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

Association between major depressive disorder or depressive symptoms and the risk of vascular complications among patients with type 2 diabetes, and the mediating role of metabolic biomarkers: an analysis of the UK Biobank cohort

Background

Depression is a severe mental disorder commonly co-morbid with diabetes, but it remains to elucidate whether depression is associated with the risks of a wide range of vascular complications in people with type 2 diabetes mellitus (T2DM) and whether metabolic biomarkers may mediate this pathway.

Methods

We conducted this prospective analysis among the participants of the UK Biobank who were diagnosed with T2DM and free of vascular complications at baseline between March 13, 2006 and September 30, 2010. Major depressive disorder (MDD) was ascertained according to the hospital admission records and self-report of doctor-diagnosed conditions, while the presence of depressive symptoms was assessed using the Patient Health Questionnaire-2. Cox proportional hazards models were performed to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of MDD and depressive symptoms with the risks of incident heart failure (HF); total and individual atherosclerotic cardiovascular disease (ASCVD) including coronary artery disease (CAD), ischemic stroke (IS), and peripheral artery disease (PAD); total and individual microvascular complications of diabetic kidney disease (DKD), diabetic retinopathy (DR), and diabetic neuropathy (DN). Mediation analyses were conducted to quantify the potential mediation effects of circulating metabolites (involved in insulin-resistance, lipid profile, liver function, renal function, and inflammation) in the association of MDD with the outcomes.

Findings

Of the total 23,856 patients with T2DM in the UK Biobank, 13,706 participants (61% males) were eligible and included in this study. During an average of 13 years of follow-up, 2927 (21.36%) ASCVD, 1070 (7.81%) HF, and 2579 (18.82%) microvascular complications occurred. The adjusted HR (95% CI) for MDD was 1.32 (1.09-1.61) with HF, 1.17 (1.03-1.32) with ASCVD, and 1.29 (1.14-1.46) with microvascular complications, while those for depressive symptoms were 1.47 (1.20-1.79), 1.25 (1.10-1.42) and 1.20 (1.05-1.37), respectively. The HRs ranged from 1.26 (1.09-1.44) to 1.96 (1.57-2.45) for MDD with individual complications and mortality, and from 1.26 (1.08-1.47) to 1.49 (1.16-1.93) for depressive symptoms. Up to 7.8% of adverse complications were attributable to MDD and 3.8% to depressive symptoms. A series of circulating metabolites involving lipid profile, renal function, and inflammation were observed to mediate the associations of MDD with vascular complications. The identified mediators jointly accounted for 7.29%-26.87% of the disparities in incident vascular complications between patients with and without MDD.

Interpretation

Our findings highlight the role of MDD and depressive symptoms in the development of vascular complications among people with T2DM, and suggest that the effect of improving mental health on vascular outcomes in patients with T2DM should be investigated in future work.

Funding

Three-Year Public Health Action Plan of Shanghai.

Diabetes in China part 1: epidemiology and risk factors

The prevalence of diabetes in China is rapidly increasing. China now has the largest number of people living with diabetes worldwide, accounting for approximately one-quarter of the global diabetes population. Since the late 1970s, China has experienced profound changes and rapid economic growth, leading to shifts in lifestyle. Changing dietary patterns, reduced physical activity, and stress have contributed to the growing prevalence of overweight and obesity, which are important determinants potentiating the link between insulin resistance and diabetes. Social and environmental factors, such as education, air pollution, and exposure to endocrine-disrupting chemicals, have also contributed to the growing diabetes epidemic in China. The country has one of the fastest ageing populations in the world, which forecasts continued increases in the prevalence of diabetes and its complications. This Review provides an overview of the ongoing diabetes epidemic and risk factors, providing evidence to support effective implementation of public health interventions to slow and prevent the diabetes epidemic in China.

Individual and joint effects of diabetes and depression on incident cardiovascular diseases and all-cause mortality: Results from a population-based cohort study

AIMS

To assess the individual and joint effects of diabetes and depression on all-cause mortality and cardiovascular disease (CVD) in the middle-aged and elderly Chinese populations.

METHODS

9105 individuals without CVD from the China Health and Retirement Longitudinal Study (CHARLS) were included and followed up for 9 years. Participants were divided into four comparative groups: diabetes alone, depression alone, both conditions, and neither condition. Multivariate binary logistic regression models were performed to compare the risks of all-cause mortality and CVD among the four groups.

RESULTS

When compared to those without diabetes and depression, the multivariate adjusted odds ratios (aORs) for CVD in individuals who had diabetes only, depression only, and both diabetes and depression were 1.245 (95 % CI 1.023 to 1.515), 1.318 (95 % CI 1.171 to 1.485) and 1.722 (95 % CI 1.361 to 2.178), respectively. The aORs for all-cause mortality were 1.366 (95 % CI 1.035-1.804) for diabetes alone, 1.082 (95 % CI 0.916-1.279) for depression alone, and 1.590 (95 % CI 1.152-2.195) for both conditions when compared with those with neither condition.

CONCLUSIONS

Individuals with both diabetes and depression had greater risk of CVD and all-cause mortality when compared to those with diabetes or depression alone, or those without either condition.

Associations of comorbid depression with cardiovascular-renal events and all-cause mortality accounting for patient reported outcomes in individuals with type 2 diabetes: a 6-year prospective analysis of the Hong Kong Diabetes Register

Background

Psychosocial status and patient reported outcomes (PRO) [depression and health-related quality-of-life (HRQoL)] are major health determinants. We investigated the association between depression and clinical outcomes in Chinese patients with type 2 diabetes (T2D), adjusted for PRO.

Methods

Using prospective data from Hong Kong Diabetes Register (2013-2019), we estimated the hazard-ratio (HR, 95%CI) of depression (validated Patient Health Questionnaire 9 (PHQ-9) score≥7) with incident cardiovascular disease (CVD), ischemic heart disease (IHD), chronic kidney disease (CKD: eGFR<60 ml/min/1.73m2) and all-cause mortality in 4525 Chinese patients with T2D adjusted for patient characteristics, renal function, medications, self-care and HRQoL domains (mobility, self-care, usual activities, pain/discomfort, anxiety/depression measured by EQ-5D-3L) in linear-regression models.

Results

In this cohort without prior events [mean ± SD age:55.7 ± 10.6, 43.7% women, median (IQR) disease duration of 7.0 (2.0-13.0) years, HbA1c, 7.2% (6.6%-8.20%), 26.4% insulin-treated], 537(11.9%) patients had depressive symptoms and 1923 (42.5%) patients had some problems with HRQoL at baseline. After 5.6(IQR: 4.4-6.2) years, 141 patients (3.1%) died, 533(11.8%) developed CKD and 164(3.6%) developed CVD. In a fully-adjusted model (model 4) including self-care and HRQoL, the aHR of depression was 1.99 (95% confidence interval CI):1.25-3.18) for CVD, 2.29 (1.25-4.21) for IHD. Depression was associated with all-cause mortality in models 1-3 adjusted for demographics, clinical characteristics and self-care, but was attenuated after adjusting for HRQoL (model 4- 1.54; 95%CI: 0.91-2.60), though HR still indicated same direction with important magnitude. Patients who reported having regular exercise (3-4 times per week) had reduced aHR of CKD [0.61 (0.41-0.89)]. Item 4 of PHQ-9 (feeling tired, little energy) was independently associated with all-cause mortality with aHR of 1.66 (1.30-2.12).

Conclusion

Depression exhibits significant association with CVD, IHD, and all-cause mortality in patients with diabetes, adjusting for their HRQoL and health behaviors. Despite the association between depression and all-cause mortality attenuated after adjusting for HRQoL, the effect size remains substantial. The feeling of tiredness or having little energy, as assessed by item Q4 of the PHQ-9 questionnaire, was found to be significantly associated with an increased risk of all-cause mortality after covariate adjustments. Our findings emphasize the importance of incorporating psychiatric evaluations into holistic diabetes management.

Prospective study of depressive symptoms and incident cardiovascular diseases in people with type 2 diabetes

BACKGROUND

To prospectively examine whether depressive symptoms were associated with higher risks of incident cardiovascular diseases (CVD) in individuals with type 2 diabetes.

METHODS

Included were 17,031 participants from UK Biobank with type 2 diabetes who were free of depression (identified by self-reported medical history, hospital record, and antidepressant use), and composite CVD, including atherosclerotic cardiovascular disease (ASCVD) and heart failure (HF). Cox proportional hazards models were applied to examine the association between depressive symptoms measured by Patient Health Questionaire-2 (PHQ-2) and incident composite CVD and its subtypes, adjusting for potential confounders.

RESULTS

During a median follow-up of 12.3 years, we documented 2875 incident composite CVD cases (including 1303 coronary artery disease, 531 ischemic stroke, 530 peripheral arterial disease, and 1142 HF cases). The presence of depressive symptoms had higher risks of composite CVD (adjusted HR, 1.34; 95 % CI, 1.17-1.54) among individuals with type 2 diabetes. Dose-response relationships were observed between depressive symptoms and the composite CVD, ASCVD, and three individual CVD outcomes (P-trend <0.05 for all).

CONCLUSIONS

Depressive symptoms were associated with a higher risk of CVD events across all degrees of metabolic control and diabetes severity. Dose-response associations were also found between depressive symptoms score and all incident CVD outcomes, except for ischemic stroke, after adjustment for cardiovascular and diabetes-related risk factors. Therefore, simple screening questions regarding depressive symptoms might be applied to people with type 2 diabetes to predict CVD outcomes.

Association of comorbid mental disorders with cardiovascular disease risk in patients with type 2 diabetes: A nationwide cohort study

OBJECTIVE

To examine the association between comorbid mental disorders and cardiovascular disease (CVD) risk among patients with type 2 diabetes.

METHOD

This retrospective cohort study was conducted using the claims data of 2,227,394 South Korean patients with type 2 diabetes. We analyzed the occurrence of CVD including myocardial infarction (MI) and ischemic stroke, CVD-specific mortality, and all-cause mortality according to comorbid mental disorders including depressive disorders, bipolar and related disorders, schizophrenia spectrum disorders, insomnia, and anxiety disorders.

RESULTS

Among the patients, 9.1% had a comorbid mental disorder. The adjusted hazard ratios (aHR) for MI, ischemic stroke, CVD-specific mortality, and all-cause mortality in patients with any mental disorder were 1.20 (95% CI, 1.17-1.24), 1.13 (95% CI, 1.11-1.16), 1.16 (95% CI, 1.12-1.20), and 1.21 (95% CI, 1.19-1.23), respectively. Each mental disorder increased the risk of all outcomes, particularly bipolar and related disorders and schizophrenia spectrum disorders.

CONCLUSION

Comorbid mental disorders increased the CVD risk in patients with type 2 diabetes, with significantly increased risks associated with schizophrenia spectrum disorders (aHR: 1.27 for MI and 1.50 for ischemic stroke) and bipolar and related disorders (aHR: 1.27 for MI and 1.45 for ischemic stroke).

Severe mental illness and quality of care for type 2 diabetes: A retrospective population-based cohort study

AIMS

To compare quality of care for type 2 diabetes in people with severe mental illness (SMI) versus no mental illness.

METHODS

We used routinely collected linked data to create a retrospective cohort study. We included 158,901 people diagnosed with type 2 diabetes in Scotland during 2009-2018 of whom 1701 (1%), 768 (0.5%) and 5211 (3%) had a prior hospital admission record for schizophrenia, bipolar disorder, and major depression, respectively. We compared recording of HbA1c, cholesterol, creatinine, blood pressure, urinary albumin, foot examination, retinopathy screening, body mass index and smoking during the first year after diabetes diagnosis using logistic regression and recording of HbA1c and retinopathy screening over longer follow-up using generalised linear mixed effects model, adjusting for confounding factors.

RESULTS

Receipt of care during the first year was generally similar, or better, for people with each SMI than for people without any mental illness. During mean follow up of 4.8 (SD 2.5) years, depression and bipolar disorder were associated with lower odds of receiving retinopathy screening.

CONCLUSIONS

Receipt of diabetes care was similar or better among people with SMI versus without SMI. However, mechanisms to support improved retinopathy screening for people with SMI are needed.

Severe Mental Illness and the Risk of Diabetes Complications: A Nationwide, Register-based Cohort Study

CONTEXT

Individuals with severe mental illness (SMI) are at increased risk of developing type 2 diabetes.

OBJECTIVE

This work explores whether individuals with diabetes and SMI are also at increased risk of diabetes complications and the potential age-specific differences in development of these.

METHODS

Using nationwide registry data, we followed the entire Danish population with type 2 diabetes from January 1, 1996 to December 31, 2018. Exposure was SMI (schizophrenia, bipolar, or depression disorders). Outcome was diabetes complications (nephropathy, retinopathy, lower limp amputations, and cardiovascular disease). We applied Poisson regression models to estimate overall incidence rate ratios (IRRs) and age-specific incidence rates (IRs) and IRRs of the first event of each complication in individuals with SMI compared to individuals without SMI. The models were adjusted for sex, age, diabetes duration, calendar year, education, and migration status.

RESULTS

We followed 371 625 individuals with type 2 diabetes, of whom 30 102 had coexisting diagnosed SMI. Individuals with SMI had a higher IR of nephropathy (IRR: 1.15; 95% CI, 1.12-1.18), amputations (IRR: 1.15; 95% CI, 1.04-1.28), and cardiovascular disease (men: IRR: 1.10; 95% CI, 1.05-1.15, women: IRR: 1.18; 95% CI, 1.13-1.22) but a lower IR of retinopathy (IRR: 0.75; 95% CI, 0.70-0.81) when compared to individuals without SMI, after adjustment for confounders. For all complications except amputations, the difference in IR was highest in the younger age groups.

CONCLUSION

Individuals with type 2 diabetes and SMI had a higher risk and an earlier onset of several diabetes complications diagnoses, emphasizing focusing on improving diabetes management in younger age groups with SMI.

Depression and the risk of hospitalization in type 2 diabetes patients: A nested case-control study accounting for non-persistence to antidiabetic treatment

INTRODUCTION

Depression is one of the most common comorbidities of type 2 diabetes. The relationship between these two diseases seems to be bidirectional. Both conditions separately lead to significant morbidity and mortality, including hospitalization. Moreover, depression is associated with non-persistence with antidiabetic drugs.

OBJECTIVES

To measure the effect of depression on morbidity and particularly on all-cause, diabetes-related, cardiovascular-related and major cardiovascular events-related hospitalization, adjusting for non-persistence to antidiabetic drugs and other confounders.

METHODS

We performed a nested case-control study within a cohort of type 2 diabetic individuals initiating antidiabetic drugs. Using the health administrative data of the province of Quebec, Canada, we identified all-cause, diabetes-related, cardiovascular-related and major cardiovascular hospitalizations during a maximum follow-up of eight years after the initiation of antidiabetic drug treatment. A density sampling method matched all cases with up to 10 controls by age, sex, and the Elixhauser comorbidity index. The effect of depression on hospitalization was estimated using conditional logistic regressions adjusting for non-persistence to antidiabetic drug treatment and other variables.

RESULTS

We identified 41,550 all-cause hospitalized cases, of which 34,437 were related to cardiovascular (CV) diseases, 29,584 to diabetes, and 13,867 to major CV events. Depression was diagnosed in 2.51% of all-cause hospitalizations and 1.16% of matched controls. 69.11% of cases and 72.59% of controls were on metformin monotherapy. The majority (71.62% vs 75.02%, respectively) stayed on metformin monotherapy without adding or switching drugs during follow-up. Non-persistence was at similar rates (about 30%) in both groups. In the multivariable analyses, depression was associated with an increased risk for all-cause hospitalizations, with odds ratios (ORs) ranging from 2.21 (95% CI: 2.07-2.37) to 1.32 (95% CI: 1.22-1.44) according to the model adjustment (from the univariate to the fully adhjusted).

CONCLUSION

Depression increased the risk of all-cause hospitalizations among patients treated for diabetes, even after accounting for non-persistence and other potentially confounding factors. These results stress the impact of depression on diabetic patients' use of health care resources.

Depression, Diabetes Mellitus and Mortality in Older Adults: A National Cohort Study in Taiwan

PURPOSE

Diabetes mellitus (DM) increases the risk of cardiovascular and all-cause mortality. The coexistence of depression and DM is associated with an increased risk of DM complications and functional morbidity. The independent effect of depression on mortality in patients with DM is unclear, and relevant Asian studies have provided inconsistent results. Accordingly, this study assessed the independent and additive effects of DM and depression on mortality in a nationally representative cohort of older adults in Taiwan over a 10-year observation period.

PATIENTS AND METHODS

A total of 5041 participants aged 50 years or older were observed between 1996 and 2007. We defined depression as a score of ≥8 on the 10-item Center for Epidemiologic Studies Depression (CES-D 10) scale. Additionally, we defined participants as having type 2 DM if they had received a diagnosis of type 2 DM from a health-care provider. Cox proportional hazard models were applied to analyze predictors of mortality in depression and DM comorbidity groups.

RESULTS

During the 10-year follow-up period, 1637 deaths were documented. After adjustment for potential confounders, the hazard ratios for mortality in participants with both depression and DM, DM only, and depression only were 2.47 (95% confidence interval [CI]: 2.02-3.03), 1.95 (95% CI: 1.63-2.32), and 1.23 (95% CI: 1.09-1.39), respectively.

CONCLUSION

The co-occurrence of depression with DM in Asian adults increased overall mortality rates. Our results indicate that the increased mortality hazard in individuals with DM and depression was independent of sex.

Art Therapy Alleviates the Levels of Depression and Blood Glucose in Diabetic Patients: A Systematic Review and Meta-Analysis

Objective: To systematically analyze the effects of art therapy on the levels of depression, anxiety, blood glucose, and glycated hemoglobin in diabetic patients.

Methods: We searched Cochrane Library, PubMed, Embase, and ClinicalTrials.gov databases from inception to January 24, 2021. The language of publication was limited to English. Randomized controlled trials (RCTs) that used art therapy to improve mental disorders in diabetic patients were involved. After selection of eligible studies, data were extracted, including the first author's full-name, year of publication, the first author's country of residence, number of intervention and control groups, the mean age of participants, method of intervention, duration of follow-up, and outcome measures. Assessment of quality of the included studies and data extraction were independently carried out by two researchers. RevMan 5.3 software was used to perform statistical analysis.

Results: A total of 396 samples from five studies were included, and the eligible studies were RCTs with a parallel design. Methods of art therapy included music therapy and painting therapy. The results showed that compared with the control group, art therapy could positively affect the levels of depression [standardized mean difference (SMD), −1.36; 95% confidence interval (CI), (−1.63, −1.09); P < 0.00001] and blood glucose in diabetic patients [mean difference (MD), −0.90; 95% CI, (−1.03, −0.77); P < 0.0001], while it had no influence on the levels of anxiety [SMD, −0.31; 95% CI, (−0.93, 0.31); P = 0.32] and glycated hemoglobin [MD, 0.22; 95% CI, (−0.02, 0.46); P = 0.07].

Conclusion: Art therapy may have significant effects on the levels of depression and blood glucose for diabetic patients.

Depression and cardiovascular disease events among patients with type 2 diabetes: A systematic review and meta-analysis with bias analysis

AIMS

To provide updated systematic and quantitative summary of the association between depression and the risk of CVD events among individuals with type 2 diabetes. We also aimed to examine the sensitivity of the association to uncontrolled confounding.

METHODS

Data sources included Medline, Embase, and PsycInfo through September 2019. Two independent reviewers selected cohort studies that evaluated the association between depression and fatal or non-fatal CVD events among individuals with type 2 diabetes. Bias analysis was performed using the bias formula approach.

RESULTS

Of 2527 citations screened, 17 eligible studies with a total of 1,033,131 participants were identified. Based on random-effects meta-analysis, depression was associated with higher risks of non-fatal CVD events (relative risk 1.35, 95% confidence interval [CI] 1.20 to 1.53) and fatal CVD event (relative risk 1.47, 95% CI 1.21 to 1.77). Bias analysis indicated that unmeasured confounders alone may not explain the observed association between depression and CVD events among individuals with type 2 diabetes.

CONCLUSIONS

Depression was associated with a higher risk of non-fatal and fatal CVD events among individuals with type 2 diabetes. Our findings provide updated and robust evidence about the association between depression and CVD events among individuals with type 2 diabetes.

Association of depression and diabetes complications and mortality: a population-based cohort study

AIMS

Several studies suggested that depression might worsen the clinical outcome of diabetes mellitus; however, such association was confounded by duration of illness and baseline complications. This study aimed to assess whether depression increases the risk of diabetes complications and mortality among incident patients with diabetes.

METHODS

This was a population-based matched cohort study using Taiwan's National Health Insurance Research Database. A total of 38 537 incident patients with diabetes who had depressive disorders and 154 148 incident diabetes patients without depression who were matched by age, sex and cohort entry year were randomly selected. The study endpoint was the development of macrovascular and microvascular complications, all-cause mortality and cause-specific mortality.

RESULTS

Among participants, the mean (±SD) age was 52.61 (±12.45) years, and 39.63% were male. The average duration of follow-up for mortality was 5.5 years, ranging from 0 to 14 years. The adjusted hazard ratios were 1.35 (95% confidence interval [CI], 1.32-1.37) for macrovascular complications and 1.08 (95% CI, 1.04-1.12) for all-cause mortality. However, there was no association of depression with microvascular complications, mortality due to cardiovascular diseases or mortality due to diabetes mellitus. The effect of depression on diabetes complications and mortality was more prominent among young adults than among middle-aged and older adults.

CONCLUSIONS

Depression was associated with macrovascular complications and all-cause mortality in our patient cohort. However, the magnitude of association was less than that in previous studies. Further research should focus on the benefits and risks of treatment for depression on diabetes outcome.

Longitudinal associations between depression and diabetes complications: a systematic review and meta-analysis

To conduct a systematic review and meta-analysis of longitudinal studies assessing the bi-directional association between depression and diabetes macrovascular and microvascular complications. Embase, Medline and PsycINFO databases were searched from inception through 27 November 2017. A total of 4592 abstracts were screened for eligibility. Meta-analyses used multilevel random/mixed-effects models. Quality was assessed using the Newcastle-Ottawa scale. Twenty-two studies were included in the systematic review. Sixteen studies examined the relationship between baseline depression and incident diabetes complications, of which nine studies involving over one million participants were suitable for meta-analysis. Depression was associated with an increased risk of incident macrovascular (HR = 1.38; 95% CI: 1.30-1.47) and microvascular disease (HR = 1.33; 95% CI: 1.25-1.41). Six studies examined the association between baseline diabetes complications and subsequent depression, of which two studies involving over 230 000 participants were suitable for meta-analysis. The results showed that diabetes complications increased the risk of incident depressive disorder (HR = 1.14; 95% CI: 1.07-1.21). The quality analysis showed increased risk of bias notably in the representativeness of selected cohorts and ascertainment of exposure and outcome. Depression in people with diabetes is associated with an increased risk of incident macrovascular and microvascular complications. The relationship between depression and diabetes complications appears bi-directional. However, the risk of developing diabetes complications in depressed people is higher than the risk of developing depression in people with diabetes complications. The underlying mechanisms warrant further research.

Comorbid depression and risk of cardiac events and cardiac mortality in people with diabetes: A systematic review and meta-analysis

OBJECTIVE

To examine the association of comorbid occurrence of diabetes and depression with risk of cardiovascular endpoints including cardiovascular mortality, coronary heart disease and stroke.

RESEARCH DESIGN AND METHODS

A systematic review and metaanalysis. We searched PUBMED/MEDLINE, Medscape, Cochrane Library, CINAHL, EMBASE and Scopus databases assessing cardiac events and mortality associated with depression in diabetes up until 1 December 2018. Pooled hazard ratios were calculated using random- effects models.

RESULTS

Nine studies met the inclusion criteria. The combined pooled hazard ratios showed a significant association of cardiac events in people with depression and type 2 diabetes, compared to those with type 2 diabetes alone. For cardiovascular mortality the pooled hazard ratio was 1.48 (95% CI: 1.185, 1.845), p = 0.001, for coronary heart disease 1.37 (1.165, 1.605), p < 0.001 and for stroke 1.33 (1.291, 1.369), p < 0.001. Heterogeneity was high in the meta-analysis for stroke events (I-squared = 84.7%) but was lower for coronary heart disease and cardiovascular mortality (15% and 43.4% respectively). Meta-regression analyses showed that depression was not significantly associated with the study level covariates mean age, duration of diabetes, length of follow-up, BMI, sex and ethnicity (p < 0.05 for all models). Only three studies were found that examined the association of depression in type 1 diabetes, there was a high degree of heterogeneity and data synthesis was not conducted for these studies.

CONCLUSIONS

We have demonstrated a 47.9% increase in cardiovascular mortality, 36.8% increase in coronary heart disease and 32.9% increase in stroke in people with diabetes and comorbid depression. The presence of depression in a person with diabetes should trigger the consideration of evidence-based therapies for cardiovascular disease prevention irrespective of the baseline risk of cardiovascular disease or duration of diabetes.

Depressive Symptoms, Co-Morbidities, and Glycemic Control in Hong Kong Chinese Elderly Patients With Type 2 Diabetes Mellitus

BACKGROUND AND OBJECTIVES

Undiagnosed depression is an important comorbidity in type 2 diabetes (T2D) which can be detected using the Geriatric Depression Scale (GDS-15) questionnaire. In this cross-sectional study, we examined the associations of depression using GDS score with control of cardiometabolic risk factors and health status in elderly patients with T2D.

SETTING AND PARTICIPANTS

Between February and December 2013, patients aged ≥65 years who underwent structured comprehensive assessment as a quality improvement program at the Diabetes Center of a teaching hospital were invited to complete the GDS-15 questionnaire.

MAIN OUTCOME MEASURES

Depression was defined as a GDS score ≥7. Demographic data, prior history of co-morbidities, frequency of self-reported hypoglycemia, and attainment of treatment targets defined as HbA_1c, <7%, blood pressure <130/80 mmHg, and LDL-C <2.6 mmol/L were documented.

RESULTS

Among 325 participants (65% male, median [interquartile range] age: 69 [8] years), 42 (13%) had depression. Patients with depression had longer disease durations (mean ± SD: 15.1 ± 9.1 vs. 11.6 ± 8.1 years, P = 0.02), more frequent self-reported hypoglycemic events (17 vs. 6%, P = 0.03) and were less likely to attain all three treatment targets (0 vs. 16%, P = 0.004) than those without depression. On multivariable analysis, patients with depression had an odds ratio of 2.84 (95% confidence intervals: 1.35-6.00, P = 0.006) of reporting prior history of co-morbidities.

CONCLUSION

In elderly patients with T2D, depression was not uncommon especially in those with poor control of risk factors, hypoglycemia, and co-morbidities. Inclusion of GDS-15 questionnaire during structured assessment for complications and risk factors can identify these high-risk patients for more holistic management of their physical and mental health.

The association of depressive symptoms and diabetes distress with glycaemic control and diabetes complications over 2 years in newly diagnosed type 2 diabetes: a prospective cohort study

AIMS/HYPOTHESIS

We examined the associations between depressive symptoms and diabetes distress with glycaemic control and diabetes complications over 2 years, after diagnosis of type 2 diabetes.

METHODS

In a multi-ethnic, primary care cohort (n = 1735) of adults, all with recent (<6 months) diagnosis of type 2 diabetes, we measured the associations between depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) and diabetes distress (Problem Areas in Diabetes [PAID] score ≥40), with change in 2 year HbA_1c as the primary outcome and with incident rates of diabetes complications as secondary outcomes. Multivariate models were used to account for potential confounders.

RESULTS

Of the 1651 participants (95.2%) of the total primary care cohort with available baseline PHQ-9 and PAID scores, mean ± SD age was 56.2 ± 11.1 years, 55.1% were men and 49.1% were of non-white ethnicity; 232 (14.1%) and 111 (6.7%) had depressive symptoms and diabetes distress, respectively. After adjustment for confounders, depressive symptoms were not associated with worsening HbA_1c. After adjustment for age, sex, ethnicity, vascular risk factors and diabetes treatments, depressive symptoms were associated with increased risk of incident macrovascular complications (OR 2.78 [95% CI 1.19, 6.49], p = 0.018) but not microvascular complications. This was attenuated (p = 0.09) after adjustment for IL-1 receptor antagonist concentration. Diabetes distress was not associated with worsening HbA_1c or incident complications.

CONCLUSIONS/INTERPRETATION

In the first 2 years of type 2 diabetes, the effect of depressive symptoms and diabetes distress on glycaemic control is minimal. There was, however, an association between depressive symptoms and incidence of macrovascular complications. Elevated innate inflammation may be common to both depression and macrovascular diabetes complications, but these findings require replication.

Type 2 diabetes mellitus and psychological stress - a modifiable risk factor

Psychological stress is common in many physical illnesses and is increasingly recognized as a risk factor for disease onset and progression. An emerging body of literature suggests that stress has a role in the aetiology of type 2 diabetes mellitus (T2DM) both as a predictor of new onset T2DM and as a prognostic factor in people with existing T2DM. Here, we review the evidence linking T2DM and psychological stress. We highlight the physiological responses to stress that are probably related to T2DM, drawing on evidence from animal work, large epidemiological studies and human laboratory trials. We discuss population and clinical studies linking psychological and social stress factors with T2DM, and give an overview of intervention studies that have attempted to modify psychological or social factors to improve outcomes in people with T2DM.

Diabetes Complications and Depressive Symptoms: Prospective Results From the Montreal Diabetes Health and Well-Being Study

OBJECTIVE

Prospective studies testing the potential impact of diabetes complications on depression are limited. The present study examined the longitudinal associations between diabetes complications and the risk and recurrence/persistence of depressive symptoms.

METHODS

Data were from a prospective community cohort telephone survey of adults with diabetes (N = 1314). Diabetes complications and depressive symptoms were assessed via self-report (Diabetes Complications Index and Patient Health Questionnaire-9, respectively) at baseline and annually for 5 years. Statistical models adjusted for sociodemographic, lifestyle, and diabetes characteristics.

RESULTS

The number of diabetes complications at baseline was positively associated with a greater risk of elevated depressive symptoms, with the highest risk found for those with four to six complications at baseline (risk ratio = 2.73, 95% confidence interval = 1.64-4.56). Cerebrovascular disease was the complication most strongly associated with incident depressive symptoms (risk ratio = 2.22, 95% confidence interval = 1.59-3.10). Coronary artery disease, peripheral vascular disease, and neuropathy were also associated with the risk of depression, whereas foot problems and eye problems were not. In addition, a greater number of diabetes complications were associated with recurrent/persistent depression, though with a small effect size (Δr = .02). A parallel process latent growth curve model indicated that increases in diabetes complications were associated with increases in depressive symptoms during the course of the follow-up period (β = .74, p < .001).

CONCLUSIONS

This study demonstrates the temporal relation between diabetes complications and depressive symptoms and underscores the psychological burden of diabetes complications by prospectively demonstrating the increased risk and recurrence of depressive symptoms associated with diabetes complications.

Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls

People with severe mental illness (SMI) - schizophrenia, bipolar disorder and major depressive disorder - appear at risk for cardiovascular disease (CVD), but a comprehensive meta-analysis is lacking. We conducted a large-scale meta-analysis assessing the prevalence and incidence of CVD; coronary heart disease; stroke, transient ischemic attack or cerebrovascular disease; congestive heart failure; peripheral vascular disease; and CVD-related death in SMI patients (N=3,211,768) versus controls (N=113,383,368) (92 studies). The pooled CVD prevalence in SMI patients (mean age 50 years) was 9.9% (95% CI: 7.4-13.3). Adjusting for a median of seven confounders, patients had significantly higher odds of CVD versus controls in cross-sectional studies (odds ratio, OR=1.53, 95% CI: 1.27-1.83; 11 studies), and higher odds of coronary heart disease (OR=1.51, 95% CI: 1.47-1.55) and cerebrovascular disease (OR=1.42, 95% CI: 1.21-1.66). People with major depressive disorder were at increased risk for coronary heart disease, while those with schizophrenia were at increased risk for coronary heart disease, cerebrovascular disease and congestive heart failure. Cumulative CVD incidence in SMI patients was 3.6% (95% CI: 2.7-5.3) during a median follow-up of 8.4 years (range 1.8-30.0). Adjusting for a median of six confounders, SMI patients had significantly higher CVD incidence than controls in longitudinal studies (hazard ratio, HR=1.78, 95% CI: 1.60-1.98; 31 studies). The incidence was also higher for coronary heart disease (HR=1.54, 95% CI: 1.30-1.82), cerebrovascular disease (HR=1.64, 95% CI: 1.26-2.14), congestive heart failure (HR=2.10, 95% CI: 1.64-2.70), and CVD-related death (HR=1.85, 95% CI: 1.53-2.24). People with major depressive disorder, bipolar disorder and schizophrenia were all at increased risk of CVD-related death versus controls. CVD incidence increased with antipsychotic use (p=0.008), higher body mass index (p=0.008) and higher baseline CVD prevalence (p=0.03) in patients vs.

CONTROLS

Moreover, CVD prevalence (p=0.007), but not CVD incidence (p=0.21), increased in more recently conducted studies. This large-scale meta-analysis confirms that SMI patients have significantly increased risk of CVD and CVD-related mortality, and that elevated body mass index, antipsychotic use, and CVD screening and management require urgent clinical attention.

Prevention and Care Programs Addressing the Growing Prevalence of Diabetes in China

According to a 2010 national survey, 11 % of adults in China have diabetes, affecting 109.6 million individuals. The high prevalence of diabetes has been attributed to the aging of the population, the rapid adoption of energy-dense foods, and a reduction in physical activity. Collectively, these secular changes have created an obesogenic environment that can unmask diabetes in subjects with a genetic predisposition. The growing prevalence of maternal obesity, gestational diabetes, childhood obesity, and early-onset disease can lead to premature morbidity and mortality. Rising to meet these public health challenges, researchers in China have conducted randomized studies to demonstrate the benefits of lifestyle modification in preventing diabetes (the Da Qing Study), as well as that of team-based integrated care, using multiple strategies including peer support and information technology, in order to reduce hospitalizations, cardiovascular-renal complications, and premature deaths. With growing evidence supporting the benefits of these diabetes prevention and management programs, the next challenge is to use policies and systems to scale up the implementation of these programs through raising awareness, building capacity, and providing resources to reduce the human and socioeconomic burden of diabetes.

Psychosocial Factors in Diabetes and Cardiovascular Risk

Type 2 diabetes is a chronic disease that is increasing in prevalence globally. Cardiovascular disease is a major cause of mortality and morbidity in diabetes, and lifestyle and clinical risk factors do not fully account for the link between the conditions. This article provides an overview of the evidence concerning the role of psychosocial stress factors in diabetes risk, as well as in cardiovascular complications in people with existing diabetes. Several types of psychosocial factors are discussed including depression, other types of emotional distress, exposure to stressful conditions, and personality traits. The potential behavioral and biological pathways linking psychosocial factors to diabetes are presented and implications for patient care are highlighted.

Depression in Chinese patients with type 2 diabetes: associations with hyperglycemia, hypoglycemia, and poor treatment adherence

BACKGROUND

We hypothesize that depression in type 2 diabetes might be associated with poor glycemic control, in part due to suboptimal self-care. We tested this hypothesis by examining the associations of depression with clinical and laboratory findings in a multicenter survey of Chinese type 2 diabetic patients.

METHOD

2538 patients aged 18-75 years attending hospital-based clinics in four cities in China underwent detailed clinical-psychological-behavioral assessment during a 12-month period between 2011 and 2012. Depression was diagnosed if Patient Health Questionnaire-9 (PHQ-9) score ≥10. Diabetes self-care and medication adherence were assessed using the Summary of Diabetes Self-care Activities and the 4-item Morisky medication adherence scale respectively.

RESULTS

In this cross-sectional study (mean age: 56.4 ± 10.5[SD] years, 53% men), 6.1% (n = 155) had depression. After controlling for study sites, patients with depression had higher HbA(1c) (7.9 ± 2.0 vs. 7.7 ± 2.0%, P = 0.008) and were less likely to achieve HbA(1c) goal of <7.0% (36.2% vs 45.6%, P = 0.004) than those without depression. They were more likely to report hypoglycemia and to have fewer days of being adherent to their recommended diet, exercise, foot care and medication. In logistic regression, apart from young age, poor education, long disease duration, tobacco use, high body mass index, use of insulin, depression was independently associated with failure to attain HbA(1c) target (Odds Ratio [OR] = 1.56, 95%CI:1.05-2.32, P = 0.028). The association between depression and glycemic control became non-significant after inclusion of adherence to diet, exercise and medication (OR = 1.48, 95% CI 0.99-2.21, P = 0.058).

CONCLUSION

Depression in type 2 diabetes was closely associated with hyperglycemia and hypoglycemia, which might be partly mediated through poor treatment adherence.

The link between depression and diabetes: the search for shared mechanisms

Depression is twice as common in people with type 1 or type 2 diabetes as in the general population, and is associated with poor outcomes. Evidence is growing that depression and type 2 diabetes share biological origins, particularly overactivation of innate immunity leading to a cytokine-mediated inflammatory response, and potentially through dysregulation of the hypothalamic-pituitary-adrenal axis. Throughout the life course, these pathways can lead to insulin resistance, cardiovascular disease, depression, increased risk of type 2 diabetes, and increased mortality. Proinflammatory cytokines might directly affect the brain, causing depressive symptoms. In type 1 diabetes, mediators of depression are not well studied, with research hindered by inconsistent definitions of depression and scarcity of observational, mechanistic, and interventional research along the life course. Despite few studies, evidence suggests that familial relationships and burden of a lifelong disorder with an onset early in personality development might contribute to increased vulnerability to depression. Overall, longitudinal research is needed to identify risk factors and mechanisms for depression in patients with diabetes, particularly early in the life course. Ultimately, improved understanding of shared origins of depression and diabetes could provide the potential to treat and improve outcomes of both disorders simultaneously. These shared origins are targets for primary prevention of type 2 diabetes.

Cardiovascular risk profiles in Type 2 diabetes and the impact of geographical setting

Cardiovascular (CV) disease is a leading morbidity and mortality in Type 2 diabetes (T2DM). Previous studies have shown geographic differences in the prevalence of CV and renal diseases. A literature review of longitudinal (≥5 years) studies including ≥1000 T2DM patients and reporting CV endpoints was performed to compare risk profiles. Key differences between geographies included a relatively higher prevalence of microalbuminuria in East Asian relative to North American and European patients, which in turn is an important CV risk factor. Patients from East Asia also have a relatively higher incidence of stroke and lower incidence of coronary heart disease. Overall, there are differences in CV risk in T2DM patients between different regions and that long-term studies from Africa, the Middle East and Latin America are lacking.

Diabetes in the Western Pacific Region--past, present and future

In the 2013 issue of the International Diabetes Federation (IDF) Diabetes Atlas, the prevalence of diabetes in the Western Pacific (WP) Region was reported to be 8.6% in 2013, or 138 million adults, and estimated to rise to 11.1%, or 201 million adults, in 2035. The prevalence estimates of impaired glucose tolerance in 2013 and 2035 were 6.8% and 9.0%, respectively. Over 50% of people with diabetes were undiagnosed. In 2013, 187 million deaths were attributable to diabetes, 44% of which occurred in the under the age of 60. The WP Region is home to one quarter of the world's population, and includes China with the largest number of people with diabetes as well as Pacific Islands countries with the highest prevalence rates. There is a rapid increase in diabetes prevalence in the young-to-middle aged adults, possibly driven by high rates of childhood obesity and gestational diabetes as well as rapid demographic and sociocultural transitions. Differences in genetics, ethnicity, cultures and socioeconomic development have led to complex host-environment-lifestyle interactions with marked disease heterogeneity, further influenced by access to care and treatment. Despite these challenges, the WP Region has provided notable examples to prevent and control diabetes.

Depression as a risk factor for mortality in individuals with diabetes: a meta-analysis of prospective studies

Objective

To quantify the impact of depression measured by self-reports and depression measured by clinical interview on all-cause mortality in individuals with diabetes and to analyze the strength of both associations, the influence of covariates, and possible differences between studies assessing self-rated depressive symptoms and those using a clinical interview to measure depression as predictors of mortality.

Research Design and Methods

PUBMED and PsycINFO were searched up to July 2013 for prospective studies assessing depression, diabetes and mortality. The pooled hazard ratios were calculated using random-effects models.

Results

Sixteen studies met the inclusion criteria. After adjustment for demographic variables depression measured by self-reports was associated with an increased all-cause mortality risk (pooled HR = 2.56, 95% CI 1.89–3.47), and the mortality risk remained high after additional adjustment for diabetes complications (HR = 1.76, 95% CI 1.45–2.14,). Six studies reporting adjusted HRs for depression measured by clinical interviews supported the results of the other models (HR = 1.49, 95% CI 1.15–1.93).

Conclusions

Both depression measured by self-report and depression measured by clinical interview have an unfavorable impact on mortality in individuals with diabetes. The results, however, are limited by the heterogeneity of the primary studies. It remains unclear whether self-reports or clinical interviews for depression are the more precise predictor.

Measuring depressive symptoms using the Patient Health Questionnaire-9 in Hong Kong Chinese subjects with type 2 diabetes

BACKGROUND

Depression is common in type 2 diabetes although the prevalence in Chinese patients remains unclear. We validated the Patient Health Questionnaire(PHQ-9), a popular depression screening tool, in Chinese with type 2 diabetes, and documented the prevalence, demographic,and clinical characteristics associated with depression.

METHODS

A consecutive cohort of 586 Hong Kong Chinese outpatients completed the PHQ-9 during comprehensive diabetes complication assessment. Within 2-4 weeks, 40 patients were retested via telephone survey. Ninety-nine randomly selected patients were interviewed by psychiatrists using the Mini International Neuropsychiatric Interview as a golden standard. Receiver operating characteristic curve was used to assess performance of the PHQ-9.

RESULTS

The internal consistency of the PHQ-9 was 0.86 and test-retest reliability was 0.70. The 3 somatic items explained 53.6% of the PHQ-9 score. The optimal cutoff value was 7 with 82.6% sensitivity and 73.7% specificity, giving a depression prevalence of 18.3% (n=107). Of these, 18.7% had been previously diagnosed with depression. Depression was more prevalent in women than men. After controlling for confounders, patients with depression had higher HbA1c (7.80 ± 1.86% versus 7.43 ± 1.29%, [61.7 ± 20.4 versus 57.8 ± 14.1 mmol/mol], P<0.05), reduced likelihood of achieving HbA1c target of <7.0% (33.6% versus 41.8%, P<0.05), and were more likely to have self-reported hypoglycemia in the previous 3 months (18.7% versus 6.7%, P<0.01).

LIMITATION

A small sample was used in the criterion validation and the cross-sectional design precludes causal inference.

CONCLUSIONS

PHQ-9 is a validated tool for screening for depression, which is common and frequently undiagnosed in Chinese type 2 diabetic patients and is associated with suboptimal glycemic control, hypoglycemia, and somatization.