title: Exploring the relationship between cognitive illness representations and poor emotional health and their combined association with diabetes self-care. A systematic review with meta-analysis.
abstract: OBJECTIVE
  Depression and anxiety are common in diabetes and are associated with lower diabetes self-care adherence. How this occurs is unclear. Our systematic review explored the relationship between cognitive illness representations and poor emotional health and their combined association with diabetes self-care.
  
  
  METHODS
  Medline, Psycinfo, EMBASE, and CINAHL were searched from inception to June 2013. Data on associations between cognitive illness representations, poor emotional health, and diabetes self-care were extracted. Random effects meta-analysis was used to test the relationship between cognitive illness representations and poor emotional health. Their combined effect on diabetes self-care was narratively evaluated.
  
  
  RESULTS
  Nine cross-sectional studies were included. Increased timeline cyclical, consequences, and seriousness beliefs were associated with poorer emotional health symptoms. Lower perceived personal control was associated with increased depression and anxiety, but not mixed anxiety and depressive symptoms. Remaining cognitive illness representation domains had mixed statistically significant and non-significant relationships across emotional states or were measured only once. Effect sizes ranged from small to large (r=±0.20 to 0.51). Two studies explored the combined effects of cognitions and emotions on diabetes self-care. Both showed that cognitive illness representations have an independent effect on diabetes self-care, but only one study found that depression has an independent effect also.
  
  
  CONCLUSIONS
  Associations between cognitive illness representations and poor emotional health were in the expected direction - negative diabetes perceptions were associated with poorer emotional health. Few studies examined the relative effects of cognitions and emotions on diabetes self-care. Longitudinal studies are needed to clarify directional pathways.
authors.affiliation: Health Psychology Section, Psychology Department, Institute of Psychiatry, King's College London, UK; NIHR Collaboration for Leadership in Applied Health Research and Care for Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, UK. Electronic address: Joanna.Hudson@kcl.ac.uk.
authors.forename: Joanna L
authors.initials: JL
authors.lastname: Hudson
authors.affiliation: NIHR Collaboration for Leadership in Applied Health Research and Care for Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, UK. Electronic address: Christine.Bundy@manchester.ac.uk.
authors.forename: Chris
authors.initials: C
authors.lastname: Bundy
authors.affiliation: NIHR Collaboration for Leadership in Applied Health Research and Care for Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, UK. Electronic address: Peter.A.Coventry@manchester.ac.uk.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Coventry
authors.affiliation: Mental Health Research Group, Institute of Health Research, University of Exeter Medical School, UK; The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for the South West Peninsula (PenCLAHRC), UK. Electronic address: C.M.Dickens@exter.ac.uk.
authors.forename: Chris
authors.initials: C
authors.lastname: Dickens
mesh_terms: D001007:Anxiety / Q000209:etiology* / Q000523:psychology; D003071:Cognition; D003430:Cross-Sectional Studies; D003863:Depression / Q000209:etiology* / Q000523:psychology; D003920:Diabetes Mellitus / Q000523:psychology*; D004644:Emotions; D005260:Female; D006801:Humans; D007389:Internal-External Control; D008297:Male; D008603:Mental Health; D026684:Personal Autonomy; D012648:Self Care
keywords: Anxiety; Cognitive illness representations; Depression; Diabetes mellitus; Self-care behaviours; Systematic review