D&D, 糖尿病与抑郁症的致命联合

Diabetes and Depression Can Be a Lethal Combination 

News Author: Caroline Cassels

 

 

October 9, 2008 ? The combination of diabetes 糖尿病and depression 抑郁症in the elderly population 老年人is linked to higher all-cause mortality vs diabetes alone, a new study suggests.台州市中心医院中西医结合科张茂华

In a prospective 2-year follow-up study, investigators at the University of Washington in Seattle found that individuals older than 65 years with both diabetes and depression had approximately a 38% increased risk for all-cause mortality vs their counterparts who had diabetes but who were not depressed.为期2年的跟踪研究，华盛顿大学的研究者发现D&D糖尿病合并抑郁症者与单纯糖尿病者相比之下“全因死亡率”大约增加38%。

Previous research has linked depression in young and middle-aged patients with diabetes to increased mortality risk. However, this most recent study is the first to show that this risk also applies to older individuals.

"The findings of this study correlate with our earlier findings in younger populations with diabetes that depression is a major risk factor for mortality and again highlights the importance of screening for, and effectively treating, depression because it is a major risk factor for mortality in these folks," principal investigator Wayne Katon, MD, told Medscape Psychiatry.

The study is published in the October issue of the Journal of General Internal Medicine.

 

Poor Adherence to Self-Care Regimens

According to Dr. Katon, depression has been linked to poor outcomes in patients with chronic medical conditions, including heart disease and stroke.

In diabetes it is associated with poor adherence to self-care regimens including glucose monitoring, diet, exercise, and taking medication as prescribed. Furthermore, individuals with depression are more likely to smoke, be overweight, and have a sedentary lifestyle.

"In diabetes depression interferes with, and adversely affects, many of the aspects of self-care that patients need to adhere to in order to control diabetes. We"ve shown in longitudinal studies of younger populations that depression is associated with more complications from diabetes as well as increased mortality," said Dr. Katon.

Depression has also been linked with physiologic dysregulation of the hypothalamic pituitary axis and sympathetic nervous system as well as an increase in inflammatory markers.

To examine the effect of comorbid depression on all-cause mortality and macrovascular mortality in a large, older cohort, the investigators tracked 10,704 fee-for-service Medicare beneficiaries with diabetes who were 65 years or older and were enrolled in a disease management program.

Evidence of depression was based on a clinician diagnosis, self-reported prescription of an antidepressant in the previous year, or a score of 3 or greater on the Patient Health Questionnaire 2-item questionnaire.

Mortality rate was assessed bimonthly by checking Medicare claims and eligibility files or from information from telephone contact with the participants" families.

Of the total study group, 1657 patients had a diagnosis of depression in the 12 months before screening. The researchers found that individuals with depression were significantly younger, more likely to be women, less likely to be African American, more likely to be Hispanic, and had more severe medical illness.

In addition, patients with depression were significantly more likely to have had a previous cerebrovascular accident (CVA) but were less likely to have experienced a recent cardiovascular disease (CVD) procedure.

 

Depression Screening Recommended

At 2-year follow-up, 12.1% of participants with comorbid depression vs 10.4% of nondepressed patients died.

According to the study authors, there were no differences in the percentage of depressed and nondepressed participants regarding CVA, cardiovascular events, end-stage renal disease, or amputation in the 2-year follow-up period.

Previous research has shown that depression and diabetes are both independently associated with increased mortality rates from myocardial infarction and stroke. However, said Dr. Katon, the current study did not find that the combination of depression and diabetes was linked to increased cardiovascular mortality rates.

"Given that cardiovascular disease and stroke are the most common causes of death in patients with diabetes, we were somewhat surprised by this finding. However, it could be that our study was not adequately powered to detect this and that we need a larger population before we can rule this possibility out," he said.

In the meantime, he said, these latest findings, coupled with previous research demonstrating the negative effect on outcomes in this growing patient population, suggest a need for aggressive screening for depression in patients with diabetes.

According to Dr. Katon, there is growing recognition within the medical community that depression has a strong influence on health outcomes. He pointed out that the American Diabetes Association and, most recently, the American Heart Association both recommend depression screening in their respective constituents with diabetes and coronary heart disease.

Team Approach Needed

However, studies show that only 50% to 60% of patients with diabetes who have comorbid depression are accurately diagnosed, and of these, only 25% receive effective treatment.

"There"s still quite a significant gap in terms of better screening and better treatment that we need to close in order to improve outcomes in folks with diabetes," he said.

For the last 10 to 15 years, there has been a push in primary care towards increased productivity. This means clinicians have substantially increased their daily patient load. At the same time, he said, there has been a growing emphasis on improving the management of chronic illness.

"The trouble is these 2 goals don"t mesh very well. Research groups like ours as well as others have shown that using a team approach that employs a nurse case manager under specialist supervision offers more effective management and significantly improves outcomes," said Dr. Katon.

One of the major challenges in implementing such an approach lies in designing an effective model of remuneration.

"Right now we don"t have the proper incentives in the American healthcare system to support a team approach to chronic illness," he said. "There"s no doubt it is the right thing to do. We"ve shown in 2 large trials consisting of 700 to 800 diabetic patients that you can dramatically improve outcomes and make a real difference in people"s lives."

The study was supported by the National Institute of Mental Health. The study authors have disclosed no relevant financial relationships.

J Gen Intern Med. 2008;23:1571-1575.

Clinical Context

Depression may adversely affect the outcomes of chronic illnesses. Longitudinal studies of patients with diabetes suggest that the rate of microvascular and macrovascular disease in patients with diabetes may be increased with comorbid depression.

This is a cohort study of Medicare beneficiaries with diabetes with or without congestive heart failure in 9 counties in Florida who had 2-year follow-up to assess the effect of comorbid diabetes and depression on mortality rates and macrovascular disease.

 

Study Highlights

• The Green Ribbon Health services Medicare beneficiaries (≥ age 65 years) participated in a multidisciplinary model of care with telephone contact with a personal nurse who supported patient disease management.
• Those with diabetes and/or congestive heart failure were included in the original cohort.
• For this study, only those with diabetes with or without congestive heart failure were included.
• All participants received a health assessment at baseline and at least every 6 to 12 months with use of the Medicare Domain Assessment Tool.
• The 2-item depression screener, the Patient Health Questionnaire 2 was used to screen for depression, and those who screened positive were further evaluated with the Patient Health Questionnaire 9.
• Those with depression were referred to specialists or to their primary care clinicians for treatment and management.
• Information about diagnosis was derived from beneficiary use of prescription drugs and Medicare eligibility and claims data.
• Participants" level of illness severity was determined by the Charlson comorbidity index.
• The International Classification of Diseases, Ninth Revision, codes, and Current Procedural Terminology codes were used to derive information about CVA, CVD, coronary procedures, end-stage renal disease, and amputation.
• The diagnosis of depression was derived from 3 sources: International Classification of Diseases, Ninth Revision, depression codes from Medicare claims data in the year before program enrollment, the Patient Health Questionnaire 2 screening at baseline and at follow-up, and participant reports of use of antidepressant medication.
• Mortality rate for the 1-year period after screening was determined by Medicare claims data and eligibility files checked twice a month and telephone contact with relatives and family.
• 15.5% of 10,704 Medicare beneficiaries with diabetes also had depression in the 12 months before screening.
• Those with an International Classification of Diseases, Ninth Revision, diagnosis of depression were younger, more likely to be women, less likely to be African American, more likely to be Hispanic, and had a higher comorbidity index.
• They were more likely to have had a previous CVA and less likely to have had a cardiac procedure.
• 12.1% with diabetes and depression vs 10.4% with diabetes without depression died in the 2 years after screening (P < .05).
• Comorbid depression was associated with a 36% increase in the risk for death within 2 years of baseline screening (HR, 1.36, 95% CI, 1.16 - 1.59).
• With an expanded diagnosis for depression, the HR for mortality was 1.38.
• There was no difference in combined CVA and CVD events between those treated with antidepressants vs those without depression indicators.
• In the 2-year period after screening, 34.6% and 19.6% of depressed participants experienced a CVA and CVD event, respectively, vs 35.1% and 20.0% of those without depression (no significant difference).
• No differences were seen between those with diabetes with and without depression for rates of CVA, CVD, end-stage renal disease, or amputation in the 2 years after screening.
• The results remained similar after controlling for age; ethnicity; sex; Charlson score; and previous CVA, CVD, or cardiac procedure.

 

Pearls for Practice

• Comorbid depression and diabetes are associated with increased mortality rates within 2 years of screening for depression.
• Comorbid depression and diabetes are not associated with increased risks for CVD, CVA, end-stage renal disease, or amputation.

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