Type 2 diabetes and depressive symptoms in older adults: a population-based study

Comorbidity of depression and type 2 diabetes in Egypt results from the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study

BACKGROUND

Diabetes mellitus and depression are serious common diseases, and the number of people with both conditions is rising steadily. Depression in people with diabetes mellitus results in poorer prognosis through different mechanisms. On the other hand, the presence of diabetes in individuals with depression increases functional impairment that is associated with depression.

AIMS

The study aimed to assess the prevalence and factors associated with depression among adults with type 2 diabetes mellitus attending a diabetes clinic in Cairo, Egypt.

METHODS

A cross-sectional study was conducted among adult patients with diabetes type 2 attending a diabetes clinic in the endocrinology department in Ain Shams University Teaching Hospital, Cairo, Egypt. Data were collected through face-to-face interviews by trained psychiatrists and from patients' records.

RESULTS

The prevalence of depression among diabetic patients was 21.8% (95% CI [15.6%, 29.1%]). Depression was more common among younger age groups and those with a higher level of education. There was no significant difference between those with lifetime depression compared to those without depression regarding physical health complications.

CONCLUSIONS

The prevalence of depression among patients with type 2 diabetes is high. Given the impact of co-morbid diabetes and depression, diabetic patients should be routinely screened for the latter condition.

Depressive disorder subtypes, depressive symptom clusters, and risk of obesity and diabetes: A systematic review

BACKGROUND

Overlapping but divided literatures suggest certain depression facets may pose greater obesity and diabetes risk than others. Our objectives were to integrate the major depressive disorder (MDD) subtype and depressive symptom cluster literatures and to clarify which facets are associated with the greatest cardiometabolic disease risk.

METHODS

We conducted a systematic review of published studies examining associations of ≥2 MDD subtypes or symptom clusters with obesity or diabetes risk outcomes. We report which facets the literature is "in favor" of (i.e., having the strongest or most consistent results).

RESULTS

Forty-five articles were included. Of the MDD subtype-obesity risk studies, 14 were in favor of atypical MDD, and 8 showed similar or null associations across subtypes. Of the symptom cluster-obesity risk studies, 5 were in favor of the somatic cluster, 1 was in favor of other clusters, and 5 were similar or null. Of the MDD subtype-diabetes risk studies, 7 were in favor of atypical MDD, 3 were in favor of other subtypes, and 5 were similar or null. Of the symptom cluster-diabetes risk studies, 7 were in favor of the somatic cluster, and 5 were similar or null.

LIMITATIONS

Limitations in study design, sample selection, variable measurement, and analytic approach in these literatures apply to this review.

CONCLUSIONS

Atypical MDD and the somatic cluster are most consistently associated with obesity and diabetes risk. Future research is needed to establish directionality and causality. Identifying the depression facets conferring the greatest risk could improve cardiometabolic disease risk stratification and prevention programs.

Comparison of the incidence of depression before and after endovascular treatment in patients with lower limb peripheral artery disease

Depression is a chronic illness that affects mood, physical health, and overall vitality and quality of life. Depression has been associated with an increased risk of all-cause and cardiovascular mortality among patients with peripheral arterial disease (PAD). Therefore, this study aimed to compare the incidence of depression before and after endovascular treatment in patients with lower limb PAD. This is an important clinical issue considering the worldwide increase in PAD with the aging population and the known negative impact of depression on recovery. This was a retrospective sub-analysis of data from the Tokyo Peripheral Vascular Intervention Study using the TOMA-CODE registry. The presence and extent of depressive symptoms were evaluated using the patient health questionnaire (PHQ-9), with a depressive tendency score of ≥ 5. The PHQ-9 score was evaluated before endovascular treatment (EVT) and at 4 (± 1) weeks after EVT. The study population consisted of 87 patients who completed the PHQ-9 before EVT, with 76 completing the post-EVT PHQ-9. Of these 76, 19 had a pre-EVT score ≥ 5. Overall, there was no difference in the pre- and post-EVT scores (P = 0.091). There was no significant change in the 19 patients with a pre-EVT score ≥ 5 (mean 9.2 ± 4.4); however, there was a tendency to improve in the pre- to post-EVT score (mean, 6.9 ± 5.2; P = 0.059). Diabetes was a significant negative factor for pre- to post-EVT score improvement (P = 0.023). Overall, symptoms of depression showed the tendency to improve at 30 days post-EVT. However, diabetes was associated with lower improvement in symptoms.

Frequency of depression and quality of life in patients with diabetes mellitus in public health facilities in Metropolitan Lima

INTRODUCTION

Diabetes is one of the main pandemics in recent years. Its association with depression increases the risk of mortality and morbidity. The coexistence of both diseases leads to poor management of diabetes, which leads to a worse quality of life.

OBJECTIVE

To determine the frequency of depression in patients with diabetes mellitus and the effect of both pathologies on the quality of life in patients who attend outpatient appointments at public health facilities in Lima and Callao.

METHODOLOGY

Secondary analysis of the Epidemiological Study of Mental Health of depression in diabetic adults. The instrument used to determine the depressive episode was the MINI (Mini-International Neuropsychiatric Interview) while quality of life was measured using the Mezzich Quality of Life Index. Diagnosis information of type 1 or 2 diabetes was obtained from the daily medical record (HIS) of care.

RESULTS

The frequency of depression in the 471 patients with diabetes was 5.8% in the last two weeks. While the annual frequency was 8.6% and 31.8% at some point in life. Being a woman was associated with a greater frequency of depression. Quality of life was lower in patients with diabetes and depression (p < 0.005).

CONCLUSIONS

The frequency of depression in patients with diabetes who are treated on an outpatient basis in public health centres is higher than the general population and their quality of life is significantly reduced, which raises the need for considering depression as an additional factor to the burden of morbidity of this condition.

The relationship between depression and metabolic control parameters in type 2 diabetic patients: A cross-sectional and feasibility interventional study

BACKGROUND

Substantial evidence supports a bidirectional relationship between diabetes and clinical depression. However, little is known about the effect of treating one condition on the control of the other. Thus, this study aimed to determine the prevalence of depression among Type II diabetes mellitus (T2DM) patients and to assess the efficacy and feasibility of escitalopram treatment of depression on their metabolic control parameters.

METHODS

T2DM patients attending primary care clinics in the North of Jordan were enrolled in a cross-sectional study during the period from February to December 2019 (n = 157). Depressive symptoms were screened utilising the patient health questionnaire-9 (PHQ-9) tool. Metabolic control was assessed by measurement of glycated haemoglobin (HbA1c), triglycerides, cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL). Patients with moderate to severe depressive symptoms by PHQ-9 (n = 58) were interviewed by a psychiatrist to confirm a clinical diagnosis of depression. Eligible depressed patients were administered escitalopram 10 mg orally once daily for 3 months (n = 12). Thereafter, depressive symptoms and metabolic control measures were reassessed.

RESULTS

The prevalence of moderate to severe depressive symptoms among T2DM patients, according to PHQ-9, was 36.94%, while the prevalence of clinical depression based on interview was 7.64%. Baseline PHQ-9 scores correlated significantly with baseline levels of HbA1c, HDL, cholesterol and triglycerides. Escitalopram treatment intervention resulted in significant improvement of PHQ-9 scores without significantly improving any of the metabolic control measures.

CONCLUSION

The relationship between depression and T2DM in the context of metabolic syndrome is plausible. However, our results show that escitalopram treatment may not be associated with significant improvement in metabolic control parameters among these patients. Our study has laid the groundwork for future randomised clinical trials with larger sample size and longer follow-up.

Frequency of Depression and Quality of Life in Patients with Diabetes Mellitus in Public Health Facilities in Metropolitan Lima

INTRODUCTION

Diabetes is one of the main pandemics in recent years. Its association with depression increases the risk of mortality and morbidity. The coexistence of both diseases leads to poor management of diabetes, which leads to a worse quality of life.

OBJECTIVE

To determine the frequency of depression in patients with diabetes mellitus and the effect of both pathologies on the quality of life in patients who attend outpatient appointments at public health facilities in Lima and Callao.

METHODOLOGY

Secondary analysis of the Epidemiological Study of Mental Health of depression in diabetic adults. The instrument used to determine the depressive episode was the MINI (Mini-International Neuropsychiatric Interview) while quality of life was measured using the Mezzich Quality of Life Index. Diagnosis information of type 1 or 2 diabetes was obtained from the daily medical record (HIS) of care.

RESULTS

The frequency of depression in the 471 patients with diabetes was 5.8% in the last two weeks. While the annual frequency was 8.6% and 31.8% at some point in life. Being a woman was associated with a greater frequency of depression. Quality of life was lower in patients with diabetes and depression (p <0.005).

CONCLUSIONS

The frequency of depression in patients with diabetes who are treated on an outpatient basis in public health centres is higher than the general population and their quality of life is significantly reduced, which raises the need for considering depression as an additional factor to the burden of morbidity of this condition.

Adherence to Medication, Physical Activity and Diet in Older Adults With Diabetes: Its Association With Cognition, Anxiety and Depression

Background

Adherence to medication, physical activity (PA) and diet in diabetes mellitus (DM) patients is crucial for its good management, avoiding acute and chronic complications. There are several risk factors associated with non-adherence, including cognitive impairment, depression and anxiety. Nevertheless, studies on therapeutic adherence in older patients with DM are scarce. In this context, the present study aimed to analyze whether adherence to medication, PA and diet are associated with cognitive impairment, anxiety and depression. It also aimed to identity predictors of medication non-adherence.

Methods

A cross-sectional study of older patients (≥ 65 years old) with DM was carried out in the Outpatient Department of Internal Medicine Service of CHUSJ-Porto, Portugal. Those unable to communicate were excluded. Cognition (mini-mental state examination), anxiety and depression (hospital anxiety and depression scale) were assessed. Adherence to medication, PA and diet was measured, based on self-reporting patient/family, questionnaires, physician clinical opinion, hemoglobin test and pharmacy records. Patient groups were compared, using the Mann-Whitney or the Kruskal-Wallis test for continuous variables and the Chi-square test for paired categorical variables (significance level of 0.05). The odds ratio (OR) was calculated to identify independent predictors of non-adherence to medication.

Results

The final sample (n = 94) had a mean age of 75.2 years (standard deviation: 6.7) and mostly were female (53.2%), married (63.8%) and with a low education level (61.7%). Also, 22.3% with cognitive impairment, 16% with depression and 23.4% with anxiety were found. Patients non-adherent to medication had higher depression (P = 0.048) and anxiety (P = 0.010), compared to adherents/partial adherents. Patients non-adherent to PA showed higher anxiety (P = 0.035) and depression (P = 0.004), compared to adherents. Non-adherents to PA had more cognitive impairment than adherents (26.3% vs. 0%; P = 0.034). Patients who had insulin prescribed presented a higher risk of non-adherence to medication (OR: 4.041, 95% confidence interval (CI): 1.404 - 11.628; P = 0.010). Also, the risk of non-adherence to medication is higher by an increase of one unit in anxiety (OR: 1.252, 95% CI: 1.046 - 1.499; P = 0.014).

Conclusions

Higher anxiety and depression were associated with non-adherence to medication and to PA. Insulin prescribed and high anxiety scores were predictors of medication non-adherence. This study appears to contribute to the knowledge about the influence of cognitive and psychological factors in therapeutic adherence in these older diabetic patients.

The Bidirectional Relationship between Diabetes and Depression: A Literature Review

Diabetes is a major public health problem worldwide. Depression is a serious mental condition that decreases mental and physical functioning and reduces the quality of life. Several lines of evidence suggest a bidirectional relationship between diabetes and depression: diabetes patients are twice as likely to experience depression than nondiabetic individuals. In contrast, depression increases the risk of diabetes and interferes with its daily self-management. Diabetes patients with depression have poor glycemic control, reduced quality of life, and an increased risk of diabetes complications, consequently having an increased mortality rate. Conflicting evidence exists on the potential role of factors that may account for or modulate the relationship between diabetes and depression. Therefore, this review aims to highlight the most notable body of literature that dissects the various facets of the bidirectional relationship between diabetes and depression. A focused discussion of the proposed mechanisms underlying this relationship is also provided. We systematically reviewed the relevant literature in the PubMed database, using the keywords “Diabetes AND Depression”. After exclusion of duplicate and irrelevant material, literature eligible for inclusion in this review was based on meta-analysis studies, clinical trials with large sample sizes (n≥1,000), randomized clinical trials, and comprehensive national and cross-country clinical studies. The evidence we present in this review supports the pressing need for long, outcome-oriented, randomized clinical trials to determine whether the identification and treatment of patients with these comorbid conditions will improve their medical outcomes and quality of life.

Quantitative assessment of the bidirectional relationships between diabetes and depression

Diabetes and depression impose an enormous public health burden and the present study aimed to assess quantitatively the bidirectional relationships between the two disorders. We searched databases for eligible articles published until October 2016. A total of 51 studies were finally included in the present bidirectional meta-analysis, among which, 32 studies were about the direction of depression leading to diabetes, and 24 studies about the direction of diabetes leading to depression. Pooled results of the 32 eligible studies covering 1274337 subjects showed that depression patients were at higher risk for diabetes (odds ratio (OR) = 1.34, 95% confidence intervals (CI) = [1.23, 1.46]) than non-depressive subjects. Further gender-subgroup analysis found that the strength of this relationship was stronger in men (OR = 1.63, 95%CI = [1.48, 1.78]) than in women (OR = 1.29, 95%CI = [1.07, 1.51]). For the direction of diabetes leading to depression, pooled data of 24 articles containing 329658 subjects showed that patients with diabetes were at higher risk for diabetes (OR = 1.28, 95%CI = [1.15, 1.42]) than non-diabetic subjects. The available data supports that the relationships between diabetes and depression are bidirectional and the overall strengths are similar in both directions. More mechanistic studies are encouraged to explore the molecular mechanisms underlying the relationships between the two diseases.

Association of depression with pre-diabetes, undiagnosed diabetes, and previously diagnosed diabetes: a meta-analysis

We performed a meta-analysis to analyze the associations of depression with pre-diabetes (PreDM), undiagnosed diabetes (UDM), and previously diagnosed diabetes (PDM), and whether the association was affected by important study characteristics. We searched relevant articles published in PubMed and EMBASE up to August, 2015. Studies reporting cross-sectional associations of depression with PreDM, UDM, or PDM compared with normal glucose metabolism (NGM) were included. Odds ratios (ORs) were pooled with random-effect and fixed-effect models. Subgroup analyses by sex, study mean age, different degrees of adjustment, publication year, quality score, and depression assessment scales were also performed. Twenty studies were eligible and included in current analysis. Summary estimates showed that compared with NGM individuals, prevalence of depression was moderately increased in PreDM (random-effect odds ratio (OR) 1.11, 95 % confidence interval (CI) 1.03-1.19) and UDM (OR 1.27, 95 % CI 1.02-1.59), and markedly increased in PDM (OR 1.80, 95 % CI 1.40-2.31). Subgroup analyses showed that the positive association remained only among studies with mean age <60 years old but not among those with mean age ≥60 years old. Summary estimates of ORs with cardiovascular disease adjustment substantially attenuated the association. Our findings suggested that risk of prevalent depression was gradually increased with the deterioration of glucose metabolism among younger age groups but not among older age groups. Comorbid cardiovascular diseases might be an important intermediate factor underlying the association between depression and diabetes.

The relationship between depressive symptoms and diabetic complications in elderly patients with diabetes: Analysis using the Diabetes Study from the Center of Tokyo Women's Medical University (DIACET)

AIMS

To investigate the association between likelihood or severity of depression and symptoms associated with diabetic complications in elderly Japanese patients with diabetes.

METHODS

This single-center cross-sectional study included 4283 patients with diabetes, 65 years and older (mean age was 73 ± 6 years, 38.7% were women, 3.9% had type 1 diabetes). Participants completed a self-administered questionnaire including items on subjective symptoms associated with diabetic microangiopathy, frequency of clinical visits due to vascular diseases (heart diseases, stroke, or gangrene), hospitalization, and the Patient Health Questionnaire-9 (PHQ-9), a simple but reliable measure of depression. The associations between severity of depression and diabetic complications were examined using logistic regression analysis.

RESULTS

According to the PHQ-9 scores, patients were classified into the following 3 categories: 0-4 points (n=2975); 5-9 points (n=842); and 10 or more points (n=466). Higher PHQ-9 scores were associated with increased odds ratios for retinopathy, symptoms related to peripheral polyneuropathy and autonomic neuropathy, and end-stage renal disease requiring dialysis after adjustment for age, gender, smoking status, and HbA1c (all p<0.05).

CONCLUSIONS

Significant relationships were found between depression severity and chronic diabetic complications among elderly Japanese patients with diabetes.

The Prevalence and Predictors of Depression in Type 2 Diabetic Population of Punjab

The present cross sectional study was carried out on 787 type 2 diabetic subjects from tertiary health care hospitals to identify the prevalence and predictors of depression in diabetes. Depression was tested using Patient Health Questionnaire-9. Of the study participants, 199 (25.29%) met the criteria for mild to moderate depression, 252 (32.02%) were severely depressed and 336 (42.69%) were clinically non-depressed. The prevalence of depression was 65.02 % in women, which is 1.87 fold higher (p < 0.0001) than men (49.87%). Depression was observed to be strongly associated with advancing age >30 years (p < 0.05), low income (p = 0.0001), sedentary life style (p = 0.001), Plasma levels of low density lipoproteins (LDL) >100 mg/dl and triglycerides (TG) >150 mg/dl (p < 0.05), drinking alcohol (p < 0.001), statin use (p < 0.001), BMI >35-39.9 kg m(-2) (p = 0.018), WHR >0.9 cm (p < 0.0001), Glucose levels >125 mg/dl (p < 0.0001) and duration of diabetes 2-4 years (p = 0.003). In multivariate logistic regression model, risk factors such as, being a woman, duration of diabetes ≥10 years, BMI ≥30 kg m(-2), LDL >100 mg/dl, TG >150 mg/dl and sedentary life style emerged as independent predictors of depression in diabetes. In the present study, 86.4 % diabetic subjects were not diagnosed for depression prior participation. In conclusion, the present study revealed that higher prevalence of depression in diabetes was evident in population of Punjab, especially in women and majority of these patients remain undiagnosed for depression.

Depressive symptoms, antidepressant medication use, and new onset of diabetes in participants of the diabetes prevention program and the diabetes prevention program outcomes study

OBJECTIVE

To assess in the Diabetes Prevention Program and Diabetes Prevention Program Outcomes Study whether diagnosis of diabetes predicted elevated depressive symptoms (DS) or use of antidepressant medicine (ADM) following diagnosis; whether diabetes status or duration had significant effect on DS or ADM use; and to determine the associations between A1C, fasting plasma glucose (FPG), normalization of FPG, and DS or ADM use after diagnosis.

METHODS

Diabetes Prevention Program participants in three treatment arms (intensive life style, metformin, placebo) were assessed for diabetes, glucose control, ADM use, and DS, measured using the Beck Depression Inventory (BDI). Among 3234 participants, 1285 developed diabetes. Depression levels were measured before and after diabetes diagnosis.

RESULTS

Neither DS nor use of ADM increased after diagnosis; higher FPG was associated with greater ADM use in the intensive life style arm; a 10-mg/dl rise in FPG is associated with greater odds of ADM use. Higher FPG and A1C were associated with higher BDI scores in all three arms; A 10-mg/dl rise in FPG had a 0.07 increase in BDI. A 1% higher A1c was associated with a 0.21-point increase in BDI. Normalization of FPG was associated with lower BDI. When FPG had normalized, there was a decrease of 0.30 points in the BDI score compared when FPG had not normalized.

CONCLUSIONS

Contrary to clinical attributions, diabetes diagnosis did not show an immediate impact on BDI scores or ADM use. Higher glucose levels after diagnosis were associated with a small but significantly higher BDI score and more ADM use.

TRIAL REGISTRATION

DPPOS: NCT00038727; DPP: NCT00004992.

Incidence and risk of depression associated with diabetes in adults: evidence from longitudinal studies

This meta-analysis examined depression as a consequence of diabetes by conducting a meta-analysis, using data from longitudinal studies. Databases were systematically searched for relevant studies. Incidence of depression is presented as cumulative incident proportion (CIP). Pooled effect sizes were calculated using random-effects model. The data were reconstructed to compute relative risk (RR) and CIP. The 16 studies selected for review generated 16 datasets of which 11 studies reporting binary estimates (RR) and 5 studies reporting time-to-event estimates [hazard ratio (HR)]. Both RR and HR were significant at 1.27 (95% CI 1.17-1.38) and 1.23 (95% CI 1.08-1.40) for incident depression associated with diabetes mellitus. Our observations also revealed greater cumulative incidence of depression in diabetes than in non diabetes groups. Our study shows that diabetes is a significant risk factor for the onset of depression.

Depression among older adults with diabetes mellitus

Older adults with Diabetes Mellitus (DM) experience greater risk for comorbid depression compared to those who do not have DM. Undetected, untreated or under-treated depression impinges an individual's ability to manage their DM successfully, hinders their adherence to treatment regime, and undermines provider-patient relationships. Thus, in the context of caring for older adults with DM, comorbid depression presents special challenges and opportunities for clinicians. In this article, we summarize the clinical presentation of late-life depression, potential mechanisms of comorbidity of depression and DM, importance of depression in the successful management of DM, and available best practice models for depression treatment.

Prevalence of depression among people with type 2 diabetes mellitus: a cross sectional study in Palestine

BACKGROUND

Diabetes mellitus is a common chronic metabolic disorder and one of the main causes of death in Palestine. Palestinians are continuously living under stressful economic and military conditions which make them psychologically vulnerable. The purpose of this study was to investigate the prevalence of depression among type II diabetic patients and to examine the relationship between depression and socio-demographic factors, clinical factors, and glycemic control.

METHODS

This was a cross-sectional study at Al-Makhfiah primary healthcare center, Nablus, Palestine. Two hundred and ninety-four patients were surveyed for the presence of depressive symptoms using Beck Depression Inventory (BDI-II) scale. Patients' records were reviewed to obtain data pertaining to age, sex, marital status, Body Mass Index (BMI), level of education, smoking status, duration of diabetes mellitus, glycemic control using HbA1C test, use of insulin, and presence of additional illnesses. Patients' medication adherence was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8).

RESULTS

One hundred and sixty four patients (55.8%) of the total sample were females and 216 (73.5%) were < 65 years old. One hundred and twenty patients (40.2%) scored ≥ 16 on BDI-II scale. Statistical significant association was found between high BDI-II score (≥ 16) and female gender, low educational level, having no current job, having multiple additional illnesses, low medication adherence and obesity (BMI ≥ 30 kg/m2). No significant association between BDI score and glycemic control, duration of diabetes, and other socio-demographic factors was found. Multivatriate analysis showed that low educational level, having no current job, having multiple additional illnesses and low medication adherence were significantly associated with high BDI-II scores.

CONCLUSION

Prevalence of depression found in our study was higher than that reported in other countries. Although 40% of the screened patients were potential cases of depression, none were being treated with anti-depressants. Psychosocial assessment should be part of routine clinical evaluation of these patients at primary healthcare clinics to improve quality of life and decrease adverse outcomes among diabetic patients.

Population impact of depression either as a risk factor or consequence of type 2 diabetes in adults: a meta-analysis of longitudinal studies

This meta-analysis examined the reciprocal relationship between depression and diabetes mellitus type 2 (T2DM) by conducting a bias adjusted meta-analysis of longitudinal studies using relative and absolute risk estimates. Specifically, the data were reconstructed to compute relative risk (RR), risk difference (RD), and the number needed to be exposed for one additional person to be harmed (NNEH) or benefited (NNEB). The 25 studies selected for review generated 29 datasets of which 15 examined endpoint A (depression as a risk factor for T2DM), and 14 examined endpoint B (T2DM as a risk factor for depression). For both endpoints, there was a small relative risk increase (for both the RR and hazard ratio (HR)) though with significant heterogeneity between studies. This however translated to a non-significant NNEH of 87 (NNEB 161 to ∞ to NNEH 35) and NNEH of 233 (NNEB 28 to ∞ to NNEH 23) for studies examining endpoint A and endpoint B respectively. This study suggests that the magnitude of the relative risk increase for depression as a risk factor or consequence of T2DM is small without significant impact on absolute risk indices. While these risks may be considered in terms of individual patient management, they are unlikely to have an impact on a population perspective.

Evidence supporting an association between hypoglycemic events and depression

OBJECTIVES

This retrospective study investigated the association between hypoglycemic events (HEs) and depression events (DEs) in patients with diabetes mellitus (type 1 and type 2).

METHODS

Analyzed data were from health care claims for individuals with employer-sponsored primary or Medicare supplemental insurance from the Thomson Reuters Market Scan database during the years 2008 and 2009. A baseline period (January 2008 to December 2008) was used to identify eligible patients and collect baseline clinical and demographic characteristics. Eligible patients were aged ≥18 years with diabetes (ICD-9-CM codes: 250.00, 250.01, 250.02, 250.03) who had not experienced any HEs or DEs and were not on antidepressant therapy during the baseline period. We studied the relationships between the DEs and HEs before and after adjusting for the covariates.

RESULTS

Of the 923,024 patients meeting the inclusion criteria, 22,735 (2.46%) patients had HEs (ICD-9-CM coded: 251.0, 251.1, 251.2, 250.8) and 6164 (0.67%) patients had DEs (ICD-9-CM: 311) during the evaluation period. Patients reporting HEs had 78% higher odds of experiencing depression than patients without HEs before adjusting for the covariates. Similarly, after adjusting for the covariates, data indicated that patients with HEs had higher odds of experiencing depression (OR = 1.726; 95% CI = 1.52-1.96). Similar analyses in different age categories showed that the OR monotonically increases with age regardless of whether the other covariates are included in the model.

CONCLUSIONS

ICD-9-CM-coded HEs were independently associated with an increased risk of DEs in patients with diabetes, and this incidence increased with the patients' age.

KEY LIMITATIONS

A key limitation to this study is that only those HEs that resulted in health care provider contact and subsequent claims coding indicative of hypoglycemia were included. It is likely that many cases of mild hypoglycemia, particularly those not severe enough to warrant medical attention, were not captured in this study.

The neuronal insulin sensitizer dicholine succinate reduces stress-induced depressive traits and memory deficit: possible role of insulin-like growth factor 2

Background

A number of epidemiological studies have established a link between insulin resistance and the prevalence of depression. The occurrence of depression was found to precede the onset of diabetes and was hypothesized to be associated with inherited inter-related insufficiency of the peripheral and central insulin receptors. Recently, dicholine succinate, a sensitizer of the neuronal insulin receptor, was shown to stimulate insulin-dependent H₂O₂ production of the mitochondrial respiratory chain leading to an enhancement of insulin receptor autophosphorylation in neurons. As such, this mechanism can be a novel target for the elevation of insulin signaling.

Results

Administration of DS (25 mg/kg/day, intraperitoneal) in CD1 mice for 7 days prior to the onset of stress procedure, diminished manifestations of anhedonia defined in a sucrose test and behavioral despair in the forced swim test. Treatment with dicholine succinate reduced the anxiety scores of stressed mice in the dark/light box paradigm, precluded stress-induced decreases of long-term contextual memory in the step-down avoidance test and hippocampal gene expression of IGF2.

Conclusions

Our data suggest that dicholine succinate has an antidepressant-like effect, which might be mediated via the up-regulation of hippocampal expression of IGF2, and implicate the neuronal insulin receptor in the pathogenesis of stress-induced depressive syndrome.

Patient age: a neglected factor when considering disease management in adults with type 2 diabetes

OBJECTIVE

The average age at diagnosis for type 2 diabetes is decreasing. However, because age is most often controlled for in clinical research, little is known regarding how adult age is associated with diabetes disease-related variables.

METHODS

In a community based study with type 2 diabetes patients (N=506), after adjusting for potentially confounding variables, we examined associations between patients' age and: stress, depression, diabetes-related distress, self-efficacy, diet, exercise, and glycemic control. We then explored to what extent age interacts with these variables in their association with glycemic control.

RESULTS

Younger age was independently associated with: greater chronic stress and negative life events, higher levels of diabetes-related distress, higher depressed affect, eating healthier foods and exercising less frequently, lower diabetes self-efficacy, and higher HbA1c. Interactions showed that younger patients with high stress and/or low self-efficacy were more likely to have higher HbA1c levels than older patients.

CONCLUSIONS

Results suggest younger adult patients with type 2 diabetes represent a unique patient subgroup with specific needs and health risks based on their developmental stage and life context.

PRACTICE IMPLICATIONS

Treatment programs need to target younger adult patients and may need to utilize different media or modalities (e.g., social media) to reach this group.

Depression among adults with diabetes in Jordan: risk factors and relationship to blood sugar control

OBJECTIVES

The aims of this study were to estimate the prevalence of undiagnosed depression among adults with diabetes mellitus in Jordan and to determine the factors that may indicate the presence of depression and to examine the relationship between depression and blood sugar control among Jordanian subjects with diabetes.

METHODS

A systemic random sample of 649 type 1 and type 2 diabetic patients aged 18-75 years was selected during the period from July 2009 to January 2010. A prestructured questionnaire was used for collecting the information about sociodemographic data and clinical characteristics. Depression was evaluated using the Patients' Health Questionnaire-8 (PHQ-8). A PHQ-8 score ≥10 has been recommended as a cutoff point for depression. Self-care management behaviors and barrier to adherence were collected. Weights and heights were measured. Glycated hemoglobin was abstracted from each patient directly after the interview.

RESULT

Of the 649, 128 (19.7) have depression according to the PHQ-8 scores. According to the multivariate analysis, females are more likely to develop depression than males with [odds ratio (OR), 1.91; P=001] and low-educated people versus educated people (OR, 3.09; P≤.002). Being on insulin treatment also has a significant association with depression (OR, 3.31; P=.001). Not following eating plans as recommended by dietitians, lacking self-monitoring blood glucose and increased barriers to adherence scale scores were also associated with depression among the subjects with diabetes.

CONCLUSION

The prevalence of depression among Jordanian subjects with type 1 and type 2 diabetes is high compared with some developed countries. This was associated with gender, educational level, insulin treatment, low self-management behaviors and increased barriers to adherence. This result shows the urgent need to include the routine screening of depression during outpatient visit, which might help prevention, early detection and management of depression.

[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.

Prevalence of depression in individuals with impaired glucose metabolism or undiagnosed diabetes: a systematic review and meta-analysis of the European Depression in Diabetes (EDID) Research Consortium

OBJECTIVE

Meta-analyses have shown that the risk for depression is elevated in type 2 diabetes. Whether this risk in individuals with impaired glucose metabolism (IGM) or undiagnosed diabetes (UDD) is elevated relative to normal glucose metabolism (NGM) or decreased relative to previously diagnosed type 2 diabetes (PDD) has not been the subject of a systematic review/meta-analysis. This study examined the prevalence of depression in IGM and UDD subjects relative to each other and to NGM and PDD subjects by reviewing the literature and conducting a meta-analysis of studies on this topic.

RESEARCH DESIGN AND METHODS

EMBASE and MEDLINE databases were searched for articles published up to May 2010. All studies that compared the prevalence of depression in subjects with IGM and UDD were included. Odds ratios (ORs) were calculated using fixed and random-effects models.

RESULTS

The meta-analysis showed that the risk for depression was not increased in IGM versus NGM subjects (OR 0.96, 95% CI 0.85-1.08). Risk for depression did not differ between individuals with UDD and individuals with either NGM (OR 0.94, 95% CI 0.71-1.25) or IGM (OR 1.16, 95% CI 0.88-1.54). Finally, individuals with IGM or UDD both had a significantly lower risk of depression than individuals with PDD (OR 0.59, 95% CI 0.48-0.73, and OR 0.57, 95% CI 0.45-0.74, respectively).

CONCLUSIONS

Results of this meta-analysis show that the risk of depression is similar for NGM, IGM, and UDD subjects. PDD subjects have an increased risk of depression relative to IGM and UDD subjects.

Fasting glucose, diagnosis of type 2 diabetes, and depression: the Vietnam experience study

BACKGROUND

Recent findings suggest that both low and very high fasting blood glucose concentrations may be linked with depression, though whether type 2 diabetes is associated with depression may depend on awareness of the diagnosis. We explored the association between fasting glucose and type 2 diabetes (undiagnosed and diagnosed) and depression in middle-aged men.

METHODS

Participants were 4293 US veterans who underwent an examination during which fasting blood glucose was measured, major depression diagnosed using DSM-III criteria, and depressive symptoms assessed with Minnesota Multiphasic Personality Inventory (MMPI) clinical scale for depression.

RESULTS

Compared with those with normal fasting glucose, men with undiagnosed type 2 diabetes had nearly double the odds of major depression, odds ratio (95% confidence interval) 1.80 (1.01, 3.22), and men with diagnosed diabetes had triple the odds of major depression, 3.82 (1.68, 8.70), after adjustment for confounding variables. Men with undiagnosed or diagnosed diabetes had higher MMPI depression scores. There was no curvilinear association between fasting glucose and depression (p > .45).

CONCLUSIONS

These findings do not support a U-shaped association between fasting glucose and depression. They suggest that the positive association between type 2 diabetes and depression extends beyond those who are aware they have the disease.

Does diabetes double the risk of depression?

PURPOSE

In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits.

METHODS

We matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients.

RESULTS

With matching for age and sex alone, patients with prevalent diabetes having few primary care visits were significantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confidence interval [CI], 1.19-1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77-1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07-1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80-1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients.

CONCLUSIONS

Patients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

Association of depressive symptoms and metabolic syndrome in men

OBJECTIVE

To explore the relationship between several indicators of depression and metabolic syndrome (MetS).

METHOD

A population-based sample with high (HMS group) or low (LMS group) levels of mental symptoms, including those of depression, in three follow-ups participated in a clinical examination in 2005 (n = 223). MetS was determined according to the NCEP criteria.

RESULTS

The prevalence of MetS was 49% in men and 21% in women. Men with MetS had higher rates of major depressive disorder than other men. They also displayed higher Hamilton Rating Scale for Depression (HDRS) scores and more often signs of suicidality. In logistic regression analyses, higher HDRS scores (OR 1.31, 95% CI 1.04-1.64) and belonging to the HMS group (OR 10.1, 95% CI 1.98-51.3) were independent associates for MetS but only in men.

CONCLUSION

The results highlight that there is an association between long-term depressive symptoms and the emergence of MetS, especially in men.

Comorbid depression is associated with increased healthcare utilization and lost productivity in persons with diabetes: a large nationally representative Hungarian population survey

OBJECTIVE

To estimate the prevalence of depression among people with diabetes and to examine the association of comorbid depression with lost productivity and health resource utilization in persons with and without diabetes.

METHODS

Cross-sectional survey, enrolling 12,643 individuals aged >18 years. Clustered, stratified sampling procedure was utilized. This sample represented 0.16% of the Hungarian adult population according to age, gender, and geographic regions. The severity of depressive symptoms was measured by the abbreviated Beck Depression Inventory.

RESULTS

The prevalence of diabetes in the sample was 6.2% (95% Confidence Interval (CI) = 5.7-6.6), and 13.4% (95% CI = 12.8-13.9) were classified as depressed. Adults with diabetes were two times more likely to have depression (adjusted odds ratio (OR) = 1.83, 95% CI = 1.53-2.19, p < .001) versus individuals without diabetes. Compared with nondepressed people with diabetes, those with diabetes and comorbid depression were older, less educated, more likely to be female and physically inactive, less likely to be employed, and married and had more comorbidities. In multivariate regression analyses, people with diabetes and depression had significantly greater odds of prolonged bed days due to illness (>or=20 days) (OR = 2.6, 95% CI = 1.69-3.88, p < .001), prolonged length of hospital stay (>or=18 days) (OR = 2.1, 95% CI = 1.27-3.45, p = .004), and multiple hospital admissions (>or=2) (OR = 1.8, 95% CI = 1.13-2.82, p = .01) compared with nondepressed diabetic patients.

CONCLUSIONS

These findings further document the association between depression and health resource utilization and lost productivity in people with diabetes. Screening and treating depression are important for everyday clinical care and public health initiatives to improve health outcomes for people with diabetes.

Antidepressant use before and after initiation of diabetes mellitus treatment

AIMS/HYPOTHESIS

Although current literature suggests an association between diabetes and depression, the direction of the association is unclear. We examined the temporal association between diabetes and depression by studying antidepressant and benzodiazepine use around the initiation of diabetes treatment.

METHODS

From a pharmacy registry database we selected 49,593 diabetic patients and a random sample of non-diabetic individuals (n = 154,441), all >40 years old. Antidepressant and benzodiazepine use was calculated for the 7 years before and 7 years after the index date. The index date in diabetes patients was defined as the date of initiation of diabetes medication. A random index date was assigned to non-diabetic individuals. Time-specific incidence rate ratios of antidepressant and benzodiazepine use were calculated for intervals of 1 year, 3 months and 1 month.

RESULTS

Antidepressant and benzodiazepine use was increased 2 months before and 3 months after the initiation of diabetes treatment compared with non-diabetic individuals. The strongest increase in incidence of antidepressant and benzodiazepine use was seen in the month after initiation of diabetes treatment with incidence rate ratios of 2.4 (95% CI 2.0-3.0) and 3.4 (95% CI 3.0-3.8) respectively, after adjustment for age, sex and Chronic Disease Score.

CONCLUSIONS/INTERPRETATION

The increased incidence of antidepressant and benzodiazepine use may be a consequence of the burden of disease, of starting with diabetes medication or of being diagnosed with diabetes. Our findings could also reflect earlier detection by their physician.

Changes in diabetes distress related to participation in an internet-based diabetes care management program and glycemic control

BACKGROUND

This article investigated how changes in diabetes distress relate to receiving care management through an Internet-based care management (IBCM) program for diabetes and level of participation in this program. Further, it examined the relationship between diabetes distress and changes in glycemic control.

METHODS

We enrolled patients of the Veterans Affairs Boston Healthcare System with diabetes who had hemoglobin A1c (HbA1c) levels of ≥9.0%. Subjects were randomized to usual care (n=52) or IBCM (n=52) for 1 year. We measured diabetes distress at baseline and quarterly thereafter using the Problem Areas in Diabetes (PAID) questionnaire. Glycemic control was determined by baseline and quarterly HbA1c. For subjects randomized to IBCM, we measured participation by observing frequency and consistency of their usage of the IBCM patient portal over 12 months. Linear mixed models were used to analyze THE data.

RESULTS

PAID scores declined over time for both treatment groups. Among subjects randomized to IBCM, the decline in PAID scores over time was significant for sustained users of the IBCM patient portal but not for nonusers. Moreover, subjects whose usage of the patient portal was sustained throughout the study had lower PAID scores at baseline. With respect to changes in glycemic control, HbA1c reduced individual differences in PAID scores by 44%; a lower baseline HbA1c was associated with lower baseline PAID scores, and over time, the decrease in HbA1c was associated with further decreases in the PAID score.

CONCLUSIONS

Participation in IBCM varies by initial diabetes distress, with people with less distress participating more. For people who participate, IBCM further mitigates diabetes distress. There is also a relationship between achievements in glycemic control and subsequent lowering of diabetes distress. Future research should identify how to maximize fit between patient needs and the provisions of IBCM, with the aim of increasing patient engagement in the active management of their health using this care modality. A key to maximizing fit might be first addressing metabolic control aggressively and then using IBCM for sustainment of health.

Screening for type 2 diabetes is feasible, acceptable, but associated with increased short-term anxiety: a randomised controlled trial in British general practice

Background

To assess the feasibility and uptake of a diabetes screening programme; to examine the effects of invitation to diabetes screening on anxiety, self-rated health and illness perceptions.

Methods

Randomised controlled trial in two general practices in Cambridgeshire. Individuals aged 40–69 without known diabetes were identified as being at high risk of having undiagnosed type 2 diabetes using patient records and a validated risk score (n = 1,280). 355 individuals were randomised in a 2 to 1 ratio into non-invited (n = 238) and invited (n = 116) groups. A stepwise screening programme confirmed the presence or absence of diabetes. Six weeks after the last contact (either test or invitation), a questionnaire was sent to all participants, including non-attenders and those who were not originally invited. Outcome measures included attendance, anxiety (short-form Spielberger State Anxiety Inventory-STAI), self-rated health and diabetes illness perceptions.

Results

95 people (82% of those invited) attended for the initial capillary blood test. Six individuals were diagnosed with diabetes. Invited participants were more anxious than those not invited (37.6 vs. 34.1 STAI, p-value = 0.015), and those diagnosed with diabetes were considerably more anxious than those classified free of diabetes (46.7 vs. 37.0 STAI, p-value = 0.031). Non-attenders had a higher mean treatment control sub-scale (3.87 vs. 3.56, p-value = 0.016) and a lower mean emotional representation sub-scale (1.81 vs. 2.68, p-value = 0.001) than attenders. No differences in the other five illness perception sub-scales or self-rated health were found.

Conclusion

Screening for type 2 diabetes in primary care is feasible but may be associated with higher levels of short-term anxiety among invited compared with non-invited participants.

Trial registration

ISRCTN99175498

Elevated depression symptoms, antidepressant medicine use, and risk of developing diabetes during the diabetes prevention program

OBJECTIVE

To assess the association between elevated depression symptoms or antidepressant medicine use on entry to the Diabetes Prevention Program (DPP) and during the study and the risk of developing diabetes during the study.

RESEARCH DESIGN AND METHODS

DPP participants (n = 3,187) in three treatment arms (intensive lifestyle [ILS], metformin [MET], and placebo [PLB]) completed the Beck Depression Inventory (BDI) and reported their use of antidepressant medication at randomization and throughout the study (average duration in study 3.2 years).

RESULTS

When other factors associated with the risk of developing diabetes were controlled, elevated BDI scores at baseline or during the study were not associated with diabetes risk in any arm. Baseline antidepressant use was associated with diabetes risk in the PLB (hazard ratio 2.25 [95% CI 1.38-3.66]) and ILS (3.48 [1.93-6.28]) arms. Continuous antidepressant use during the study (compared with no use) was also associated with diabetes risk in the same arms (PLB 2.60 [1.37-4.94]; ILS 3.39 [1.61-7.13]), as was intermittent antidepressant use during the study in the ILS arm (2.07 [1.18-3.62]). Among MET arm participants, antidepressant use was not associated with developing diabetes.

CONCLUSIONS

A strong and statistically significant association between antidepressant use and diabetes risk in the PLB and ILS arms was not accounted for by measured confounders or mediators. If future research finds that antidepressant use independently predicts diabetes risk, efforts to minimize the negative effects of antidepressant agents on glycemic control should be pursued.

Depression and type 2 diabetes mellitus: the multiethnic study of atherosclerosis

OBJECTIVE

To assess the cross-sectional association between depression and glucose tolerance status.

METHODS

We conducted a study of 6754 White, Black, Hispanic, and Chinese men and women aged 45 to 84 years in the Multiethnic Study of Atherosclerosis (MESA). Depression was defined as Center for Epidemiologic Studies Depression scale score of > or =16 and/or antidepressant use. Glucose tolerance status was defined as normal, impaired fasting glucose (IFG) or Type 2 diabetes mellitus (untreated and treated).

RESULTS

In the minimally adjusted model, although depression was not associated with a greater odds of IFG (odds ratio (OR) = 1.01; 95% confidence interval (CI): 0.87-1.18) or untreated diabetes (OR = 1.03; 95% CI: 0.74-1.45), it was associated with a greater odds of treated diabetes (OR = 1.57; 95% CI: 1.27-1.96). This persisted following adjustment for body mass index (OR = 1.52; 95% CI: 1.22-1.90), metabolic (OR = 1.54; 95% CI: 1.23-1.93), and inflammatory (OR=1.53; 95% CI: 1.21-1.92) factors, daily caloric intake and smoking (OR = 1.48; 95% CI: 1.16-1.88), and socioeconomic markers (OR = 1.47; 95% CI: 1.17-1.85). Among individuals with treated diabetes, median depression scores were higher in those with microalbuminuria compared with those without microalbuminuria (median = 7; interquartile range: 3-13 versus median = 6; interquartile range: 2-11; p = .046). Depression scores were not associated with homeostatic model assessment of insulin resistance among individuals without diabetes.

CONCLUSIONS

In MESA, depression was significantly associated with treated diabetes. Further studies are needed to determine the temporality of this association.

Depressive symptoms in subjects with diagnosed and undiagnosed type 2 diabetes

OBJECTIVE

To investigate if disturbed glucose homeostasis or known diagnosis of diabetes was associated with depressive symptoms. The reason for the increased prevalence of depression in patients with Type 2 diabetes mellitus (DM2) is unknown.

METHODS

Within the Utrecht Health Project, an ongoing longitudinal study among inhabitants of a residential area of a large city in The Netherlands, 4747 subjects (age: 39.4 +/- 12.5 years) were classified into four mutually exclusive categories: normal fasting plasma glucose (FPG) (<5.6 mmol/l), impaired FPG (> or =5.6 and <7.0 mmol/l), undiagnosed DM2 (FPG > or =7.0 mmol/l), and diagnosed DM2. Presence of depressive symptoms was defined as a score of > or =25 on the depression subscale of the Symptom Check List (SCL-90) or self-reported use of antidepressants.

RESULTS

Diagnosed DM2 was associated with an increased risk of depressive symptoms (odds ratio (OR) = 1.69; 95% confidence interval (CI) 1.06-2.72) after adjustment for demographic and lifestyle variables. Additional adjustment for number of chronic diseases reduced the OR to 1.36 (95% CI 0.83-2.23). Impaired fasting glucose and undiagnosed DM2 were not associated with depressive symptoms.

CONCLUSIONS

Our findings suggest that disturbed glucose homeostasis is not associated with depressive symptoms. The increased prevalence of depressive symptoms among patients with diagnosed DM2 suggests that depressive symptoms might be a consequence of the burden of diabetes. The number of chronic diseases seems to explain part of the association between DM2 and depressive symptoms.

Changes in depressive symptoms and glycemic control in diabetes mellitus

OBJECTIVE

To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes.

METHODS

Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels.

RESULTS

Mean and standard deviation baseline BDI and HbA1c levels were 17.9 +/- 5.8 and 7.6 +/- 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group.

CONCLUSION

Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes.

Use of diabetes resources in adults attending a self-management education program

OBJECTIVE

To identify the types of resources used to acquire information or assistance in the management of diabetes, and to identify persons who are more or less likely to use a variety of diabetes resources.

METHODS

Through the use of a questionnaire and review of patient records, sociodemographic, clinical, and health care service utilization characteristics were obtained for 267 individuals with type 2 diabetes from a culturally diverse diabetes education centre. Descriptive analyses were performed to provide information on the types of diabetes resources used by age, sex and primary language spoken. Multivariable Poisson regression was used to predict low from high users of a variety of diabetes resources.

RESULTS

On average, most patients used four different resources. The most commonly cited were physicians or endocrinologists; diabetes educators; and magazines, newspapers, books or television. Those who did not speak English, were born outside of Canada, had a lower level of education, or who were older used fewer diabetes resources.

CONCLUSION

Notably, the characteristics of individuals who are less likely to use resources or a variety of resources reflect the basic determinants of health (i.e., age, sex, ethnicity or primary language spoken, and education).

PRACTICE IMPLICATIONS

We need to develop resources that are equitably accessible and of interest to all patients, particularly for individuals who do not speak English, who have lower education and literacy levels, and who are older. Furthermore, imparting the skills on how to find and utilize currently existing resources to assist in chronic disease self-management should be promoted as a core aspect of self-management education.

The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis

AIM

To conduct a systematic literature review in order to estimate the prevalence and odds ratio of clinically relevant depression in adults with Type 2 diabetes compared with those without.

METHODS

MEDLINE, EMBASE and PSYCINFO databases were searched using MeSH terms and free text to identify relevant controlled studies. Published reference lists were also examined. Study selection and appraisal were conducted independently by two reviewers and a meta-analysis was performed to synthesize and analyse the data.

RESULTS

Ten controlled studies including a total of 51 331 people were published between January 1980 and May 2005. The prevalence of depression was significantly higher in patients with Type 2 diabetes compared with those without [17.6 vs. 9.8%, OR = 1.6, 95%, confidence interval (CI) 1.2-2.0]. However, in most studies, patients with diabetes differed from those without on variables known to be associated with an increased risk of depression. The prevalence of depression was higher in females with diabetes (23.8%) compared with males (12.8%); however, the odds ratio for depression in patients with Type 2 diabetes compared with those without was higher in males (OR = 1.9, 95% CI 1.7-2.1) than females (OR = 1.3, 95% CI 1.2-1.4). Failure to report potential confounders prevented a more rigorous meta-analysis of risk.

CONCLUSION

We identified raised rates of depression in people with Type 2 diabetes, however, there is a need for well-controlled and better-reported studies to inform the development of effective treatments for depression in these patients.

Disease-focused or integrated treatment: diabetes and depression

This article reviewed the literature on the adverse health outcomes of the coexistence of diabetes and depression, the challenges of treating coexisting diabetes and depression in a fragmented health care system, and the need for integrated care as a strategy to improve the quality of care for patients who have complex medical illnesses (eg, patients who have coexisting diabetes and depression).

Diabetes-related symptoms and negative mood in participants of a targeted population-screening program for type 2 diabetes: The Hoorn Screening Study

OBJECTIVE

To determine the level of diabetes-related symptom distress and its association with negative mood in subjects participating in a targeted population-screening program, comparing those identified as having type 2 diabetes vs. those who did not.

RESEARCH DESIGN AND METHODS

This study was conducted within the framework of a targeted screening project for type 2 diabetes in a general Dutch population (age 50-75 years). The study sample consisted of 246 subjects, pre-selected on the basis of a high-risk profile; 116 of whom were subsequently identified as having type 2 diabetes, and 130 who were non-diabetic subjects. Diabetes-related symptom distress and negative mood was assessed approximately 2 weeks, 6 months, and 12 months after the diagnosis of type 2 diabetes, with the Type 2 Diabetes Symptom Checklist and the Negative well-being sub scale of the Well-being Questionnaire (W-BQ12), respectively.

RESULTS

Screening-detected diabetic patients reported significantly greater burden of hyperglycemic (F = 6.0, df = 1, p = 0.015) and of fatigue (F = 5.3, df = 1, p = 0.023) symptoms in the first year following diagnosis type 2 diabetes compared to non-diabetic subjects. These outcomes did not change over time. The total symptom distress (range 0-4) was relatively low for both screening-detected diabetic patients (median at approximately 2 weeks, 6 months, and 12 months; 0.24, 0.24, 0.29) and non-diabetic subjects (0.15, 0.15, 0.18), and not significantly different. No average difference and change over time in negative well-being was found between screening-detected diabetic patients and non-diabetic subjects. Negative well-being was significantly positive related with the total symptom distress score (regression coefficient beta = 2.86, 95% CI 2.15-3.58).

CONCLUSIONS

The screening-detected diabetic patients were bothered more by symptoms of hyperglycemia and fatigue in the first year following diagnosis type 2 diabetes than non-diabetic subjects. More symptom distress is associated with increased negative mood in both screening-detected diabetic patients and non-diabetic subjects.

Depression and diabetes: a large population-based study of sociodemographic, lifestyle, and clinical factors associated with depression in type 1 and type 2 diabetes

OBJECTIVE

The purpose of this study was to investigate factors associated with depression in type 1 and type 2 diabetes and test whether these differ from factors associated with depression in the nondiabetic population.

RESEARCH DESIGN AND METHODS

In an unselected population study comprising 60,869 individuals, potential sociodemographic, lifestyle, and clinical factors were investigated in participants with and without diabetes. The associations between hyperglycemia and depression in types 1 and 2 diabetes were also studied. The levels of depression were self-rated by using the Hospital Anxiety and Depression Scale.

RESULTS

Several factors were correlated with depression in types 1 and 2 diabetes. However, these factors were not different from those of the nondiabetic population. Comorbid chronic somatic diseases were associated with depression in type 2 but not type 1 diabetes. In type 2 diabetes, those without comorbidity had the same odds of depression as the nondiabetic population with no chronic somatic diseases. No significant associations were found for hyperglycemia in relation to depression in type 1 and type 2 diabetes.

CONCLUSIONS

Type 2 diabetes without other chronic somatic diseases did not increase the risk of depression. Factors associated with depression in type 1 and type 2 diabetes were shared with the nondiabetic population.

Prevalence of depression among elderly Chinese with diabetes

BACKGROUND

To examine the association between diabetes and depression among older Chinese and to determine the extent to which depression is mediated by physical disability and diabetes-related comorbid conditions.

METHOD

Cross-sectional analysis of data from a population-based study composed of a representative sample of 2003 non-institutionalized older adults aged 60 and older living in Hong Kong who agreed to participate in the study. We examined the relation between diabetes and depression (measured with the Geriatric Depression Scale).

RESULT

12% of the older adults reported physician-diagnosed diabetes and amongst these older persons with diabetes, 26% of them reported elated level of depressive symptoms. Logistic regression analyses revealed that diabetes was significantly related to depression even when controlling for age, gender, marital status, and education. More importantly, adjusted for self-reported disability in three domains including self-care, mobility, and higher functioning did not attenuate this association but the association disappeared after we adjusted for four diabetes-related complications including heart disease, high blood pressure, stroke, and vision problems.

CONCLUSION

Diabetes is associated with depression and this association appears to be mediated by prevalent diabetes complications. This is of particular clinical important because although depression is often overlooked in the aged population, effective treatment is available and can result in improved medical outcomes.

Prevalence and correlates of depressive symptoms among rural older African Americans, Native Americans, and whites with diabetes

OBJECTIVE

Depression is associated with morbidity, mortality, and decreased quality of life and is a well-established complication among people with diabetes. Little is known about the prevalence and correlates of depressive symptoms among older adults living in rural communities, particularly among ethnic minority groups, who are at increased risk of developing diabetes and complications.

RESEARCH DESIGN AND METHODS

Data were analyzed from the ELDER (Evaluating Long-term Diabetes Self-management Among Elder Rural Adults) diabetes study in which face-to-face interviews were conducted with 696 older (> or =65 years of age) African-American, Native American, and white men and women in two rural counties in central North Carolina.

RESULTS

Using a criterion of > or =9 on a modified CES-D (Center for Epidemiologic Study of Depression) scale, 15.8% of the sample had depressive symptoms. In bivariate analyses, depressive symptomatology was more common among women and individuals who were unmarried and had less than a high school education, fewer financial resources, more chronic conditions, more prescription medications, and lower physical functioning. In multivariate analyses, sex, education, living arrangement, BMI, number of prescription medications, number of chronic conditions, and physical functioning remained significant.

CONCLUSIONS

These results show that older rural adults with diabetes are at high risk for depressive symptoms, regardless of their ethnic group, and that certain demographic and health characteristics are important factors in this association. These findings add to the limited body of knowledge of comorbid depression in this population. Greater attention should be paid to diagnosing and treating this condition by those who provide care to these populations.

Depression symptoms and antidepressant medicine use in Diabetes Prevention Program participants

OBJECTIVE

To assess depression markers (symptoms and antidepressant medicine use) in Diabetes Prevention Program (DPP) participants and to determine whether changes in depression markers during the course of the study were associated with treatment arm, weight change, physical activity level, or participant demographic characteristics.

RESEARCH DESIGN AND METHODS

DPP participants (n = 3,187) in three treatment arms (intensive lifestyle, metformin, and placebo) completed the Beck Depression Inventory (BDI) and reported on use of antidepressant medicines at randomization and subsequently at each annual visit (average duration in study 3.2 years).

RESULTS

On study entry, 10.3% of participants had BDI scores > or =11, which was used as a threshold for mild depression, 5.7% took antidepressant medicines, and 0.9% had both depression markers. During the DPP, the proportion of participants with elevated BDI scores declined (from 10.3% at baseline to 8.4% at year 3), while the proportion taking antidepressant medicines increased (from 5.7% at baseline to 8.7% at year 3), leaving the proportion with either marker unchanged. These time trends were not significantly associated with the DPP treatment arm. Depression markers throughout the study were associated with some participant demographic factors, adjusted for other factors. Men were less likely to have elevated depression scores and less likely to use antidepressant medicine at baseline (9.0% of men and 17.9% of women had at least one marker of depression) and throughout the study (P <0.0001). Those with more education were less likely to have elevated symptom scores (P = 0.0007) but more likely to be taking antidepressant medicine (P = 0.002). Non-Hispanic white participants were less likely than African Americans to have BDI scores > or =11 (P = 0.03), but white participants were more likely to be taking antidepressant medicine than any other racial/ethnic group (P <0.0001).

CONCLUSIONS

DPP participation was not associated with changes in levels of depression. Countervailing trends in the proportion of DPP participants with elevated depression symptoms and the proportion taking antidepressant medicine resulted in no significant change in the proportion with either marker. The finding that those taking antidepressant medicine often do not have elevated depression symptoms indicates the value of assessing both markers when estimating overall depression rates.

A prospective study of Type 2 diabetes and depressive symptoms in the elderly: the Rancho Bernardo Study

AIMS

The association between Type 2 diabetes and depressive symptoms was examined prospectively to assess possible causal relationships between the two diseases.

METHODS

A cohort of 971 men and women aged 50 and older from the adult population of Rancho Bernardo, California had an oral glucose tolerance test and completed the Beck Depression Inventory (BDI) at two clinic visits, 1984-87 and 1992-96.

RESULTS

Depressive symptoms at baseline were associated with higher follow-up levels of non-fasting plasma glucose (P = 0.001) and an increased risk of developing Type 2 diabetes [odds ratio (OR) = 2.50; 95% confidence interval (CI) = 1.29-4.87], independent of sex, age, exercise and body mass index. Conversely, baseline non-fasting plasma glucose was not significantly associated with follow-up depressive symptoms and Type 2 diabetes at baseline was not significantly associated with the onset of BDI scores > or = 11 by the second visit (OR = 0.73; 95% CI = 0.41-1.30).

CONCLUSIONS

Depressed mood is more likely to be a risk factor for Type 2 diabetes in older adults than the reverse.

Diabetes mellitus and psychological well-being. Change between 1984-1986 and 1995-1997. Results of the Nord-Trøndelag Health Study

Previous research has documented that people with diabetes report lower psychological well-being than do people with no reported disease. In recent years, new treatment regimens for diabetes have been introduced, including improved insulin and tablet treatment, easier blood sugar tests, and transfer of responsibility from doctor to patient. Have these improved methods for controlling diabetes resulted in enhanced psychological well-being for this group of patients? In this paper, we analyze changes in psychological well-being between 1984-1986 and 1995-1997 among diabetic patients. On these two occasions, the entire adult population of one county in Norway was invited to a health screening (the Nord-Trøndelag Health Studies, HUNT 1 and HUNT 2). Participants reached 77,224 and 65,599 persons, respectively (90.7% in HUNT 1 and 71.0% in HUNT 2). The participants responded to questionnaires, including questions on several diseases and impairments, as well as self-assessed health and psychological well-being. People with diabetes reported significantly lower well-being than people with no reported diabetes in HUNT 1 as well as in HUNT 2. However, the relationship between diabetes and well-being was significantly weaker in HUNT 2 than in HUNT 1. Self-reported Subjective health, the feeling of being strong and fit, the use of Tranquilizers, and Psychological distress had improved between the two surveys, for people with diabetes compared to people with no reported diabetes. Other outcome variables - Calmness, Cheerfulness, and Life satisfaction - were only weakly related to diabetes, and the relationship did not change significantly from HUNT 1 to HUNT 2.

Biological, psychosocial, and sociodemographic variables associated with depressive symptoms in persons with type 2 diabetes

Studies have found an association between glycemic status and indices of health-related quality of life in people with diabetes mellitus and comorbid depression. No study to date has examined the relative strength of influences of glycemic status and health-related quality of life on depression in people with diabetes mellitus, nor have important moderators in this relationship been examined. This study examined the relative strength of correlations between glycemic status and health-related quality of life and depressive symptoms and the degree to which those correlations were moderated by sociodemographic variables in 146 people with type 2 diabetes. Depressive symptoms were measured with the Centers for Epidemiological Studies--Depression (CES-D) scale. Health-related quality of life was measured with the SF-36 Health Survey. Hemoglobin A1c (HbA1c) was used as a measure of glycemic status and body mass index and waist-hip ratio were measured. Results indicated that SF-36 scores accounted for a greater proportion of the variance in CES-D scores. The association between CES-D and SF-36 scores was moderated by HbA1c, sex, education, marital status, and social support. The implications and limitations of these results were discussed in the context of past studies.