Malia Oliver

Depression and Advanced Complications of Diabetes A prospective cohort study

OBJECTIVE To prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000–2002 and followed through 2005–2007. Advanced microvascular complications included blindness, end-stage renal disease, amputations, and renal failure deaths. Advanced macrovascular complications included myocardial infarction, stroke, cardiovascular procedures, and deaths. Medical record review, ICD-9 diagnostic and procedural codes, and death certificate data were used to ascertain outcomes in the 5-year follow-up. Proportional hazard models analyzed the association between baseline depression and risks of adverse outcomes. RESULTS After adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes (hazard ratio 1.36 [95% CI 1.05–1.75]) and adverse macrovascular outcomes (1.24 [1.0–1.54]). CONCLUSIONS Among people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities. Clinical and public health significance of these findings rises as the incidence of type 2 diabetes soars. Further research is needed to clarify the underlying mechanisms for this association and to test interventions to reduce the risk of diabetes complications among patients with comorbid depression.

Depression and Increased Mortality in Diabetes: Unexpected Causes of Death

PURPOSE Recent evidence suggests that depression is linked to increased mortality among patients with diabetes. This study examines the association of depression with all-cause and cause-specific mortality in diabetes. METHODS We conducted a prospective cohort study of primary care patients with type 2 diabetes at Group Health Cooperative in Washington state. We used the Patient Health Questionnaire (PHQ-9) to assess depression at baseline and reviewed medical records supplemented by the Washington state mortality registry to ascertain the causes of death. RESULTS Among a cohort of 4,184 patients, 581 patients died during the follow-up period. Deaths occurred among 428 (12.9%) patients with no depression, among 88 (17.8%) patients with major depression, and among 65 (18.2%) patients with minor depression. Causes of death were grouped as cardiovascular disease, 42.7%; cancer, 26.9%; and deaths that were not due to cardiovascular disease or cancer, 30.5%. Infections, dementia, renal failure, and chronic obstructive pulmonary disease were the most frequent causes in the latter group. Adjusting for demographic characteristics, baseline major depression (relative to no depression) was significantly associated with all-cause mortality (hazard ratio [HR]=2.26, 95% confidence interval [CI], 1.79–2.85), with cardiovascular mortality (HR = 2.00; 95% CI, 1.37–2.94), and with noncardiovascular, noncancer mortality (HR = 3.35; 95% CI, 2.30–4.89). After additional adjustment for baseline clinical characteristics and health habits, major depression was significantly associated only with all-cause mortality (HR = 1.52; 95% CI, 1.19–1.95) and with death not caused by cancer or atherosclerotic cardiovascular disease (HR = 2.15; 95% CI, 1.43–3.24). Minor depression showed similar but nonsignificant associations. CONCLUSIONS Patients with diabetes and coexisting depression face substantially elevated mortality risks beyond cardiovascular deaths.

Effects of enhanced depression treatment on diabetes self-care.

PURPOSE Among patients with diabetes, major depression is associated with more diabetic complications, lower medication adherence, and poorer self-care of diabetes. We reported earlier that enhanced depression care reduces depression symptoms but not hemoglobin A1c level. This study examined effects of depression interventions on self-management among depressed diabetic patients. METHODS A total of 329 patients in 9 primary care clinics were randomized to an evidence-based collaborative depression treatment (pharmacotherapy, problem-solving treatment, or both in combination) or usual primary care (routine medical services). Outcome measures included the Summary of Diabetes Self-Care Activities (SDSCA), reported at baseline and 3, 6, and 12 months, and medication non-adherence as assessed by automated pharmacy refill data of oral hypoglycemic agents, lipid-lowering agents, and angiotensin-converting enzyme inhibitors. We used mixed regression models adjusted for baseline differences to compare the intervention with usual care groups at follow-up assessments. RESULTS During the 12-month intervention period, enhanced depression care and outcomes were not associated with improved diabetes self-care behaviors (healthy nutrition, physical activity, or smoking cessation). Relative to the usual care group, the intervention group reported a small decrease in body mass index (mean difference = 0.70 kg/m2, 95% CI, 0.17 to 1.24 kg/m2) and a higher rate of nonadherence to oral hypoglycemic agents (mean difference = −6.3%, 95% CI, −11.91% to −0.71%). Adherence to lipid-lowering agents and to antihypertensive medicines was similar for the 2 groups. CONCLUSIONS In general, diabetes self-management did not improve among the enhanced depression treatment group during a 12-month period, except for small between-group differences of limited clinical importance. Research needs to assess whether self-care interventions tailored for specific conditions, in addition to enhanced depression care, can achieve better diabetes and depression outcomes.

Treatment Adjustment and Medication Adherence for Complex Patients With Diabetes, Heart Disease, and Depression: A Randomized Controlled Trial

PURPOSE Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression. METHODS A randomized controlled trial was conducted (2007–2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA1c] ≥8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score ≥10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring. RESULTS Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P <.001), threefold higher for insulin (RR = 2.97; P <.001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P <.001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P <.001) and glucose more frequently (RR = 1.28; P = .006). CONCLUSIONS Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.

Potentially modifiable factors associated with disability among people with diabetes.

Objective: This article seeks to identify potentially modifiable factors associated with disability among people with diabetes. Study Design and Setting: Among people with diabetes (N = 4357) in a large health maintenance organization, disease severity, psychologic and behavioral risk factors for disability were assessed. Disability was evaluated by the WHO Disability Assessment Scale (WHO-DAS-II), the SF-36 Social Functioning scale, and days of reduced household work. Results: Depression was associated with a tenfold increase in elevated WHO-DAS-II and low SF-36 Social Functioning scores, and a fourfold increase in 20+ days of reduced household work. Minor depression and the presence of three or more diabetic complications were associated with approximately a twofold increase in disability risk. Diabetic symptoms, chronic disease comorbidity, and reduced exercise were also associated with disability. Conclusion: Among people with diabetes, depression, diabetic complications, and exercise are potentially modifiable factors associated with disability. This suggests that integrated, biopsychosocial approaches may be needed to understand and to ameliorate disability among people with diabetes. BMI = body mass index; GHC = Group Health Cooperative; DSM-IV = Diagnostic and Statistical Manual, 4th Edition; PHQ-9 = Patient Health Questionnaire; ICD-9 = International Classification of Diseases, 9th Revision; HbA1c = glycosylated hemoglobin; WHO-DAS-II = World Health Organization Disability Assessment Schedule II.

Racial and Ethnic Differences in Microalbuminuria Prevalence in a Diabetes Population: The Pathways Study

The objective of this study was to determine whether racial or ethnic differences in prevalence of diabetic microalbuminuria were observed in a large primary care population in which comparable access to health care exists. A cross-sectional analysis of survey and automated laboratory data 2969 primary care diabetic patients of a large regional health maintenance organization was conducted. Study data were analyzed for racial/ethnic differences in microalbuminuria (30 to 300 mg albumin/g creatinine) and macroalbuminuria (>300 mg albumin/g creatinine) prevalence among diabetes registry-identified patients who completed a survey that assessed demographics, diabetes care, and depression. Computerized pharmacy, hospital, and laboratory data were linked to survey data for analysis. Racial/ethnic differences in the odds of microalbuminuria and macroalbuminuria were assessed by unconditional logistic regression, stratified by the presence of hypertension. Among those tested, the unadjusted prevalence of micro- or macroalbuminuria was 30.9%, which was similar among the various racial/ethnic groups. Among those without hypertension, microalbuminuria was twofold greater (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.14 to 3.53) and macroalbuminuria was threefold greater (OR 3.17; 95% CI 1.09 to 9.26) for Asians as compared with whites. Among those with hypertension, adjusted odds of microalbuminuria were greater for Hispanics (OR 3.82; 95% CI 1.16 to 12.57) than whites, whereas adjusted odds of macroalbuminuria were threefold greater for blacks (OR 3.32; 95% CI 1.26 to 8.76) than for whites. For most racial/ethnic minorities, hypertriglyceridemia was significantly associated with greater odds of micro- and macroalbuminuria. Among a large primary care population, racial/ethnic differences exist in the adjusted prevalence of microalbuminuria and macroalbuminuria depending on hypertension status. In this setting, racial/ethnic differences in early diabetic nephropathy were observed despite comparable access to diabetes care.

Depression and Incident Diabetic Foot Ulcers: A Prospective Cohort Study

OBJECTIVE To test whether depression is associated with an increased risk of incident diabetic foot ulcers. METHODS The Pathways Epidemiologic Study is a population-based prospective cohort study of 4839 patients with diabetes in 2000-2007. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio and 95% confidence interval (CI) for incident diabetic foot ulcers, comparing patients with major and minor depression with those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin, diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses also adjusted for peripheral neuropathy and peripheral arterial disease as defined by diagnosis codes. RESULTS Compared with patients without depression, patients with major depression by Patient Health Questionnaire-9 had a 2-fold increase in the risk of incident diabetic foot ulcers (adjusted hazard ratio 2.00; 95% CI, 1.24-3.25). There was no statistically significant association between minor depression by Patient Health Questionnaire-9 and incident diabetic foot ulcers (adjusted hazard ratio 1.37; 95% CI, 0.77-2.44). CONCLUSION Major depression by Patient Health Questionnaire-9 is associated with a 2-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders or mediators.

Association of major depression and mortality in Stage 5 diabetic chronic kidney disease

OBJECTIVES Depression is the most common psychiatric disorder in patients with chronic kidney disease (CKD). We sought to determine the association of major depression with mortality among diabetic patients with late stage CKD. METHOD The Pathways Study is a longitudinal, prospective cohort study initiated to determine the impact of depression on outcomes among primary care diabetic patients. Subjects were followed from 2001 until 2007 for a mean duration of 4.4 years. Major depression, identified by the Patient Health Questionnaire-9, was the primary exposure of interest. Stage 5 CKD was determined by dialysis codes and estimated glomerular filtration rate (<15 ml/min). An adjusted Cox proportional hazards multivariable model was used to determine the association of baseline major depression with mortality. RESULTS Of the 4128 enrolled subjects, 110 were identified with stage 5 CKD at baseline. Of those, 34 (22.1%) had major depression. Over a period of 5 years, major depression was associated with 2.95-fold greater risk of death (95% CI=1.24-7.02) compared to those with no or few depressive symptoms. CONCLUSION Major depression at baseline was associated with a 2.95-fold greater risk of mortality among stage 5 CKD diabetic patients. Given the high mortality risk, further testing of targeted depression interventions should be considered in this population.

Preteen attitudes about smoking and parental factors associated with favorable attitudes.

Purpose. To describe youth smoking-related attitudes and evaluate the effects of parental factors on child adoption of positive attitudes about smoking. Design. This study used baseline and 20-month data from a family-based smoking-prevention study (82.9% completed both surveys). Setting. Telephone recruitment from two health maintenance organizations. Subjects. Children aged 10 to 12 years and one parent of each child (n = 418 families) were randomly assigned to a frequent assessment cohort (12.5% of participants). Intervention. Families received a mailed smoking-prevention packet (parent handbook, videotape about youth smoking, comic book, pen, and stickers), outreach telephone counselor calls to the parent, a newsletter, and medical record prompts for providers to deliver smoking-prevention messages to parents and children. Measures. Demographics, tobacco status, attitudes about smoking (Teenage Attitudes and Practices Survey), family discussions about tobacco, family cohesiveness (family support and togetherness), parent involvement, parent monitoring, and parenting confidence. Results. One-third of the children endorsed beliefs that they could smoke without becoming addicted, and 8% to 10% endorsed beliefs on the benefits of smoking. Childrens positive attitudes about smoking were associated with lower family cohesiveness (p = .01). Parental use of tobacco was the only significant predictor of childrens positive attitudes about tobacco at 20 months (p = .03). Conclusions. Children as young as 10 years underestimate addictive properties of smoking, which may place them at risk for future smoking. Parental use of tobacco and family cohesiveness are important factors in the formulation of preteen attitudes about smoking.

The association between intensive care unit admission and subsequent depression in patients with diabetes.

To examine whether intensive care unit (ICU) admission is independently associated with increased risk of major depression in patients with diabetes.