Diabetes and depression: Global perspectives

doi:10.1016/j.diabres.2010.01.024

Diabetes Research and Clinical Practice

Volume 87, Issue 3, March 2010, Pages 302-312

https://doi.org/10.1016/j.diabres.2010.01.024 Get rights and content

Abstract

Background

Diabetes and depression are highly prevalent conditions and have significant impact on health outcomes. This study reviewed the literature on the prevalence, burden of illness, morbidity, mortality, and cost of comorbid depression in people with diabetes as well as the evidence on effective treatments.

Methods

Systematic review of the literature on the relationship between diabetes and depression was performed. A comprehensive search of the literature was performed on Medline from 1966 to 2009. Studies that examined the association between diabetes and depression were reviewed. A formal meta-analysis was not performed because of the broad area covered and the heterogeneity of the studies. Instead, a qualitative aggregation of studies was performed.

Results

Diabetes and depression are debilitating conditions that are associated with significant morbidity, mortality, and healthcare costs. Coexisting depression in people with diabetes is associated with decreased adherence to treatment, poor metabolic control, higher complication rates, decreased quality of life, increased healthcare use and cost, increased disability and lost productivity, and increased risk of death.

Conclusion

The coexistence of diabetes and depression is associated with significant morbidity, mortality, and increased healthcare cost. Coordinated strategies for clinical care are necessary to improve clinical outcomes and reduce the burden of illness.

Section snippets

Global burden of diabetes

Reports from the International Diabetes Federation (IDF) indicate that the prevalence of diabetes mellitus has reached epidemic levels globally. Estimates for 2010 indicate that 285 million adults have diabetes in the seven regions of the IDF [1]. These numbers represent an increase of 39 million from 2007 and an expected continued increase to 439 million in 2030 [1]. Given prevalence figures approaching 290 million, the worldwide human, economic, and social costs of diabetes are staggering.

Global burden of depression

Depression is another condition with high prevalence worldwide. Approximately 340 million people worldwide suffer from depression at any given time including 18 million in the United States [5]. According to the World Health Organization (WHO), depression is responsible for the greatest proportion of burden associated with non-fatal health outcomes accounting for approximately 12% total years lived with disability [6]. In 2000, it was estimated that depressive disorders were higher in women

Screening for depression

The diagnosis of depression is based on clinical findings. Several valid and reliable screening instruments are available for use in primary care [15], [16], [17], [18], [19], [20]. The 9-item Patient Health Questionnaire (PHQ-9) [20] is an easy to use depression screening instrument. The PHQ-9 is a brief questionnaire that scores each of the 9 DSM-IV criteria for depression as “0” (not at all) to “3” (nearly every day). PHQ-9 score ≥10 have a sensitivity of 88% and a specificity of 88% for

The prevalence of depression in individuals with diabetes

More than 300 years ago Dr. Thomas Willis, a British physician made the observation that there was a relationship between diabetes and depression when he suggested that diabetes was the result of “sadness or long sorrow” [22]. Anderson et al. conducted a meta-analysis of 42 published studies that included 21,351 adults and found that the prevalence of major depression in people with diabetes was 11% and the prevalence of clinically relevant depression was 31% [23]. However, worldwide estimates

Causal pathways between depression and diabetes

Evidence suggests a bi-directional relationship between depression and type 2 diabetes. For example research by Knol et al. suggests that in addition to depression being a consequence of diabetes, depression may also be a risk factor for the onset of diabetes [35]. Mezuk et al. completed a review of studies from 1950 to 2007 of diabetes and depression to examine the bi-directional relationship between diabetes and type 2 diabetes [36]. The pooled relative risk for incident depression associated

Effect of depression on glycemic control and self-care behaviors

There is substantial evidence that comorbid depression among individuals with diabetes is associated with poor diabetes outcomes such as glycemic control. Lustman et al. completed a meta-analysis of 24 studies and found that depression was significantly associated with poor glycemic control in individuals with type 1 and type 2 diabetes [42]. The standard effect size was 0.17 (small to moderate) and was consistent (95% CE 0.13–0.21). Similar effect sizes were noted for type 1 and type 2

Effect of depression on risk for diabetes complications

Diabetes complications are also greater among individuals with depression. In a meta-analysis of 27 studies including adults with type 1 and type 2 diabetes, de Groot et al. found significantly greater diabetes complications including: diabetic retinopathy, nephropathy, neuropathy, microvascular complications and sexual dysfunction [53]. Effect sizes were in the small to moderate range (0.17–0.32). Clouse et al. found that the onset and prevalence of coronary heart disease was affected in women

Effect of depression on disability, work productivity and quality of life in individuals with diabetes

Diabetes and depression are common chronic conditions that are significantly associated with increased odds of disability [59]. In a study of more than 30,000 adults ≥18 years of age from the National Health Interview Survey (NHIS) conducted in the U.S., Egede found that the odds of functional disability was more than 7-fold greater among adults with diabetes and major depression compared with adults without diabetes and depression [59]. Results from the Hispanic Established Population for

Effect of depression on healthcare utilization and costs in individuals with diabetes

Recent studies indicate increased healthcare utilization and healthcare costs among individuals with diabetes and coexisting depression. In a study of 55,972 adults with diabetes, Le et al. found that patient with diabetes and depression had higher diabetes-related medical costs ($3264) than patients with diabetes alone ($1297) [63]. They also found that depressed patients with diabetes had higher total medical costs ($19,298) than patients without depression ($4819). Ciechanowski et al. found

Effect of depression on mortality in individuals with diabetes

Recent studies have shown that coexisting depression increases the risk of death among people with diabetes [68], [69], [70]. In a study of 10,704 Medicare beneficiaries in the U.S., Katon et al. reported that beneficiaries with diabetes and comorbid depression had a 36–38% increased risk for all-cause mortality over a 2-year period [69]. In a study using the first National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study, results indicated that diabetic

The effectiveness of treating depression in individuals with diabetes

Evidence suggests that recognition and treatment for depression is less than ideal, particularly in primary care settings where most patients with diabetes receive care [71].

Despite increased efforts to identify and manage depression among patients with diabetes, several important questions remain. First, does recognition of depression improve patient outcomes? Second, is recognition of depression based on a single visit appropriate? Third, what is a reasonable timeframe to determine failure of

The cost of treating depression in individuals with diabetes

Studies of the economics of treatments of depressed individuals with diabetes have yielded positive results. A recent study of the cost-effectiveness of treatment of depression among individuals with diabetes by Simon et al. concluded that systematic depression treatment significantly increased time free of depression resulting in an economic benefit from the perspective of the health plan [80]. Patients who received the systematic depression treatment accumulated a mean of 61 additional days

Challenges and future directions for treatment of depression in individuals with diabetes

Most people with diabetes who have depression are treated in primary care settings [4]. However, studies suggest that consistent recognition and treatment of depression is less than optimal in primary care settings [71]. One barrier to early recognition and treatment of depression among individuals with diabetes is the difficulty in separating the symptoms of depression from the symptoms of poor management of diabetes. For example, fatigue, gain or loss of weight, change in appetite, and sleep

Conflict of interest

The authors declare that they have no conflict of interest.

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Diabetes AtlasDiabetes and depression: Global perspectives

Abstract

Background

Methods

Results

Conclusion

Section snippets

Global burden of diabetes

Global burden of depression

Screening for depression

The prevalence of depression in individuals with diabetes

Causal pathways between depression and diabetes

Effect of depression on glycemic control and self-care behaviors

Effect of depression on risk for diabetes complications

Effect of depression on disability, work productivity and quality of life in individuals with diabetes

Effect of depression on healthcare utilization and costs in individuals with diabetes

Effect of depression on mortality in individuals with diabetes

The effectiveness of treating depression in individuals with diabetes

The cost of treating depression in individuals with diabetes

Challenges and future directions for treatment of depression in individuals with diabetes

Conflict of interest

Med. Clin. North Am.

J. Psychosom. Res.

Diabetes Res Clin Pract

Diabetes Res. Clin. Pract.

Biol. Psychiatry

Gen. Hosp. Psychiatry

Gen. Hosp. Psychiatry

Diabetes Atlas

Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections

Diabetes Care

Physical symptoms of depression: unmet needs

J. Clin. Psychiatry

Global burden of depressive disorders in the year 2000

Br. J. Psychiatry

The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)

JAMA

Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

Acta. Psychiatr. Scand. Suppl.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys

JAMA

Burden of disease—implications for future research

JAMA

Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study

JAMA

An inventory for measuring depression

Arch. Gen. Psychiatry

A self-rating depression scale

Arch. Gen. Psychiatry

The CES-D scale: a self-report depression scale for research in the general population

Appl. Psychol. Meas.

Case-finding instruments for depression. Two questions are as good as many

J. Gen. Intern. Med.

The PHQ-9: validity of a brief depression severity measure

J. Gen. Intern. Med.

Screening for depression: recommendations and rationale

J. Gen. Intern. Med.

Diabetes: A Medical Odyssey

The prevalence of comorbid depression in adults with diabetes: a meta-analysis

Diabetes Care

Prevalence of depression among U.S. adults with diabetes: findings from the 2006 behavioral risk factor surveillance system

Diabetes Care

Prevalence of depression and diabetes: a population-based study from rural Bangladesh

Diabet. Med.

Prevalence of depressive symptoms among non insulin treated Greek type 2 diabetic subjects

BMC Res. Notes

Depression and diabetes in Iranian patients: a comparative study

Int. J. Psychiatry Med.

Association of comorbid depression, anxiety, and stress disorders with Type 2 diabetes in Bahrain, a country with a very high prevalence of Type 2 diabetes

J. Endocrinol. Invest.

Clinical depressive symptoms and diabetes in a binational border population

J. Am. Board Fam. Med.

Correlates of elevated depressive symptoms among rural African American adults with type 2 diabetes

Ethn. Dis.

Depressive symptoms and metabolic control in African-Americans with type 2 diabetes

Diabetes Care

The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis

Diabet. Med.

Depression as a risk factor for the onset of type 2 diabetes mellitus. A meta-analysis

Diabetologia

Diabetes Atlas
Diabetes and depression: Global perspectives