Elsevier

General Hospital Psychiatry

Volume 26, Issue 6, November–December 2004, Pages 430-436
General Hospital Psychiatry

Depression and diabetes symptom burden

https://doi.org/10.1016/j.genhosppsych.2004.08.010Get rights and content

Abstract

Objective

To examine the relationship among patient-reported diabetes symptoms, severity of depressive illness and objective measures of diabetes control and severity among a population-based sample of patients with diabetes.

Methods

A mailed survey was sent to all patients with diabetes from nine primary care clinics of a Health Maintenance Organization. The Patient Health Questionnaire (PHQ-9) was used to diagnose major depression, the Self-Completion Patient Outcome instrument assessed diabetes symptoms and automated medical record data were used to measure diabetes treatment intensity, HbA1c levels, diabetes complications and medical comorbidity. Analysis of covariance (ANCOVA) was used to determine if the number of diabetes symptoms was related to having major depression and to number of depressive symptoms. Logistic regression analyses determined the relative strengths of the associations between each individual diabetic symptom and presence of major depression, HbA1c levels above 8.0% and two or more diabetes complications.

Results

Among 4168 patients with diabetes, those with major depression (N=487) reported significantly more diabetes symptoms (mean=4.40) than participants without depression (mean=2.46) after adjusting for demographic characteristics, objective measures of diabetes severity and medical comorbidity [F(1,4029)=339.31, P<.0001]. The overall number of diabetes symptoms was related to the number of depressive symptoms (from 0 to 9) endorsed by participants [F(9,4021)=110.05, P<.0001]. Logistic regression analyses found that depression was significantly related to each of the 10 diabetes symptoms (all P<.001).

Conclusions

The depression-diabetes symptom association is stronger than the association of diabetes symptoms with measures of glycemic control and diabetes complications.

Introduction

The burden of diabetes includes managing troublesome symptoms (e.g., pain and tingling in hands and feet), as well as adhering to medication regimens, following dietary guidelines and monitoring blood glucose. The symptom burden of diabetes can significantly impair quality of life and contribute to functional disability and psychological distress. The correspondence between diabetic symptoms and glucose control has been found to be weak [1], [2]. Nevertheless, troublesome diabetic symptoms may prompt patients to seek medical care that could lead to diagnostic testing and increased medical costs. Subjective symptoms may also be a poor guide for self-management. For these reasons, understanding patient factors that are associated with diabetic symptoms may be important for improving clinical and functional outcomes of diabetes.

Epidemiologic studies among community respondents have found that anxiety and depression are associated with high rates of both medical symptom reporting and health care seeking [3], [4], [5], [6], [7]. Psychological symptoms and psychiatric disorders are associated with many medical syndromes that have less clearly defined pathology such as irritable bowel syndrome, fibromyalgia and chronic pelvic pain [8], [9], [10] Across a wide range of chronic medical illnesses, patients with psychological distress also report more medical symptoms and more functional impairment than do patients with medical illness alone even when controlling for severity of medical illness [11]. For example, among patients with coronary heart disease, anxiety and depressive symptoms predict symptom severity and functional impairment occurring up to 5 years later, even after adjusting for severity of coronary disease [12]. Among patients with inflammatory bowel disease, those with comorbid anxiety and depression have significantly more gastrointestinal symptoms, nongastrointestinal symptoms and functional impairment than do patients with no psychiatric illness after adjustment for severity of inflammatory bowel disease [13].

Depressive symptoms and major depressive disorder are common among persons with diabetes. A recent meta-analysis reported twofold higher odds of depression in persons with diabetes compared to individuals without diabetes [14]. Previous research among diabetic patients has shown that patients' subjective symptom perception is more related to depressed mood than to objective measures of blood glucose control such as hemoglobin A1c [1], [2]. Kohen et al. [15] found that depression was associated with self-reported quality of life, but only moderately associated with reporting of hypoglycemic symptoms. The generalizability of these studies is uncertain due to small sample size, recruitment restricted to patients treated in tertiary care settings or the use of narrow (i.e., HbA1c only) or nonobjective measures of diabetes severity such as self-reported diabetic complications.

In this paper, we examine the relationship between patient-reported diabetes symptoms, severity of depressive illness and objective measures of diabetes severity among a large population-based primary care sample of diabetic patients. Our objective is to assess whether diabetic symptoms are more common and severe among patients with depressive illness among a representative sample of persons with diabetes in a large HMO population. We predicted there would be a significant association between depression and diabetes symptom burden after controlling for glycemic control (i.e., HbA1c), diabetic complications and other medical comorbidity measured from automated medical records data. Our expectation was that the depression-diabetes symptom association would be stronger than the association of diabetes symptoms with measures of glycemic control and diabetes complications, after controlling for patient characteristics and physical comorbidity.

Section snippets

Setting

Participants were recruited from nine primary care clinics of Group Health Cooperative (GHC), a nonprofit health maintenance organization with 30 primary care clinics in Western Washington State. From the clinics that were within a 40-mile geographic radius of Seattle, we selected those that had the largest number of diabetic patients and the greatest representation of racial and ethnic diversity.

Participant recruitment

Details of recruitment procedures are described in earlier publications [16], [17]. The study

Results

Details of recruitment and participation are described in earlier publications [16], [17]. Of the 9064 questionnaires mailed, 7842 patients were deemed eligible to participate; 1222 were ineligible because they were not diabetic (n=259), had gestational diabetes (n=8), cognitive impairment (n=80), or were too ill (n=202), deceased (n=128), had language or hearing impairments (n=99) or had disenrolled or planned to move (n=444). We received a total 4839 returned questionnaires (61.7% of those

Discussion

In a large population-based sample of patients with diabetes, we found that patients with major depression reported a greater number of physical diabetes symptoms after controlling for objective measures of diabetes severity including number of diabetes complications, diabetes treatment intensity and glycemic control (HbA1c). Patients with major depression were approximately two to five times more likely to report each of the 10 symptoms of diabetes we assessed after controlling for these

Acknowledgments

This research was supported by NIMH grant no. MH 41739. Others making significant contributions to this project include Malia Oliver (computer programming) and Stephanie Hauge (project management).

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