Depression and diabetes: a potentially lethal combination

Association of major depressive episode with negative outcomes of tuberculosis treatment

BACKGROUND

Pulmonary tuberculosis (TB) persists an important contributor to the burden of diseases in developing countries. TB control success is based on the patient's compliance to the treatment. Depressive disorders have been negatively associated with compliance of therapeutic schemes for chronic diseases. This study aimed to estimate the significance and magnitude of major depressive episode as a hazard factor for negative outcomes (NO), including abandon or death in patients receiving TB treatment.

METHODOLOGY/PRINCIPAL FINDINGS

A longitudinal study was conducted to evaluate the association of major depressive episode (MDE), as measured by a 5-item version of the Center for Epidemiological Studies Depression Scale (CES-D) with NO to TB treatment. Patients with confirmed TB were enrolled before the start of TB treatment. Baseline measurements included socio-demographic variables as well as the CES-D, which was also applied every month until the end of the treatment. Death and treatment default were assessed monthly. Survivor function (SF) for NO according to MDE status (CES-D≥6) at baseline (MDEb) was estimated. Cox's Regression was performed for bivariate analyses as well as for the multivariate model. A total of 325 patients accepted to participate in the study, of which 34 where excluded for diagnosis of MDR-TB. NO was observed in 24 patients (8.2%); 109 (37%) presented MDEb. Statistically significant difference was found on the SF of patients with and without MDEb (0.85 vs. 0.96, p-value = 0.002). The hazard ratio for NO, controlled for age, sex, marital status and instruction level was 3.54 (95%CI 1.43-8.75; p-value = 0.006).

CONCLUSION

The presence of MDE at baseline is associated to NO of TB treatment. Targeting detection and treatment of MDE may improve TB treatment outcomes.

High risk for cardiovascular disease in Chinese type 2 diabetic patients with major depression--a 7-year prospective analysis of the Hong Kong Diabetes Registry

BACKGROUND

Depression is known to be associated with premature mortality and cardiovascular disease (CVD) in type 2 diabetes, although there is a paucity of similar data in Chinese population. In this study, we examined the risk association of major depression with premature mortality and CVD in a hospital clinic-based cohort.

METHODS

In a prospective cohort of 7835 Hong Kong Chinese with type 2 diabetes but without CVD at baseline, 153 patients were diagnosed with major depression by psychiatrists in public hospitals. After a median follow-up period of 7.4 years, 827 patients died and 829 patients developed CVD mainly due to stroke (n=384). We used Cox proportional hazard regression to obtain the hazard ratio (HR, 95% confidence interval, CI) of depression for the risk of mortality and CVD.

RESULTS

Depressed patients were younger (51.6 versus 56.6 years, p<0.001), more likely to be female (78.4% versus 53.0%, p<0.001), had higher LDL-cholesterol (3.2 versus 3.0 mmol/L, p=0.038) at baseline and longer hospitalization stays per year (median:0.8 nights per 100-person-years versus 0.1 nights per 100-person-years, p<0.001). After adjusting for conventional risk factors, depression independently predicted CVD [HR=2.18(95% CI=1.45-3.27)], mainly due to stroke [HR=3.55(95% CI=2.15-5.84)].

LIMITATIONS

The young age and small sample size of patients with depression did not give sufficient power to confirm risk association of depression with premature mortality and myocardial infarction.

CONCLUSIONS

In Chinese type 2 diabetic patients, depression was associated with a 2-3 fold increase in the risk of incident CVD, especially stroke.

Depression and death in diabetes; 10-year follow-up of all-cause and cause-specific mortality in a diabetic cohort

BACKGROUND

When depression co-occurs with type 2 diabetes, adverse bidirectional interactions increase the burden of both illnesses. In addition to affecting patient's health, functioning, and quality of life, this relationship also results in increased mortality compared with those with depression or diabetes alone.

OBJECTIVE

The purpose of this study was to examine the relationship between depression and all-cause as well as cause-specific mortality in patients with type 2 diabetes by extending findings from our 5-year mortality study. Specifically, we re-examined the risk of depression and all-cause, cardiovascular, cancer, and non-cardiovascular, non-cancer related deaths.

METHOD

We used an ICD-10 algorithm combined with death certificate data to classify mortality types among type 2 diabetic patients who participated in the Pathways Epidemiologic Study. Cox proportional hazard modeling was used to examine the relationships between depression status and mortality over a 10-year period.

RESULTS

We found a significant positive relationship between depression and all-cause as well as non-cardiovascular, non-cancer mortality in this sample (n = 4128). Cardiovascular mortality failed to reach significance in fully adjusted models and, in contrast to the 5-year data, no trend or significant relationship was observed between depression status and cancer related deaths.

CONCLUSIONS

Our study confirmed a significant positive relationship between depression and mortality in patients with type 2 diabetes. Major depression demonstrated a stronger relationship than did minor depression, and among cause-specific groups, non-cardiovascular, non-cancer death types demonstrated the largest magnitude of association with depression status.

Screening, evaluation and management of depression in people with diabetes in primary care

Family physicians are responsible for diagnosing and treating the majority of people with type 2 diabetes mellitus and co-morbid depression. As a result of the impact of co-morbid depression on patient self-care and treatment outcomes, screening for depression in the context of a structured approach to case management and patient follow up is recommended in people with diabetes and cardiovascular disease. This review summarizes the need for improved recognition and treatment of depression in diabetes; and makes expert recommendations with regard to integrating screening tools and therapies into a busy family or general medical practice setting.

Depression and risk of mortality in people with diabetes mellitus: a systematic review and meta-analysis

Objective

To examine the association between depression and all-cause and cardiovascular mortality in people with diabetes by systematically reviewing the literature and carrying out a meta-analysis of relevant longitudinal studies.

Research Design and Methods

PUBMED and PSYCINFO were searched for articles assessing mortality risk associated with depression in diabetes up until August 16, 2012. The pooled hazard ratios were calculated using random-effects models.

Results

Sixteen studies met the inclusion criteria, which were pooled in an overall all-cause mortality estimate, and five in a cardiovascular mortality estimate. After adjustment for demographic variables and micro- and macrovascular complications, depression was associated with an increased risk of all-cause mortality (HR = 1.46, 95% CI = 1.29–1.66), and cardiovascular mortality (HR = 1.39, 95% CI = 1.11–1.73). Heterogeneity across studies was high for all-cause mortality and relatively low for cardiovascular mortality, with an I-squared of respectively 78.6% and 39.6%. Subgroup analyses showed that the association between depression and mortality not significantly change when excluding three articles presenting odds ratios, yet this decreased heterogeneity substantially (HR = 1.49, 95% CI = 1.39–1.61, I-squared = 15.1%). A comparison between type 1 and type 2 diabetes could not be undertaken, as only one study reported on type 1 diabetes specifically.

Conclusions

Depression is associated with an almost 1.5-fold increased risk of mortality in people with diabetes. Research should focus on both cardiovascular and non-cardiovascular causes of death associated with depression, and determine the underlying behavioral and physiological mechanisms that may explain this association.

Self-rated health: a predictor for the three year incidence of major depression in individuals with Type II diabetes

BACKGROUND

To determine whether self-rated health was a predictor for the three year incidence of major depression in people with Type II diabetes.

METHODS

Data was collected as part a population-based telephone survey of adults with diabetes, in Québec, Canada (2008-2011). Adults with Type II diabetes who did not have major depression at baseline were assessed at three follow-up interviews conducted 12, 24 and 36 months after baseline. Depression was assessed using the Patient Health Questionnaire (PHQ-9). Self-rated health status was determined by asking participants to rate their health on a scale from excellent to poor.

RESULTS

The sample consisted of 1265 adults with Type II diabetes who did not have major depression at baseline. 36% of individuals who had developed major depression at follow up rated their health as fair or poor at baseline compared to 14.4% of those who had not developed major depression. Logistic regression analyses indicated fair or poor self-rated health at baseline to be predictive of a twofold increased risk for major depression at follow-up, even after adjusting for socio-demographic characteristics, lifestyle-related behaviors, disability and diabetes characteristics (OR=2.05, 95% CI 1.20-3.48).

LIMITATIONS

We have focused on current depression (last two weeks) and we have used a questionnaire (PHQ-9) rather than a clinical interview for the assessment of depression.

CONCLUSIONS

Self-rated health status might be a predictor for developing major depression in people with diabetes in addition to well established risk factors.

Evaluating the translation process of an Internet-based self-help intervention for prevention of depression: a cost-effectiveness analysis

Background

Depression is common and treatable with cognitive behavior therapy (CBT), for example. However, access to this therapy is limited. Internet-based interventions have been found to be effective in reducing symptoms of depression. The International Society for Research on Internet Interventions has highlighted the importance of translating effective Internet programs into multiple languages to enable worldwide dissemination.

Objective

The aim of the current study was to determine if it would be cost effective to translate an existing English-language Internet-based intervention for use in a non-English-speaking country.

Methods

This paper reports an evaluation of a trial in which a research group in Norway translated two English-language Internet-based interventions into Norwegian (MoodGYM and BluePages) that had previously been shown to reduce symptoms of depression. The translation process and estimates of the cost-effectiveness of such a translation process is described. Estimated health effect was found by using quality-adjusted life years (QALY).

Results

Conservative estimates indicate that for every 1000 persons treated, 16 QALYs are gained. The investment is returned 9 times and the cost-effectiveness ratio (CER) is 3432. The costs of the translation project totaled to approximately 27% of the estimated original English-language version development costs.

Conclusions

The economic analysis shows that the cost-effectiveness of the translation project was substantial. Hopefully, these results will encourage others to do similar analyses and report cost-effectiveness data in their research reports.

Socioeconomic status and mortality: contribution of health care access and psychological distress among U.S. adults with diagnosed diabetes

OBJECTIVE

Although several studies have examined the association between socioeconomic status (SES) and mortality in the general population, few have investigated this relationship among people with diabetes. This study sought to determine how risk of mortality associated with measures of SES among adults with diagnosed diabetes is mitigated by association with demographics, comorbidities, diabetes treatment, psychological distress, or health care access and utilization.

RESEARCH DESIGN AND METHODS

The study included 6,177 adults aged 25 years or older with diagnosed diabetes who participated in the National Health Interview Surveys (1997-2003) linked to mortality data (follow-up through 2006). SES was measured by education attained, financial wealth (either stocks/dividends or home ownership), and income-to-poverty ratio.

RESULTS

In unadjusted analysis, risk of death was significantly greater for people with lower levels of education and income-to-poverty ratio than for those at the highest levels. After adjusting for demographics, comorbidities, diabetes treatment and duration, health care access, and psychological distress variables, the association with greater risk of death remained significant only for people with the lowest level of education (relative hazard 1.52 [95% CI 1.04-2.23]). After multivariate adjustment, the risk of death was significantly greater for people without certain measures of financial wealth (e.g., stocks, home ownership) (1.56 [1.07-2.27]) than for those with them.

CONCLUSIONS

The findings suggest that after adjustments for demographics, health care access, and psychological distress, the level of education attained and financial wealth remain strong predictors of mortality risk among adults with diabetes.

Depression and risk of mortality in individuals with diabetes: a meta-analysis and systematic review

OBJECTIVES

To estimate risk of comorbid depression on all-cause mortality over time among individuals with diabetes.

METHODS

The Medline, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase and Science Direct databases were searched through September 30, 2012. We limited our search to longitudinal or prospective studies reporting all-cause mortality among those having depression and diabetes, compared with those having diabetes alone that used hazard ratios (HRs) as the main outcome. Two reviewers independently extracted primary data and evaluated the quality of studies using predetermined criteria. The pooled random effects adjusted HRs were estimated using meta-analysis. The impact of moderator variables on study effect size was examined with meta-regression.

RESULTS

A total of 42,363 respondents from 10 studies were included in the analysis. Depression was significantly associated with risk of mortality (pooled HR=1.50, 95% confidence interval=1.35-1.66). Little evidence for heterogeneity was found across the studies (Cochran Q=13.52, P=.20, I(2)=26.03). No significant possibility of publication bias was detected (Egger's regression intercept=0.98, P=.23).

CONCLUSION

Depression significantly increases the risk of mortality among individuals with diabetes. Early detection and treatment of depression may improve health outcomes in this population.

Psychometrics of the PHQ-9 as a measure of depressive symptoms in patients with heart failure

BACKGROUND

Depression in patients with heart failure commonly goes undiagnosed and untreated. The Patient Health Questionnaire-9 (PHQ-9) is a simple, valid measure of depressive symptoms that may facilitate clinical assessment. It has not been validated in patients with heart failure.

AIMS

To test the reliability, and concurrent and construct validity of the PHQ-9 in patients with heart failure.

METHODS

A total of 322 heart failure patients (32% female, 61 ± 12 years, 56% New York Heart Association class III/IV) completed the PHQ-9, the Beck Depression Inventory-II (BDI-II), and the Control Attitudes Scale (CAS).

RESULTS

Cronbach's alpha of .83 supported the internal consistency reliability of the PHQ-9 in this sample. Inter-item correlations (range .22-.66) and item-total correlation (except item 9) supported homogeneity of the PHQ-9. Spearman's rho of .80, (p < .001) between the PHQ-9 and the BDI-II supported the concurrent validity as did the agreement between the PHQ-9 and the BDI-II (Kappa = 0.64, p < .001). At cut-off score of 10, the PHQ-9 was 70% sensitive and 92% specific in identifying depressive symptoms, using the BDI-II scores as the criterion for comparison. Differences in PHQ-9 scores by level of perceived control measured by CAS (t(318) = -5.05, p < .001) supported construct validity.

CONCLUSION

The PHQ-9 is a reliable, valid measure of depressive symptoms in patients with heart failure.

Association of treatment modality for depression and burden of comorbid chronic illness in a nationally representative sample in the United States

OBJECTIVE

We examined associations between treatment modality for depression and morbidity burden. We hypothesized that patients with higher numbers of co-occurring chronic illness would be more likely to receive recommended treatment for depression with both antidepressant medication and psychotherapy.

METHODS

Using a retrospective cross-sectional design, we analyzed data on 165,826 people over 16 years from 2004 to 2008. Using a single multinomial logistic regression model, we examined the likelihood of treatment modality for depression: no treatment, psychotherapy alone, medication alone, and psychotherapy and medication. We examined the following predictors of therapy: (a) morbidity burden; (b) five specific chronic conditions individually: diabetes mellitus II, coronary artery disease, congestive heart failure, hypertension, and chronic obstructive pulmonary disease or asthma; and (c) sociodemographic factors.

RESULTS

The likelihood of any treatment for depression, specifically psychotherapy with medication, increased with the number of co-occurring illnesses. We did not find a clear pattern of association between the five specific conditions and treatment modality, although we identified treatment patterns associated with multiple sociodemographic factors.

CONCLUSIONS

This study provides insight into the relationship between multimorbidity and treatment modalities which could prove helpful in developing implementation strategies for the dissemination of evidence-based approaches to depression care.

Epidemiology of depression and diabetes: a systematic review

BACKGROUND

Research suggests that co-morbid diabetes and depression is common; however, the implications for clinical practice remain unclear. This paper reviews the current epidemiological evidence on comorbid diabetes and depression, in order to identify the key publications which could both inform practice and identify gaps in knowledge and research.

METHODS

A systematic review was conducted to identify published literature on the epidemiology of diabetes and depression. In order to review evidence on up-to-date knowledge of recent research and innovations in care literature searches for the last five years (August 2006-August 2011) were conducted. To identify relevant literature, electronic databases MEDLINE, Psych-INFO and EMBASE were searched for English language articles in peer-reviewed journals.

RESULTS

High rates of co-morbidity of depression and diabetes have been reported. The prevalence rate of depression is more than three-times higher in people with type 1 diabetes (12%, range 5.8-43.3% vs. 3.2%, range 2.7-11.4%) and nearly twice as high in people with type 2 diabetes (19.1%, range 6.5-33% vs. 10.7%, range 3.8-19.4%) compared to those without. Women with diabetes and also women without diabetes experience a higher prevalence of depression than men. Reviewed studies provide support for a modest relationship between diabetes and depressive symptoms, but the exact direction of this relationship remains unclear.

LIMITATIONS

Most studies reviewed were cross-sectional and this limits any conclusions about the causal nature and direction of the relationship between diabetes and depression. Variation in measurement methods, lack of longitudinal data and few studies outside Europe and America limit the generalizability of the findings of this review.

CONCLUSIONS

Current research suggests that the risk of developing depression is increased in people with diabetes; however, further studies are required in order to establish the nature of the relationship between depression, glycaemic control and the development of diabetes complications, and make appropriate recommendations for treatment and to support self-management of diabetes.

Economic aspects of the association between diabetes and depression: a systematic review

BACKGROUND

The importance of co-morbid diabetes and depression is gaining increased attention. Quantifying the socio-economic and clinical impacts of co-morbidity is important given the high costs of these diseases. This review synthesised evidence on the economic impact of co-morbidity and potential cost-effectiveness of prevention and treatment strategies.

METHODS

11 databases from 1980 until June 2011 searched. In addition, websites and reference lists of studies scrutinised and hand search of selected journals performed. Reviewers independently assessed abstracts, with economic data extracted from relevant studies.

RESULTS

62 studies were identified. 47 examined the impact of co-morbidity on health care and other resource utilisation. 11 of these included productivity losses, although none quantified the impact of mortality. Most demonstrated an association between co-morbidity and increasing health service utilisation and cost. Adverse impacts on workforce participation and absenteeism were found. 15 economic evaluations were also identified. Most focused on primary care led collaborative and/or stepped care, suggesting actions may be cost effective. We did not identify any studies looking at actions to reduce the risk of diabetes in people with depression.

LIMITATIONS

Most studies are set in the US, which may be due to focus on English language databases. Few studies looked at impacts beyond one year or outside the health care system.

CONCLUSIONS

There is an evidence base demonstrating the adverse economic impacts of co-morbid diabetes and depression and potential for cost effective intervention. This evidence base might be strengthened through modelling studies on cost effectiveness using different time periods, contexts and settings.

NMDA receptor involvement in antidepressant-like effect of pioglitazone in the forced swimming test in mice

RATIONALE

Previously, we showed that pioglitazone exerts its antidepressant-like effect through peroxisome proliferator-activated receptor gamma receptors and demonstrated the possible involvement of calcium-dependent nitric oxide synthase inhibitors. Based upon the in vitro results, pioglitazone reduces N-methyl-D-aspartate (NMDA)-mediated calcium currents in hippocampal neurons.

OBJECTIVE

In this study, we evaluated the involvement of the NMDA receptor (NMDAR) on the antidepressant-like effect of pioglitazone in the forced swimming test (FST) in mice.

METHOD

After the assessment of locomotor activity in the open-field test, mice were forced to swim individually and the immobility time of the last 4 min was evaluated. Pioglitazone was administered orally with doses of 5, 10, and 20 mg/kg 4 h before FST. To assess the involvement of NMDARs in the possible antidepressant-like effect of pioglitazone, a selective glutamate receptor agonist, NMDA (75 mg/kg, intraperitoneally [i.p.] or 20 ng/mouse, intracerebroventricularly [i.c.v.]), was administered before pioglitazone (20 mg/kg). To further determine a possible role of NMDARs in this effect, a noncompetitive antagonist of the NMDA, MK-801 (0.05 mg/kg, i.p. or 100 ng/mouse, i.c.v.), was coadministered with pioglitazone (10 mg/kg) 4 h prior to FST.

RESULTS

Pioglitazone (20 mg/kg) administered 4 h prior to FST significantly reduced the immobility time. Coadministration of the noneffective doses of pioglitazone and MK-801 revealed an antidepressant-like effect in FST. Moreover, NMDA significantly reversed the antidepressant-like effect of pioglitazone administered 4 h prior to FST.

CONCLUSION

The antidepressant-like effect of pioglitazone in the FST is mediated partly through NMDAR signaling. This study provides a new approach for the treatment of depression.

Depression predicts all-cause mortality: epidemiological evaluation from the ACCORD HRQL substudy

OBJECTIVE

Depression affects up to 20-25% of adults with type 2 diabetes and may increase all-cause mortality, but few well-designed studies have examined the effects of depression on the full range of cardiovascular disease outcomes in type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 2,053 participants in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) Health-Related Quality of Life substudy completed the Patient Health Questionnaire (PHQ)-9 measure of depression symptoms at baseline and 12, 36, and 48 months. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) (95% CI) for the time-varying impact of depression on protocol-defined clinical outcomes with and without adjustment for demographic, trial-related, clinical, and behavioral variables.

RESULTS

In fully adjusted models, depression was not significantly related to the ACCORD primary composite outcome (cardiovascular death, nonfatal heart attack, or stroke) (HR 1.53 [95% CI 0.85-2.73]) or to the ACCORD microvascular composite outcome (0.93 [0.53-1.62]), but all-cause mortality was significantly increased both in those with PHQ-assessed probable major depression (2.24 [1.24-4.06]) and PHQ score of ≥ 10 (1.84 [1.17-2.89]). The effect of depression on all-cause mortality was not related to previous cardiovascular events or to assignment to intensive or standard glycemia control. Probable major depression (by PHQ-9) had a borderline impact on the ACCORD macrovascular end point (1.42 [0.99-2.04]).

CONCLUSIONS

Depression increases the risk of all-cause mortality and may increase the risk of macrovascular events among adults with type 2 diabetes at high risk for cardiovascular events.

Primary care physician perceptions on caring for complex patients with medical and mental illness

BACKGROUND

Mental illness is common and associated with poor outcomes for co-occurring medical illness. Since primary care physicians manage the treatment of complex patients with both mental and medical illnesses, their perspectives on the care of these patients is vital to improving clinical outcomes.

OBJECTIVE

To examine physician perceptions of patient, physician and system factors that affect the care of complex patients with mental and medical illness.

DESIGN

Inductive, participatory, team-based qualitative analysis of transcripts of in-depth semi-structured interviews.

PARTICIPANTS

Fifteen internal medicine physicians from two university primary care clinics and three community health clinics.

RESULTS

Participant characteristics were balanced in terms of years in practice, practice site, and gender. Physicians identified contributing factors to the complexity of patient care within the domains of patient, physician and system factors. Physicians identified 1) type of mental illness, 2) acuity of mental illness, and 3) communication styles of individual patients as the principal patient characteristics that affected care. Physicians expressed concern regarding their own lack of medical knowledge, clinical experience, and communication skills in treating mental illness. Further, they discussed tensions between professionalism and emotional responses to patients. Participants expressed great frustration with the healthcare system centered on: 1) lack of mental health resources, 2) fragmentation of care, 3) clinic procedures, and 4) the national healthcare system.

CONCLUSIONS

Physicians in this study made a compelling case for increased training in the treatment of mental illness and improvements in the delivery of mental health care. Participants expressed a strong desire for increased integration of care through collaboration between primary care providers and mental health specialists. This approach could improve both comfort in treating mental illness and the delivery of care for complex patients.

Depression is a common and chronic comorbidity in patients with interstitial lung disease

BACKGROUND AND OBJECTIVE

Little is known about depression in interstitial lung disease (ILD). The aim of this study was to determine the prevalence of depression, characterize the association of depression with clinical variables and describe the natural history of depression in patients with ILD.

METHODS

In this prospective cohort study, clinical variables were recorded at baseline and 6 months. Depression was measured with the Centre for Epidemiologic Studies Depression scale. Depression prevalence was determined using the established threshold of >15 points. Multivariate linear regression was used to determine the baseline features that independently correlated with baseline depression score and that predicted depression severity at follow-up.

RESULTS

Fifty-two subjects were enrolled, and 45 returned for follow-up (three deaths, one lung transplant). Prevalence of depression was 21% at baseline. Independent predictors of depressive symptoms at baseline included dyspnoea severity, pain severity, sleep quality and forced vital capacity (R(2) 0.67). The odds of clinically meaningful depression at follow-up were 34-fold higher for subjects who had clinically meaningful depression at baseline compared with those who were not (95% confidence interval 3.5-422, P < 0.0005). Baseline depression score was the strongest predictor of depression score at follow-up (r 0.59, P < 0.00005).

CONCLUSIONS

Depressive symptoms in ILD are common, persistent, and strongly and independently correlated with dyspnoea, pain, sleep quality and forced vital capacity. Clinically meaningful depression at baseline is the most important predictor of depressive symptoms at follow-up. Patients with ILD should routinely be screened for depression.

Depression in diabetes mellitus: a comprehensive review

Although the prevalence of a mental disorder, in general, in patients with diabetes mellitus is regarded to be comparable to the general population, an increased prevalence of depressive disorders, often comorbid with anxiety, has been reported in patients with diabetes mellitus. The co-occurrence of depression in diabetes is attributed to a variety of factors, including the psychological and psychosocial impact of the disease, a potential common genetic susceptibility and common pathophysiological abnormalities involving neuroimmunological and neuroendocrinical pathways, as well as microvascular brain lesions due to diabetes mellitus. However, issues concerning pathogenesis and causality of this high co-occurrence are not fully determined yet. Still, the presence of depression in patients with diabetes mellitus is of vast importance, as it is usually associated with poor disease control, adverse health outcomes and quality of life impairment. This article aims to provide a comprehensive review of epidemiological findings, clinical considerations and management strategies concerning depression in patients with diabetes mellitus.

Prevalence of diabetes in patients with major depressive disorder: a population-based study

OBJECTIVE

We conducted this population-based study to detect the prevalence and associated factors of diabetes in patients with major depressive disorder (MDD) in Taiwan.

METHODS

The National Health Research Institute provided a database of 1,000,000 random subjects for health service study. We obtained a random sample of 766,427 subjects 18 years or older, in 2005. Study subjects who had at least one service claim during 2005 for either outpatient or inpatient care, with a primary diagnosis of MDD or with a primary or secondary diagnosis of diabetes, were identified.

RESULTS

The 1-year prevalence of diabetes in patients with MDD was higher than that in the general population (11.65% vs 6.53%; odds ratio, 1.53; 95% confidence interval, 1.39-1.69) in 2005. Compared with the general population, patients with MDD had a higher prevalence of diabetes in all age groups, except age 18 to 29 years; among men and women; among all insurance amount groups; among those living in the northern and southern regions; and among residents living in urban, suburban, and rural areas. A higher prevalence of diabetes in patients with MDD was associated with increased age, use of antipsychotic agents, use of mood stabilizers, and residence in suburban areas.

CONCLUSIONS

Patients with MDD had a much higher prevalence of diabetes in young adult age group and in men than in the general population. Consequently, we must emphasize prevention, early detection, and adequate treatment of diabetes in patients with MDD.

The relationship between depressive symptoms and medication nonadherence in type 2 diabetes: the role of social support

OBJECTIVE

Medication adherence promotion interventions are needed that target modifiable behavioral factors contributing to the link between depressive symptoms and poor adherence to diabetes self-care behaviors. In an effort to identify what factors contribute to this link, we examined the role of social support as a mediator of the relationship between depressive symptoms and medication nonadherence.

METHOD

We recruited 139 subjects with type 2 diabetes. Using an indirect effect test with bias-corrected (BC) bootstrapping, we tested whether depressive symptoms had an indirect effect on medication nonadherence through a lack of social support.

RESULTS

More depressive symptoms were associated with medication nonadherence (total effect=.06, P<.001), more depressive symptoms were associated with less social support (direct effect of the predictor on the mediator=-.96, P=.02), and less social support was associated with medication nonadherence (direct effect of the mediator on the outcome=-.01, P<.01). While the relationship between more depressive symptoms and medication nonadherence persisted with social support in the predicted pathway, the degree of this relationship was partially explained by a relationship between more depressive symptoms and less social support (indirect effect=.01, 95% BC bootstrapped confidence interval of .0005 to .0325).

CONCLUSION

Providing social support to patients with diabetes who have symptoms of depression may ameliorate some of the deleterious effects of depressive symptoms on medication nonadherence, but social support alone is not enough.

The effect of changes in depressive symptoms on disability status in patients with diabetes

OBJECTIVE

To examine the association between changes in depressive symptoms and disability status in patients with diabetes.

METHODS

This 5-year prospective cohort study included 2733 patients with diabetes enrolled in the Pathways Epidemiologic Follow-Up Study who had completed depression and activities of daily living questionnaires at baseline and 5 years. Four depression groups were created using changes in depression scores over 5 years: no depression, improved depression, persistent depression, and development of depression. After controlling for sociodemographic and clinical characteristics, we examined the association between changes in depressive symptoms and incident disability at 5 years using Poisson regression.

RESULTS

In patients nondisabled at baseline (n = 2155), the improved depression group had a risk of disability comparable to the no depression reference group [relative risk (RR): 0.70, 95% CI (0.44-1.12)]. The development of depression and persistent depression groups were significantly more likely to develop disability compared with the no depression group [RR: 2.86, 95% CI (2.12-3.86) and RR: 2.16, 95% CI (1.47-3.18), respectively]. Among those who were disabled at baseline, there was no significant change in the disability status of the three depression groups compared with disabled patients with no depressive symptoms at either time point.

CONCLUSIONS

Among initially nondisabled patients with diabetes, those whose depression improved had functional outcomes comparable to those who were nondepressed at baseline and 5 years. Patients who developed depression and had persistent depression were more likely to experience disability at 5 years than those who were nondepressed at baseline and 5 years.

Association of coexisting diabetes and depression with mortality after myocardial infarction

OBJECTIVE

Diabetes and depression are both linked to an increased mortality risk after myocardial infarction (MI). Population-based studies suggest that having both diabetes and depression results in an increased mortality risk, beyond that of having diabetes or depression alone. The purpose of this study was to examine the joint association of diabetes and depression with mortality in MI patients.

RESEARCH DESIGN AND METHODS

Data were derived from two multicenter cohort studies in the Netherlands, comprising 2,704 patients who were hospitalized for MI. Depression, defined as a Beck Depression Inventory score ≥10, and diabetes were assessed during hospitalization. Mortality data were retrieved for 2,525 patients (93%).

RESULTS

During an average follow-up of 6.2 years, 439 patients died. The mortality rate was 14% (226 of 1,673) in patients without diabetes and depression, 23% (49 of 210) in patients with diabetes only, 22% (118 of 544) in patients with depression only, and 47% (46 of 98) in patients with both diabetes and depression. After adjustment for age, sex, smoking, hypertension, left ventricular ejection fraction, prior MI, and Killip class, hazard ratios for all-cause mortality were 1.38 (95% CI 1.00-1.90) for patients with diabetes only, 1.39 (1.10-1.76) for patients with depression only, and as much as 2.90 (2.07-4.07) for patients with both diabetes and depression.

CONCLUSIONS

We observed an increased mortality risk in post-MI patients with both diabetes and depression, beyond the association with mortality of diabetes and depression alone.

Outpatient costs in pharmaceutically treated diabetes patients with and without a diagnosis of depression in a Dutch primary care setting

Background

To assess differences in outpatient costs among pharmaceutically treated diabetes patients with and without a diagnosis of depression in a Dutch primary care setting.

Methods

A retrospective case control study over 3 years (2002-2004). Data on 7128 depressed patients and 23772 non-depressed matched controls were available from the electronic medical record system of 20 general practices organized in one large primary care organization in the Netherlands. A total of 393 depressed patients with diabetes and 494 non-depressed patients with diabetes were identified in these records. The data that were extracted from the medical record system concerned only outpatient costs, which included GP care, referrals, and medication.

Results

Mean total outpatient costs per year in depressed diabetes patients were €1039 (SD 743) in the period 2002-2004, which was more than two times as high as in non-depressed diabetes patients (€492, SD 434). After correction for age, sex, type of insurance, diabetes treatment, and comorbidity, the difference in total annual costs between depressed and non-depressed diabetes patients changed from €408 (uncorrected) to €463 (corrected) in multilevel analyses. Correction for comorbidity had the largest impact on the difference in costs between both groups.

Conclusions

Outpatient costs in depressed patients with diabetes are substantially higher than in non-depressed patients with diabetes even after adjusting for confounders. Future research should investigate whether effective treatment of depression among diabetes patients can reduce health care costs in the long term.

Screening tools used for measuring depression among people with Type 1 and Type 2 diabetes: a systematic review

BACKGROUND

Depression is common in patients with Type 1 or Type 2 diabetes, has a strong negative impact on the quality of life of patients and is associated with poor outcomes and higher mortality rates. Several guidelines encourage screening of patients with diabetes for depression. It is unclear which depression screening tools are currently being used in people with diabetes and which are most appropriate.

METHODS

A systematic review was conducted to examine which depression screening instruments are currently being used in diabetes research, and the operating characteristics of these tools in diabetes populations. Literature searches for the period January 1970 to October 2010 were conducted using MEDLINE, PSYCH-INFO, ASSIA, SCOPUS, ACADEMIC SEARCH COMPLETE, CINAHL and SCIENCE DIRECT.

RESULTS

Data are presented for the 234 published studies that were examined. The Beck Depression Inventory and the Centre for Epidemiologic Studies Depression Scale were the most popular screening tools (used in 24% and 21% of studies). Information on the cultural applicability of screening tools was mostly unavailable and, where reported, included only details of the language translation process. A small number of studies reported reliability data, most of which showed moderate-good sensitivity and specificity but a high rate of false positives.

CONCLUSIONS

Although a range of depression screening tools have been used in research, there remains few data on their reliability and validity. Information on the cultural applicability of these instruments is even scantier. Further research is required in order to determine the suitability of screening tools for use in clinical practice and to address the increasing problem of co-morbid diabetes and depression.

Serious psychological distress and diabetes: a review of the literature

With the development of a measure of serious psychological distress (SPD) in 2002, more attention is being paid to the association of SPD with diabetes outcomes and processes of care. We review the literature on the relationship between SPD and diabetes processes of care and outcomes, as well as the literature on the relationship between specific mental health diagnoses and diabetes processes of care and outcomes during the 2010 to 2011 period. There is an extensive literature on the association of mental health diagnoses with diabetes outcomes, especially for depression. Because the Kessler scale measures a much broader range of mental health issues than any specific DSM-IV/Structured Clinical Interview for DSM Disorders diagnosis and is designed to assess SPD at the population level, additional research needs to be conducted both in clinical settings and using large administrative datasets to examine the association between SPD and diabetes outcomes and processes of care.

Purchase of antidepressant agents by patients with type 1 diabetes is associated with increased mortality rates in women but not in men

AIMS/HYPOTHESIS

Individuals with diabetes have increased mortality rates compared with the general population. In patients with type 2 diabetes depression further contributes to the increased mortality. Depression and mortality rates in patients with type 1 diabetes are an understudied phenomenon. We therefore studied their association in a prospective setting.

METHODS

We followed 4,174 participants (51% men, age 39 ± 12 years, diabetes duration 22 ± 12 years [mean ± SD]) in the Finnish Diabetic Nephropathy Study (FinnDiane) for an average of 9 years. Depression was defined as purchase of antidepressant agents at baseline and during follow-up. These data were obtained from the Finnish Drug Prescription Register. Data on all-cause mortality and cause of death were obtained from the Finnish Cause of Death Register.

RESULTS

At baseline, 313 (7.5%) patients had purchased antidepressant agents. During follow-up 758 (18.2%) additional cases were observed. Purchasers of antidepressant agents at baseline had the highest 10-year cumulative mortality rate (22.5% [95% CI 18.1, 26.6]), followed by those with such purchases during follow-up (18.0% [15.4, 20.5]) and those with no purchases (10.1% [9.0, 11.2], p < 0.001). In the adjusted Cox regression models (age, diabetes duration, diastolic blood pressure, smoking, HbA(1c) and nephropathy), the purchase of antidepressant agents at baseline was associated with mortality in women, but not in men. Cardiovascular diseases were the major cause of death in non-purchasers of antidepressant agents. In antidepressant purchasers, chronic diabetic complications were the most frequent underlying cause of death.

CONCLUSIONS/INTERPRETATION

In a population of patients with type 1 diabetes, purchase of antidepressant agents was associated with increased mortality rates in women, but not in men.

Diabetes and co-morbid depression among racially diverse, low-income adults

BACKGROUND

Research suggests individuals with diabetes are twice as likely as those without diabetes to be clinically depressed. Still unknown is the relationship between diabetes and depression in socioeconomically disadvantaged populations.

PURPOSE

We examined the relationship between diabetes and depressive symptoms in a large, racially diverse, low-income cohort in the southeastern USA.

METHODS

A total of 69,068 adults were recruited from community health centers in 12 southeastern states. A fully adjusted polytomous logistic regression model tested the relationship between demographics, lifestyle behaviors, antidepressant use, body mass index, diabetes diagnosis, diabetes duration, diabetes medication compliance, and depressive symptoms using the Centers for Epidemiological Studies Depression scale.

RESULTS

Diabetes was present in 21.7% of sample. While a diabetes diagnosis was associated with having severe depressive symptoms (AOR, 1.24; 95% CI, 1.14-1.34), demographics, lifestyle behaviors, body mass index and antidepressant use were more strongly associated with severe depressive symptoms than a diabetes diagnosis.

CONCLUSIONS

Having diabetes was associated with the presence and severity of depressive symptoms in a large, low-income sample of racially diverse adults. However, the relationship between diabetes and depressive symptoms was weaker than in other studies with higher socioeconomic groups.

Validation of the Turkish version of the Centre for Epidemiologic Studies Depression Scale (CES-D) in patients with type 2 diabetes mellitus

Background

Depression is a common co-morbid health problem in patients with diabetes that is underrecognised. Current international guidelines recommend screening for depression in patients with diabetes. Yet, few depression screening instruments have been validated for use in this particular group of patients. Aim of the present study was to investigate the psychometric properties of the Turkish version of the Centre for Epidemiologic Studies Depression Scale (CES-D) in patients with type 2 diabetes.

Methods

A sample of 151 Turkish outpatients with type 2 diabetes completed the CES-D, the World Health Organization-Five Well-Being Index (WHO-5), and the Problem Areas in Diabetes scale (PAID). Explanatory factor analyses, various correlations and Cronbach's alpha were investigated to test the validity and reliability of the CES-D in Turkish diabetes outpatients.

Results

The original four-factor structure proposed by Radloff was not confirmed. Explanatory factor analyses revealed a two-factor structure representing two subscales: (1) depressed mood combined with somatic symptoms of depression and (2) positive affect. However, one item showed insufficient factor loadings. Cronbach's alpha of the total score was high (0.88), as were split-half coefficients (0.77-0.90). The correlation of the CES-D with the WHO-5 was the strongest (r = -0.70), and supported concurrent validity.

Conclusion

The CES-D appears to be a valid measure for the assessment of depression in Turkish diabetes patients. Future studies should investigate its sensitivity and specificity as well as test-retest reliability.

Depression Screening and Interventions for Older Home Health Care Patients

The increasing prevalence of depression in elderly home health care patients led to a statewide initiative in Connecticut to enhance evidence-based depression treatment for older adults. A training curriculum on depression screening and interventions was developed and disseminated to 25 home care professionals representing 14 agencies in Connecticut using a train-the-trainer model. Home care trainers included nurses and social workers. This article describes Phase I curriculum design and initial evaluation of the impact of the training on the preparation of trainers to provide depression care education at their home care agencies. Several evaluation measures, including an appraisal of the self-reported attitudes and self-efficacy of home care professionals towards depressed older adults, a pre/post-test to assess the trainers’ knowledge, and willingness of trainers to implement the education program at their agencies were used to assess program outcomes. Participants’ self-efficacy levels in screening and caring for depressed older adults was significantly increased following the education program compared to immediately before the education program (t, (24) = -4.204; p < .001).

[Clinical aspects of the link between diabetes and depression]

Diabetes mellitus and depression are public health concerns of the present and, as predicted, also the future. The observation that depression is seen more frequently in diabetic patients compared to the non-diabetic population has been proven by several recent studies. The co-occurrence carries further risks for the affected patients, as depression in diabetics may affect sufficient treatment of diabetes and enhance the development of diabetic complications. These may further worsen depressive symptoms causing a vicious cycle in these patients. In the present paper authors discuss in detail the theoretic and practical issues of the complex two directional relationships between diabetes and depression. Their goal is to draw attention to depression as co-morbidity of diabetes that may interfere with the optimization of diabetic patient's carbohydrate metabolism. If sufficient glycaemic control is not achieved using routine clinical methods depression should be evaluated as a probable cause. If needed, depression should be treated to improve the medical outcomes and quality of life of diabetic patients.

Epidemiology and treatment of depression in patients with chronic medical illness

There is a bidirectional relationship between depression and chronic medical disorders. The adverse health risk behaviors and psychobiological changes associated with depression increase the risk for chronic medical disorders, and biological changes and complications associated with chronic medical disorders may precipitate depressive episodes. Comorbid depression is associated with increased medical symptom burden, functional impairment, medical costs, poor adherence to self-care regimens, and increased risk of morbidity and mortality in patients with chronic medical disorders. Depression may worsen the course of medical disorders because of its effect on proinflammatory factors, hypothalamic-pituitary axis, autonomic nervous system, and metabolic factors, in addition to being associated with a higher risk of obesity, sedentary lifestyle, smoking, and poor adherence to medical regimens. Both evidence-based psychotherapies and antidepressant medication are efficacious treatments for depression. Collaborative depression care has been shown to be an effective way to deliver these treatments to large primary care populations with depression and chronic medical illness.

Depression and incident lower limb amputations in veterans with diabetes

PROBLEM

Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes.

METHODS

This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data. Depression was defined by diagnostic codes or antidepressant prescriptions. Amputations were defined by diagnostic and procedural codes. We determined the HR and 95% CI for incident non-traumatic lower limb amputation by major (transtibial and above) and minor (ankle and below) subtypes, comparing veterans with and without diagnosed depression and adjusting for demographics, health care utilization, diabetes severity and comorbid medical and mental health conditions.

RESULTS

Over a mean 4.1 years of follow-up, there were 1289 major and 2541 minor amputations. Diagnosed depression was associated with an adjusted HR of 1.33 (95% CI: 1.15-1.55) for major amputations. There was no statistically significant association between depression and minor amputations (adjusted HR 1.01, 95% CI: 0.90-1.13).

CONCLUSIONS

Diagnosed depression is associated with a 33% higher risk of incident major lower limb amputation in veterans with diabetes. Further study is needed to understand this relationship and to determine whether depression screening and treatment in patients with diabetes could decrease amputation rates.

Using a brief 10-item generic measure of quality of life in English and Spanish speaking diabetic patients

OBJECTIVES

Validation of the Multicultural Quality of Life Index (MQLI), a 10-item self-rated generic multilingual quality of life (QOL) measure in ethnically-diverse diabetic patients.

METHODS

Diabetic adult patients (n = 180) in New York City completed the MQLI, English or Spanish version. Its internal consistency, factorial structure, and construct validity were analyzed. Depression screening (PHQ-9) scores were used to divide subjects into two sub-samples with presumed different QOL levels.

RESULTS

A Cronbach's alpha of 0.92 demonstrated its internal consistency (English-version = 0.90, Spanish-version = 0.94). A one-single factor structure was documented (all items loadings > or = 0.64), accounting for 59% of the items variance in the total sample; similar results were found for each language version. Correlation of the MQLI and PHQ-9 scores yielded an r = -0.58. Mild negative correlations with self-disclosed diagnosis of depression or other mental disorders, diabetes duration, and abnormal sensation on foot exam were found, but were non-significant with other diabetes aspects (e.g., HbA1c, retinopathy). A significant difference (p < 0.001) between the scores of two subsamples with presumed different levels of QOL (means = 8.02 vs. 5.84) was found.

CONCLUSIONS

The MQLI demonstrated coherence around the QOL concept. It correlated significantly with mental health (particularly depression), duration of diabetes, and possible neuropathy, but not with some diabetes-related factors. Its use in diabetic care settings is recommended, possibly supplemented by QOL diabetic-specific instruments.

Depression and treatment nonadherence in type 2 diabetes: Assessment issues and an integrative treatment approach

Research has found that depression is more common among individuals with diabetes and is associated with worse diabetes outcomes including treatment nonadherence, worse glycemic control, higher risk of diabetes complications, greater functional impairment, and increased risk of mortality. These patterns of association have led to an increase in research investigating the relationship between diabetes and depression. There remain important questions about the relationship between depression and diabetes and an unmet need for treatment approaches that are successful in ameliorating depression and improving diabetes outcomes. The current commentary discusses several conceptual issues related to the measurement of depression in diabetes, argues for the importance of health behavior and treatment adherence in approaching the problem of depression in diabetes, and provides an example of a treatment approach that incorporates the treatment of depression with strategies aimed at improving treatment adherence in order to maximize effects on diabetes outcomes.

A tune in "a minor" can "b major": a review of epidemiology, illness course, and public health implications of subthreshold depression in older adults

BACKGROUND

With emphasis on dimensional aspects of psychopathology in development of the upcoming DSM-V, we systematically review data on epidemiology, illness course, risk factors for, and consequences of late-life depressive syndromes not meeting DSM-IV-TR criteria for major depression or dysthymia. We termed these syndromes subthreshold depression, including minor depression and subsyndromal depression.

METHODS

We searched PubMed (1980-Jan 2010) using the terms: subsyndromal depression, subthreshold depression, and minor depression in combination with elderly, geriatric, older adult, and late-life. Data were extracted from 181 studies of late-life subthreshold depression.

RESULTS

In older adults subthreshold depression was generally at least 2-3 times more prevalent (median community point prevalence 9.8%) than major depression. Prevalence of subthreshold depression was lower in community settings versus primary care and highest in long-term care settings. Approximately 8-10% of older persons with subthreshold depression developed major depression per year. The course of late-life subthreshold depression was more favorable than that of late-life major depression, but far from benign, with a median remission rate to non-depressed status of only 27% after ≥1 year. Prominent risk factors included female gender, medical burden, disability, and low social support; consequences included increased disability, greater healthcare utilization, and increased suicidal ideation.

LIMITATIONS

Heterogeneity of the data, especially related to definitions of subthreshold depression limit our ability to conduct meta-analysis.

CONCLUSIONS

The high prevalence and associated adverse health outcomes of late-life subthreshold depression indicate the major public health significance of this condition and suggest a need for further research on its neurobiology and treatment. Such efforts could potentially lead to prevention of considerable morbidity for the growing number of older adults.

Increased mortality risk in women with depression and diabetes mellitus

CONTEXT

Depression and diabetes mellitus have been associated with an increased risk of all-cause and cardiovascular disease (CVD) mortality. However, data evaluating the joint effects of these 2 conditions on mortality are sparse.

OBJECTIVES

To evaluate the individual and joint effects of depression and diabetes on all-cause and CVD mortality rate.

DESIGN

Prospective cohort study.

SETTING

The 11 states of the Nurses' Health Study.

PARTICIPANTS

A total of 78 282 women who participated in the Nurses' Health Study aged 54 to 79 years at baseline in 2000 were followed up until 2006. Depression was defined as having self-reported diagnosed depression, treatment with antidepressant medications, or a score indicating severe depressive symptoms (ie, a 5-item Mental Health Index score ≤52). Self-reported type 2 diabetes was confirmed using a supplementary questionnaire.

MAIN OUTCOME MEASURES

All-cause and CVD-specific mortality rate.

RESULTS

During 6 years of follow-up (433 066 person-years), 4654 deaths were documented, including 979 deaths from CVD. Compared with participants without either condition, the age-adjusted relative risks (RRs) (95% confidence interval) for all-cause mortality were 1.76 (1.64-1.89) for women with depression only, 1.71 (1.54-1.89) for individuals with diabetes only, and 3.11 (2.70-3.58) for women with both conditions. The corresponding age-adjusted RRs of CVD mortality were 1.81 (1.54-2.13), 2.67 (2.20-3.23), and 5.38 (4.19-6.91), respectively. These associations were attenuated after multivariate adjustment for other demographic variables, body mass index, smoking status, alcohol intake, physical activity, and major comorbidities (including hypertension, hypercholesterolemia, heart diseases, stroke, and cancer) but remained significant, with the highest RRs for all-cause and CVD mortality found in those with both conditions (2.07 [1.79-2.40] and 2.72 [2.09-3.54], respectively). Furthermore, the combination of depression with a long duration of diabetes mellitus (ie, >10 years) or insulin therapy was associated with a particularly higher risk of CVD mortality after multivariate adjustment (RRs, 3.22 and 4.90, respectively).

CONCLUSIONS

Depression and diabetes are associated with a significantly increased risk of all-cause and CVD mortality rate. The coexistence of these conditions identifies women at particularly high risk.

Confirmatory factor analysis of the depressive cognition scale

The purpose of this study was to validate the single-factor structure of the Depressive Cognition Scale (DCS) among individuals from the U.S. general population. The sample was composed of 629 adults from 42 states of the United States. All measures of model fit of the DCS exceeded the recommended criteria for the good model fit (χ(2)/df = 2.57, goodness-of-fitness index = .98, adjusted goodness-of-fitness index = .96, comparative fit index = .99, Tucker Lewis index = .98, root mean square error of approximation = .05, root mean residual = .01, and the P value for test of close fit = .464). Thus, the DCS was found to be a reliable and valid instrument to measure depressive cognitions among individuals from the general population.

Progression of symptoms and functioning among female cardiac patients with and without diabetes

OBJECTIVE

To determine if older women with both heart disease and diabetes experience worse physical and psychosocial functioning and higher symptom burden over an 18-month period compared with those with heart disease alone.

METHODS

Data from older women with heart disease (≥60 years, n = 1008, 18% with diabetes) were used to assess the impact of diabetes on physical functioning (Sickness Impact Profile [SIP]-Physical and Six-Minute Walk test [6MWT]), psychosocial functioning (SIP-Psychosocial and depressive symptoms), and physical symptom burden (cardiac and general) at baseline and 4, 12, and 18 months later. Generalized estimating equation models compared trends in outcomes over time between groups with and without diabetes.

RESULTS

Across all four time points, women with heart disease and diabetes had greater functional impairment, as indicated by higher SIP scores, than those without diabetes (43%-71% higher SIP-Physical scores and 32%-65% higher SIP-Pyschosocial scores; all p ≤ 0.002). 6MWT distance was 17%-30% less in the diabetes group across time points (all p ≤ 0.002). Depressive symptoms were 27%-39% higher in the diabetes group (all p < 0.03) except at month 4. Women with diabetes scored 15%-29% higher on a physical symptom index across time points (all p < 0.05) than those without diabetes; no significant differences were observed in cardiac symptoms until month 18 (diabetes group 29% higher, p = 0.02). Subgroups with and without diabetes in this sample experienced significantly different trends over time in SIP-Physical scores (p = 0.02) and 6MWT distance (p = 0.05), such that the disadvantage of the diabetes group at baseline was greater 18 months later.

CONCLUSIONS

Women with comorbid diabetes and heart disease are vulnerable to poor health-related quality of life, particularly in terms of physical functioning and symptoms, and require special efforts from clinical care providers to ameliorate a potential downward trend in these outcomes over time.

Diabetes prevalence, diabetes regimen and co-morbidity in depressed patients compared with non-depressed patients in primary care in the Netherlands

AIMS

To assess the prevalence of diabetes in depressed patients compared with non-depressed matched controls and to compare diabetes regimen and co-morbidity in depressed patients with diabetes vs. non-depressed patients with diabetes in primary care in the Netherlands.

METHODS

A retrospective case-control study over 3 years (2002-2004). Data for depressed patients (n = 7128) and non-depressed matched controls (n = 23,772) were available from an electronic medical record system of 20 general practices organized in one large primary care organization in the Netherlands. Matching was based on year and month of birth, sex and general practitioner. Diabetes, diabetes regimen (i.e. oral glucose medication, insulin or both) and co-morbidity were defined using Anatomical Therapeutic Chemical classification codes of delivered medication.

RESULTS

The prevalence of diabetes was 5.5% (n = 393) among depressed patients, which was 2.6 times higher than in non-depressed matched controls where the figure was 2.1% (n = 494; P < 0.001). Diabetes regimen, i.e. the proportions of subjects on oral glucose medication, insulin or both did not differ among depressed patients with diabetes (51, 27 and 22%, respectively) compared with non-depressed patients with diabetes (51, 30, 19%; P = 0.53). Co-morbidity was significantly more prevalent among depressed patient with diabetes than in non-depressed patients with diabetes.

CONCLUSIONS

Compared with non-depressed matched controls, adults with treated depression have almost three times higher rates of diabetes. Depressed patients with diabetes had more co-morbidities compared with non-depressed patients with diabetes, whereas diabetes regimen did not differ.

Depression in relation to long-term control of glycemia, blood pressure, and lipids in patients with diabetes

BACKGROUND

Little information is available about the association of depression with long-term control of glycemia, blood pressure, or lipid levels in patients with diabetes.

OBJECTIVE

To determine whether minor and major depression at study enrollment compared with no depression are associated with higher average HbA(1c), systolic blood pressure (SBP) and LDL cholesterol over the long term in patients with an indication for or receiving drug treatment.

DESIGN

Cohort study.

PATIENTS

A total of 3,762 patients with type 2 diabetes mellitus enrolled in the Pathways Epidemiologic Study in 2001-2002 and followed for 5 years.

MAIN MEASURES

Depression was assessed at study enrollment using the Patient Health Questionnaire-9 (PHQ-9). SBP and information on cardiovascular co-morbidity were abstracted from medical records, and LDL cholesterol and HbA(1c) measured during clinical care were obtained from computerized laboratory data during a median of 4.8 years' follow-up.

KEY RESULTS

Among those with an indication for or receiving drug treatment, after adjustment for demographic and clinical characteristics, average long-term HbA(1c), SBP, and LDL cholesterol did not differ in patients with comorbid diabetes and minor or major depression compared with those with diabetes alone.

CONCLUSIONS

The adverse effect of depression on outcomes in patients with diabetes may not be mediated in large part by poorer glycemic, blood pressure, or lipid control. Further study is needed of the biologic effects of depression on patients with diabetes and their relation to adverse outcomes.

Racial disparities in the treatment of depression in low-income persons with diabetes

OBJECTIVE

Individuals with diabetes are at higher risk for depression than the general population. Although depression can be treated with antidepressant medications, patients with diabetes and comorbid depression often go untreated. The goal of this study was to examine racial disparities in the treatment of depression with antidepressant medication in the southeastern U.S.

RESEARCH DESIGN AND METHODS

Cross-sectional data were collected at baseline from 69,068 participants (71% African American, 60% female, and 82% with incomes <$25,000) recruited from community health centers and enrolled in the Southern Cohort Community Study (SCCS). The SCCS is a prospective epidemiological cohort study designed to explore causes of health disparities in adults aged 40-79 years. Binary logistic regression was used to identify factors associated with antidepressant use among those with diabetes (n = 14,279).

RESULTS

Individuals with diagnosed diabetes (14,279) were classified with no depressive symptoms (54.7%), or with mild (24.2%), moderate (12.8%), or severe depressive symptoms (8.3%). After controlling for sex, age, insurance, income, education, BMI, smoking status, alcohol consumption, and level of depression, African Americans with diabetes were much less likely to report taking antidepressant medication than whites (adjusted odds ratio 0.32 [95% CI 0.29-0.35], P < 0.0001).

CONCLUSIONS

Antidepressant use is much less common among African Americans than among whites with diabetes. Reasons for racial disparities in treatment of depressive symptoms are unclear but may include a combination of differential diagnosis and treatment by health professionals as well as cultural differences in seeking help for emotional distress.

Prevalence of pain and association with quality of life, depression and glycaemic control in patients with diabetes

AIMS

To determine the prevalence of pain and its association with glycaemic control, mental health and physical functioning in patients with diabetes.

METHODS

Cross-sectional data from a multi-site, prospective cohort study of 11 689 participants with diabetes. We analysed the associations of pain severity and interference with glycated haemoglobin (HbA(1c)) measurements and Medical Outcomes Study SF-Mental and Physical Component Summary-12 (MCS-12 and PCS-12) scores.

RESULTS

Of participants, 57.8% reported moderate to extreme pain and, compared with those without pain, were somewhat older (60.8 vs. 59.9 years, P < 0.001), more obese (body mass index of 32.1 vs. 29.8 kg/m(2), P < 0.001), more likely to report being depressed or anxious (41.3 vs. 16.2%, P < 0.001) and more likely to report fair or poor health (48.5 vs. 23.1%, P < 0.001). Bivariate comparisons demonstrated that patients with extreme pain had higher HbA(1c) than those without pain (8.3 vs. 8.0%, P = 0.001). In multivariable analyses, pain was not associated with HbA(1c) (P = 0.304) but was strongly associated with worse MCS-12 (P < 0.001), PCS-12 (P < 0.001) and depression (P < 0.001). Depression was 1.3 (95% CI: 1.12, 1.96) times more likely in patients with moderate pain and 2.0 (95% CI: 1.56, 2.46) times more likely in patients with extreme pain.

CONCLUSIONS

Moderate to extreme pain was present in 57.8% of diabetic patients. Pain was strongly associated with poorer mental health and physical functioning, but not worse glycaemic control. Recognizing the high prevalence of pain and its strong association with poorer health-related quality of life may be important to improve the comprehensive management of diabetes.