcomes is leading to diabetes care delivery becoming more patient-centred. Diabetes technology in the form of medical devices, digital health and big data analytics have the potential to improve clinical care and psychosocial support, resulting in lower rates of acute and chronic complications, decreased burden of diabetes care, and improved quality of life. This article is protected by copyright. All rights reserved.
View details for PubMedID 29356074
Trust in hybrid closed loop among people with diabetes: Perspectives of experienced system users.
Journal of health psychology
Automated closed loop systems will greatly change type 1 diabetes management; user trust will be essential for acceptance of this new technology. This qualitative study explored trust in 32 individuals following a hybrid closed loop trial. Participants described how context-, system-, and person-level factors influenced their trust in the system. Participants attempted to override the system when they lacked trust, while trusting the system decreased self-management burdens and decreased stress. Findings highlight considerations for fostering trust in closed loop systems. Systems may be able to engage users by offering varying levels of controls to match trust preferences.
View details for PubMedID 28810490
Expectations and Attitudes of Individuals With Type 1 Diabetes After Using a Hybrid Closed Loop System
2017; 43 (2): 223-232
Purpose The first hybrid closed loop (HCL) system, which automates insulin delivery but requires user inputs, was approved for treatment of type 1 diabetes (T1D) by the US Food and Drug Administration in September 2016. The purpose of this study was to explore the benefits, expectations, and attitudes of individuals with T1D following a clinical trial of an HCL system. Methods Thirty-two individuals with T1D (17 adults, 15 adolescents) participated in focus groups after 4 to 5 days of system use. Content analysis generated themes regarding perceived benefits, hassles, and limitations. Results Some participants felt misled by terms such as "closed loop" and "artificial pancreas," which seemed to imply a more "hands-off" experience. Perceived benefits were improved glycemic control, anticipated reduction of long-term complications, better quality of life, and reduced mental burden of diabetes. Hassles and limitations included unexpected tasks for the user, difficulties wearing the system, concerns about controlling highs, and being reminded of diabetes. Conclusion Users are willing to accept some hassles and limitations if they also perceive health and quality-of-life benefits beyond current self-management. It is important for clinicians to provide a balanced view of positives and negatives to help manage expectations.
View details for DOI 10.1177/0145721717697244
View details for PubMedID 28340542
Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets.
2017; 40 (2): 181-187
Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target.We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices.Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one's body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6-26.0 vs. 21.4-24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18-25 years) had the lowest CGM (26% vs. 40-48%) and insulin pump (64% vs. 69-77%) uptake, highest diabetes distress (2.2 vs. 1.8-2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2-7.4% [55-57 mmol/mol]).Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.
View details for DOI 10.2337/dc16-1536
View details for PubMedID 27899489
Implementation of Depression Screening and Global Health Assessment in Pediatric Subspecialty Clinics.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
Adolescents with chronic illness face greater risk of psychosocial difficulties, complicating disease management. Despite increased calls to screen for patient-reported outcomes, clinical implementation has lagged. Using quality improvement methods, this study aimed to investigate the feasibility of standardized screening for depression and assessment of global health and to determine recommended behavioral health follow-up, across three pediatric subspecialty clinics.A total of 109 patients aged 12-22 years (median = 16.6) who were attending outpatient visits for treatment of diabetes (80% type 1), inflammatory bowel disease, or cystic fibrosis completed the 9-item Patient Health Questionnaire (PHQ-9) depression and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health measures on electronic tablets. Patients screening positive on the PHQ-9 received same-day behavioral health assessment and regular phone check-ins to facilitate necessary follow-up care.Overall, 89% of 122 identified patients completed screening during a 6-month window. Patients completed measures in a timely manner (within 3 minutes) without disruption to clinic flow, and they rated the process as easy, comfortable, and valuable. Depression scores varied across disease type. Patients rated lower global health relative to a previously assessed validation cohort. Depression and global health related significantly to certain medical outcomes. Fifteen percent of patients screened positive on the PHQ-9, of whom 50% confirmed attending behavioral health appointments within 6 months of screening.A standardized depression and global health assessment protocol implemented across pediatric subspecialties was feasible and effective. Universal behavioral health screening for adolescents and young adults living with chronic disease is necessary to meet programmatic needs in pediatric subspecialty clinics.
View details for PubMedID 28830798
Optimal Use of Diabetes Devices: Clinician Perspectives on Barriers and Adherence to Device Use.
Journal of diabetes science and technology
2017; 11 (3): 484–92
Insulin pumps and continuous glucose monitors (CGM) can improve glycemic control for individuals with type 1 diabetes (T1D). Device uptake rates continue to show room for improvement, and consistent adherence is needed to achieve better outcomes. Diabetes health care providers have important roles to play in promoting device use and adherence.We surveyed 209 clinicians who treat people with type 1 diabetes to examine perceptions of barriers to device uptake, attitudes toward diabetes technology, and resources needed for clinicians to improve device uptake. We compared findings with our survey of adults with T1D.Younger clinicians treated more patients using insulin pumps ( r = -.26, P < .001) and CGM ( r = -.14, P = .02), and had more positive attitudes about diabetes technology ( r = -.23, P = .001). The most frequently endorsed modifiable barriers were perceptions that patients dislike having the device on their body (73% pump; 63% CGM), dislike the alarms (61% CGM), and do not understand what to do with device information or features (40% pump; 46% CGM). Clinicians wanted lower cost and better insurance coverage for their patients, and they recommended counseling and education to help address barriers and improve adherence to devices.Clinicians perceive many barriers to their patients initiating and adhering to diabetes devices. Findings highlight opportunities for intervention to improve clinician-patient communication around device barriers to help address them.
View details for PubMedID 28745093
View details for PubMedCentralID PMC5505431
Overeat today, skip the scale tomorrow: An examination of caloric intake predicting nonadherence to daily self-weighing.
2016; 24 (11): 2341-2343
Daily self-weighing is an effective weight loss strategy. Little is known about "micro" factors influencing nonadherence to self-weighing (e.g., daily overeating). It was hypothesized that increased caloric intake on a given day would increase odds of not self-weighing the following day.Daily self-reports of weight and caloric intake were collected from 74 adults with overweight and obesity (mean BMI = 31.2 ± 4.5 kg/m(2) , age = 50.6 ± 10 years, 69% female, 87% Caucasian) throughout a 12-week Internet-based weight management intervention. Multilevel logistic regression investigated odds of nonadherence to self-weighing on a given day based on the previous day's caloric intake.Self-monitoring adherence was high (weights: 87%; calories: 85%); adherence was associated with greater 12-week weight loss (weighing: r = -0.24, P = 0.04; calories: r = -0.26, P = 0.04). Increased caloric intake on a given day, relative to the individual's average intake, was associated with increased odds of nonadherence to self-weighing the next day (F(1,5106) = 12.66, P = 0.0004, β = 0.001). For example, following a day of eating 300 calories more than usual, odds of not self-weighing increased by 1.33.Odds of nonadherence to self-weighing increased following a day with higher-than-usual caloric intake. Weight management interventions collecting daily self-monitoring data could provide support to participants who report increased caloric intake to prevent self-weighing nonadherence.
View details for DOI 10.1002/oby.21650
View details for PubMedID 27619935
Psychosocial Factors in Medication Adherence and Diabetes Self-Management: Implications for Research and Practice
2016; 71 (7): 539-551
Diabetes is a chronic illness that places a significant self-management burden on affected individuals and families. Given the importance of health behaviors-such as medication adherence, diet, physical activity, blood glucose self-monitoring-in achieving optimal glycemic control in diabetes, interventions designed and delivered by psychologists hold promise in assisting children, adolescents, and adults with diabetes in improving their health status and lowering their risk of serious complications. This article first provides an overview of diabetes self-management and associated challenges and burdens. Socioeconomic status factors that may influence diabetes management and outcomes are briefly highlighted. We then review the evidence base for select psychosocial factors that may be implicated in diabetes self-management. Modifiable targets of psychological intervention are presented across 3 overarching domains: (a) knowledge, beliefs, and related cognitive constructs; (b) emotional distress and well-being; and (c) behavioral skills and coping. Important methodological issues facing future research are discussed, along with opportunities for psychologists in improving the care and treatment outcomes of individuals and families living with diabetes. In conclusion, we advocate for continued research emphasis on improving psychosocial aspects of living with diabetes, with greater attention to the situational context in which the self-regulatory processes underlying self-management occur. Psychologists have important roles to play in reducing emotional distress, improving patient knowledge, and providing training in behavioral skills to promote successful self-management and to support patient-centered diabetes care. (PsycINFO Database Record
View details for DOI 10.1037/a0040388
View details for PubMedID 27690483
Diabetes distress from the patient's perspective: Qualitative themes and treatment regimen differences among adults with type 2 diabetes.
Journal of diabetes and its complications
2016; 30 (6): 1060-1068
To explore diabetes distress in a sample of adults with type 2 diabetes, treated and not treated with insulin.Six focus groups were conducted with 32 adults with type 2 diabetes, divided by treatment regimen (insulin-treated N=15; 67% female; 60% black; 46% Hispanic; M age 54; M HbA1c 73mmol/mol (8.8%); non-insulin-treated N=17; 53% female; 65% black; 13% Hispanic; M age 58; M HbA1c 55mmol/mol (7.2%)). A coding team transcribed and analyzed interviews to describe themes. Themes were then compared between groups and with existing diabetes distress measures.Participants in both groups described a range of sources of diabetes distress, including lack of support/understanding from others, difficulties communicating with providers, and distress from the burden of lifestyle changes. Insulin-treated participants described significant emotional distress related to the burden of their insulin regimen. They were more likely to report physical burden related to diabetes; to describe feeling depressed as a result of diabetes; and to express distress related to challenges with glycemic control. Non-insulin-treated participants were more likely to discuss the burden of comorbid medical illnesses.Our data generate hypotheses for further study into the emotional burdens of diabetes for insulin-treated adults with type 2 diabetes and are in line with quantitative research documenting increased diabetes-related distress among insulin-treated individuals. Data describe needs, currently unmet by most models of care, for comprehensive assessment and tailored management of diabetes-related distress.
View details for DOI 10.1016/j.jdiacomp.2016.04.023
View details for PubMedID 27217023
Diabetes Technology: Uptake, Outcomes, Barriers, and the Intersection With Distress.
Journal of diabetes science and technology
2016; 10 (4): 852-858
Patients managing type 1 diabetes have access to new technologies to assist in management. This manuscript has two aims: 1) to briefly review the literature on diabetes technology use and how this relates to psychological factors and 2) to present an example of human factors research using our data to examine psychological factors associated with technology use. Device/technology uptake and use has increased over the years and at present day is a common clinical practice. There are mixed results in terms of health and psychosocial outcomes, with specific subgroups doing better than others with technology. Our data demonstrated that patients have moderately elevated diabetes distress across differing types of technology used, from low-tech to high-tech options, possibly meaning that technology does not add or take away distress. In addition, users on multiple daily injections compared to all other technology groups have less positive attitudes about technology. Finally, we discuss implications for clinical practice and future research.
View details for DOI 10.1177/1932296816650900
View details for PubMedID 27234809
Use of self-monitoring tools in a clinic sample of adults with type 2 diabetes.
Translational behavioral medicine
Self-monitoring is an effective strategy for chronic disease management; many readily available mobile applications allow tracking of diabetes-related health behaviors but their use has not yet been integrated into routine clinical care. How patients engage with these applications in the real world is not well understood. The specific aim of this study is to survey adults with type 2 diabetes (T2D) regarding self-monitoring behaviors, including mobile application use. In 2015, we surveyed an adult diabetes clinic population (n = 96) regarding self-monitoring behaviors: diet, physical activity, weight, and blood glucose. Self-monitoring with any method ranged from 20-90 %. About half of the participants owned smartphones; few had mobile applications. The most common app-tracked behavior was physical activity, then weight and diet. Despite numerous available mobile health-tracking applications, few T2D adults from our sample used them, though many reported self-monitoring with other methods.
View details for PubMedID 27270913
Cognitive and neurobehavioral symptoms in patients with non-metastatic prostate cancer treated with androgen deprivation therapy or observation: A mixed methods study
SOCIAL SCIENCE & MEDICINE
2016; 156: 80-89
Few studies have investigated prostate cancer patients' experiences of cognitive functioning or neurobehavioral symptoms (i.e., behavioral changes associated with neurological dysfunction) following androgen deprivation therapy (ADT).Semi-structured interviews conducted from the US by phone and in-person were used to explore and characterize the: 1) experience of cognitive and neurobehavioral functioning in non-metastatic prostate cancer patients undergoing ADT (n = 19) compared with patients who had not undergone ADT (n = 20); 2) perceived causes of cognitive and neurobehavioral symptoms; 3) impact of these symptoms on quality of life; and 4) strategies used to cope with or compensate for these symptoms. Neuropsychological performance was assessed to characterize the sample.Overall, ADT patients experienced marginally more cognitive problems than non-ADT (nADT) patients even though there were no significant differences between groups in neuropsychological performance. ADT patients also experienced more declines in prospective memory and multi-tasking than nADT patients. Significant proportions of participants in both groups also experienced retrospective memory, attention and concentration, and information processing difficulties. With respect to neurobehavioral symptoms, more ADT patients experienced emotional lability and impulsivity (both aspects of disinhibition) than nADT patients. Among the causes to which participants attributed declines, both groups attributed them primarily to aging. A majority of ADT patients also attributed declines to ADT. For both groups, increased cognitive and neurobehavioral symptoms negatively impacted quality of life, and most participants developed strategies to ameliorate these problems.ADT patients are more vulnerable to experiencing specific cognitive and neurobehavioral symptoms than nADT patients. This study highlights the importance of capturing: a) cognitive symptoms not easily detected using neuropsychological tests; b) neurobehavioral symptoms that can be confused with psychological symptoms, and c) causal beliefs that may affect how people cope with these symptoms. Effective interventions are needed to assist prostate cancer patients in managing these symptoms.
View details for DOI 10.1016/j.socscimed.2016.03.016
View details for PubMedID 27019142
Successful self-management among non-insulin-treated adults with Type 2 diabetes: a self-regulation perspective.
2015; 32 (11): 1504-1512
To clarify the role of self-monitoring of blood glucose (SMBG) in the self-management of Type 2 diabetes from the patient's perspective, using in-depth interviews with non-insulin-treated adults to investigate how they learned to manage their diabetes effectively and whether SMBG played a significant role in this process.Individual interviews were conducted with 14 non-insulin-treated adults with Type 2 diabetes who had significantly improved their glycaemic control [64% women; 50% black; 21% Hispanic; mean age 60 years; mean HbA(1c) concentration 43 mmol/mol (6.1%)]. Interviews were transcribed and analysed by a coding team, applying the concept of illness coherence from the Common Sense Model of Self-Regulation.The majority of participants relied on SMBG to evaluate their self-management efforts. Key themes included: adopting an experimental approach; experiencing 'a-ha' moments; provider-assisted problem-solving; using SMBG and other feedback to evaluate when their efforts were working; and normalizing diabetes-specific behaviour changes as being healthy for everyone.Our qualitative data are consistent with the argument that SMBG, if implemented appropriately with enough education and provider access, can be a powerful tool for non-insulin-treated adults with Type 2 diabetes to monitor their self-management. Establishing sufficient conditions for illness coherence to develop while individuals are learning to use SMBG could increase their sense of personal control in managing a complex and demanding illness.
View details for DOI 10.1111/dme.12745
View details for PubMedID 25764081
"Knowing That You're Not the Only One": Perspectives on Group-Based Cognitive-Behavioral Therapy for Adherence and Depression (CBT-AD) in Adults With Type 1 Diabetes
COGNITIVE AND BEHAVIORAL PRACTICE
2015; 22 (3): 393-406
Depression and illness-specific distress are more common among adults with Type 1 diabetes (T1DM) than the general population and have been associated with poorer control of blood glucose and increased risk for serious diabetes-related complications. Treatment nonadherence has also been associated with depressive symptoms and diabetes-related distress, and has repeatedly been suggested as an important modifiable behavioral pathway linking depression and diabetes outcomes. The present study reports on the feasibility and acceptability of a pilot intervention using group-based cognitive-behavioral therapy to improve treatment adherence among adults with T1DM and elevated levels of diabetes-related distress or depressive symptoms. We describe the components of the intervention and utilize qualitative data along with descriptive outcome data. Our findings suggest that participation in the group was acceptable and associated with reductions in depressive symptoms and diabetes-specific distress. Challenges to feasibility and future directions are discussed.
View details for Web of Science ID 000356908100013
View details for PubMedID 26279614
Diabetes Burden and Diabetes Distress: the Buffering Effect of Social Support
ANNALS OF BEHAVIORAL MEDICINE
2014; 48 (2): 145-155
Few studies have examined protective factors for diabetes distress.This study aimed to examine the moderating role of social support in the relationship between the burden of diabetes and diabetes distress.Adults with type 2 diabetes (N = 119; 29 % Latino, 61 % Black, 25 % White) completed validated measures of diabetes distress and social support. Multiple linear regression evaluated the moderating role of social support in the relationship between diabetes burden, indicated by prescription of insulin and presence of complications, and distress.Greater support satisfaction was significantly associated with lower distress after controlling for burden. Support satisfaction and number of supports significantly moderated the relationship between diabetes burden and distress. Post hoc probing revealed a consistent pattern: Insulin was significantly associated with more diabetes distress at low levels of support but was not at high levels of support.Findings support the stress-buffering hypothesis and suggest that social support may protect against diabetes distress.
View details for DOI 10.1007/s12160-013-9585-4
View details for Web of Science ID 000341808600004
View details for PubMedID 24550072
Probing for depression and finding diabetes: a mixed-methods analysis of depression interviews with adults treated for type 2 diabetes
JOURNAL OF AFFECTIVE DISORDERS
2013; 150 (2): 533-539
Depression has increased prevalence and consistently predicts poor health outcomes among patients with diabetes. The impact of stressors related to diabetes and its treatment on depression assessment is infrequently considered.We used mixed methods to evaluate depressive symptoms in adults with type 2 diabetes. We categorized responses related to diabetes and its treatment during interviews (n=70) using the Montgomery-Åsberg Depression Rating Scale (MADRS) and administered questionnaires to measure diabetes-related distress and depressive symptoms.Participants (M age=56, SD=7; 67% female; 64% Black; 21% Latino) had mild depression on average (MADRS M=10, SD=9). Half of those with symptoms spontaneously mentioned diabetes context; 61% said diabetes contributed to their symptoms when questioned directly. Qualitative themes included: overlapping symptoms of diabetes and depression; burden of diabetes treatment; emotional impact of diabetes; and the bidirectional influence of depression and diabetes. Diabetes was mentioned more often at higher levels of depression severity (r=.38, p=.001). Higher HbA1c was associated with mentioning diabetes as a context for depressive symptoms (r=.32, p=.007). Insulin-users mentioned diabetes more often than those on oral medications only (p=.005).MADRS is not a traditional qualitative interview so themes may not provide an exhaustive view of the role of diabetes context in depression assessment.The burden of type 2 diabetes and its treatment often provide an explanatory context for depressive symptoms assessed by structured clinical interviews, the gold standard of depression assessment. Diabetes context may influence accuracy of assessment and should inform intervention planning for those needing treatment.
View details for DOI 10.1016/j.jad.2013.01.029
View details for Web of Science ID 000323563300051
View details for PubMedID 23453278
THE INFLUENCE OF DIABETES DISTRESS ON A CLINICIAN-RATED ASSESSMENT OF DEPRESSION IN ADULTS WITH TYPE 1 DIABETES
SPRINGER. 2012: S270–S270
View details for Web of Science ID 000302092401136
- "Does That Make Me A Woman?": Breast Cancer, Mastectomy, and Breast Reconstruction Decisions Among Sexual Minority Women PSYCHOLOGY OF WOMEN QUARTERLY 2011; 35 (3): 401-414