Cathy E. Lloyd

Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis

Aims/hypothesisAn earlier meta-analysis showed that diabetes is a risk factor for the development and/or recurrence of depression. Yet whether this risk is different for studies using questionnaires than for those relying on diagnostic criteria for depression has not been examined. This study examined the association of diabetes and the onset of depression by reviewing the literature and conducting a meta-analysis of longitudinal studies on this topic.MethodsEMBASE, MEDLINE and PsycInfo were searched for articles published up to September 2009. All studies that examined the relationship between type 2 diabetes and the onset of depression were included. Pooled relative risks were calculated using fixed and random effects models.ResultsEleven studies met our inclusion criteria for this meta-analysis. Based on the pooled data, including 48,808 cases of type 2 diabetes without depression at baseline, the pooled relative risk was 1.24 (95% CI 1.09–1.40) for the random effects model. This risk was significantly higher for studies relying on diagnostic criteria of depression than for studies using questionnaires. However, this difference was no longer significant when controlled for year of publication.Conclusions/interpretationCompared with non-diabetic controls, people with type 2 diabetes have a 24% increased risk of developing depression. The mechanisms underlying this relationship are still unclear and warrant further research.

Epidemiology of depression and diabetes: A systematic review

BACKGROUND Research suggests that co-morbid diabetes and depression is common; however, the implications for clinical practice remain unclear. This paper reviews the current epidemiological evidence on comorbid diabetes and depression, in order to identify the key publications which could both inform practice and identify gaps in knowledge and research. METHODS A systematic review was conducted to identify published literature on the epidemiology of diabetes and depression. In order to review evidence on up-to-date knowledge of recent research and innovations in care literature searches for the last five years (August 2006-August 2011) were conducted. To identify relevant literature, electronic databases MEDLINE, Psych-INFO and EMBASE were searched for English language articles in peer-reviewed journals. RESULTS High rates of co-morbidity of depression and diabetes have been reported. The prevalence rate of depression is more than three-times higher in people with type 1 diabetes (12%, range 5.8-43.3% vs. 3.2%, range 2.7-11.4%) and nearly twice as high in people with type 2 diabetes (19.1%, range 6.5-33% vs. 10.7%, range 3.8-19.4%) compared to those without. Women with diabetes and also women without diabetes experience a higher prevalence of depression than men. Reviewed studies provide support for a modest relationship between diabetes and depressive symptoms, but the exact direction of this relationship remains unclear. LIMITATIONS Most studies reviewed were cross-sectional and this limits any conclusions about the causal nature and direction of the relationship between diabetes and depression. Variation in measurement methods, lack of longitudinal data and few studies outside Europe and America limit the generalizability of the findings of this review. CONCLUSIONS Current research suggests that the risk of developing depression is increased in people with diabetes; however, further studies are required in order to establish the nature of the relationship between depression, glycaemic control and the development of diabetes complications, and make appropriate recommendations for treatment and to support self-management of diabetes.

Prevalence of symptoms of depression and anxiety in a diabetes clinic population

Aims To investigate the use of a short questionnaire to measure psychological symptoms in a busy clinic setting, and to examine the prevalence of these symptoms in adults with diabetes. The perceived need for psychological treatment services was also measured.

Predictors of Microalbuminuria in Individuals with IDDM: Pittsburgh Epidemiology of Diabetes Complications Study

OBJECTIVE To examine the relationships between microalbuminuria and the development of overt diabetic nephrology, elevated blood pressure, and a more atherogenic lipid profile; and to identify risk factors for the development of microalbuminuria in individuals with IDDM. Microalbuminuria has been associated with the subsequent development of overt diabetic nephropathy in individuals with IDDM. It is associated with elevated blood pressure and a more atherogenic lipid profile, but the temporal relationship between the development of microalbuminuria and the changes in these factors is unclear. RESEARCH DESIGN AND METHODS Baseline characteristics were examined in 256 individuals with IDDM who had normal albumin excretion (urinary AER ≤20 μg/min in ≥2 timed urine collections) and were re-examined 2 yr later. RESULTS At follow-up, 24 had developed microalbuminuria (AER 20–200 (Ag/min in ≥2 timed urine collections) and 1 had developed overt nephropathy (AER ≥200 μg/min). Overall, the significant independent predictors of microalbuminuria were HbA1 (P < 0.001), low-density lipoprotein (P < 0.01), duration of IDDM (P < 0.05), and systolic blood pressure (P = 0.05). Sex-specific analyses showed HbA1 age, and baseline AER were particularly important for men; whereas, for women, the main predictors were duration of IDDM and triglycerides. Duration-specific analyses showed that HbA1 was an important predictor both for individuals with < and >20-yr duration. Low-density lipoprotein cholesterol was more important for subjects with shorter durations; whereas triglycerides were important for those with longer durations. CONCLUSIONS These results suggest that glycemic control, age or duration of IDDM, disturbed lipids, and possibly elevated blood pressure all may contribute to the development of microalbuminuria; and, further, that the adverse cardiovascular risk profile seen in individuals with overt nephropathy may begin to develop even before the detection of microalbuminuria.

Coronary Artery Disease in IDDM: Gender Differences in Risk Factors but Not Risk

Insulin-dependent diabetes mellitus (IDDM) increases the risk of developing coronary artery disease (CAD) compared with that seen in the general population, while the sex differential in rates of CAD is considerably reduced in IDDM populations. To further our understanding of these observations, the effects of gender on baseline risk factors for CAD incidence were examined. Participants in the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study were recruited from the Childrens Hospital of Pittsburgh IDDM registry and had been diagnosed between 1950 and 1980. Subjects completed a series of questionnaires and were given a full clinical examination at baseline (1986 through 1988) and every subsequent 2 years. This report is based on the first 4 years of follow-up. Similar incidence rates of new CAD events were observed in men and women. In neither sex was glycemic control a predictor of later CAD. Sex-specific Cox proportional hazards models showed that for men, duration of IDDM, HDL cholesterol, fibrinogen, hypertension, and smoking were all significantly associated with the onset of CAD. Hypertension, fibrinogen, and smoking were all replaced by nephropathy when this latter variable was added to the model. For women, duration, hypertension, waist-hip ratio, physical activity, and depressive symptomatology were all significant independent predictors of CAD. Nephropathy status did not enter the model for women. While 4-year incidence of CAD in IDDM varies little by sex in this population, the predictive risk factors vary considerably. In particular, the effect of renal disease was stronger in men, while the cluster of physical activity, waist-to-hip ratio, and depressive symptomatology were more important in women. These results may help explain the relatively greater impact IDDM has on CAD risk for women and suggest new potential preventive approaches.

Prevalence of Depression in Individuals With Impaired Glucose Metabolism or Undiagnosed Diabetes: A systematic review and meta-analysis of the European Depression in Diabetes (EDID) Research Consortium

OBJECTIVE Meta-analyses have shown that the risk for depression is elevated in type 2 diabetes. Whether this risk in individuals with impaired glucose metabolism (IGM) or undiagnosed diabetes (UDD) is elevated relative to normal glucose metabolism (NGM) or decreased relative to previously diagnosed type 2 diabetes (PDD) has not been the subject of a systematic review/meta-analysis. This study examined the prevalence of depression in IGM and UDD subjects relative to each other and to NGM and PDD subjects by reviewing the literature and conducting a meta-analysis of studies on this topic. RESEARCH DESIGN AND METHODS EMBASE and MEDLINE databases were searched for articles published up to May 2010. All studies that compared the prevalence of depression in subjects with IGM and UDD were included. Odds ratios (ORs) were calculated using fixed and random-effects models. RESULTS The meta-analysis showed that the risk for depression was not increased in IGM versus NGM subjects (OR 0.96, 95% CI 0.85–1.08). Risk for depression did not differ between individuals with UDD and individuals with either NGM (OR 0.94, 95% CI 0.71–1.25) or IGM (OR 1.16, 95% CI 0.88–1.54). Finally, individuals with IGM or UDD both had a significantly lower risk of depression than individuals with PDD (OR 0.59, 95% CI 0.48–0.73, and OR 0.57, 95% CI 0.45–0.74, respectively). CONCLUSIONS Results of this meta-analysis show that the risk of depression is similar for NGM, IGM, and UDD subjects. PDD subjects have an increased risk of depression relative to IGM and UDD subjects.

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

Diabet. Med. 29, 164–175 (2012)

Systematic literature review: quality of life associated with insulin pump use in Type 1 diabetes.

Aim  To review systematically the published literature addressing whether continuous subcutaneous insulin infusion (CSII) provides any quality of life benefits to people with Type 1 diabetes.

The progression of retinopathy over 2 years: the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study.

This study examined potential risk factors for the incidence and progression of retinopathy in a large representative cohort of childhood onset insulin-dependent diabetic patients. Participants in the Epidemiology of Diabetes Complications (EDC) Study underwent a full clinical examination at baseline and again at a 2-year follow-up. Retinopathy status was ascertained using stereo fundus photographs graded according to the modified Airlie House System. The study population is based on a large cohort of childhood-onset insulin-dependent diabetic patients, seen within 1 year of diagnosis at the Childrens Hospital of Pittsburgh between January 1950 and May 1980. A total of 657 subjects participated at baseline (1986-1988), with 80% of eligible survivors taking part in the follow-up examination. This report concerns risk factors associated with the progression of diabetic retinopathy over a 2-year period, and the interaction of these factors with the presence of nephropathy. Analyses showed that baseline diastolic blood pressure was significantly associated with the incidence of any retinopathy, while glycosylated hemoglobin, baseline severity of retinopathy, serum triglycerides, and, to a lesser extent, higher levels of low-density lipoprotein (LDL) cholesterol and fibrinogen were associated with the progression of retinopathy. Progression to proliferative retinopathy was related to higher LDL cholesterol, fibrinogen, serum triglycerides, albumin excretion rate, and glycosylated hemoglobin (GHb). Risk factors varied with the presence of nephropathy. In the absence of nephropathy, GHb was a significant predictor of progression, whilst this was not the case in the presence of nephropathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Why does diabetic autonomic neuropathy predict IDDM mortality? An analysis from the Pittsburgh Epidemiology of Diabetes Complications Study

BACKGROUND Previous studies have suggested that IDDM subjects with diabetic autonomic neuropathy (DAN) have a greatly increased risk of mortality which may relate to a specific cardiologic etiology. OBJECTIVES To examine the predictors of DAN in IDDM and its relationship to subsequent mortality. STUDY POPULATION The Epidemiology of Diabetes Complications Study based on an incident cohort of childhood onset IDDM subjects. Data from two examinations, separated by 2 years, are utilized. METHODS Diabetic autonomic neuropathy was determined by Expiration/Inspiration (E/I ratio). A variety of baseline risk factors were related to its subsequent incidence (n = 57 out of 325 subjects free of DAN at baseline). Two-year mortality by DAN status was also determined for all 479 subjects seen at baseline. RESULTS Duration of diabetes, the cardiovascular risk profile (hypertension, elevated LDL cholesterol and triglycerides), and other complications (e.g. nephropathy) were all univariately associated with subsequent DAN (P < 0.01). Smoking status and hemoglobin A1 (HbA1) but less strongly, related (P < 0.05). Cox proportional hazards modeling showed diabetes duration and HbA1 to be significant independent predictors. Distal Symmetrical Polyneuropathy also contributed if added to the model. Mortality was increased four-fold in those with DAN (P = 0.005), although this difference no longer was significant after adjustment for baseline nephropathy (P = 0.35) or hypertension (P = 0.42). CONCLUSIONS Duration of diabetes and HbA1 are the major predictors of DAN. However, although DAN is clearly associated with increased mortality, this is largely explained by associations with complications (e.g. nephropathy) and increased cardiovascular risk factors (e.g. hypertension).