Prevalence and correlates of undiagnosed depression among U.S. adults with diabetes: The Behavioral Risk Factor Surveillance System, 2006☆
Introduction
In 2007, approximately 23.5 million U.S. adults aged 20 years or older (10.7%) had diabetes, with 90% to 95% of all diagnosed cases being type 2 diabetes [1]. Among people with diabetes, depression has been associated with poor general health [2], functional limitations or disabilities [2], [3], and increased health care use and expenditure [4]. In addition, depression is associated with poor glycemic control [5] and increased risk for diabetes complications [6], [7]. Furthermore, emerging evidence shows that depression is associated with increased risk for death from coronary heart disease and from all causes [8].
Estimates of the prevalence of depression in the United States have varied widely, ranging from 3.8% to 27.3% in studies based on structured patient interviews, and from 11.5% to 60.7% in studies based on self-administered questionnaires [9]. In a recent report based on 2006 data from Behavioral Risk Factor Surveillance System (BRFSS), we estimated the prevalence of both major and minor depression among people with diabetes to be 8.3% [10]. Depression, however, is often undiagnosed or unrecognized in clinical settings. For example, results from the World Health Organization (WHO) Collaborative Study on Psychological Problems in General Health Care in 14 countries have showed that 42% to 48% of depressed people were not recognized as being “psychiatric cases” by primary care physicians [11]. And a recent study showed that less than 25% of hospital patients with acute coronary syndrome and moderate to severe depressive symptoms had documentation indicating their symptoms were recognized before they were discharged from the hospital [12]. According to the Pathway Study [13], about 49% of patients with major depression and diabetes were unrecognized by the primary health care system. However, little is known about the prevalence of undiagnosed depression among people with diabetes in the general population.
Previous studies have shown that female sex, younger age, low education level, low family income, perceived poor physical health, smoking, body mass index (BMI) ≥30 kg/m2, a glycosylated hemoglobin A1C concentration ≥8.0%, and ≥2 diabetes complications were each significantly associated with increased risk for major depression [14], [15]; that a high level of supportive relationships was associated with a decreased risk for depressive symptoms (defined as a score of 16 or higher on the Center for Epidemiological Studies-Depression [CES-D] scale) among rural African American adults with type 2 diabetes [16]; and that cardiovascular disease was associated with an increased risk for diagnosed depression (ascertained by International Classification of Diseases, Ninth Revision [ICD-9] standards or the use of antidepressant medication) [17].
It is unknown whether these factors have an association with undiagnosed depression similar to their association with diagnosed depression. Assessment of correlates for undiagnosed depression may have etiological implications because people who have depression that has never been diagnosed or recognized by physicians may have characteristics different from those of people whose depression has been diagnosed [17]. Therefore, in this study we sought to (a) assess the prevalence of undiagnosed depression among U.S. adults with diabetes, (b) identify the possible correlates for undiagnosed depression, and (c) examine the possible effect modification of social and emotional support on the association between patients’ sense of “life satisfaction” and their risk for undiagnosed depression.
Section snippets
Study setting and design
The BRFSS collects data from standardized telephone surveys conducted by state and territorial health departments with assistance and support from the Centers for Disease Control and Prevention (CDC); survey data are used to assess the prevalence of key behavioral risk factors and chronic disease conditions in all U.S. states and territories annually [18]. Trained interviewers collect data on a monthly basis from an independent household probability sample drawn from the noninstitutionalized
Characteristics of the total and analytic sample
The results of our analyses indicated that among 153.6 million U.S. adults in the jurisdictions surveyed in 2006 BRFSS, 12.6 million had diagnosed diabetes (unadjusted rate: 8.2%), 5.7 million (4.2%) had current major depression, 6.8 million (5.0%) had current minor depression, 22.7 million (15.7%) had lifetime physician-diagnosed depression, and 1.6 million (1.2%) had both diabetes and major or minor depression. Men had a higher age-adjusted prevalence of diabetes (8.8%) then women (7.2%; P <
Discussion
In this study, we assessed the prevalence of undiagnosed depression among U.S. adults with diabetes and found that female sex, poor or fair health, no health plan, lack of social and emotional support, dissatisfaction with life, use of special equipment, no leisure-time physical activity, and comorbid cardiovascular disease were each independently associated with undiagnosed depression.
Under recognition and under treatment of depression in primary care practice have been considered a major
Conflict of interest
There are no conflicts of interest.
Acknowledgments
We thank the Behavioral Risk Factor Surveillance System state coordinators for their assistance in data collection.
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The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.