Assessing the prevalence of depression among individuals with diabetes in a Medicaid managed-care program

Depression and antecedent medication adherence in a cohort of new metformin users

AIMS

The association between depression and poor medication adherence is based on cross-sectional studies and cohort studies that measure adherence rates after depression status is determined. However, depressive symptoms occur well before diagnosis. This study examined adherence patterns in the year before a depressive episode.

METHODS

This retrospective cohort study followed new metformin users identified in Alberta Health's administrative data between 2008 and 2018. Depressive episodes starting ≥1 year after metformin initiation were identified using a validated case definition. Controls were randomly assigned a pseudo depression date. Adherence to oral antihyperglycemic medications was estimated using proportion of days covered (PDC) and group-based trajectory models to explore the association between depression and poor adherence (PDC<0.8).

RESULTS

A depressive episode occurred in 17,418 (10.6%) of 165,056 new metformin users. Individuals with depression were more likely to have poor adherence compared to controls (adjusted odds ratio 1.21; 95% CI 1.17, 1.26). Five trajectories were identified: nearly perfect adherence (PDC >0.95 [34.8% of cohort]), discontinued (PDC=0 [18.3% of cohort], poor initial adherence (PDC 0.75) that declined either rapidly (9.2% of cohort) or gradually (30.1% of cohort), and poor initial adherence (PDC 0.26) that increased gradually (7.6% of cohort). Individuals with depression were more likely to be in one of the four trajectories of poor adherence compared to controls (adjusted odds ratio 1.24; 95% CI 1.19-1.29).

CONCLUSIONS

Poor medication adherence occurs in the year before a depressive episode; therefore, poor medication use patterns could be used as an early warning sign for depression.

Depression but not non-persistence to antidiabetic drugs is associated with mortality in type 2 diabetes: A nested case-control study

AIMS

To measure the effect of depression on mortality of individuals newly treated with antidiabetic drugs, accounting for non-persistence to treatment.

METHODS

We conducted a nested case-control study within a cohort of newly treated individuals with diabetes. Using Quebec administrative data, we identified all-cause, diabetes-related, cardiovascular-related and major cardiovascular event deaths during a maximum follow-up of eight years. Each case was matched with up to 10 controls by age, sex, follow-up, and comorbidity index. We used conditional logistic regressions to estimate the effect of depression on mortality, adjusting for non-persistence to antidiabetic drug treatment, and other variables.

RESULTS

We retrieved 13,558 deaths, of which 3,652 were related to cardiovascular diseases, 2,112 to major cardiovascular events, and 311 to diabetes. Depression was associated with an increased risk of all-cause and cardiovascular-related deaths, with adjusted odds ratios (ORs) ranging from 1.32 (95% CI: 1.21-1.45) to 1.72 (95% CI: 1.57-1.88) depending on the model, but not with diabetes-related mortality.

CONCLUSION

Depression is independently associated with all-cause and cardiovascular-related mortality in individuals with type 2 diabetes, even when adjusting for non-persistence to antidiabetic drug treatment. Identifying risk factors for depression and implementing a screening and proper treatment for depression may help reducing mortality.

The effects of alcoholic extract of saffron (Crocus satious L.) on mild to moderate comorbid depression-anxiety, sleep quality, and life satisfaction in type 2 diabetes mellitus: A double-blind, randomized and placebo-controlled clinical trial

OBJECTIVE

Depression and anxiety are major health problems throughout the world. Metabolic changes in type 2 diabetes mellitus induces and aggravates mental disorders, such as depression and anxiety. Saffron as a therapeutic herb may attenuate Comorbid Depression- Anxiety (CDA). So, this trial is designed to investigate the effect of saffron alcoholic extract on symptoms of CDA in type 2 diabetic patients.

METHODS

Fifty-four outpatients suffered from mild to moderate CDA diagnosed by using Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV), were assessed by Hamilton Depression and anxiety measurements, the Pittsburgh Sleep Quality Index (PSQI), and the Satisfaction with Life Scale (SWLS). The participants of this double-blind, placebo-controlled, single center and randomized trial were randomly assigned to intake 30 mg/day saffron or placebo capsules for 8 weeks.

RESULTS

After the intervention, mild to moderate CDA, anxiety and sleep disturbance, but not depression alone, were relieved significantly in the saffron group (P < 0.05), whereas, the changes were not significant in the placebo group. Anthropometric measures and blood pressure parameters of the patients in either groups did not change significantly (P > 0.05) during the intervention. Moreover, dietary intake and physical activity did not differ during the study in the two groups. Changes in the life satisfaction were not significant.

CONCLUSION

The results indicate the beneficial effect of saffron on the mild to moderate CDA in type 2 diabetic patients.

The impact of incident depression on medication adherence in patients with type 2 diabetes

BACKGROUND

Depression has been correlated with suboptimal adherence to antidiabetic drugs (ADs). Most studies on this topic were cross-sectional; thus, the directionality of this relationship could not be established. The objective of this study was to measure the association between incident depression and AD nonadherence among newly treated patients with diabetes.

METHODS

We performed a population-based cohort study among new AD users using the Quebec public health insurance data. To avoid immortal time bias, we carried out depression diagnosis-time distribution matching by assigning a date of depression diagnosis to individuals without depression. Nonadherence (i.e.,<90% of days covered by≥1 AD) during the year following depression diagnosis (real or assigned date) was the outcome. Multivariate logistic regression analyses that adjusted for baseline adherence and other confounders were used to estimate the adjusted effect of depression on AD nonadherence.

RESULTS

Between 2000 and 2006, we identified 3,106 new AD users with a subsequent diagnosis of depression and 70,633 without depression, of which 52% and 49% became non-adherent to AD treatment, respectively. Among patients with depression, 52.0% were considered AD non-adherent in the year after depression diagnosis compared with 49.0% of matched patients without depression. Depression was associated with AD nonadherence after accounting for baseline adherence and other confounders with an adjusted odds ratio of 1.24 (95% confidence interval: 1.13-1.37).

CONCLUSIONS

The results suggest that depression is an independent risk factor for AD nonadherence. Patients with type 2 diabetes and depression might benefit from adherence-enhancing interventions.

The Association between Depression and Medication Nonpersistence in New Users of Antidiabetic Drugs

OBJECTIVES

To measure the association between depression and nonpersistence with antidiabetic drugs (ADs) among new users of oral ADs and to estimate factors associated with nonpersistence among these new users with depression.

METHODS

We used administrative claims data to identify an adult cohort (≥18 years) of new oral AD users who were free of depression. We followed the patients from AD initiation until either discontinuation, ineligibility for the public drug plan, death, or the end of the study. A proportional hazard Cox regression model with depression as a time-dependent variable was used to compute the adjusted hazard ratio of nonpersistence. A proportional hazard Cox regression model was also used to identify factors associated with nonpersistence in the subcohort of patients with depression.

RESULTS

We identified 114,366 new oral AD users, of whom 4,808 were diagnosed with depression during the follow-up. A greater proportion (55.4%) of patients with depression (vs. 42.5% without depression) discontinued their treatment during the follow-up. The adjusted hazard ratio of nonpersistence with ADs was 1.52 (95% confidence interval 1.41-1.63). Among patients with depression, independent factors associated with nonpersistence included younger age at oral AD initiation (<45 years) and starting treatment with drugs other than metformin (especially polytherapy with insulin).

CONCLUSIONS

Patients with depression are more likely to discontinue their treatment. Health care professionals should pay attention to patients on AD therapy who also suffer from depression, especially if the patients are young or are using insulin because these patients are at an increased risk of nonpersistence.

Incidence of Depression and Associated Factors in Patients With Type 2 Diabetes in Quebec, Canada: A Population-Based Cohort Study

It has been reported that the risk of depression is higher among people with type 2 diabetes compared with a nondiabetic population. Among diabetic patients, depression has been associated with worse self-care behaviors, poor glycemic control, and an increased risk of diabetes complications. Identifying factors associated with the occurrence of depression may help physicians identify earlier diabetic patients at a high risk of developing depression, improve prevention, and accelerate proper treatment. To our knowledge, very few population-based studies have reported on the incidence of clinically diagnosed depression as a consequence of type 2 diabetes over a long follow-up period. The objective of this study was to estimate the incidence of clinically diagnosed depression among type 2 diabetic patients newly treated with oral antidiabetic drugs (ADs) and to identify factors associated with the occurrence of depression.Administrative claims data from the public health insurance plan were used to identify a cohort of new oral AD users aged ≥18 years between 2000 and 2006. Patients were followed from oral AD treatment initiation until the diagnosis of depression, ineligibility for the public drug plan, death, or the end of the study, whichever came first. Incidence rates were determined using person-time analysis. Factors associated with depression were identified using multivariable Cox regression analysis.We identified 114,366 new oral AD users, of which 4808 had a diagnosis of depression. The overall incidence rate of depression was 9.47/1000 person-years (PYs) (10.72/1000 PYs for women and 8.27/1000 PYs for men). The incidence of depression was higher during the year after oral AD treatment initiation. Independent factors associated with depression included having had mental disorders other than depression, hospitalization, a higher number of different drugs taken and of physicians visited during the year before oral AD initiation. Moreover, we observed a statistically significant age-by-socioeconomic status interaction.The incidence of diagnosed depression is higher during the first year after oral AD treatment initiation. Clinicians could pay particular attention to women, patients starting an AD at a young age, those with a low socioeconomic status, and especially those with a history of anxiety or dementia.

Concordance Between Clinical Diagnosis and Medicare Claims of Depression Among Older Primary Care Patients

OBJECTIVE

To identify patient characteristics associated with concordance of Medicare claims with clinically identified depression.

METHODS

The authors studied a cohort of 742 older primary care patients linked to Medicare claims data using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition major depressive disorder and clinically significant minor depression.

RESULTS

Among 474 patients with depression, 198 patients had a Medicare claim for depression (sensitivity: 42%; 95% confidence interval [CI]: 37%-46%). Among 268 patients who did not meet criteria for depression, 235 patients did not have a Medicare claim for depression (specificity: 88%; 95% CI: 83%-91%). After adjustment for demographic and clinical characteristics, non-white participants were nearly twice as likely not to have Medicare claims for depression among patients who met criteria for depression ("false negatives"). Smoking status, depression severity (Hamilton Depression Rating Scale), cardiovascular disease, and more primary care physician office visits were also significantly associated with decreased odds to be false negatives. In contrast, after covariate adjustment, white race and chronic pulmonary disease were associated with increased odds of a Medicare claim for depression among patients who did not meet criteria for depression ("false positives"). Using weights based on the screened sample, the positive predictive value of a Medicare claim for depression was 66% (95% CI [63%, 69%]), whereas the negative predictive value was 77% (95% CI [76%, 78%]).

CONCLUSION

Investigators using Medicare data to study depression must recognize that diagnoses of depression from Medicare data may be biased by patient ethnicity and the presence of medical comorbidity.

Depression and Quality of Life in Patients With Type 2 Diabetes

Background:

Frequency of mood disorders in patients with chronic diseases, especially diabetes and its effects on life quality are dramatically increasing.

Objectives:

This study aimed to investigate the relation between depression and quality of life in patients with diabetes.

Patients and Methods:

This is a cross sectional survey. Subjects were selected from 330 eligible people referred to the only diabetes clinic in Gorgan City during 6 months, using systematic random sampling. Beak Depression questionnaire and the brief questioner with 26 questions recommended by the World Health Organization (WHOQOL-BREF) were used to measure depression and quality of life, respectively. Data were analyzed through descriptive methods, Chi-square, Independent t test and linear regression model using SPSS16; moreover, P value < 0.05 was considered as significant.

Results:

In total, 330 patients with diabetes (35.5 % male and 64.5% women) were studied. The mean and standard deviation of their age and years involved with diabetes were 50.6 ± 9.0 and 5.4 ± 4.5 years, respectively. Range of age was 25 - 75 years, as well. The prevalence of depression in all patients with diabetes was 58.2% (124 mild, 56 medium, and 12 with severe depression). Hypertension was 13.9% more in diabetic patients with depression (P value < 0.001) and physical activity in 24.7% of the cases was less with a meaningful difference (P value = 0.01). The mean and standard deviation of quality of life in diabetic patients with and without depression was 50.7 ± 14 and 60.5 ± 13.3, respectively that was significant in two groups (P < 0.0001).

Conclusions:

The prevalence of depression is high in patients with diabetes and has a considerable impact on the consequences of diabetes and quality of life too.

Culture-centered approaches: the relevance of assessing emotional health for Latinos with type 2 diabetes

OBJECTIVE

Within Latino culture, there is a belief that strong emotions can cause diabetes. Because of this belief and evidence regarding the bi-directional relationship between depression and diabetes, the objectives of this study were to determine if medical doctors are asking Latinos with diabetes about emotional problems and to assess attitudes toward professional help for emotional problems.

RESEARCH DESIGN AND METHODS

Data come from the nationally representative National Latino and Asian American Study and the National Comorbidity Survey Replication study. Only Latino subsamples were included (n=3076). A smaller subsample with complete data (n=2568) was used for the inquiry outcome variable. Weighted χ(2) analysis and logistic regression were conducted to determine the likelihood of being asked about emotional problems and attitudes toward professional help.

RESULTS

Latinos with mood disorders or anxiety (MD/AX; OR 2.84, 95% CI 2.02 to 4.00), diabetes only (OR 1.69, 95% CI 1.06 to 2.69), and co-occurring diabetes and MD/AX (OR 6.67, 95% CI 2.33 to 19.04) were more likely to be asked about emotional problems, relative to Latinos without diabetes or MD/AX. A minority of respondents with diabetes (32%) were asked about emotional problems. Respondents with diabetes only were more likely to feel comfortable talking to a professional for personal problems compared with those without diabetes or MD/AX (OR 1.44, 95% CI 0.99 to 2.09). Although the relationship between having diabetes and feeling comfortable taking to a professional is not statistically significant, z-test statistics indicate that having diabetes influences attitudes about discussing emotional problems.

CONCLUSIONS

Among Latinos, having diabetes is associated with greater likelihood of being asked about emotional problems and feeling comfortable talking to a professional about personal problems. Consistent with the cultural relevance of emotions as a cause of diabetes, asking about emotional problems may be a useful approach for engaging Latinos into a discussion about their diabetes self-care activities.

Prescription Pattern of Antihypertensive Agents in T2DM Patients Visiting Tertiary Care Centre in North India

Background. Hypertension management is of a paramount importance in diabetic patients for cardiovascular risk reduction. Aim. To evaluate prescribing pattern of antihypertensive in T2DM (type 2 diabetes) patients and compare with existing recent guidelines. Methods. A cross-sectional study involving evaluation of all T2DM patients referred to endocrinology unit at tertiary care centre for hypertension, comorbid complications, and recording prescription. Utilization of 5 different antihypertensive drug classes was compared for all patients receiving 1, 2, 3, 4, or more drugs. Logistical regression was used to assess likelihood of prescription of drugs and/or therapy for specific conditions mentioned in the guidelines. Results. Out of 1358, T2DM enrolled patients 1186 (87%) had hypertension (males 52%, females 48%). The median duration (IQ) of hypertension diabetics was 4 (1–10) years. A total of 25% patients had controlled BP and 75% with uncontrolled blood pressure (13% isolated systolic hypertension, 6% isolated diastolic hypertension, and 55% both elevated). Overall, ACE inhibitors (ACEIs) were prescribed the highest (59%) followed by angiotensin receptor blockers (ARBs) (52%), calcium channel blockers (CCBs) (29%), diuretics (27%), and beta-blockers (14%). Overall, 55% of T2DM patients were on polytherapy, 41% on monotherapy, and 4% had no antihypertensive treatment. Polytherapy was more predominant with age, duration of diabetes, duration of hypertension, and comorbid complications. Conclusion. Although prescribing pattern of antihypertensive showed adherence to existing evidence-based guidelines, higher proportion of uncontrolled hypertensive patients was found.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treating co-morbid chronic medical conditions and anxiety/depression

AIMS

This systematic review examines interventions for care of people with co-morbid chronic medical illness and anxiety/depression disorders--a group with high risks for morbidity and mortality.

METHODS

Systematic search of Medline 1995 to January 2011 for randomized controlled trials of treatment interventions designed for adult outpatients with diagnosed chronic medical illness (diabetes mellitus, cardiovascular disorders, and chronic respiratory disorders) and anxiety/depression disorders.

RESULTS

Six trials studied complex interventions based on the chronic care model, and eight trials studied psychosocial interventions. Most interventions addressed the mental health aspect of the co-morbidity and showed improvements in anxiety/depression but not in the co-morbid medical disorder.

CONCLUSIONS

Further research might focus on interventions integrating mental health treatment with enhanced medical care components, incorporating shared-decision making and information technology advances.

Fasting Blood Glucose and Depressive Mood among Patients with Mental Illness in a Medicaid Managed Care Program

Objective. This study explores the relationship between depressive symptoms, as measured by the PHQ-9 depression screen and blood glucose levels among patients with diabetes enrolled in Gold Choice, a Medicaid managed care program for individuals with mental illness and/or substance abuse. Methods. The PHQ-9 was mailed to 454 Gold Choice members and a questionnaire was mailed to their physicians requesting current HbA1c% and fasting blood glucose (FBG) levels. The pearson product-moment correlation was used to describe the association between PHQ-9 scores and FBG levels. Results. The PHQ-9 response rate was 55% (N = 249). Laboratory results were received for 141 patients. The correlation between FBG and PHQ-9 scores was modest but statistically significant: r = 0.21 , P = 0.015. Conclusion. A statistically significant association was found between FBG and PHQ-9 depression scores. This finding supports current recommendations that physicians be alert to depressive symptoms among patients with diabetes or impaired glucose metabolism.

Impact of Depression on Health Related Quality of Life in Patients with Diabetes

Introduction: Diabetes mellitus (DM) is a serious chronic illness that has a major impact on the quality of life of the individuals. Our aim was to examine the determinants of health-related quality of life (HRQOL) in patients with DM. Materials and Methods: Adult outpatients attending a Diabetes Centre were recruited on consecutive basis between August 2006 and February 2007. Clinical data were collected from interviews with the subjects and from medical records. Assessment of depressive symptoms was done using the Center for Epidemiologic Studies Depression Scale (CES-D) and HRQOL using the Short Form 36 Health Survey (SF-36). A two-step regression analysis was conducted for identifying factors affecting patients’ quality of life. Results: Five hundred and thirty-seven patients participated in the study. The mean (SD) age of the participants was 54.7 (13.3) years and 315 (58.7%) were males. The prevalence of depressive symptoms was 31.1% (n = 167). After adjusting for other variables, the effects of depressive symptoms persisted for all the 8 domains of SF-36 (P <0.001 for all). The medical factors that were negatively associated with HRQOL were a diagnosis of Type 1 DM, duration of the illness of more than 10 years, HbA1c levels of ≥7%, and comorbidity of stroke and retinopathy. Being male and a regular exerciser had a positive effect on HRQOL. Conclusion: These findings highlight the importance of detecting and treating comorbid depression in DM. Key words: CES-D, Diabetes mellitus, SF-36

Review of type 2 diabetes management interventions for addressing emotional well-being in Latinos

PURPOSE

The purpose of this article is (1) to investigate if type 2 diabetes management programs with Latino participants address emotional well-being in addition to the standard diabetes self-care behaviors and (2) to describe the approaches taken to improve psychological and diabetes management outcomes.

METHODS

Online article and research databases, Internet searches, and review of article citations were used to identify relevant articles published 1995-2008. Type 2 diabetes management interventions with a psychological (emotion or cognitive) component or outcome measure and Latino sample were selected. Articles were limited to randomized clinical/controlled trials and pre-post comparative studies.

RESULTS

Thirteen interventions met the inclusion criteria for this review. Eight studies included emotion outcome measures, and 13 included at least one cognitive outcome measure. One study was specifically designed to improve emotional well-being. This study was not targeted for Latinos but did include Latino participants. A specialized depression case manager and collaborative care model showed significant improvements in depression and mental functioning. Psychological improvements were also found in those studies that assessed cognitive outcomes and were based on cognitive theories. The most frequent cognitive outcomes assessed were diabetes knowledge, problem solving, and self-efficacy.

CONCLUSIONS

Few type 2 diabetes interventions address emotional well-being in Latinos. More attention has been directed toward designing culturally sensitive community-based programs for improving behavior and physical outcomes. Because some Latino groups believe that negative emotions cause diabetes and because depression and anxiety are associated with poor self-management, programs should address emotional well-being as an important aspect of diabetes management.

Psychosocial issues in youth with type 2 diabetes mellitus

Little published research exists on psychosocial issues in adolescents with type 2 diabetes mellitus (T2DM), because until two decades ago, diabetes diagnosed in children and adolescents was almost exclusively type 1 diabetes mellitus or insulin-dependent diabetes. In the past two decades, rates of T2DM have increased, especially in adolescents from families of minority racial and ethnic groups. Youth with T2DM are most often obese, have a parent or other first-degree relative with T2DM, and are of low socioeconomic status. To understand the complex set of interrelated psychological and social influences that affect the well-being of youth with T2DM, levels of influence from determinants of genetics, family, and community/societal and minority ethnic groups must be included.