Depressive symptomatology and coronary heart disease in Type I diabetes mellitus: a study of possible mechanisms

Psychosocial determinants of healthcare use costs in kidney transplant recipients

INTRODUCTION

Psychosocial factors frequently occur in kidney transplant recipients (KTRs), leading to behavioral alterations and reduced therapeutic adherence. However, the burden of psychosocial disorders on costs for KTRs is unknown. The aim of the study is to identify predictors of healthcare costs due to hospital admissions and emergency department access in KTRs.

METHODS

This is a longitudinal observational study conducted on KTRs aged >18 years, excluding patients with an insufficient level of autonomy and cognitive disorder. KTRs underwent psychosocial assessment via two interviews, namely the Mini-International Neuropsychiatric Interview 6.0 (MINI 6.0) and the Diagnostic Criteria for Psychosomatic Research Interview (DCPR) and via the Edmonton Symptom Assessment System Revised (ESAS-R) scale, a self-administrated questionnaire. Sociodemographic data and healthcare costs for hospital admissions and emergency department access were collected in the 2016-2021 period. Psychosocial determinants were as follows: (1) ESAS-R psychological and physical score; (2) symptomatic clusters determined by DCPR (illness behavior cluster, somatization cluster, and personological cluster); and (3) ICD diagnosis of adjustment disorder, anxiety disorder, and mood disorder. A multivariate regression model was used to test the association between psychosocial determinants and total healthcare costs.

RESULTS

A total of 134 KTRs were enrolled, of whom 90 (67%) were men with a mean age of 56 years. A preliminary analysis of healthcare costs highlighted that higher healthcare costs are correlated with worse outcomes and death (p < 0.001). Somatization clusters (p = 0.020) and mood disorder (p < 0.001) were positively associated with costs due to total healthcare costs.

CONCLUSIONS

This study showed somatization and mood disorders could predict costs for hospital admissions and emergency department access and be possible risk factors for poor outcomes, including death, in KTRs.

Sex-Related Differences in Cardiovascular Disease Risk Profile in Children and Adolescents with Type 1 Diabetes

Cardiovascular disease (CVD) is the primary cause of higher and earlier morbidity and mortality in people with type 1 diabetes (T1D) compared to people without diabetes. In addition, women with T1D are at an even higher relative risk for CVD than men. However, the underlying pathophysiology is not well understood. Atherosclerotic changes are known to progress early in life among people with T1D, yet it is less clear when excess CVD risk begins in females with T1D. This review explores the prevalence of classical CVD risk factors (such as glycemic control, hypertension, dyslipidemia, obesity, albuminuria, smoking, diet, physical inactivity), as well as of novel biomarkers (such as chronic inflammation), in children and adolescents with T1D with particular regard to sex-related differences in risk profile. We also summarize gaps where further research and clearer clinical guidance are needed to better address this issue. Considering that girls with T1D might have a more adverse CVD risk profile than boys, the early identification of and sex-specific intervention in T1D would have the potential to reduce later CVD morbidity and excess mortality in females with T1D. To conclude, based on an extensive review of the existing literature, we found a clear difference between boys and girls with T1D in the presence of individual CVD risk factors as well as in overall CVD risk profiles; the girls were on the whole more impacted.

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

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

Depressive symptoms and cerebral microvascular disease in adults with Type 1 diabetes mellitus

AIM

To assess the prevalence of, and risk factors for, depressive symptoms, comparing a sample of middle-aged adults with and without juvenile-onset Type 1 diabetes mellitus, and to determine if depressive symptoms were associated with white matter hyperintensity volume among those with Type 1 diabetes.

METHODS

Depressive symptoms and white matter hyperintensities were compared between adults (age range 30-65 years) with juvenile-onset Type 1 diabetes (n=130) and adults without Type 1 diabetes (n=133). The association of Type 1 diabetes with depression was computed before and after adjustment for white matter hyperintensities. Among the Type 1 diabetes group, the primary associations of interest were between depressive symptoms (Beck Depression Inventory score ≥10) and white matter hyperintensities (n=71), hyperglycaemia and physical activity. Associations between depressive symptoms and diabetes-related complications, cognitive impairment, smoking and self-reported disability were examined. Analyses were controlled for education, sex, age and antidepressant use.

RESULTS

Depressive symptoms were more prevalent among those with vs those without Type 1 diabetes (28% vs 3%; P<0.001). White matter hyperintensities explained 40% of the association of Type 1 diabetes with depressive symptoms, while Type 1 diabetes had a direct effect of 68% on depressive symptoms. Among those with Type 1 diabetes, depressive symptoms were related to white matter hyperintensity volume, a 16-year average HbA1c ≥58 mmol/mol (7.5%), and lower physical activity levels. Associations with other characteristics were not significant.

CONCLUSION

These findings suggest a cerebrovascular origin for depressive symptoms in adults with Type 1 diabetes, perhaps triggered by hyperglycaemia. Future longitudinal studies should investigate whether targeting hyperglycaemia and physical inactivity alleviates depressive symptoms, possibly by slowing the development of cerebral microvascular disease, in people with Type 1 diabetes.

Metabolic syndrome and incident depressive symptoms in young and middle-aged adults: A cohort study

BACKGROUND

Recent studies on the prospective association between metabolic syndrome (MetS) and depression have reported conflicting findings.

METHODS

A cohort study was performed with 115,223 middle-aged adults, free of depression at baseline, who underwent at least 2 comprehensive exams between 2012 and 2015. MetS was assessed according to the National Cholesterol Education Program Adult Treatment Panel III. The study endpoint was new onset of depression, defined as a Center for Epidemiologic Studies-Depression Scale score ≥ 16.

RESULTS

Over 253,451.6 person-years, 6,833 participants developed depression. When the participants with 0 MetS components were set as a reference, the multivariable-adjusted hazard ratio (HR, 95% confidence interval [CI]) for incident depression formed a U-shaped curve with the number of MetS components (p for trend = 0.229): 1 (1.07 [1.02-1.15]); 2 (0.92 [0.82-1.06]); 3 (0.85 [0.78-1.07]); 4 (1.16 [1.06-1.32]); and 5 MetS components (1.25 [1.10-1.54]). The presence or absence of MetS was not significant in new-onset depression. In examining potential clustering and synergistic effects of the constituent parts, waist circumference was the major driving factor of incident depression, and its relative excess risk due to interaction increased with the number of combinations.

LIMITATIONS

We used a self-reported depression scale, and the follow-up period was relatively short.

CONCLUSIONS

Future studies investigating the risk for incident depression should place more focus on the number of MetS abnormalities and specific MetS factors, such as waist circumference, than the presence or absence of MetS.

Positive Correlation of Serum N-Acetyl-β-hexosaminidase with Markers of Atherosclerosis in Diabetes Type 2 Patients with Mild Symptoms of Depression and Anxiety

Background

Analysis of the correlation between diabetes type 2 (DT2) and serum N-acetyl-β-hexosaminidase (HEX) activity with parameters of fat metabolism and symptoms of anxiety and depression.

Material and Method

The study was performed using a random sample of 40 DT2 patients (22 women and 18 men) between the ages of 43 and 71 (median 59) and 40 control persons (28 women and 12 men) between the ages of 18 and 64 (median 46). The activity of HEX was determined by a colorimetric method. The activity of the serum exoglycosidase was expressed in pkat/mL. Each participant underwent Hamilton tests, to evaluate level of anxiety and depression. Additionally, the HEX activity and concentration of particular lipidograms were monitored using a blood sample from each participant.

Results

In DT2 patients, a significant positive correlation was found between serum HEX activity and the concentration of serum cholesterol LDL fractions, triacylglycerols (TAG), and Castelligro atherogenic indexes. A significantly increased level of anxiety and depression in comparison to the control group was found as well.

Conclusion

Serum HEX activity in DT2 patients is a better marker of atherosclerosis than serum total cholesterol level in persons with mild symptoms of depression and anxiety. In DT2 patients, a routine testing of anxiety and depression is recommended. Early detection of these disorders creates the possibility for treatment, an improvement in a patient's quality of life, and the overall longevity of DT2 patients.

Neural dysfunction and retinopathy in persons with type 1 diabetes

OBJECTIVE

To determine associations of microvascular and neuropathic complications of diabetes cross-sectionally and longitudinally in persons with long-term type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Persons receiving care for T1D in South Central Wisconsin were identified in 1979-1980 and examined approximately every 5 years. Associations between neuropathic and microvascular complications were examined at most prior visits, when information on several neuropathic complications was collected. Temporal relationships were examined by modeling incidence between examinations across the visits.

RESULTS

Adjusting for duration of diabetes, glycated hemoglobin, and systolic blood pressure, the following were cross-sectionally associated with prevalent PDR (proliferative diabetic retinopathy): the presence of sensory neuropathy (SN) as reported at each Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) examination (odds ratio (OR) = 2.76, confidence interval (CI) = 1.71, 4.48) and the heartrate variability measures RMSD (square root of the mean of squared differences of successive RR intervals) (OR = 0.24, CI = 0.16, 0.37) and SDNN (standard deviation of successive RR intervals) (OR = 0.26, CI = 0.17, 0.39). Findings were similar for prevalent ME (macular edema) as assessed from spectral-domain optical coherence tomography (SD-OCT). The presence of PDR (OR = 2.13, CI = 1.63, 2.78) and ME (OR = 2.36, CI = 1.66, 3.34) were both significantly associated with incident WESDR SN. WESDR SN was associated with incident PDR (OR = 1.53, CI = 1.09, 2.15) but not incident ME (OR = 1.31, CI = 0.92, 1.87).

CONCLUSIONS

Sensory neuropathy and heartrate variability were significantly associated with prevalent PDR and ME in people with long-term T1D. PDR and ME were significantly associated with incident sensory neuropathy, and sensory neuropathy was significantly associated with incident PDR. Studies using earliest detectable markers of microvascular and neurologic abnormalities are needed to determine which of the two systems 'fails' first. Such information might suggest a temporal sequence of diabetes complications.

Antidepressant medication use before and after kidney transplant: implications for outcomes - a retrospective study

We examined a novel database wherein national US transplant registry identifiers were linked to records from a large pharmaceutical claims warehouse (2008-2015) to characterize antidepressant use before and after kidney transplantation, and associations [adjusted hazard ratio (aHR) 95% CI] with death and graft failure. Among 72 054 recipients, 12.6% filled antidepressant medications in the year before transplant, and use was more common among women and patients who were white, unemployed, and had limited functional status. Pre-transplant antidepressant use was associated with 39% higher 1-year mortality (aHR 1.39, 95% CI 1.18-1.64) and 15% higher all-cause graft loss risk (aHR 1.15, 95% CI 1.02-1.30). More than 50% of patients who filled antidepressants pre-transplant continued fill post-transplant. Antidepressant use in the first year after transplant was associated with twofold higher risk of death (aHR 1.94, 95% CI 1.60-2.35), 38% higher risk of death-censored graft failure, and 61% higher risk of all-cause graft failure in the subsequent year. Pre-listing antidepressant use was also associated with increased mortality, but transplantation conferred a survival benefit regardless of prelisting antidepressant use status. While associations may in part reflect underlying behaviors or comorbidities, kidney transplant candidates and recipients treated with antidepressant medications should be monitored and supported to reduce the risk of adverse outcomes.

Anxiety and diabetes: Innovative approaches to management in primary care

Type 2 diabetes mellitus is a chief concern for patients, healthcare providers, and health care systems in America, and around the globe. Individuals with type 2 diabetes mellitus exhibit clinical and subclinical symptoms of anxiety more frequently than people without diabetes. Anxiety is traditionally associated with poor metabolic outcomes and increased medical complications among those with type 2 diabetes mellitus. Collaborative care models have been utilized in the multidisciplinary treatment of mental health problems and chronic disease, and have demonstrated success in managing the pathology of depression which often accompanies diabetes. However, no specific treatment model has been published that links the treatment of anxiety to the treatment of type 2 diabetes mellitus. Given the success of collaborative care models in treating depression associated with diabetes, and anxiety unrelated to chronic disease, it is possible that the collaborative care treatment of primary care patients who suffer from both anxiety and diabetes could be met with the same success. The key issue is determining how to implement and sustain these models in practice. This review summarizes the proposed link between anxiety and diabetes, and offers an innovative and evidence-based collaborative care model for anxiety and diabetes in primary care.

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.

Type D personality, suboptimal health behaviors and emotional distress in adults with diabetes: results from Diabetes MILES-The Netherlands

AIMS

Type D personality - defined as high negative affectivity (NA) and high social inhibition (SI) - has been associated with adverse cardiovascular prognosis. We explored the differential associations of Type D personality and its constituent components with health behaviors, emotional distress and standard biomedical risk factors as potential risk mechanisms in adults with diabetes.

METHODS

3314 Dutch adults with self-reported type 1 or 2 diabetes completed an online survey, including the DS14 Type D Scale. AN(C)OVAs and X(2) tests were used to compare participants scoring (i) low on NA and SI; (ii) high on SI only; (iii) high on NA only; (iv) high on NA and SI (Type D).

RESULTS

Participants with Type D personality (29%) were less likely to follow a healthy diet or to consult healthcare professionals in case of problems with diabetes management than those scoring high on neither or only one component. They also reported more barriers surrounding medication use, diabetes-specific social anxiety, loneliness and symptoms of depression and anxiety. There were no differences in standard biomedical risk factors (body mass index, blood pressure, cholesterol, HbA1c). After adjustment for demographics, clinical characteristics, NA, and SI in multivariable logistic regression analyses, Type D personality was independently associated with 2 to 3-fold increased odds of suboptimal health behaviors and over 15-fold increased odds of general emotional distress.

CONCLUSIONS

Type D personality was not related to standard biomedical risk factors, but was associated with unhealthy behaviors and negative emotions that are likely to have adverse impact on adults with diabetes.

Depressive symptomatology and respiratory sinus arrhythmia in a non-clinical sample of middle-aged African Americans

Decreased heart rate variability and depression are both independent risk factors for cardiac mortality in clinical and non-clinical samples. The purpose of the current study is to examine the hypothesis that severity of depressive symptomatology is inversely associated with respiratory sinus arrhythmia (RSA) in a non-clinical sample of African Americans. The sample included 77 African Americans with a mean age of 48.4 (SD = 11.7). Participants completed the Beck Depression Inventory-II (BDI-II) and a 5-min resting baseline measurement of RSA was collected. The BDI-II total score was positively associated with RSA (β = .334, p = .008). Given the unexpected direction of the association, we separated the BDI-II into cognitive and somatic affective subscales to identify which construct was driving the relationship. The somatic affective, was related to RSA (β = .328, p = .010), but not the cognitive subscale. Given this unexpected positive result, future research should further examine the nature of the relationship between depressive symptomatology and RSA in African Americans, as the relationship may vary based on levels of depressive symptomatology.

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

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

Family functioning in Chinese type 2 diabetic patients with and without depressive symptoms: a cross-sectional study

BACKGROUND

Patients with depression or type 2 diabetes mellitus (T2DM) often have associated impaired family functioning. The purpose of this study was: (1) to explore the family functioning of T2DM patients with and without depressive symptoms and (2) to explore the relationship between depressive symptoms and family impairment in T2DM patients with depressive symptoms. This study used a cross-sectional design.

SAMPLING AND METHODS

A sample of 32 patients with T2DM who had depressive symptoms and 229 patients with T2DM who did not have depressive symptoms completed the Chinese versions of the Family Assessment Device (FAD) and the Beck Depression Inventory.

RESULTS

This study showed that there were differences in duration of diabetes and some FAD dimensions between T2DM patients with and without depressive symptoms (p < 0.01). There were also differences in the frequencies of FAD dimensions between T2DM patients with and without depressive symptoms (p < 0.01). Age, duration of diabetes and family function were predicting factors of depressive symptoms among T2DM patients (p < 0.01).

CONCLUSIONS

The T2DM patients with depressive symptoms had more unhealthy FAD dimensions than the T2DM patients without depressive symptoms. The family functioning of T2DM patients with depressive symptoms was worse than that of T2DM patients without depressive symptoms. Age, duration of diabetes and some dimensions of FAD were associated with depressive symptoms in the T2DM patients.

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

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

Utilizing correspondence analysis to characterize the mental health of cardiac patients with diabetes

The aim of this study was to examine the mental health of cardiac patients with diabetes and whether symptoms varied by gender and/or age. Screening for depression and posttraumatic stress symptoms was conducted on 1003 patients with cardiovascular disease. Correspondence analysis was utilized to identify clinical core profiles. Results suggested that cardiovascular disease patients with diabetes, particularly males, experience high rates of depression, suicide ideation, and posttraumatic stress symptoms. Clinical implications of these findings include targeted mental health screening options as well as offering a closer look at the specific concerns of cardiovascular disease patients with diabetes.

Adaptação cultural e confiabilidade para o Brasil do Automated Telephone Disease Management: resultados preliminares

OBJETIVOS: Traduzir, adaptar culturalmente para o Brasil o ATDM Satisfaction Scales e avaliar a confiabilidade da versão adaptada em adultos brasileiros com DM. MÉTODOS: Estudo metodológico, cujo processo de adaptação cultural incluiu: tradução, comitê de juízes, retrotradução, análise semântica e pré-teste. Este estudo incluiu uma amostra de 39 adultos brasileiros com DM cadastrados em um programa educativo do interior paulista. RESULTADOS: A versão adaptada do instrumento mostrou boa aceitação com fácil compreensão dos itens pelos participantes, com confiabilidade variando entre 0,30 e 0,43. CONCLUSÃO: Após a análise das propriedades psicométricas e finalização do processo de validação no País, o instrumento poderá ser utilizado por pesquisadores brasileiros, possibilitando ser comparado com outras culturas.

Nursing intervention in insulin administration: telephone follow-up

OBJECTIVE: To analyze the competency of people with diabetes mellitus to perform the insulin administration process, before and after telephone monitoring. METHODS: A quantitative, observational, longitudinal, comparative study. Participants were 26 people enrolled in the at-home capillary glycemia self-monitoring program. Data collection occurred in three phases, in January and February of 2010, for a period of 30 days for each person, by means of interview guided by a data collection instrument and an intervention manual. RESULTS: Of the 38 (100%) questions referring to the insulin administration process, telephone monitoring was demonstrated to be efficient in 30 (78.9%), but in 19 (50%) the intervention was statistically significant (p<0.05), in 11 (28.9%) there were no errors in responses to the final competency evaluation, and seven (18.4%) were not amenable to intervention. CONCLUSION: Telephone mornitoring was effective, as a nursing intervention strategy for the insulin administration process in the home.

The bidirectional relationship of depression and diabetes: a systematic review

Depression and diabetes are both serious chronic conditions common in Western cultures. These conditions impart a significant burden on the patients and society. Depression is often comorbid with chronic illness, and past research has found an increased prevalence of depressive symptoms in patients with Type 2 Diabetes Mellitus (T2DM). However, the exact nature and direction of this relationship are unknown. Depression is often thought to be a consequence of diabetes, perhaps due to the burden of chronic illness. Research has also suggested that depression may be a risk factor for development of diabetes, in part due to biochemical changes in depression and in part because of a reduction of health care behaviors in individuals with depression. This paper reviews the literature behind both lines of investigation and includes special diagnostic and clinical considerations for at risk populations. We discuss clinical implications, limitations of current research, and areas of interest for future research.

The prevalence and correlates of depression and anxiety in a sample of diabetic patients in Sharjah, United Arab Emirates

BACKGROUND

Type 2 diabetes is very prevalent in the Gulf region, particularly in the United Arab Emirates (UAE) which has the second highest prevalence in the world. Factors contributing to this include changes in diet, adoption of sedentary lifestyles, and the consequent increase in rates of obesity. These changes are primarily due to rapid economic development and affluence. The aim of this study was to estimate the prevalence of psychological distress and its correlates in diabetic patients in the United Arab Emirates.

METHODS

Patients diagnosed with diabetes attending diabetes mini-clinics in the primary health care centres or hospitals of Sharjah were invited to participate in this cross-sectional study. Patients were interviewed using structured questionnaires to gather data on socio-demographics, lifestyle factors, diabetes complications, and medication usage. The K6 was administered as a screening tool for mental health concerns.

RESULTS

Three hundred and forty-seven participants completed the interview. The majority of participants were females (65.4%) and the mean age was 53.2 (sd = 14.6). Approximately 12.5% of patients obtained a score of 19 or above (cut-off score) on the K6, indicating possible mental health concerns. Twenty-four percent had diabetes complications, mainly in the form of retinopathy, peripheral vascular disease and peripheral neuropathy. A significant relationship was found between scores on the K6, these complications of diabetes and the use of oral hypoglycemic and lipid lowering therapies.

CONCLUSIONS

The results of this study demonstrate a strong correlation between mental health status and diabetic complications. In particular, patients who are depressed tended to have poorer self-care, more severe physical symptoms and were less likely to adhere to prescribed care regimens. These findings raise the possibility that improving the mental health as part of a comprehensive management plan for diabetes may improve the overall long term outcomes of these patients.

Depression, coronary artery disease, type 2 diabetes, metabolic syndrome and quality of life in Taiwanese adults from a cardiovascular department of a major hospital in Southern Taiwan

AIMS

To examine the relationships between depression, coronary artery disease, type 2 diabetes, metabolic syndrome and quality of life in Taiwanese adults from a cardiovascular department of a major hospital in Taiwan.

BACKGROUND

Research suggests associations between depression, metabolic syndrome and quality of life. Despite this fact, few studies have investigated these relationships among Taiwanese.

DESIGN

A cross-sectional descriptive correlational design was used to conduct this study.

METHODS

A convenience sample of 140 adults participated in the study. Data were analysed with descriptive statistics, Pearson's correlations, hierarchical regression and t-tests.

RESULTS

Almost a half of the subjects (46.5%) had metabolic syndrome. The most common combination of metabolic syndrome criteria was elevated blood glucose, central obesity and high blood pressure (23.7%). A greater number of individuals had coronary artery disease (72.9%), type 2 diabetes (35%) and/or depression (21.4%). Type 2 diabetes and depression were significant predictors of overall quality of life (β = -0.16, p < 0.01 and β = -0.63, p < 0.001, respectively). In addition, there were significant differences between individuals with and without type 2 diabetes and/or depression regarding overall quality of life scores; t (138) = 3.50, p < 0.01); and t (138) = 7.80, p < 0.001), respectively.

CONCLUSIONS

Coronary artery disease, type 2 diabetes and depression were common among our sample of individuals with metabolic syndrome. Those with diabetes and/or depression had worse quality of life than those without those diseases.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to be prepared to assess and intervene in preventing or treating depression among patients with chronic diseases, especially those with coronary artery disease, type 2 diabetes and metabolic syndrome. When individuals are treated for depression, they are more likely to engage in self-management of their diseases, which will prevent complications and improve their quality of life.

Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Comorbid depression in diabetes is highly prevalent, negatively impacting well-being and diabetes control. How depression in diabetes is best treated is unknown.

OBJECTIVE

This systematic review and meta-analysis aims to establish the effectiveness of existing anti-depressant therapies in diabetes.

DATA SOURCES

PubMed, Psycinfo, Embase and Cochrane library. Study eligibility criteria, participants, interventions: randomized controlled trials (RCTs) evaluating the outcome of treatment by psychotherapy, pharmacotherapy or collaborative care of depression in persons with Type 1 and Type 2 diabetes mellitus.

STUDY APPRAISAL

risk of bias assessment; data extraction. Synthesis methods: data synthesis, random model meta analysis and publication bias analysis.

RESULTS

Meta analysis of 14 RCTs with a total of 1724 patients show that treatment is effective in terms of reduction of depressive symptoms: -0.512; 95% CI -0.633 to -0.390. The combined effect of all interventions on clinical impact is moderate, -0.370; 95% CI -0.470 to -0.271; it is large for psychotherapeutic interventions that are often combined with diabetes self management: -0.581; 95% CI -0.770 to -0.391, n=310 and moderate for pharmacological treatment: -0.467; 95% CI -0.665 to -0.270, n=281. Delivery of collaborative care, which provided a stepped care intervention with a choice of starting with psychotherapy or pharmacotherapy, to a primary care population, yielded an effect size of -0.292; 95% CI -0.429 to -0.155, n=1133; indicating the effect size that can be attained on a population scale. Pharmacotherapy and collaborative care aimed at and succeeded in the reduction of depressive symptoms but, apart from sertraline, had no effect on glycemic control.

LIMITATIONS

amongst others, the number of RCTs is small.

CONCLUSION

The treatment of depression in people with diabetes is a necessary step, but improvement of the general medical condition including glycemic control is likely to require simultaneous attention to both conditions. Further research is needed.

Prevalence and correlates of depressive disorders in elderly with type 2 diabetes in primary health care settings

OBJECTIVE

Depression is associated with poor glycemic control and complications in people with type 2 diabetes. We assessed the prevalence of depressive symptoms and antidepressant medication use among elderly with and without type 2 diabetes and the association between depression and diabetes complications.

RESEARCH DESIGN AND METHODS

In 2004-2006, the Primary Health Care research in Type 2 Diabetes Study applied the Beck Depression Inventory II (BDI-II) to 458 participants with type 2 diabetes (47% male, aged 65 + or -8.9 years, type 2 diabetes duration 19 + or - 8.7 years) and 546 participants without diabetes (non diabetic group) (51% male, aged 59 + or - 8.7 years). Use of antidepressant medication was self-reported. Depressive disorder was defined as a BDI-II score >14 and/or use of antidepressant medication. Occurrence of diabetes complications (retinopathy, blindness, neuropathy, diabetes-related amputation, and kidney or pancreas transplantation) was self-reported.

RESULTS

Mean BDI-II score, adjusted for age and sex, was significantly higher in participants with type 2 diabetes than in non diabetic participants (least-squares mean + or - SE: 7.4 + or - 0.3 vs. 5.0 + or - 0.3; P<0.0001). The prevalence of depressive disorder (as defined by BDI-II>14 and/or antidepressant use) in participants with type 2 diabetes was significantly higher than that of age- and sex-adjusted non diabetic participants (32.1 vs. 16.0%, P<0.0001). Type 2 diabetic participants reported using more antidepressant medications (20.7 vs. 12.1%, P = 0.0003). More type 2 diabetic than non diabetic participants were classified as depressed by BDI-II cut score (17.5 vs. 5.7%, P<0.0001) or by either BDI-II cut score or antidepressant use (32.1 vs. 16.0%, P<0.0001). Participants reporting diabetes complications (n = 209) had higher mean BDI-II scores than those without complications (10.7 + or - 9.3 vs. 6.4 + or - 6.3, P<0.0001).

CONCLUSIONS

Depression is highly prevalent in type 2 diabetes and requires further study on assessment and treatment.

Does diabetes-related distress explain the presence of depressive symptoms and/or poor self-care in individuals with Type 1 diabetes?

AIMS

To examine the relationship between depressive symptomatology, diabetes-related distress and aspects of diabetes self-care in a cohort of individuals with Type 1 diabetes.

METHODS

Individuals with Type 1 diabetes taking part in the Pittsburgh Epidemiology of Diabetes Complications Study completed the Beck Depression Inventory (BDI), the Center for Epidemiologic Studies Depression (CES-D) Scale and the Problem Areas in Diabetes (PAID) scale. Self-care was measured by physical activity in the past week and over the previous year, frequency of blood glucose/urine testing, smoking status and alcohol intake.

RESULTS

Clinically significant levels of depressive symptomatology (i.e. scores >or= 16) were reported by 14% of the study population on the BDI and by 18% on the CES-D. There were strong correlations between depressive symptoms and diabetes-related distress (PAID scores) and physical activity. Multivariate analyses indicated that depression was independently associated with diabetes-related distress scores and with physical activity, but not with frequency of blood glucose testing.

CONCLUSIONS

These findings have implications for clinical practice and treatment of both psychological morbidity and diabetes. There may be significant effects of depression on aspects of diabetes self-care. Further prospective studies are required to confirm these findings.

Prevalence and correlates of depression in individuals with and without type 1 diabetes

OBJECTIVE

Depression is associated with poor glycemic control and complications in people with type 1 diabetes. We assessed the prevalence of depression and antidepressant medication use among adults with and without type 1 diabetes and the association between depression and diabetes complications.

RESEARCH DESIGN AND METHODS

In 2006-2008, the Coronary Artery Calcification in Type 1 Diabetes Study applied the Beck Depression Inventory II (BDI-II) to 458 participants with type 1 diabetes (47% male, aged 44 +/- 9 years, type 1 diabetes duration 29 +/- 9 years) and 546 participants without diabetes (nondiabetic group) (51% male, aged 47 +/- 9 years). Use of antidepressant medication was self-reported. Depression was defined as a BDI-II score >14 and/or use of antidepressant medication. Occurrence of diabetes complications (retinopathy, blindness, neuropathy, diabetes-related amputation, and kidney or pancreas transplantation) was self-reported.

RESULTS

Mean BDI-II score, adjusted for age and sex, was significantly higher in participants with type 1 diabetes than in nondiabetic participants (least-squares mean +/- SE: 7.4 +/- 0.3 vs. 5.0 +/- 0.3; P < 0.0001). Type 1 diabetic participants reported using more antidepressant medications (20.7 vs. 12.1%, P = 0.0003). More type 1 diabetic than nondiabetic participants were classified as depressed by BDI-II cut score (17.5 vs. 5.7%, P < 0.0001) or by either BDI-II cut score or antidepressant use (32.1 vs. 16.0%, P < 0.0001). Participants reporting diabetes complications (n = 209) had higher mean BDI-II scores than those without complications (10.7 +/- 9.3 vs. 6.4 +/- 6.3, P < 0.0001).

CONCLUSIONS

Compared with nondiabetic participants, adults with type 1 diabetes report more symptoms of depression and more antidepressant medication usage. Depression is highly prevalent in type 1 diabetes and requires further study on assessment and treatment.

Depressive symptoms and the metabolic syndrome in childhood and adulthood: a prospective cohort study

OBJECTIVE

To examine the reciprocal associations between depressive symptoms and clinical definitions of the metabolic syndrome in childhood and adulthood.

DESIGN

Population-based prospective cohort study of 921 participants (538 women and 383 men) in Finland. The components of the metabolic syndrome were measured in childhood (mean age 12 years) and again in adulthood (mean age 33 years). A revised version of the Beck Depression Inventory was used to assess depressive symptoms at the mean ages of 24 and 33.

MAIN OUTCOME MEASURES

Metabolic syndrome defined by the National Cholesterol Education Program Adult Treatment Panel III (NCEP), the European Group for the Study of Insulin Resistance, and the International Diabetes Federation criteria.

RESULTS

In women, depressive symptoms were associated with increased risk of the metabolic syndrome in adulthood (odds ratio for NCEP metabolic syndrome per 1 SD increase in depressive symptoms 1.40, 95% confidence interval 1.05-1.85). The metabolic syndrome in childhood, in turn, predicted higher levels of depressive symptoms in adulthood (p = .03). In men, no associations were found between depressive symptoms and the clinical definitions of the metabolic syndrome.

CONCLUSION

The process linking depressive symptoms with the metabolic syndrome may go into both directions and may begin early in life.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

The comorbidity of diabetes mellitus and depression

Several factors, including sedentary lifestyle, obesity, and an aging population, contribute to epidemic rates of type 2 diabetes mellitus. Depression frequently occurs comorbidly with diabetes although it is unrecognized and untreated in approximately two thirds of patients with both conditions. The course of depression in patients with both diabetes and depression is chronic and severe. Up to 80% of patients with diabetes and depression will experience a relapse of depressive symptoms over a 5-year period. Depression is associated with nonadherence to diabetes self-care--including following dietary restrictions, medication compliance, and blood glucose monitoring--resulting in worse overall clinical outcomes. Due to potential negative health consequences associated with comorbid diabetes and depression, both conditions should be optimally treated to maximize patient outcomes.

Clinically relevant depressive symptoms and peripheral arterial disease in elderly men and women. Results from a large cohort study in Southern China

OBJECTIVE

Results from previous epidemiological studies on the relationship between depression and peripheral arterial diseases (PADs) were mixed. Therefore, a study was conducted to investigate this relationship in a large Chinese elderly sample.

METHODS

Cross-sectional data from the baseline examination of a large cohort study on Chinese elderly were used in this current study. A stratified convenience sample of 3985 Hong Kong men and women aged 65 to 92 were recruited from the community. Clinically relevant depressive symptoms were assessed by the use of a validated screening instrument for depression: the Chinese version of the Short Form of Geriatric Depression Scale. PAD was assessed by the ankle-brachial index, with an index of <0.9 indicating the presence of PAD. Multiple logistic regression was used to compare the presence of PAD in depressed and nondepressed subjects, controlling for confounding variables for the relationship.

RESULTS

In the total subject population, more severe peripheral atherosclerosis was associated with a higher prevalence of depressive disorders. The presence of peripheral atherosclerosis was associated with an adjusted odds ratio of 1.46 (95% confidence interval=1.01-2.10) of having clinically relevant depressive symptoms.

CONCLUSION

We showed that depressive symptoms were associated with peripheral atherosclerosis in the Asian elderly after adjusting for stroke and cardiovascular diseases. Prospective studies are needed to provide conclusive evidence on the causality of the relationship between peripheral atherosclerosis and depressive symptoms.

Depression and the risk for cardiovascular diseases: systematic review and meta analysis

BACKGROUND

Depression and cardiovascular diseases are both common among elderly. Depression is suspected to be an independent risk factor for the onset of coronary heart disease, yet it is not clear to what extent and if depression also is associated with the onset of other diseases of the circulatory system.

AIMS

To estimate the risk of depression as an independent risk factor for various cardiovascular diseases (CVD) and explore the effects of heterogeneity and methodological quality.

METHOD

Meta-analyses and meta-regression analyses of longitudinal cohort and case-control studies reporting depression at baseline and CVD outcomes at follow-up.

DATA SOURCES

MEDLINE (1966-2005) and PSYCHINFO (1966-2005).

RESULTS

Of the 28 studies that met the inclusion criteria, 11 were assesed as high quality studies. Although depressed mood increased the risk for a wide range of CVDs, heterogeneity was substantial in most cases. Only the overall combined risk of depression for the onset of myocardial infarctions (n=8, OR=1.60, 95%CI 1.34-1.92) was homogenous. Clinically diagnosed major depressive disorder was identified as the most important risk factor for developing CVD.

CONCLUSIONS

Depression seems to be an independent risk factor for the onset of a wide range of CVDs, although this evidence is related to a high level of heterogeneity.

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 relation of free plasma tryptophan to anger, hostility, and aggression in a nonpatient sample of adult men and women

BACKGROUND

Dysregulation of central nervous system serotonergic (5-HT) activity is implicated in behavioral states and psychological traits associated with depression and aggression, with some studies suggesting possible gender-related differences.

PURPOSE

This study examined the relation of free plasma tryptophan (TRP) to aggression and depression in a sample of 138 nonsmoking adults recruited from the general community. It was hypothesized that TRP would be associated with anger, hostility, and aggression.

METHODS

To minimize effects of diurnal variation and menstrual cycle, fasting blood samples were collected in the morning, and, for women, during the follicular phase of the menstrual cycle. Participants were administered questionnaires following blood draw. Plasma TRP was determined by high performance liquid chromatography.

RESULTS

In women, but not men, higher levels of TRP were associated with trait hostility, propensity for anger, a tendency to express anger outwardly, and an antagonistic interpersonal style. For men and women, greater severity of depressive symptoms, anger, and the verbal expression of anger were associated with higher TRP. These associations were independent of age, body mass index, fasting albumin, and race and ethnicity.

CONCLUSIONS

These data suggest that in women, but not men, higher plasma levels of TRP, the precursor to 5-HT, are associated with anger-hostility-aggression and that these associations are independent of various potential confounds. Implications of these observations to studies employing acute TRP depletion studies are discussed.

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.

Depression in coronary artery disease: novel pathophysiologic mechanisms and therapeutic implications

Depression is a common comorbid condition in patients with coronary artery disease and a well-documented risk factor for recurrent cardiac events and mortality. The exact mechanisms underlying the interplay between depression and ischemic heart disease remain poorly understood and the same is true for the most effective depression treatment for cardiac patients. This review summarizes current knowledge regarding the prognostic role of depression in patients with coronary artery disease, the pathophysiologic pathways involved, and the effects of antidepressant therapy on cardiovascular disease outcomes. With recent evidence suggesting that selective serotonin reuptake inhibitors may improve survival after myocardial infarction in patients with depression, diagnosis and treatment of this co-morbidity may be essential for the clinical management of coronary artery disease.

Sex differences in the relation of depressive symptoms, hostility, and anger expression to indices of glucose metabolism in nondiabetic adults

This study examined the relation of depressive symptomatology, hostility, and anger expression to indices of glucose metabolism and tested whether gender moderates these associations in a sample of 135 healthy, nondiabetic adults (75 men, 60 women). The severity of depressive symptoms, hostility, and anger expression was positively associated with estimated insulin resistance (IR) and insulin in women but not in men. Anger expression was positively associated with glucose in women only. A summary score of depressive symptoms, hostility, and anger expression was positively associated with estimated IR, insulin, and glucose in women but not in men. Hence, in women, IR and elevated levels of fasting insulin and glucose may be one pathophysiological mechanism mediating the increased risk of cardiovascular disease and Type 2 diabetes associated with these psychological attributes.

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.

Depression and all-cause and coronary heart disease mortality among adults with and without diabetes

OBJECTIVE

The aim of this study was to evaluate the effect of depression on all-cause and coronary heart disease (CHD) mortality among adults with and without diabetes.

RESEARCH DESIGN AND METHODS

We studied 10,025 participants in the population-based National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study who were alive and interviewed in 1982 and had complete data for the Center for Epidemiologic Studies Depression Scale. Four groups were created based on diabetes and depression status in 1982: 1) no diabetes, no depression (reference group); 2) no diabetes, depression present; 3) diabetes present, no depression; and i4) diabetes present, depression present. Cox proportional hazards regression models were used to calculate multivariate-adjusted hazard ratios (HRs) of death for each group compared with the reference group.

RESULTS

Over 8 years (83,624 person-years of follow-up), 1,925 deaths were documented, including 522 deaths from CHD. Mortality rate per 1,000 person-years of follow-up was highest in the group with both diabetes and depression. Compared with the reference group, HRs for all-cause mortality were no diabetes, depression present, 1.20 (95% CI 1.03-1.40); diabetes present, no depression 1.88 (1.55-2.27); and diabetes present, depression present, 2.50 (2.04-3.08). HRs for CHD mortality were no diabetes, depression present, 1.29 (0.96-1.74); diabetes present, no depression 2.26 (1.60-3.21); and diabetes present, depression present, 2.43 (1.66-3.56).

CONCLUSIONS

The coexistence of diabetes and depression is associated with a significantly increased risk of death from all causes, beyond that due to having either diabetes or depression alone.

Depression and cardiovascular disease: a reciprocal relationship

Until relatively recently, depression has been considered a purely "mental" disorder and therefore in the natural domain of psychologists and psychiatrists. However, recent epidemiological studies have revealed that aging, physical and psychological stress, chronic pain, several metabolic disorders such as insulin resistance and established diabetes, alcoholism, inflammatory conditions, and vascular disorders such as arterial hypertension all may be associated with depression. The present review examines some of these depression-associated factors and the mechanisms by which they might give rise to vascular disorders such as atherosclerosis, microcirculation endothelial dysfunction, and interstitial disturbances leading to organ damage. A number of disorders involving the circulation can lead progressively and insidiously to large artery rigidity, remodeling of peripheral arteries, and alterations of the microcirculation of large blood vessels. Perturbations in vasa vasorum blood flow may contribute to atherogenesis, in addition to the influence of numerous cellular events involved in inflammation (tumor necrosis factor alpha, interleukin 1 beta, etc). Since Hans Selye first described the neuroendocrine cascade generated by experimentally induced stress half a century ago, phenomena such as the axonal release of neurotransmitters (including serotonin), accumulation of metabolites such as homocysteine, platelet-activating factor, and nitric oxide also have been implicated in the pathogenesis of depression. Moreover, vascular consequences of depression such as heart rate and pulse pressure variations may lead to endothelial dysfunction in critical microcirculation networks (cerebral, myocardial, and renal) and initiate physicochemical alterations in interstitial compartments adjacent to vital organs. The appropriate use of ambulatory monitoring of vascular parameters, such as heart rate and pulse pressure, and eventually, early identification of genetic and metabolic markers may prove helpful in the early detection of events preceding and predicting the clinical manifestations of depression.

Reflections on depression as a cardiac risk factor

OBJECTIVE

Major North American cardiology organizations do not currently list depression among the officially recognized cardiac risk factors, yet many behavioral medicine specialists believe depression to be an important risk. We wondered what was missing from the available data.

METHODS

The Medline, Current Contents, and PsychInfo databases were used to perform a systematic review of the literature linking depression and depressive symptoms with cardiac disease outcomes. Because of previous reviews, we paid particular attention to publications from 2001 to 2003.

RESULTS

We identified 21 etiologic and 43 prognostic publications that had prospective designs, used recognized measures of depression, and included objective outcome measures. We also identified 79 review articles. In addition to issues of sample size, sample characteristics, and timing of measures, we noted heterogeneity in the definitions of depression, frequent repeat publications from the same data sets, heterogeneity of outcome measures, a variety of approaches for covariate selection, and a preponderance of review articles, all factors that cannot help to convince skeptics.

CONCLUSIONS

Despite these issues, the bulk of the data from prospective studies with recognized indices of depression and objective outcome measures is supportive of depression as a cardiac risk factor.

Depression and the adolescent with type 1 diabetes: the covert comorbidity

Diabetes and depression have become increasingly linked. The incidence of depression in the adolescent diabetic population is especially concerning. The purpose of this article is to raise awareness of the association between diabetes and depression particularly in the adolescent population. It also discusses treatment techniques for the same population. Several treatment techniques have proved successful in this population. Psychiatric nurse practitioners and advanced practiced nurses are poised to implement these treatments and interventions.

Cardiac risk factors in patients with diabetes mellitus and major depression

OBJECTIVE

The prevalence of major depression is approximately 2-fold higher in patients with diabetes mellitus compared to medical controls. We explored the association of major depression with 8 cardiac risk factors in diabetic patients with and without evidence of cardiovascular disease (CVD).

DESIGN

A mail survey questionnaire was administered to a population-based sample of 4,225 patients with diabetes to obtain data on depression status, diabetes self-care (diet, exercise, and smoking), diabetes history, and demographics. On the basis of automated data we measured diabetes complications, glycosylated hemoglobin, medical comorbidity, low-density lipid levels, triglyceride levels, diagnosis of hypertension, and evidence of microalbuminuria. Separate analyses were conducted for subgroups according to the presence or absence of CVD.

SETTING

Nine primary care clinics of a nonprofit health maintenance organization.

MAIN RESULTS

Patients with major depression and diabetes were 1.5- to 2-fold more likely to have 3 or more cardiovascular risk factors as patients with diabetes without depression (62.5% vs 38.4% in those without CVD, and 61.3% vs 45% in those with CVD). Patients with diabetes without CVD who met criteria for major depression were significantly more likely to be smokers, to have a body mass index (BMI) > or = 30 kg/m2, to lead a more sedentary lifestyle, and to have HbA1c levels of >8.0% compared to nondepressed patients with diabetes without heart disease. Patients with major depression, diabetes, and evidence of heart disease were significantly more likely to have a BMI > or = 30 kg/m2, a more sedentary lifestyle, and triglyceride levels > 400 mg/dl than nondepressed diabetic patients with evidence of heart disease.

CONCLUSIONS

Patients with major depression and diabetes with or without evidence of heart disease have a higher number of CVD risk factors. Interventions aimed at decreasing these risk factors may need to address treatment for major depression in order to be effective.

Cytokine-serotonin interaction through IDO: a neurodegeneration hypothesis of depression

There are different theories and hypotheses related to the aetiology of depression. The interaction between brain 5-HT level and the activity of its autoreceptors plays a role in mood changes and depression. In major depression, activation of the inflammatory response system (IRS) and, increased concentrations of proinflammatory cytokines, prostaglandin E2 and negative immuno-regulatory cytokines in peripheral blood have been reported. Recently, pro-inflammatory cytokines have been found to have profound effects on the metabolism of brain serotonin through the enzyme indoleamine-2,3-dioxygenase (IDO) that metabolizes the tryptophan, the precursor of 5-HT to neurodegenerative quinolinate and neuroprotective kynurenate. The cytokine-serotonin interaction that leads to the challenge between quinolinate and kynurenate in the brain explains the neurodegeneration hypothesis of depression.

Geriatric depression and vascular diseases: what are the links?

BACKGROUND

The term "vascular depression" has been proposed to describe a subset of depressive disorders that occurs in old age as a consequence of cerebrovascular disease. However, depression has been shown to result from other cardiovascular diseases such as coronary heart diseases, as well as to precipitate, worsen or precede vascular diseases. Depression also increases the likelihood of the incidence of vascular risk factors such as diabetes.

AIMS

To review clinical and epidemiological evidence linking geriatric depression and vascular diseases, and to discuss the potential mechanisms that could underlie this association.

METHOD

Systematic review of the literature of the last 5 years through Medline database search.

RESULTS

Papers report the following potential ways of association: (1) there is a direct influence of vascular disease, in particular, arteriosclerosis, on the incidence of depression; (2) depressive disorders have a direct impact on the cardiovascular system; (3) depression and vascular disease share either a common pathophysiological process or genetic determinants.

DISCUSSION

Depression can be understood as the direct consequence of brain damage in neurodegenerative disorders such as Parkinson's or Huntington's diseases. Similarly, vascular depression is mostly considered to be the consequence of microvascular lesions on prefrontal and subcortical regions. However, this functional neuroanatomical model offers no explanation for cases where depression has been shown to precede vascular diseases. Since cardiovascular diseases develop in a context of acquired environmental factors together with genetically determined disease, it may be postulated that geriatric depression could both result from brain lesions of vascular origin and also share some pathogenic or genetic determinants.

Depression and the metabolic syndrome in young adults: findings from the Third National Health and Nutrition Examination Survey

OBJECTIVE

Previous reports have suggested that depression may lead to the development of cardiovascular disease through its association with the metabolic syndrome; however, little is known about the relationship between depression and the metabolic syndrome. The aim of this study was to establish an association between depression and the metabolic syndrome in a nationally representative sample.

METHODS

The Third National Health and Nutrition Examination Survey is a population-based health survey of noninstitutionalized US citizens completed between 1988 and 1994. Three thousand one hundred eighty-six men and 3003 women, age 17 to 39, free of coronary heart disease and diabetes, completed the depression module from the Diagnostic Interview Schedule and a medical examination that provided clinical data needed to establish the presence of the metabolic syndrome, as defined by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Cholesterol in Adults.

RESULTS

Women with a history of a major depressive episode were twice as likely to have the metabolic syndrome compared with those with no history of depression. The relationship between depression and metabolic syndrome remained after controlling for age, race, education, smoking, physical inactivity, carbohydrate consumption, and alcohol use. Men with a history of depression were not significantly more likely to have the metabolic syndrome.

CONCLUSIONS

The prevalence of the metabolic syndrome is elevated among women with a history of depression. It is important to better understand the role depression may play in the effort to reduce the prevalence of the metabolic syndrome and its health consequences.

Psychosocial factors in the development of coronary artery disease

The fact that traditional risk factors only account for approximately two thirds of cases of coronary artery disease (CAD) has stimulated increasing interest in the relationship between CAD and psychosocial factors. Five areas--chronic stress, socioeconomic status (SES), personality, depression, and social support--have been most thoroughly examined. There is evidence to support a causal relationship between chronic stress, SES, depression, and social support and development of CAD. In this article, we discuss the epidemiologic evidence linking psychosocial factors and CAD, and review the effects of psychosocial factors on several pathophysiologic mechanisms that have been proposed as potential mediators of CAD. The hypothalamic-pituitary-adrenal axis, hypertension and cardiovascular reactivity, endothelial function, inflammatory markers, platelets, coagulation factors, fibrinogen, lipids, glucose metabolism, and lifestyle factors have all been implicated in this process. Recently, the first intervention trials have been carried out, although with initially disappointing results. Reducing the cardiovascular risk due to these psychosocial factors will be one of the major health care challenges in the future.