Relationship of depression and diabetes self-care, medication adherence, and preventive care

The relationship of guideline-concordant depression treatment and patient adherence to oral diabetes medications

BACKGROUND

Many patients with diabetes experience depression, yet it is unclear if the treatment of depression in diabetic patients is concordant with national guidelines, and whether appropriate antidepressant use is associated with better diabetes self-care behaviors.

OBJECTIVES

The purpose of this study was to (1) determine whether antidepressant medication use for managed care enrollees with type 2 diabetes was concordant with The Agency for Healthcare Research and Quality depression treatment guidelines; and (2) examine the relationship between guideline concordance and oral diabetes medication adherence.

METHODS

Retrospective analyses were conducted using medical/pharmacy claims for 2001 from a managed care organization in the midwestern United States. Subjects were adults with type 2 diabetes treated with oral medications only. The subjects were divided into 3 groups: (1) guideline-concordant users of antidepressants; (2) those who received antidepressants not in concordance with the guidelines; and (3) nonusers of antidepressants. Antidepressant users were determined to be in concordance with the acute phase treatment guidelines if they filled at least 90 days supply of antidepressant drugs within 118 days of the first fill. Adherence to diabetes medications was measured by the medication possession ratio. A 1-way analysis of variance with Scheffe's test was used to compare the antihyperglycemic medication possession ratio across the three groups.

RESULTS

One hundred eighty-two (12.5%) of the 1454 subjects initiated treatment with antidepressants. Eighty-nine (48.9%) of the 182 antidepressant users were in concordance with the acute phase treatment guidelines. Subjects with subconcordant antidepressant use had a lower mean diabetes medication possession ratio than those with either guideline-concordant use or no use (F=14.3, P<.01).

CONCLUSION

Over half of the diabetic patients initiating treatment for depression did not receive therapy in concordance with the Agency for Healthcare Research and Quality guidelines. Patients whose antidepressant use was not concordant with the guidelines were also less adherent to diabetes medications.

The mediating role of health beliefs in the relationship between depressive symptoms and medication adherence in persons with diabetes

BACKGROUND

Although bivariate relationships between depressive symptoms, health beliefs, and medication adherence have been identified, the complex relationship among these 3 constructs has not been explicated.

OBJECTIVE

This study examines the mediating role of patients' beliefs about diabetes and diabetes medications in relation to depressive symptoms and diabetes medication adherence.

METHODS

A survey was sent to 1700 persons with type 2 diabetes who were enrolled in a managed care organization in the United States. The bivariate relationships between depressive symptoms, diabetes-related health beliefs, and diabetes medication adherence were assessed. A structural equation model was developed to determine if health beliefs mediated the relationship between depressive symptoms and medication adherence.

RESULTS

Usable responses were received from 445 subjects. Greater depressive symptoms were associated with lower adherence to diabetes medications. The structural equation model indicated that the effect of depressive symptoms on medication adherence was mediated through perceived side effect barriers, perceived general barriers, and self-efficacy. Patients with severe depressive symptoms perceived more barriers to treatment adherence and were less confident in their ability to adhere to medication. In turn, reduced self-efficacy and heightened perceived barriers had a negative association with patients' adherence to diabetes medication regimens.

CONCLUSIONS

Decreased adherence to diabetes medications in patients with both diabetes and depressive symptoms may be partly explained by the association of depression with patients' beliefs about diabetes medications and their self-efficacy for medication use.

Antidepressant-like effect of leptin in streptozotocin-induced diabetic mice

We previously reported that streptozotocin (STZ)-induced diabetic mice showed the depressive-like behavior in the tail suspension test. It has also been reported that leptin-deficient obese mice demonstrate the depressive-like behavior. Since STZ-induced diabetes causes a marked decrease in plasma leptin levels, it is possible that decrease in leptin levels and the depressive-like behavior may somehow be related. Therefore, we examined the effect of leptin on the depressive-like behavior of STZ-induced diabetic mice in the tail suspension test. The prolonged duration of immobility in diabetic mice was dose-dependently and significantly suppressed by single treatment with leptin (0.1-1 mg/kg, i.p.) without affecting on the locomotor activity. Leptin did not affect either the duration of immobility or the locomotor activity in non-diabetic mice. The anti-immobility effect of leptin (1 mg/kg, i.p.) in diabetic mice was significantly antagonized by the selective serotonin2 (5-HT2) receptor antagonist LY53,857 (0.03 mg/kg, s.c.), but not by the selective 5-HT1A receptor antagonist WAY-100635 (0.03 mg/kg, s.c.). Antagonists administered alone did not affect either the duration of immobility or the locomotor activity in diabetic mice. In conclusion, we suggest that leptin exerts the antidepressant-like effect in diabetic mice mediated by, at least in part, 5-HT2 receptors.

Reducing the societal burden of depression: a review of economic costs, quality of care and effects of treatment

Depression is a highly prevalent condition that results in substantial functional impairment. Advocates have attempted in recent years to make the 'business case' for investing in quality improvement efforts in depression care, particularly in primary care settings. The business case suggests that the costs of depression treatment may be offset by gains in worker productivity and/or reductions in other healthcare spending. In this paper, we review the evidence in support of this argument for improving the quality of depression treatment. We examined the impact of depression on two of the primary drivers of the societal burden of depression: healthcare utilisation and worker productivity. Depression leads to higher healthcare utilisation and spending, most of which is not the result of depression treatment costs. Depression is also a leading cause of absenteeism and reduced productivity at work. It is clear that the economic burden of depression is substantial; however, critical gaps in the literature remain and need to be addressed. For instance, we do not know the economic burden of untreated and/or inappropriately treated versus appropriately treated depression. There remain considerable problems with access to and quality of depression treatment. Progress has been made in terms of access to care, but quality of care is seldom consistent with national treatment guidelines. A wide range of effective treatments and care programmes for depression are available, yet rigorously tested clinical models to improve depression care have not been widely adopted by healthcare systems. Barriers to improving depression care exist at the patient, healthcare provider, practice, plan and purchaser levels, and may be both economic and non-economic. Studies evaluating interventions to improve the quality of depression treatment have found that the cost per QALY associated with improved depression care ranges from a low of 2519 US dollars to a high of 49,500 US dollars. We conclude from our review of the literature that effective treatment of depression is cost effective, but that evidence of a medical or productivity cost offset for depression treatment remains equivocal, and this points to the need for further research in this area.

The unmet needs of the elderly with diabetes in home health care

The implementation of the Prospective Payment System (PPS) in Medicare home health care has raised concern about health outcomes of elderly patients since its intention is to curb spending. This study examines the unmet needs of older diabetic patients while receiving home health care and post-discharge from home health care (N = 129) in order to explore any effects of PPS on patients' need. The study found that a higher proportion of elders had unmet needs 30 days post-discharge compared with while receiving home health care. The specific unmet needs identified by the elderly diabetic patients included social work services, home health aide, homemaker services, and need for medical equipment. The study explores the role of social work to better manage the unmet needs of diabetic elders who live in the community.

Screening for depression in a diabetic outpatient population

Depression occurs twice as often in patients with diabetes and is associated with reduced compliance with exercise, diet, and medications. It is also associated with hyperglycemia and increased diabetic complications. Despite evidence that successful treatment is associated with improved glycemic control, many cases of depression are left untreated. Objectives. (1) Evaluate a combination screening strategy in an outpatient population; and (2) explore the association between glycemic control and depressive symptomatology. Methods. Ninety-two patients completed the Patient Health Questionnaire (PHQ-2). Patients with a PHQ-2 score ≥ 1 completed the 16-item Quick Inventory of Depressive Symptomatology (QIDS-SR16). Using the QIDS-SR16, a score of ≤5 corresponded to normal mood, with scores above 5 corresponding to increasing severity of depressive symptoms. Glycemic control was assessed by glycosylated hemoglobin (HbA1c). Results. Using a PHQ-2 cut-off score of ≥3, 37% of the sample screened positive for major depressive disorder (MDD), with an additional 27% reporting sub-threshold symptoms. The depressed group reported significantly more difficulty with reduced interests, insomnia, concentration, self-criticism, energy/fatigue and depressed mood. In terms of glycemic control, there was a marginally significant effect for race and HbA1c. Conclusion. The combined PHQ-2 and QIDS-SR16 can facilitate prompt detection of MDD and provide a means of monitoring specific symptoms and progress once treatment commences.

Psychosocial and psychiatric challenges of diabetes mellitus

Diabetes mellitus is a chronic endocrine disorder that places considerable psychologic stress on individuals and their families. This article discusses psychosocial issues associated with diabetes and its management, and common psychiatric disorders in diabetes population. Psychosocial challenges and psychiatric disorders in people with diabetes can hinder patients' successful diabetes self-management and well-being. An understanding of mental health issues in diabetes is critical for all health care professionals who provide treatment to people with diabetes.

Vascular depression in older people with diabetes

AIMS/HYPOTHESIS

Cerebrovascular disease may be causal or a vulnerability factor in late-onset depression and may explain the high rate of depression in older adults with diabetes. We explored a wide range of potential explanatory variables of depression in a longitudinal study of older diabetic subjects to investigate the vascular depression hypothesis in these patients.

METHODS

We recruited 207 subjects with diabetes selected for potential cognitive deficits from an existing observational cohort study (average age 75.7 +/- 4.6 years, 52.2% men) for an assessment of depression using a standardised diagnostic instrument (Cambridge Examination for Mental Disorders of the Elderly -- Revised). All subjects underwent a detailed clinical assessment at baseline and at follow-up (after 7.5 +/- 1.1 years).

RESULTS

Major depression was present in 45 subjects (21.7%) and minor depression in ten (4.8%). A positive history of strokes and the presence of peripheral arterial disease were significantly associated with depression at the time of diagnosis. In a subsample of 93 cases who underwent structural neuroimaging, the presence of cerebral infarcts was also significantly associated with depression. Treatment with glucose-lowering therapy, higher serum cholesterol levels and difficulties with activities of daily living at baseline were significant predictors of depression at follow-up.

CONCLUSIONS/INTERPRETATION

A history of cerebrovascular disease was strongly associated with depression and cerebrovascular risk factors were significant predictors of depression in older diabetic patients. Our findings are consistent with the hypothesis that the excess risk of depression in older diabetic patients is related to underlying cerebrovascular disease.

A psychological approach to providing self-management education for people with type 2 diabetes: the Diabetes Manual

BACKGROUND

The objectives of this study were twofold (i) to develop the Diabetes Manual, a self-management educational intervention aimed at improving biomedical and psychosocial outcomes (ii) to produce early phase evidence relating to validity and clinical feasibility to inform future research and systematic reviews.

METHODS

Using the UK Medical Research Council's complex intervention framework, the Diabetes Manual and associated self management interventions were developed through pre-clinical, and phase I evaluation phases guided by adult-learning and self-efficacy theories, clinical feasibility and health policy protocols. A qualitative needs assessment and an RCT contributed data to the pre-clinical phase. Phase I incorporated intervention development informed by the pre-clinical phase and a feasibility survey.

RESULTS

The pre-clinical and phase I studies resulted in the production in the Diabetes Manual programme for trial evaluation as delivered within routine primary care consultations.

CONCLUSION

This complex intervention shows early feasibility and face validity for both diabetes health professionals and people with diabetes. Randomised trial will determine effectiveness against clinical and psychological outcomes. Further study of some component parts, delivered in alternative combinations, is recommended.

Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes

BACKGROUND

The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality.

OBJECTIVE

To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later.

DESIGN

Prospective observational cohort study.

SETTING

Three university hospitals.

PARTICIPANTS

Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up.

MEASUREMENTS

We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used chi2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI < 10 at hospitalization and 3 months); remittent depressed (BDI > or = 10 at hospitalization; < 10 at 3 months); and persistently depressed patients (BDI > or = 10 at hospitalization and 3 months).

RESULTS

Compared with persistently nondepressed, persistently depressed patients reported lower rates of adherence to quitting smoking (adjusted odds ratio [OR] 0.23, 95% confidence interval [95% CI] 0.05 to 0.97), taking medications (adjusted OR 0.50, 95% CI 0.27 to 0.95), exercising (adjusted OR 0.57, 95% CI 0.34 to 0.95), and attending cardiac rehabilitation (adjusted OR 0.5, 95% CI 0.27 to 0.91). There were no significant differences between remittent depressed and persistently nondepressed patients.

CONCLUSIONS

Persistently depressed patients were less likely to adhere to behaviors that reduce the risk of recurrent ACS. Differences in adherence to these behaviors may explain in part why depression predicts mortality after ACS.

Resource use among patients with diabetes, diabetic neuropathy, or diabetes with depression

BACKGROUND

Diabetes is often associated with complications and comorbidities. The purpose of this research is to compare medical resources used by patients with the following diagnoses: diabetes mellitus (DM), diabetic neuropathy (DN), and diabetes mellitus combined with comorbid depression (DD).

METHODS

Adult patients who were diagnosed with DM, DN, or DD were included in the study. There were 55,972 patients in the DM cohort, 2,146 in the DN, and 2,379 in the DD. P values for comparisons between the three mutually exclusive cohorts were conducted using the Tukey-Kramer method. Cost comparisons among the cohorts were conducted using a stepwise multivariate regression that controlled for patient characteristics and comorbid conditions.

RESULTS

Individuals in the DM or DN cohorts were generally more likely to use antidiabetic medications than patients in the DD group. Those diagnosed with DN or DD generally used more pain medications than individuals in the DM cohort. The DM cohort had significantly lower diabetes-related total medical costs ($1,297 v $5,125, p < 0.0001) and lower total medical costs ($4,819 v $24,765, p < 0.0001) than the DN cohort. The DM cohort also had significantly lower diabetes-related total medical costs ($1,297 v $3,264, p < 0.0001) as well as significantly lower total medical costs ($4,819 v $19,298, p < 0.0001) than the DD cohort.

CONCLUSION

Results from this study indicated significant differences in demographic characteristics, comorbidities, and medication use among individuals diagnosed with DM, DN, or DD. These differences translated into significant cost differences. Patients diagnosed with DN or DD had higher diabetes-related costs than patients diagnosed with DM.

Sleep Impairment in Patients With Painful Diabetic Peripheral Neuropathy

OBJECTIVE

This study evaluated sleep impairment associated with painful diabetic peripheral neuropathy (DPN), a neuropathic pain condition. Sleep is of critical concern for DPN because sleep impairment and its comorbidities may influence type 2 diabetes progression.

METHODS

This is a supplemental analysis of sleep data from a burden of illness study of patients with painful DPN (N=255, 61+/-12.8 y old, 51.4% women). Sleep was evaluated using the Medical Outcomes Study Sleep measure (MOS-Sleep). MOS-Sleep scores were compared with general population norms (N=1011), the MOS chronic disease sample (N=3445), and patients with postherpetic neuralgia (N=89). The MOS-Sleep Sleep Adequacy score was compared with data from the MOS diabetes subsample (N=590).

RESULTS

Patients with painful DPN reported impaired sleep relative to the general population (P<0.001), the chronic disease sample (P<0.001), and postherpetic neuralgia patients (P<0.05). Self-rated MOS-Sleep Sleep Adequacy was significantly less for the painful DPN than for the diabetes sample (P<0.001), although self-reported hours of sleep were not significantly different. Multiple regression indicated that age, average daily pain, and anxiety and depression symptom levels were each significantly (P<0.01) associated with, and collectively accounted for, 47% of variance in the MOS-Sleep Sleep Problems Index.

DISCUSSION

Painful DPN is associated with considerable sleep impairment. Given the recognized association between sleep impairment, type 2 diabetes and metabolic and affective disturbance, and the known adverse impact of affective disturbance on diabetes self-care, addressing these features-pain, sleep, and affective disturbance-is an important aspect of care for patients with painful DPN.

Improving depression care in patients with diabetes and multiple complications

BACKGROUND

Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications.

OBJECTIVE

To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications.

DESIGN

The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications.

PATIENTS

Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan.

MEASUREMENTS

Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records.

RESULTS

The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care.

CONCLUSION

Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems.

Predictors of metabolic control at one year in a population of pediatric patients with type 2 diabetes mellitus: a retrospective study

BACKGROUND/OBJECTIVES

The rising prevalence of pediatric type 2 diabetes mellitus (DM2) and non-adherence to diabetes regimens pose challenges to obtaining optimal control. This study evaluated factors that may impact glycemic control (HbA1c): age, Tanner stage, body mass index (BMI), total daily insulin (TDD), metformin dose (MET), activity level, frequency of clinic visits and adherence.

METHODS

One-year data from 72 patients (ages 8.6-17.8 years) were collected retrospectively. From that sample, 57 patients who continued to attend clinic for the entire year were assessed and divided into optimal and suboptimal HbA1c control groups.

RESULTS

All factors measured were similar in the two groups, except for lower initial and 1.0-year HbA1c, TDD, and rates of missing MET and insulin in the optimal HbA1c control group.

CONCLUSIONS

Initial glycemic status and adherence rate predicted metabolic control at one year. Early identification of DM2 may improve metabolic outcome, which may improve medical regimen adherence.

Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes

Background

Inconsistent findings reported in the literature contribute to the lack of complete understanding of the association of literacy with health outcomes. We evaluated the association between literacy, physiologic control and diabetes complications among adults with diabetes.

Methods

A cross-sectional study of 1,002 English speaking adults with diabetes, randomly selected from the Vermont Diabetes Information System, a cluster-randomized trial of a diabetes decision support system in a region-wide sample of primary care practices was conducted between July 2003 and March 2005. Literacy was assessed by the Short-Test of Functional Health Literacy in Adults. Outcome measures included glycated hemoglobin, low density lipoprotein, blood pressure and self-reported complications.

Results

After adjusting for sociodemographic characteristics, duration of diabetes, diabetes education, depression, alcohol use, and medication use we did not find a significant association between literacy and glycemic control (beta coefficent,+ 0.001; 95% confidence interval [CI], -0.01 to +0.01; P = .88), systolic blood pressure (beta coefficent, +0.08; 95% CI, -0.10 to +0.26; P = .39), diastolic blood pressure (beta coefficent, -0.03; 95% CI, -0.12 to +0.07, P = .59), or low density lipoprotein (beta coefficent, +0.04; 95% CI, -0.27 to +0.36, P = .77. We found no association between literacy and report of diabetes complications.

Conclusion

These findings suggest that literacy, as measured by the S-TOFHLA, is not associated with glycated hemoglobin, blood pressure, lipid levels or self-reported diabetes complications in a cross-sectional study of older adults with diabetes under relatively good glycemic control. Additional studies to examine the optimal measurement of health literacy and its relationship to health outcomes over time are needed.

Isn't this just bedtime snacking? The potential adverse effects of night-eating symptoms on treatment adherence and outcomes in patients with diabetes

OBJECTIVE

Night-eating syndrome is characterized by excessive eating in the evening and nocturnal awakening with ingestion of food. Psychosocial variables and emotional triggers may be associated with these behaviors. In patients with diabetes, such behaviors may lead to glucose dysregulation and contribute to obesity and complications.

RESEARCH DESIGN AND METHODS

In 714 tertiary care patients with type 1 and 2 diabetes, we determined the proportion of patients reporting eating >25% of their daily food intake after regular suppertime. We also screened patients for major depression, childhood maltreatment histories, nonsecure attachment styles, and emotional eating triggers. We examined whether patients reporting night-eating behaviors had greater psychosocial distress, higher HbA(1c) (A1C) levels, more obesity, and more diabetes complications compared with patients without night-eating behaviors.

RESULTS

Night-eating behaviors were reported in 9.7% of patients. Compared with patients without night-eating behaviors, those with these behaviors were less adherent with diet, exercise, and glucose monitoring and more likely to be depressed, to report childhood maltreatment histories, to have nonsecure attachment styles, and to report eating in response to anger, sadness, loneliness, worry, and being upset. Controlling for age, sex, race, and major depression, patients with night-eating behaviors, compared with patients without night-eating behaviors, were more likely to be obese (odds ratio 2.6 [95% CI 1.5-4.5]), to have A1C values >7% (2.2 [1.1-4.1]) and to have two or more diabetes complications (2.6 [1.5-4.5]).

CONCLUSIONS

Night-eating behaviors are associated with adverse outcomes in patients with diabetes. Use of clinical screening tools may help identify patients with night-eating behaviors.

Post-traumatic stress disorder and diabetes: co-morbidity and outcomes in a male veterans sample

The purpose of this study was to assess the prevalence and correlates of comorbid diabetes and Post-Traumatic Stress disorder(PTSD)and potential relationships between PTSD and diabetes outcomes. Male patients enrolled in a VA primary care database (N = 73,270) were classified as having diabetes from pharmacy records (N = 14,438) and grouped into those with diagnoses of PTSD with depression (N = 649), PTSD-only (N = 480), Depression-only (N = 1696), Other psychiatric diagnosis (N = 736), or No psychiatric diagnosis (N = 10,877) based on the Purpose of Visit diagnoses in the medical record. Outcomes included glycemic control (HbA1c), cholesterol and triglycerides. Correlates were age, substance use disorder, other psychiatric diagnosis, number of primary care encounters, and medications. The prevalence of comorbid diabetes and PTSD was 8% (n = 1129). Of these, 57% (n = 649) had comorbid depression. Patients with PTSD and depression had higher rates of substance use disorder and higher cholesterol and LDL. Patients with depression had poorer glycemic control. Patients with PTSD and depression weighed more and had higher BMI than patients with neither diagnosis. Thus, male diabetes patients with PTSD and depression may be vulnerable to substance use disorders and to weight/lipid problems that can affect health. Depression is a likely contributor to poor glycemic control. Careful screening for mental health comorbidities is needed for diabetes patients.

Type 2 diabetes does not increase risk of depression

BACKGROUND

Although diabetes mellitus has a strong association with the presence of depression, it is unclear whether diabetes itself increases the risk of developing depression. The objective of our study was to evaluate whether people with diabetes have a greater incidence of depression than those without diabetes.

METHODS

We conducted a population-based retrospective cohort study using the administrative databases of Saskatchewan Health from 1989 to 2001. People older than 20 years with newly identified type 2 diabetes were identified by means of diagnostic codes and prescription records and compared with a nondiabetic cohort. Depression was ascertained via diagnostic codes and prescriptions for antidepressants. Cox regression analysis was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) after adjusting for age, sex, frequency of visits to physicians and presence of comorbidities.

RESULTS

We identified 31 635 people with diabetes and 57 141 without. Those with diabetes were older (61.4 v. 46.8 yr; p < 0.001), were more likely to be male (55.4% v. 49.8%; p < 0.001) and had more physician visits during the year after their index date (mean 14.5 v. 5.9; p < 0.001). The incidence of new-onset depression was similar in both groups (6.5 v. 6.6 per 1000 person-years among people with and without diabetes, respectively). Similarity of risk persisted after controlling for age, sex, number of physician visits and presence of prespecified comorbidities (adjusted HR 1.04, 95% CI 0.94- 1.15). Other chronic conditions such as arthritis (HR 1.18) and stroke (HR 1.73) were associated with the onset of depression.

INTERPRETATION

Using a large, population-based administrative cohort, we found little evidence that type 2 diabetes increases the risk of depression once comorbid diseases and the burden of diabetes complications were accounted for.

Mood disorders: cardiovascular and diabetes comorbidity

PURPOSE OF REVIEW

Depression is often associated with medical comorbidity. New research quantifies patterns of mood disorder in illnesses such as cardiovascular disease and diabetes, evaluates the prognostic significance of mood symptoms, and seeks to identify common mechanisms for both mood and medical disease. This review provides recent findings on comorbidity, summarizes mechanistic hypotheses, and outlines developments in treatment and services.

RECENT FINDINGS

Depression occurs in up to one-quarter of patients with cardiovascular disease and diabetes. Depressed patients with heart disease have poorer medical outcomes including increased risk of reinfarction and all-cause mortality. Patients with diabetes and depression have poorer glycemic control, more diabetes symptoms, and greater all-cause mortality. Depression is associated with both biological (hypothalamic-pituitary-adrenal axis dysregulation) and psychosocial processes (adherence, poorer diet, and exercise) that may mediate adverse medical outcomes. Antidepressant treatments are effective in treating depression in medically ill patients, but their impact on medical outcomes remains to be quantified.

SUMMARY

Depression, cardiovascular disease, and diabetes are among the most common chronic illnesses affecting an aging population. Depression is treatable in patients with medical illnesses, and collaborative care models can yield better detection and depression treatment in primary care settings in which most patients with depression are seen.

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).

Gender differences in diabetes mellitus and effects on self-care activity

BACKGROUND

Effective self-care, including adherence to diet, exercise, and medication regimens, is an essential component of health care for individuals with diabetes mellitus (DM).

OBJECTIVE

The goals of this study were to examine sex-based differences in DM and to explore the effects of gender on self-care.

METHODS

This study was conducted retrospectively using data from the 2001 Medical Expenditure Panel Survey (MEPS). People with DM were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic code; analyses were stratified by sex. Variables included age, race/ethnicity, education, income, body mass index (BMI), number of comorbidities, physical and cognitive limitations, smoking status, and depression. Outcome measures were assessed by Short Form-12 (SF-12) Mental Component Summary (MCS) and Physical Component Summary (PCS) scores. Univariate analyses were determined using t, chi(2), or Fisher exact tests, as appropriate. Multivariate analyses examined associations between sex and SF-12 MCS/PCS scores adjusted for other variables.

RESULTS

A total of 1653 MEPS respondents (883 women, 770 men) with DM were identified for the current study. The women were significantly older than the men (61.2 vs 59.1 years), had less education (11.1 vs 12.0 years), and had lower incomes. Women had higher calculated BMI (31.4 vs 30.3), more comorbidities (7.8 vs 6.4), more depression, and more physical and cognitive limitations than did men. Women also scored lower than men on the SF-12 MCS and PCS (47.8 vs 49.9 and 38.2 vs 41.4, respectively). All these measures were statistically significant (P < 0.01). In multivariate analyses, physical limitations, BMI, and number of comorbidities were negatively correlated, and income and education were positively correlated, with MCS and PCS scores.

CONCLUSIONS

Compared with their male counterparts, diabetic women scored lower on measures of health status and functioning-factors that are likely to affect self-care activities. Sex-based differences should be considered when developing screening and treatment programs for people with DM.

Adherence to calcium/vitamin D and estrogen protocols among diverse older participants enrolled in a clinical trial

PURPOSE

This study was intended to identify characteristics of those who adhere poorly to calcium/vitamin D and estrogen replacement protocols, and aimed to assess the effects of ethnicity, socio-economic status, and health status on medication adherence.

METHODS

The adherence rates of 107 older white, African American and Hispanic participants of a clinical trial involving calcium/vitamin D and either estrogen replacement or placebo therapy were analyzed. Structural equation modeling was used to test the hypothesis that minority participants would have lower adherence rates than white participants, but only if they had lower household incomes and educational achievement, more osteoporosis risk factors, negative health assessments, and fewer somatic complaints than white participants.

RESULTS

The average age of participants was 76 years. Minority participants and those with lower SES had lower adherence rates than white participants and those with higher SES. Plausible models that met goodness-of-fit criteria showed that the estrogen/placebo adherence rates were affected directly by being African American or Hispanic and the SF-36 mental health score, and indirectly by somatic complaints. History of fracture and household income directly predicted calcium/vitamin D adherence rates.

CONCLUSION

Efforts to improve adherence to medical regimens should consider differences in adherence behaviors based on ethnicity, SES, and mental health.

Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project

OBJECTIVE

The purpose of the study was to investigate the effect of comorbid depression on glycemic control and on response to a telemedicine case management intervention for elderly, ethnically diverse diabetic patients.

RESEARCH DESIGN AND METHODS

Medicare beneficiaries in underserved areas were participants (n = 1,665) in the Informatics for Diabetes Education and Telemedicine (IDEATel) project and randomized to a telemedicine case management intervention or usual care. The data analyzed include baseline demographics (age, sex, race/ethnicity, marital status, insulin use, years of education, years of diabetes, and pack-years smoked) and measures of glycemic control (HbA(1c) [A1C]), comorbidity, diabetes symptom severity, functional disability and depression, and 1-year (n = 1,578) A1C. The association between depression and glycemic control was analyzed cross-sectionally and prospectively.

RESULTS

At baseline, there was a significant correlation between depression and A1C and a trend for depression to predict A1C when other factors were controlled. However, in prospective analyses, depression did not predict change in A1C, either in the control or intervention group.

CONCLUSIONS

In this large sample of elderly diabetic patients, a weak relationship between depression and A1C was found, but depression did not prospectively predict change in glycemic control. Thus, there is no evidence that depression should be used to exclude patients from interventions. Also, we should evaluate the impact of depression on outcomes other than glycemic control.

Depression treatment and satisfaction in a multicultural sample of type 1 and type 2 diabetic patients

OBJECTIVE

To assess rates of depressive symptoms, depression treatment, and satisfaction in a multicultural sample of individuals with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

This study was conducted with a cross-sectional community-based survey design.

RESULTS

The sample (n = 221) was predominantly female (60.3%), had type 2 diabetes (75%), and was middle class with a mean (+/-SD) age of 54 +/- 12 years. A total of 53% were white. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD) (mean 16.4 +/- 11.3). Using conservative thresholds (CESD score > or =22), 25.3% of participants reported clinically significant depression. Rates of depression did not differ by ethnic group or diabetes type. The majority (76%) of depressed participants reported treatment (52% antidepressants, 63% mental health providers, 19% alternative healers, and 15% herbal remedies). African Americans were less likely to report any depression treatment, to receive antidepressant medications, or receive treatment from a mental health professional compared with whites. Participants with high depressive symptoms reported general satisfaction with depression treatment experiences.

CONCLUSIONS

High rates of depressive symptoms were observed across ethnic groups, yet significant differences in use of depression treatment existed across ethnic groups. Those seeking depression treatment reported satisfaction with a variety of depression treatment modalities. Increased depression screening and treatment may be beneficial for ethnically diverse patients with type 1 and type 2 diabetes.

Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression

OBJECTIVE

To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression.

RESEARCH DESIGN AND METHODS

This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care.

RESULTS

Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found.

CONCLUSIONS

The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care.

Effect of Chromium Picolinate on Modified Forced Swimming Test in Diabetic Rats: Involvement of Serotonergic Pathways and Potassium Channels

Depression occurs frequently in patients with diabetes mellitus. Chromium picolinate, an essential trace element is recommended for diabetes and also has been reported to benefit depression, but its mechanism is still debated. To investigate the mechanism, we studied its effects on serum insulin, serum glucose and on modified forced swimming test, a behavioural paradigm for depression in rats. The study involving co-administration of sub-active doses of glimepiride, a K(+) channel blocker and chromium picolinate on blood glucose levels and modified forced swimming test was also performed to probe any role of K(+) channels in its antidiabetic and antidepressants effects. Streptozotocin (55 mg/kg, intraperitoneally) was injected in rats to induce diabetes (Type 1). After a week, chromium picolinate (8 microg/ml in drinking water) was administered for 4 weeks. Normal rats received similar drug treatment. The sub-active doses of chromium picolinate (4 microg/ml in drinking water) and glimeperide (2.5 mg/kg, orally) were co-administered and their effects on modified forced swimming test and on glucose levels were measured. Chromium picolinate (8 microg/ml in drinking water) produced hypoglycaemia in diabetic and normal rats. It had no effects on the streptozotocin-induced reduction in insulin levels. Chromium picolinate (8 microg/ml in drinking water) increased swimming with subsequent decrease in immobility. The sub-active doses of chromium picolinate and glimeperide showed significant additive effects in modified forced swimming test and reduction in serum glucose concentrations, though statistically insignificant. In conclusion chromium picolinate shows antidepressant action on modified forced swimming test affecting only swimming that suggests serotonergic pathways involvement. The additive effects on swimming in modified forced swimming test and reduction in serum glucose levels shows involvement of K(+) channels in antidiabetic and antidepressant actions of chromium picolinate.

Effects of histamine H1 receptor antagonists on depressive-like behavior in diabetic mice

We previously reported that streptozotocin-induced diabetic mice showed depressive-like behavior in the tail suspension test. It is well known that the central histaminergic system regulates many physiological functions including emotional behaviors. In this study, we examined the role of the central histaminergic system in the diabetes-induced depressive-like behavior in the mouse tail suspension test. The histamine contents in the hypothalamus were significantly higher in diabetic mice than in non-diabetic mice. The histamine H(1) receptor antagonist chlorpheniramine (1-10 mg/kg, s.c.) dose-dependently and significantly reduced the duration of immobility in both non-diabetic and diabetic mice. In contrast, the selective histamine H(1) receptor antagonists epinastine (0.03-0.3 microg/mouse, i.c.v.) and cetirizine (0.01-0.1 microg/mouse, i.c.v.) dose-dependently and significantly suppressed the duration of immobility in diabetic mice, but not in non-diabetic mice. Spontaneous locomotor activity was not affected by histamine H(1) receptor antagonists in either non-diabetic or diabetic mice. In addition, the number and affinity of histamine H(1) receptors in the frontal cortex were not affected by diabetes. In conclusion, we suggest that the altered neuronal system mediated by the activation of histamine H(1) receptors is involved, at least in part, in the depressive-like behavior seen in diabetic mice.

Diagnosticando depressão em pacientes internados com doenças hematológicas: prevalência e sintomas associados

INTRODUÇÃO: Não encontramos estudos avaliando o diagnóstico e a prevalência de depressão em pacientes hematológicos aqui no Brasil. OBJETIVO: Verificar a prevalência dos sintomas depressivos e quais deles mais se associam à depressão em pacientes internados com doenças hematológicas. MÉTODOS: Num estudo transversal, 104 pacientes consecutivamente internados nos leitos da hematologia do Hospital Universitário da Universidade Federal de Santa Catarina (HU/UFSC) foram avaliados. Foram preenchidos questionários de variáveis sociodemográficas e de história psiquiátrica. O índice Charlson de co-morbidade (IC) foi usado para medir gravidade física. Foi aplicado, também, o inventário Beck de depressão (BDI). Aqueles que tiveram pontuação acima de 9 na soma dos 13 primeiros itens do BDI (BDI-13) foram considerados deprimidos. Também foi verificada a freqüência caso fosse utilizada a escala completa com 21 itens (BDI-21), com ponto de corte 16/17. RESULTADOS: As prevalências foram: BDI-13 = 25% e BDI-21 = 32,7%. Após controle para fatores de confusão, os sintomas que permaneceram no modelo da regressão logística, indicando que melhor detectavam os deprimidos, foram sensação de fracasso, anedonia, culpa e fadiga. CONCLUSÃO: Cerca de um quarto a um terço dos pacientes internados com doenças hematológicas tinham sintomas depressivos significativos, e os sintomas que melhor os discriminaram foram sensação de fracasso, anedonia, culpa e fadiga.

Where is the patient? The association of psychosocial factors and missed primary care appointments in patients with diabetes

OBJECTIVE

Missed appointments are associated with poorer health outcomes. We predicted that compared to secure attachment style, fearful and dismissing attachment styles would be associated with greater number of missed primary care visits in patients with diabetes.

METHODS

In patients with diabetes from nine health maintenance organization primary care clinics, we collected data on attachment style and major depression status, and determined the number of missed primary care appointments from automated data. We used Poisson and logistic regression analyses to determine if attachment style was associated with the number of missed primary care same day appointments, scheduled office visits and scheduled preventive care visits, after adjusting for demographics, clinical characteristics, appointment frequency and clustering by clinic. We included major depression as a potential effect modifier.

RESULTS

Among 3,923 patients with diabetes, prevalence rates of attachment styles were 43.9% for secure, 35.8% for dismissing, 8.1% for preoccupied and 12.2% for fearful attachment style. Major depression was present in 12.4% of patients. Among patients without major depression, there were more missed scheduled office visits (RR=1.46, 95% CI=1.18-1.81) among those with dismissing compared to secure attachment style. The likelihood of having missed same day appointments was lower for those with fearful attachment style relative to those with secure attachment style in nondepressed patients compared to patients with fearful and secure attachment style with major depression (P < .01).

CONCLUSIONS

Attachment styles characterized by low levels of collaboration are associated with more missed primary care appointments compared to secure attachment style in patients with diabetes. These associations are moderated by depression status.

Diagnosticando e tratando depressão no paciente com doença clínica

Diagnosticar depressão em um doente clínico é uma tarefa difícil por vários motivos. Muito embora tristeza e humor depressivo possam indicar síndrome depressiva subjacente, eles também podem fazer parte da adaptação normal a uma doença que ameace a vida. Os sintomas somáticos e vegetativos incluídos nos critérios diagnósticos das classificações atuais não são específicos e podem de fato ser atribuíveis à hospitalização, aos tratamentos ou à própria doença clínica. Tratar a depressão no paciente clínico é também difícil devido à preocupação com a interação de drogas, assim como questões de eficácia e segurança nesse grupo. Nesta conferência clínica os autores discutem questões como que diagnósticos podem ser feitos em pacientes clínicos com sintomas depressivos; prevalência de depressão em diferentes ambientes; mecanismos de co-morbidade (fatores fisiológicos e comportamentais) que relacionam a depressão às doenças clínicas e o manuseio da depressão nesse grupo.

Drug-Related Problems in the Community Setting

BACKGROUND AND OBJECTIVE

Adverse drug events are a leading cause of morbidity in Australia and internationally. People taking psychotropic drugs for mental illnesses may be particularly susceptible. This study aimed to classify and describe pharmacists' Home Medicines Review (HMR) findings and recommendations for people with mental illnesses.

METHODS

This was a descriptive study conducted from March to November 2003. General practitioners and community pharmacists practising in two regions of metropolitan Sydney were invited to participate. General practitioners recruited and referred community-dwelling people with mental illnesses to receive HMRs conducted by accredited pharmacists. Reviewing pharmacists interviewed 49 people in their homes. During the interviews the pharmacists provided drug information, assessed drug knowledge and beliefs, and assessed drug adherence. Pharmacists then produced written referenced reports that outlined drug-, patient- and prescriber-related findings and recommendations. These findings and recommendations were presented to the referring general practitioners at follow-up case conferences.

MAIN OUTCOME MEASURES

Drugs were classified using the Anatomical Therapeutic Chemical Classification System. Pharmacists' findings and recommendations were classified using the Clinical Pharmacy Activity Classification System.

RESULTS

The most common types of nervous system drugs taken by people who received a HMR were antidepressants (n = 39.33%), analgesics (n = 29.24%) and antipsychotics (n = 17.14%). Pharmacists reported 403 findings and made 360 recommendations for 49 people, with 90% of recommendations being accepted by the referring general practitioners. The most common findings related to potential adverse drug reactions (n = 53, for 47% of people), suspected adverse drug reactions (n = 48, for 55% of people), potential interactions (n = 30, for 37% of people), and people taking additional drugs unbeknown to their referring general practitioner (n = 26, for 25% of people). The most common recommendations were to switch a drug (n = 37, for 49% of people), suggest a non-drug treatment (n = 29, for 41% of people) and to suggest a new drug (n = 27, for 49% of people). At the time of referral, general practitioners documented people to be taking 7.8 +/- 4.4 (mean +/- SD) drugs each (range 1-18). Following home interviews, pharmacists determined people to be taking 9.1 +/- 4.8 drugs (range 1-20). This difference was statistically significant (p < 0.001).

CONCLUSIONS

Pharmacists identified a high incidence of drug-related problems among people receiving treatment for mental illnesses. Pharmacists also identified a higher incidence of overall drug use than documented by the referring general practitioners. HMRs and case conferences, undertaken collaboratively by general practitioners and pharmacists, may be a useful strategy to identify drug-related problems among people with mental illnesses.

Effects of enhanced depression treatment on diabetes self-care

PURPOSE

Among patients with diabetes, major depression is associated with more diabetic complications, lower medication adherence, and poorer self-care of diabetes. We reported earlier that enhanced depression care reduces depression symptoms but not hemoglobin A1c level. This study examined effects of depression interventions on self-management among depressed diabetic patients.

METHODS

A total of 329 patients in 9 primary care clinics were randomized to an evidence-based collaborative depression treatment (pharmacotherapy, problem-solving treatment, or both in combination) or usual primary care (routine medical services). Outcome measures included the Summary of Diabetes Self-Care Activities (SDSCA), reported at baseline and 3, 6, and 12 months, and medication non-adherence as assessed by automated pharmacy refill data of oral hypoglycemic agents, lipid-lowering agents, and angiotensin-converting enzyme inhibitors. We used mixed regression models adjusted for baseline differences to compare the intervention with usual care groups at follow-up assessments.

RESULTS

During the 12-month intervention period, enhanced depression care and outcomes were not associated with improved diabetes self-care behaviors (healthy nutrition, physical activity, or smoking cessation). Relative to the usual care group, the intervention group reported a small decrease in body mass index (mean difference = 0.70 kg/m2, 95% CI, 0.17 to 1.24 kg/m2) and a higher rate of nonadherence to oral hypoglycemic agents (mean difference = -6.3%, 95% CI, -11.91% to -0.71%). Adherence to lipid-lowering agents and to antihypertensive medicines was similar for the 2 groups.

CONCLUSIONS

In general, diabetes self-management did not improve among the enhanced depression treatment group during a 12-month period, except for small between-group differences of limited clinical importance. Research needs to assess whether self-care interventions tailored for specific conditions, in addition to enhanced depression care, can achieve better diabetes and depression outcomes.

A prospective study of depression and mortality in patients with type 2 diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

Depression is associated with excess mortality in patients with type 2 diabetes. We investigated the impact, and possible causal mechanisms, of depression on all-cause and cardiac mortality in patients with type 2 diabetes.

METHODS

We recruited 1,273 patients with type 2 diabetes from a postcode-defined community (average age 64.1+/-11.2 years, 48.7% males, median duration of diabetes 4 years [range 1.0-9.0]) and followed them for 7.8+/-2.4 years. Depression was assessed using data obtained using a quality-of-life questionnaire, and cause and date of death were obtained from the state registry.

RESULTS

Depression was present in 31.5% of subjects at recruitment. Depressed subjects had a longer duration of diabetes, more cardiovascular risk factors, CHD, cerebrovascular disease and diabetic microvascular complications at baseline, and higher all-cause and cardiac mortality rates during follow-up. In Cox proportional hazards models and after adjustment for demographic and diabetes-related variables and cardiovascular risk factors, depression was significantly associated with excess all-cause and cardiac mortality. When diabetic microvascular and macrovascular complications were added to the Cox models, depression was not significantly associated with excess all-cause or cardiac mortality.

CONCLUSIONS/INTERPRETATION

Depression in patients with type 2 diabetes is associated with a greater prevalence of complications but is not an independent predictor of all-cause or cardiac mortality. Depression may contribute to the progression of important prognostic variables in diabetes, particularly macrovascular and microvascular disease.

Abnormal benzodiazepine receptor function in the depressive-like behavior of diabetic mice

We previously reported that streptozotocin (STZ)-induced diabetic mice exhibited depressive-like behavior in the tail suspension test. In this study, we examined the involvement of benzodiazepine receptor functions in this diabetes-induced depressive-like behavior in mice. STZ-induced diabetes significantly increased the duration of immobility without affecting spontaneous locomotor activity. This increase was dose-dependently and significantly suppressed by a benzodiazepine receptor antagonist, flumazenil (0.1-1 mg/kg, i.v.). However, flumazenil (0.1-1 mg/kg, i.v.) did not affect the duration of immobility in non-diabetic mice. Furthermore, flumazenil (1 mg/kg, i.v.) had no significant effect on spontaneous locomotor activity in either non-diabetic or diabetic mice. The benzodiazepine receptor inverse agonist methyl beta-carboline-3-carboxylate (beta-CCM; 0.03-0.3 mg/kg, i.v.) dose-dependently and significantly increased the duration of immobility in non-diabetic mice, but not in diabetic mice. beta-CCM (0.3 mg/kg, i.v.) significantly suppressed spontaneous locomotor activity in non-diabetic mice, but not in diabetic mice. These results indicate that diabetic mice may have enhanced negative allosteric modulation by benzodiazepine receptor ligands, such as diazepam binding inhibitors, under stressful conditions, but not free-moving conditions, and this abnormal function of benzodiazepine receptors may cause, at least in part, the expression of depressive-like behavior in diabetic mice.

Depression and medication adherence in outpatients with coronary heart disease: findings from the Heart and Soul Study

BACKGROUND

Depression leads to adverse outcomes in patients with coronary heart disease (CHD). Medication nonadherence is a potential mechanism for the increased risk of CHD events associated with depression, but it is not known whether depression is associated with medication nonadherence in outpatients with stable CHD.

METHODS

We examined the association between current major depression (assessed using the Diagnostic Interview Schedule) and self-reported medication adherence in a cross-sectional study of 940 outpatients with stable CHD.

RESULTS

A total of 204 participants (22%) had major depression. Twenty-eight (14%) of 204 depressed participants reported not taking their medications as prescribed compared with 40 (5%) of 736 nondepressed participants (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.7-4.7; P<.001). Twice as many depressed participants as nondepressed participants (18% vs 9%) reported forgetting to take their medications (OR, 2.4; 95% CI, 1.6-3.8; P<.001). Nine percent of depressed participants and 4% of nondepressed participants reported deciding to skip their medications (OR, 2.2; 95% CI, 1.2-4.2; P = .01). The relationship between depression and nonadherence persisted after adjustment for potential confounding variables, including age, ethnicity, education, social support, and measures of cardiac disease severity (OR, 2.2; 95% CI, 1.2-3.9; P = .009 for not taking medications as prescribed).

CONCLUSIONS

Depression is associated with medication nonadherence in outpatients with CHD. Medication nonadherence may contribute to adverse cardiovascular outcomes in depressed patients.

The association of comorbid depression with mortality in patients with type 2 diabetes

OBJECTIVE

We assessed whether patients with comorbid minor and major depression and type 2 diabetes had a higher mortality rate over a 3-year period compared with patients with diabetes alone.

RESEARCH DESIGN AND METHODS

In a large health maintenance organization (HMO), 4,154 patients with type 2 diabetes were surveyed and followed for up to 3 years. Patients initially filled out a written questionnaire, and HMO-automated diagnostic, laboratory, and pharmacy data and Washington State mortality data were collected to assess diabetes complications and deaths. Cox proportional hazards regression models were used to calculate adjusted hazard ratios of death for each group compared with the reference group.

RESULTS

There were 275 (8.3%) deaths in 3,303 patients without depression compared with 48 (13.6%) deaths in 354 patients with minor depression and 59 (11.9%) deaths among 497 patients with major depression. A proportional hazards model with adjustment for age, sex, race/ethnicity, and educational attainment found that compared with the nondepressed group, minor depression was associated with a 1.67-fold increase in mortality (P = 0.003), and major depression was associated with a 2.30-fold increase (P < 0.0001). In a second model that controlled for multiple potential mediators, both minor and major depression remained significant predictors of mortality.

CONCLUSIONS

Among patients with diabetes, both minor and major depression are strongly associated with increased mortality. Further research will be necessary to disentangle causal relationships among depression, behavioral risk factors (adherence to medical regimens), diabetes complications, and mortality.

Depression and diabetes in children and adolescents

PURPOSE OF REVIEW

Diabetes and depression are each public health concerns. They frequently co-occur, compounding complications of each disease. This review provides recent information regarding the mechanisms of association between the disorders and the availability and effectiveness of interventions for youth with diabetes who are depressed. Implications for primary care physicians are considered, particularly in relation to recognition of depression, and also to preventive strategies that increase the patient's self-efficacy (evidence-based confidence in his/her ability to manage diabetes) and serve as protective factors in the development of depression.

RECENT FINDINGS

Depressive symptoms are strongly associated with diabetes complications. To date, no studies have tested effectiveness of interventions with depressed youth with diabetes. Clinical trials with adults have shown the effectiveness of pharmacotherapy, but those with more complications show the least improvement, and health gains do not persist. In the absence of other data, these findings suggest that it would be prudent to identify and treat comorbid depression in children with diabetes early in the course of their illness, before medical complications develop.

SUMMARY

Primary care physicians are in an important position to recognize early signs of depression in youth with diabetes and refer them for treatment. Furthermore, the literature provides numerous strategies that can be employed by primary care doctors that may enhance diabetes management as well as protect against depression.

Diabetes complications and depression as predictors of health service costs

OBJECTIVE

The aim of this study was to assess the relative contributions of diabetes complications, depression and comorbid medical disorders to health service costs in adults with diabetes.

METHODS

A total of 4398 adult health plan members with diabetes completed a mailed survey. Depression was assessed using the nine-item PHQ. Health service costs, diabetes complications, glycohemoglobin levels and comorbid medical conditions were assessed using computerized health plan records.

RESULTS

Total health service costs were approximately 70% higher for individuals with major depression than for those without any depressive disorder (5361 US dollars over 6 months vs. 3120 US dollars, P<.001); this difference was consistent across all categories of health service costs. Diabetes complications were the strongest predictor of total costs (6845 US dollars for those with three or more complications vs. 1719 US dollars for those with none), but depression remained strongly associated with increased costs at all levels of diabetes severity.

CONCLUSIONS

Among people with diabetes, depression is associated with 50-75% increases in health service costs. This proportional difference is similar to that in general population samples, but the absolute dollar difference is much greater. The effect of depression on health service use is undoubtedly complex and not limited to unexplained physical symptoms among the worried well.

The impact of psychiatric comorbidities on readmissions for diabetes in youth

OBJECTIVE

Comorbid psychiatric disorders have been associated with poorer disease outcomes in diabetic youth. Less is known, however, about the relationship between psychiatric disorders and repeat hospitalizations for youth with diabetes.

RESEARCH DESIGN AND METHODS

We performed a retrospective cohort study using data from the Pediatric Health Information System, which included detailed discharge data from 37 non-competing children's hospitals in the U.S. Using logistic regression, we examined whether the presence of coded diagnoses for internalizing or externalizing disorders at an index hospitalization for diabetes was associated with increased risk for rehospitalization during follow-up (duration of follow-up ranged from 3 to 24 months). The analysis was stratified by age-groups, and we controlled for potential confounders including sex, age, race/ethnicity, type 1 versus type 2 diabetes, Medicaid status, intensive care unit utilization, length of stay during index admission, and duration of follow-up.

RESULTS

Among adolescents aged 13-18, internalizing disorders were associated with significantly increased odds of rehospitalization (odds ratio 1.79 [95% CI 1.27-2.52]); the point estimate for externalizing disorders was similar, but the finding was not statistically significant at the alpha = 0.05 level (1.74 [0.96-3.15]). No significant association between psychiatric diagnoses and odds of repeat hospitalization was observed in diabetic children aged 5-12 years.

CONCLUSIONS

Internalizing disorders are associated with increases in repeat hospitalizations for diabetes among adolescents. Future research is needed to explore the reasons for this finding, such as degree to which treatment nonadherence mediates this relationship and whether appropriate treatment of internalizing disorders results in improved diabetes outcomes and decreased readmissions.

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.

Diabetes on the college campus

The college campus presents a unique scenario where older adolescents and young adults find themselves in an independent environment. The students with pre-existing diabetes face immense responsibility regarding their diabetes care and decision making, without the immediate presence of their parents and the pediatric diabetes team. In addition, there are many other students who may be faced with a diagnosis of diabetes mellitus first identified in college. Current diabetes management strategies offer comprehensive care, which results in improved glycemic control and near-normal lifestyle. Continued effort at comprehensive diabetes education goes a long way toward giving these students healthy lives. This article reviews issues involving care of college students with diabetes.