Depression Linked to Severe Hypoglycemic Events
Screening for depression recommended for patients with diabetes
Patients with diabetes and comorbid major depression may be at increased risk of hypoglycemic episodes requiring hospitalization or emergency treatment, according to a study in the May/June issue of Annals of Family Medicine.
“Our findings emphasize the importance of screening diabetics for depression and providing effective treatment,” said lead author Wayne Katon, MD, Professor, Vice-Chair, Director of Division of Health Services and Psychiatric Epidemiology Depression, University of Washington Medical School, Seattle. “Depression occurs in up to 20% of patients with diabetes and has been shown to be a risk factor for diabetes complications and mortality. Our findings add to these prior findings by demonstrating that depression increases the risk of these severe hypoglycemic episodes that cause an emergency visit or hospitalization,” he said.
The study involved a cohort of 4,117 adults with diabetes (primarily type 2) who were prospectively followed over a five-year period. Depressed patients had a significantly higher proportion of severe hypoglycemic events during the follow-up period (10.7% vs 6.4%; P<0.001). Even after controlling for sociodemographic and clinical variables, depression was linked to a shorter time to hypoglycemic event (hazard ratio, 1.42) and a greater number of hypoglycemic episodes (risk ratio, 1.34).
How May Depression Affect Glycemic Control?
“Depression is associated with increased psychobiologic changes such as increased inflammatory factors, increased sympathetic nervous system tone, and increased cortisol levels, which can all lead to dysregulation of glucose,” Dr. Katon explained. “Also, depression is associated with poor adherence to diet, exercise, and taking medications as prescribed, which all can adversely affect glucose control,” he said.
“I think we are identifying with the depression marker in this study [ie, scoring positively on the Patient Health Questionnaire-9] less-engaged individuals in their overall health care,” commented Rebecca Jaffe, MD, MPH, who is a family physician in Wilmington, Delaware, and is on the board of directors of the American Academy of Family Physicians. However, it is difficult to determine with certainty that depression is a marker for a less-engaged patient, she noted.
“The question that is left at the end of the study is, if you treat individuals with depression, will that necessarily change the increased risk for episodes of hypoglycemia?” Dr. Jaffe said. “This study did not speak to the treatment of depression. For all we know, some of these depressed patients were taking antidepressants and still had the problem,” she said.
The study authors also called for future research to assess whether effective treatment of depression prevents severe hypoglycemic episodes in patients with diabetes.
Motivating Patients to Become Engaged in Their Health Care
Dr. Jaffe has found success in helping to engage patients early in the course of their disease “and preparing them for the fact that if they do not become engaged in what they are doing for their long-term health that there will be eventual consequences. In clinical practice, I tell patients that if they do not follow their diet, exercise, and medication regimen that they will end up on insulin. It is actually quite a motivating factor in getting patients to become better engaged,” she said.