History of major depressive disorder and diabetes outcomes in diet- and tablet-treated post-menopausal women: a case control study

The Relationship Between Psychosocial Factors and Adherence to Treatment in Men, Premenopausal and Menopausal Women with Type 2 Diabetes Mellitus

Introduction

Type 2 Diabetes Mellitus (T2DM) is a chronic disease that begins in adulthood, and is caused by multiple factors. The onset of menopause involves changes that predispose women to the development of T2DM, which can worsen if the adherence to treatment is inadequate due to psychosocial factors or medications. The present study aims to describe the psychosocial factors that may affect adherence to treatment among men and premenopausal and menopausal women with T2DM.

Methods

This was a cross-sectional study of 96 patients with T2DM, who were divided into three groups: 1) men (n=32); 2) premenopausal women (n=32); and 3) menopausal women (n=32). Somatometric and metabolic control data were obtained. Adherence to treatment and psychosocial factors were evaluated: social support, belief in conventional medicine, disease denial, and depressive symptoms.

Results

Adherence to medication had a negative correlation with depressive symptoms in men (p <0.001) and menopausal women (p <0.021). Dietary adherence had a positive correlation with belief in conventional medicine in men (p <0.037) and premenopausal women (p <0.029).

Conclusion

Medication adherence in men and menopausal women was correlated with fewer depressive symptoms. Adherence to diet in men and premenopausal women was correlated with greater belief in conventional medicine. The results show the diversity of psychosocial factors among the groups that must be addressed in order to improve adherence.

Clinical risk factors for depressive syndrome in Type 2 diabetes: the Fremantle Diabetes Study

AIMS

To identify early clinical predictors of depressive syndrome in people with Type 2 diabetes.

METHODS

Depressive syndrome was assessed in 325 individuals with Type 2 diabetes 15 years after a baseline assessment, which included information on antidepressant use and depressive symptoms obtained using a quality-of-life scale. Follow-up current and lifetime depressive syndrome were assessed using the nine-item Patient Health Questionnaire and the Brief Lifetime Depression Scale and taking account of antidepressant use. Analyses were conducted inclusive and exclusive of antidepressant use where Patient Health Questionnaire criteria were not met.

RESULTS

At baseline, the participants were aged 57.2±9.3 years and the median (interquartile range) diabetes duration was 2.2 (0.6-6.0) years. After a mean of 14.7±1.1 years' follow-up, 81 participants (24.9%) had depressive syndrome (14.8% defined by the Patient Health Questionnaire, 10.2% defined by antidepressants) and 31.4% reported lifetime depression, and in 10.2% of participants this preceded diabetes onset. With logistic regression (inclusive of antidepressants), follow-up depressive syndrome was negatively associated with education level [odds ratio 0.39 (95% CI 0.20-0.75)] and antidepressant use [odds ratio 0.11 (95% CI 0.03-0.36)] and was positively associated with depression history before diabetes onset [odds ratio 2.79 (95% CI 1.24-6.27)]. In the model exclusive of antidepressants, depressive syndrome was positively associated with baseline depressive symptoms [odds ratio 2.57 (95% CI 1.32-5.03)] and antidepressant use [odds ratio 3.54 (95% CI 1.20-10.42)] and was negatively associated with education level [odds ratio 0.39 (95% CI 0.19-0.81)].

CONCLUSIONS

Risk factors for depressive syndrome can be identified early after the onset of Type 2 diabetes. The early presence of depressive symptoms or its treatment and/or history of depression are likely indicators of vulnerability. Early risk stratification for late depressive syndrome is feasible in people with Type 2 diabetes and could assist with depression treatment or prevention.

Correlates of Medication Adherence in the TODAY Cohort of Youth With Type 2 Diabetes

OBJECTIVE

To identify factors that predict medication adherence and to examine relationships among adherence, glycemic control, and indices of insulin action in TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth).

RESEARCH DESIGN AND METHODS

A total of 699 youth 10-17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication. Depressive symptoms, insulin sensitivity (1/fasting insulin), insulinogenic index, and oral disposition index (oDI) were measured. Survival analysis examined the relationship between medication adherence and loss of glycemic control. Generalized linear mixed models analyzed trends in adherence over time.

RESULTS

In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. Longitudinally, participants with high adherence had significantly greater insulin sensitivity and oDI than those with low adherence.

CONCLUSIONS

In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. Medication adherence was positively associated with insulin sensitivity and oDI, but, because of disease progression, adherence did not predict long-term treatment success.

A systematic review of baseline psychosocial characterisation in dietary randomised controlled trials for weight loss

BACKGROUND/OBJECTIVE

To investigate the extent of baseline psychosocial characterisation of subjects in published dietary randomised controlled trials (RCTs) for weight loss.

SUBJECTS/METHODS

Systematic review of adequately sized (n ≥ 10) RCTs comprising ≥ 1 diet-alone arm for weight loss were included for this systematic review. More specifically, trials included overweight (body mass index >25 kg/m(2)) adults, were of duration ≥ 8 weeks and had body weight as the primary outcome. Exclusion criteria included specific psychological intervention (for example, Cognitive Behaviour Therapy (CBT)), use of web-based tools, use of supplements, liquid diets, replacement meals and very-low calorie diets. Physical activity intervention was restricted to general exercise only (not supervised or prescribed, for example, VO2 maximum level).

RESULTS

Of 176 weight-loss RCTs published during 2008-2010, 15 met selection criteria and were assessed for reported psychological characterisation of subjects. All studies reported standard characterisation of clinical and biochemical characteristics of subjects. Eleven studies reported no psychological attributes of subjects (three of these did exclude those taking psychoactive medication). Three studies collected data on particular aspects of psychology related to specific research objectives (figure scale rating, satiety and quality-of-life). Only one study provided a comprehensive background on psychological attributes of subjects.

CONCLUSION

Better characterisation in behaviour-change interventions will reduce potential confounding and enhance generalisability of such studies.

Depression scores predict adherence in a dietary weight loss intervention trial

BACKGROUND & AIMS

Depression has a complex association with cardiometabolic risk, both directly as an independent factor and indirectly through mediating effects on other risk factors such as BMI, diet, physical activity, and smoking. Since changes to many cardiometabolic risk factors involve behaviour change, the rise in depression prevalence as a major global health issue may present further challenges to long-term behaviour change to reduce such risk. This study investigated associations between depression scores and participation in a community-based weight management intervention trial.

METHODS

A group of 64 overweight (BMI > 27), otherwise healthy adults, were recruited and randomised to follow either their usual diet, or an isocaloric diet in which saturated fat was replaced with monounsaturated fat (MUFA), to a target of 50% total fat, by adding macadamia nuts to the diet. Subjects were assessed for depressive symptoms at baseline and at ten weeks using the Beck Depression Inventory (BDI-II). Both control and intervention groups received advice on National Guidelines for Physical Activity and adhered to the same protocol for food diary completion and trial consultations. Anthropometric and clinical measurements (cholesterol, inflammatory mediators) also were taken at baseline and 10 weeks.

RESULTS

During the recruitment phase, pre-existing diagnosed major depression was one of a range of reasons for initial exclusion of volunteers from the trial. Amongst enrolled participants, there was a significant correlation (R = -0.38, p < 0.05) between BDI-II scores at baseline and duration of participation in the trial. Subjects with a baseline BDI ≥10 (moderate to severe depression symptoms) were more likely to dropout of the trial before week 10 (p < 0.001). BDI-II scores in the intervention (MUFA) diet group decreased, but increased in the control group over the 10-week period. Univariate analysis of variance confirmed these observations (adjusted R(2) = 0.257, p = 0.01). Body weight remained static over the 10-week period in the intervention group, corresponding to a relative increase in the control group (adjusted R(2) = 0.097, p = 0.064).

CONCLUSIONS

Depression symptoms have the potential to affect enrolment in and adherence to dietbased risk reduction interventions, and may consequently influence the generalisability of such trials. Depression scores may therefore be useful for characterising, screening and allocating subjects to appropriate treatment pathways.

Treatment patterns and resource use among patients with comorbid diabetes mellitus and major depressive disorder

OBJECTIVE

To descriptively analyze patient characteristics, treatment patterns, and medical resource use of individuals with diabetes mellitus (DM) with and without comorbid major depressive disorder (MDD).

RESEARCH DESIGN AND METHODS

Using an administrative claims database, commercially insured adults diagnosed with DM were studied over the calendar years 2005 and 2006. Demographic characteristics, comorbid illnesses, medication use, resource utilization, and costs were examined descriptively among patients with DM both with and without comorbid MDD.

RESULTS

Patients with DM and MDD were found to have a high resource burden, compared to patients with DM without MDD. Specifically, these patients were found to be more likely to be diagnosed with other comorbid medical conditions, to use multiple medications, and to use more healthcare services such as inpatient visits, emergency admissions, and outpatient visits. Consistent with these findings, costs for these patients were found to be $19,707 per year, compared to $11,237 for patients with DM without comorbid MDD.

LIMITATIONS

The study utilizes data from an administrative claims database of insured individuals and hence, results may not be generalizable. Furthermore, the analysis is unable to examine clinical severity or indirect costs.

CONCLUSION

Compared to patients with DM and no comorbid MDD, patients with DM and MDD tend to have a larger burden of disease and to use more healthcare resources.

A review of treatment response in type 2 diabetes: assessing the role of patient heterogeneity

The response to treatment for type 2 diabetes typically varies among individuals within a study population. This variation is known as heterogeneity of treatment response. We conducted a comprehensive literature review to identify factors that account for heterogeneity of treatment response in patients treated for type 2 diabetes. Three databases (PubMed, EMBASE and Cochrane Library) were searched for articles published in the last 10 years describing investigations of factors associated with treatment response and outcomes among people with type 2 diabetes receiving pharmacological treatment. Of the 43 articles extracted and summarized, 35 (81%) discussed clinical factors, 31 (72%) described sociodemographic factors and 17 (40%) reported on comorbidity or behavioural factors. Clinical factors identified included baseline glycated hemoglobin A1c or fasting plasma glucose (FPG) levels, insulin response or sensitivity, C-peptide, body composition, adipose tissue proteins, lipid profile, plasma albumin levels and duration of disease or insulin treatment. Other factors identified included age, sex, race, socioeconomic status and comorbidities. This review identified the following research gaps: use of multiple definitions for response, few patient-reported measures and lack of evidence regarding whether factors were associated with treatment response for only specific medications or across pharmacological therapies. Furthermore, identification of factors associated with type 2 diabetes treatment response was generally a secondary objective in the research reviewed. Understanding which patient subgroups are more likely to respond to treatment and identifying factors associated with response may result in targeted treatment decisions and alter the interpretation of efficacy or effectiveness of results. In conclusion, accounting for these factors in clinical trials and when making clinical treatment decisions may improve therapy selection and individual patient outcomes.

Lifetime depression and diabetes self-management in women with Type 2 diabetes: a case-control study

AIMS

Little is known about the association between lifetime history of major depressive disorder (L-MDD) and diabetes self-management, particularly when depression is remitted. We examined the association between L-MDD and diabetes self-management in women with Type 2 diabetes who were not depressed at the time of assessment.

METHODS

L-MDD was assessed with structured psychiatric interview. Participants completed paper-and-pencil measures of demographics, diabetes-related distress, self-care behaviours, healthcare utilization and diabetes self-efficacy.

RESULTS

One-hundred and fifty-three women participated; 41% had L-MDD. Compared with their never-depressed counterparts, women with L-MDD had more diabetes distress, reported lower overall rates of self-monitoring of blood glucose (SMBG) and greater tendency to skip SMBG, had lower diet adherence and were less likely to have seen a primary care provider in the past year. Diabetes self-efficacy mediated the relationship between L-MDD and self-management.

CONCLUSIONS

Interventions to promote self-management for patients with L-MDD may be warranted.

Endothelial dysfunction and history of recurrent depression in postmenopausal women with Type 2 diabetes: a case-control study

OBJECTIVES

This study of postmenopausal women with Type 2 diabetes mellitus (T2DM) investigated (1) history of depression as a predictor of endothelium-dependent flow-mediated dilation (FMD); (2) the relative associations of single and recurrent depressive disorders with FMD; and (3) cortisol as a potential mechanism.

METHODS

Participants were nonsmoking, naturally postmenopausal women with T2DM with no known vascular disease. All were free of current mood disorder. On average, the 44 participants were 63 years of age, White, diabetic for 6 years, and were in adequate glycemic control. Thirty-eight percent were never depressed, 19% had experienced one disorder, and 43% had experienced recurrent disorders. History of depression was assessed with Structured Clinical Interview for Diagnostic and Statistical Manual-IV. Current depressive symptoms were measured with Center for Epidemiological Studies Depression (CESD) scale. FMD was assessed by standard procedures and calculated as percent change in brachial artery diameter from baseline.

RESULTS

Women with history of recurrent depression showed vasoconstriction (mean=-1%), which was significantly different from women with history of single depression (mean=+6) and never depressed women (mean=+5) (P<.05), both of whom showed similar levels of vasodilation. In logistic regression controlling for hypertension, duration of diabetes, and glycemic control, history of recurrent depressive disorders predicted greater likelihood of vasoconstriction (P<.05, odds ratio=4.23) but history of single depressive disorder did not. Controlling for current depressive symptoms did not account for effects of past recurrent depressive disorders. Cortisol was not related to FMD.

CONCLUSIONS

In postmenopausal women with T2DM, recurrent depressive disorders, even in full remission, are associated with endothelial dysfunction. Potential mechanisms of the relationship between depression and endothelial dysfunction other than cortisol warrant investigation.

Psychiatric disorders are associated with hospital care utilization in persons with hypertension: results from the National Epidemiologic Survey on alcohol and related conditions

BACKGROUND

Psychiatric disorders and hypertension both independently increase risk for heart disease, cardiac events, and healthcare utilization. However, the contribution of specific psychiatric disorders to healthcare utilization in persons with hypertension is unknown.

OBJECTIVE

To evaluate associations between psychiatric disorders and receipt of hospital care in people with hypertension.

DESIGN

Cross-sectional epidemiologic survey.

SUBJECTS

A total of 8,812 hypertensive individuals drawn from a randomly selected sample of 43,093 US adults.

MAIN OUTCOMES

Participants were assessed in-person for a range of mental disorders (using the Diagnostic and Statistical Manual of Mental Disorders-IV), hypertension status (self-report), and past-year occurrence of emergency room treatment and overnight hospital stay (self-report).

RESULTS

After controlling for demographics and clinical variables, persons having any lifetime mood, anxiety, or personality disorders had increased likelihood of emergency room treatment [odds ratios (ORs) = 1.26, 1.18, and 1.47, respectively]. Persons having any mood or personality disorder had increased likelihood of overnight hospital stay (ORs = 1.24 and 1.31, respectively). The specific disorders significantly associated with emergency room treatment were lifetime major depression, lifetime manic disorder, past-year major depression, past-year manic disorder, past-year panic disorder without agoraphobia, and paranoid, histrionic, antisocial, obsessive-compulsive personality disorders, with ORs ranging from 1.25 to 2.41. The specific disorders significantly associated with overnight hospital stay were lifetime dysthymia, lifetime manic disorder, past-year major depression, past-year manic disorder, and histrionic, antisocial, and paranoid personality disorders, with ORs ranging from 1.40 to 1.87.

CONCLUSION

Results suggest that addressing mental health problems in persons with hypertension may decrease healthcare utilization.