A guide to symptoms of depression
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A recent study examining the relationship between diabetes, depression, and death demonstrates a need for diabetes patients
and pharmacists to be familiar with the symptoms of depression. "We know that people with diabetes who have depression are
at a much greater risk of mortality than similar people without diabetes," said Xuanping Zhang, Ph.D., a researcher with the
National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control & Prevention in Atlanta.
"Pharmacists and physicians have a professional obligation to let patients suffering from diabetes and depression know of
this risk. Absence of intervention can be life-threatening."
An awareness of studies linking depression and diabetes enhances the ability of pharmacists to properly do their job, said
Zhang. For example, they can inform diabetes patients of a possible need to address the issue of depression with their primary
care physicians. Therefore, R.Ph. awareness of the symptomology of depression is imperative.
"Treatment of depression has become a responsibility of providers in all healthcare settings," agreed Glen L. Stimmel, Pharm.D.,
professor of clinical pharmacy and psychiatry at the University of Southern California Schools of Pharmacy and Medicine. "And
successful treatment of depression requires both precision in diagnosis and careful monitoring and fine-tuning of pharmacotherapy
over time," he added.
Stimmel said that "this degree of monitoring is the responsibility of all healthcare professionals, including pharmacists.
Pharmacists can help spot depression, improve drug therapy outcomes, lower costs, and reduce the risk of suicide among depressed
patients."
Recognition of depressive symptoms among diabetes patients can be a matter of life and death, said Zhang. He led a group of
CDC and Agency for Healthcare Research and Quality researchers in an analysis of data from the National Health and Nutrition
Examination Survey (NHANES). First, they identified 558 people with diabetes and 7,063 without the disease. Depressive symptoms
of each group were determined with a questionnaire. Their findings are alarming.
The researchers found that people with diabetes who struggle with depression have a significantly greater risk of mortality
than others. Those with the highest depression scores had a 54% greater mortality rate within a 10-year follow-up period than
did people with the lowest scores. The results held true after participants were matched for socioeconomic factors, lifestyle,
and health-status variables, said Zhang. At the same time, no apparent relationship was noted between depression and mortality
among the nondiabetic population.
"Our work shows that the relationship between depression and mortality is different in people with and people without diabetes,"
said Zhang. "Depression should be considered a target for diabetes management interventions. The study also points to the
need to study subgroups, such as diabetes patients, rather than aggregated populations, when examining the effect of depression
on mortality."
The results of the study were published in the April 1 issue of the American Journal of Epidemiology in an article titled "Depressive Symptoms and Mortality among Persons with and without Diabetes." Although Zhang's work does
not determine a causal relationship between depression and diabetes, the study does support a body of research that ties the
two diseases. "Depressed persons may be more likely to adopt unhealthy behaviors, such as a sedentary lifestyle and a poor
diet, which are in turn associated with a greater likelihood of obesity and Type 2 diabetes," he said. "But the causes of
the relationship between death, depression, and diabetes remain unclear."
Whatever the cause, it is certain that people with diabetes are at greater risk for depression than the general population,
according to the National Institute of Mental Health. In addition, individuals with depression may be at greater risk for
developing diabetes, according to an NIMH position paper titled "Depression and Diabetes." NIMH's research demonstrates that
the risk of depression could be doubled in diabetes patients compared with those without the disorder and the chances of becoming
depressed increase as diabetes complications worsen.
"Depression may develop because of stress but also may result from the metabolic effects of diabetes on the brain," according
to NIMH. "Studies suggest that people with diabetes who have a history of depression are more likely to develop diabetic complications
than are those without depression. People who suffer from both diabetes and depression tend to have higher healthcare costs
in primary care. Treatment for depression helps people manage symptoms of both diseases, thus improving the quality of their
lives."
A very significant issue related to the comorbidity of depression and diabetes is lack of medication compliance. "Depressive
symptom severity is often associated with the poorer diet and medication regimen adherence in primary care diabetes patients,"
said Paul S. Ciechanowski, M.D., a physician and researcher in the department of psychiatry and behavioral sciences at the
University of Washington, Seattle, who studied depression and diabetes among 367 diabetes patients enrolled in two HMOs.
Another recent study, published in the March 2005 issue of the American Journal of Geriatric Psychiatry, explored "How Does Depression Influence Diabetes Medication Adherence in Older Patients?" Conducted by researchers at several
Veterans Affairs health centers, the study supports Ciechanowski's contention that diabetes patients who have depression are
less adherent to their medications and may also provide reasons as to possible causes underlying Zhang's findings.
VA researchers who studied 203 patients with a mean age of 67 found that "depressed patients are less likely to self-report
good adherence and had a lower median percentage of days with adequate medication coverage (on the basis of pharmacy refill
data). After adjustment for alcohol use, cognitive impairment, age, and other medication use, depression was still negatively
associated with adequate adherence, according to patient report and pharmacy data."
Lack of medication adherence is costly as well as dangerous. An article titled "Impact of Medication Adherence on Hospitalization
Risk and Healthcare Cost," published in the June 2005 issue of Medical Care, reported on a study of more than 137,000 patients under the age of 65 with either diabetes, high cholesterol, hypertension,
or congestive heart failure. The study found that the least compliant diabetes patients were more than twice as likely to
be hospitalized as those who were most compliant, and their total healthcare costs were nearly double, as well. The authors
note that people who use their diabetes medications as directed are less likely to develop the short-term and long-term health
problems that require expensive care.
"We know from these studies that the interrelationship between diabetes and depression is very perilous on many levels, including
morbidity," said Zhang. "Health professionals need to heed such warnings."
The Author is a writer based in Gettysburg, Pa.
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