Depression and Increased Mortalityin Diabetes: Unexpected Causes of Death

Group Health Research Institute, Seattle, Washington 98101, USA.
The Annals of Family Medicine (Impact Factor: 5.43). 09/2009; 7(5):414-21. DOI: 10.1370/afm.998
Source: PubMed


Recent evidence suggests that depression is linked to increased mortality among patients with diabetes. This study examines the association of depression with all-cause and cause-specific mortality in diabetes.
We conducted a prospective cohort study of primary care patients with type 2 diabetes at Group Health Cooperative in Washington state. We used the Patient Health Questionnaire (PHQ-9) to assess depression at baseline and reviewed medical records supplemented by the Washington state mortality registry to ascertain the causes of death.
Among a cohort of 4,184 patients, 581 patients died during the follow-up period. Deaths occurred among 428 (12.9%) patients with no depression, among 88 (17.8%) patients with major depression, and among 65 (18.2%) patients with minor depression. Causes of death were grouped as cardiovascular disease, 42.7%; cancer, 26.9%; and deaths that were not due to cardiovascular disease or cancer, 30.5%. Infections, dementia, renal failure, and chronic obstructive pulmonary disease were the most frequent causes in the latter group. Adjusting for demographic characteristics, baseline major depression (relative to no depression) was significantly associated with all-cause mortality (hazard ratio [HR]=2.26, 95% confidence interval [CI], 1.79-2.85), with cardiovascular mortality (HR = 2.00; 95% CI, 1.37-2.94), and with noncardiovascular, noncancer mortality (HR = 3.35; 95% CI, 2.30-4.89). After additional adjustment for baseline clinical characteristics and health habits, major depression was significantly associated only with all-cause mortality (HR = 1.52; 95% CI, 1.19-1.95) and with death not caused by cancer or atherosclerotic cardiovascular disease (HR = 2.15; 95% CI, 1.43-3.24). Minor depression showed similar but nonsignificant associations.
Patients with diabetes and coexisting depression face substantially elevated mortality risks beyond cardiovascular deaths.

Full-text preview

Available from:
    • "Furthermore, although previous studies accounted for medical comorbidity and, to different extents, further covariates, only few studies examined the mortality risk of several major medical chronic diseases in depression (Everson-Rose et al., 2004; Mykletun et al., 2007; Schoepf et al., 2014). Finally, in spite of its significance for primary care, mortality data on outpatients with depression and chronic medical disease are still scarce (Lin et al., 2009). Primary physicians serve as " gate-keepers " , and therefore are usually the first to identify and manage a variety of health problems before referring patients to specialists. "
    [Show abstract] [Hide abstract]
    ABSTRACT: As leading causes of death, chronic medical diseases, particularly common cardiovascular diseases, are associated with depression. The combination of depression and chronic medical disease in turn is linked with poorer health and premature death. Despite numerous studies on mortality in people with depression and chronic medical disease, the effects of age and gender were not consistently considered. To appropriately estimate mortality in the clinical setting, we aimed to analyse age- and gender-specific mortality profiles in outpatients with depression and chronic medical disease by considering depression severity.
    No preview · Article · Mar 2016 · Journal of Affective Disorders
  • Source
    • "The yearly prevalence of major depression is comparable in DM2 patients and patients with CHD and adds up to about 10–20%, which is considerably high compared to the prevalence of 5% in the general Dutch population (Anderson et al., 2001; Backenstrass et al., 2006; Bot et al., 2010; de Graaf et al., 2012; Harter et al., 2007; Kroenke et al., 2001; Rodriguez et al., 2012; Rudisch and Nemeroff, 2003; Thombs et al., 2006). Major depression among DM2 and/or CHD patients is associated with lower quality of life, an increased risk of mortality, poor medication adherence and increased health care costs (Ciechanowski et al., 2000; Haddad et al., 2013; Lamers et al., 2008; Lin et al., 2009; Rodriguez et al., 2012; Simon, 1992; Stafford et al., 2007). Moreover, once patients are diagnosed with major depression, only roughly one third of the associated disease burden can be averted, even when optimal Contents lists available at ScienceDirect journal homepage: "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Depression is common among type 2 diabetes mellitus (DM2)/coronary heart disease (CHD) patients and is associated with adverse health effects. A promising strategy to reduce burden of disease is to identify patients at risk for depression in order to offer indicated prevention. This study aims to assess the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) to be used as a tool to identify high risk patients. Methods In this cross-sectional study, 586 consecutive DM2/CHD patients aged >18 were recruited through 23 general practices. PHQ-9 outcomes were compared to the Mini International Neuropsychiatric Interview (MINI), which was considered the reference standard. Diagnostic accuracy was evaluated for minor and major depression, comparing both sum- and algorithm based PHQ-9 scores. Results For minor depression, the optimal cut-off score was 8 (sensitivity 71%, specificity 71% and an AUC of 0.74). For major depression, the optimal cut-off score was 10 resulting in a sensitivity of 84%, a specificity of 82%, and an AUC of 0.88. The positive predictive value of the PHQ-9 algorithm for diagnosing minor and major depression was 25% and 33%, respectively. Limitations Two main limitations apply. MINI Interviewers were not blinded for PHQ-9 scores and less than 10% of all invited patients could be included in the analyses. This could have resulted in biased outcomes. Conclusions The PHQ-9 sum score performs well in identifying patients at high risk of minor and major depression. However, the PHQ-9 showed suboptimal results for diagnostic purposes. Therefore, it is recommended to combine the use of the PHQ-9 with further diagnostics to identify depression.
    Full-text · Article · Jan 2016 · Journal of Affective Disorders
  • Source
    • "Depression and diabetes cause significant burden for patients and the healthcare system [1,2]. Individuals with diabetes have up to a 24% increased risk of developing depression [3], and individuals with depression have increased risk of developing type 2 diabetes [4]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Depression and diabetes cause significant burden for patients and the healthcare system and, when co-occurring, result in poorer self-care behaviors and worse glycemic control than for either condition alone. However, the clinical management of these comorbid conditions is complicated by a host of patient, provider, and system-level barriers that are especially problematic for patients in rural locations. Patient-centered medical homes provide an opportunity to integrate mental and physical health care to address the multifaceted needs of complex comorbid conditions. Presently, there is a need to not only develop robust clinical interventions for complex medically ill patients but also to find feasible ways to embed these interventions into the frontlines of existing primary care practices. Methods/design: This randomized controlled trial uses a hybrid effectiveness-implementation design to evaluate the Healthy Outcomes through Patient Empowerment (HOPE) intervention, which seeks to simultaneously address diabetes and depression for rural veterans in Southeast Texas. A total of 242 Veterans with uncontrolled diabetes and comorbid symptoms of depression will be recruited and randomized to either the HOPE intervention or to a usual-care arm. Participants will be evaluated on a host of diabetes and depression-related measures at baseline and 6- and 12-month follow-up. The trial has two primary goals: 1) to examine the effectiveness of the intervention on both physical (diabetes) and emotional health (depression) outcomes and 2) to simultaneously pilot test a multifaceted implementation strategy designed to increase fidelity and utilization of the intervention by coaches interfacing within the primary care setting. Discussion: This ongoing blended effectiveness-implementation design holds the potential to advance the science and practice of caring for complex medically ill patients within the constraints of a busy patient-centered medical home.
    Full-text · Article · Apr 2014 · BMC Health Services Research
Show more