Patients simultaneously treated for both Type 2 diabetes and depression improve medication compliance and significantly improve blood sugar and depression levels compared to patients receiving usual care, according to a new study by researchers from the Perelman School of Medicine at the University of Pennsylvania. Of patients receiving integrated care combined with a brief period of intervention to assist with adherence to prescribed medication regimens, more than 60 percent had improved blood sugar test results and 58 percent had reduced depression symptoms, compared to only 36 percent and 31 percent, respectively, of patients receiving usual care.
The full results of the study are published in the January/February issue of The Annals of Family Medicine.
There is a link between depression and diabetes - as depression is a risk factor for diabetes, diabetes also increases the risk for the onset of depression. Not only is depression common in patients with diabetes, but it also contributes to poor adherence to medication regimens, which often results in worsening diabetes management.
"Though research demonstrates the link between depression and diabetes, few integrated programs are being implemented in practice,” said lead author Hillary Bogner, MD, MSCE, an assistant professor of Family Medicine and Community Health in the Perelman School of Medicine, and a senior scholar at the Center for Clinical Epidemiology and Biostatistics, both at the University of Pennsylvania. “Our results demonstrate that integrated treatment for both conditions, combined with a brief program focused on adherence for primary care patients with Type 2 diabetes and depression can result in a significant improvement in clinical outcomes. We hope the findings will encourage the adoption of adherence programs aimed at improving outcomes.”
Researchers randomly assigned participants to integrated care or usual care groups. Treatment for the integrated care group combined typical primary care with a brief medication adherence program. Primary care physicians and patients worked with integrated care managers to identify and address potential barriers to maintaining the prescribed medication regimen, such as the cost of medications, or a lack of social support. Integrated care managers developed individualized programs aimed at improving adherence to antidepressants and diabetes medication. Through the use of electronic monitors affixed to pill bottles, researchers were able track the precise date and time participants took their prescribed medications over the course of a 12-week period.
It’s no secret that mental illness and physical health are closely linked. Diabetes is a case in point: People who have it are twice as likely to suffer from depression, and at the same time studies have shown that depression is a risk factor for diabetes.
As a primary care physician in Philadelphia, Hillary Bogner, MD, sees lots of patients struggling with both diabetes and depression - and expects the numbers to grow in the future. “Diabetes is such a huge problem in primary care right now,” she says, and “the rates of depression are so high in patients with diabetes, and diabetes patients with depression do so much worse than patients without.”
Research shows that treating depression can have dramatic effects on physical health. A 2007 study, for example, showed that treating depression in older diabetes patients reduced the likelihood of death by half in the five years that followed. And it’s clear that it improves mental health, too. But what Bogner, an assistant professor at the University of Pennsylvania, wants to find out is whether treating depression has a direct impact on the symptoms of diabetes.
What connects diabetes and depression remains something of a mystery. Part of the relationship is coincidental: Adherence to routines and schedules is very important in managing both depression and diabetes, but people who suffer from depression are less likely to take medications and deal with their diabetes, which makes things worse. It’s a vicious cycle that in turn can amplify the symptoms of depression. “Poor functioning may make it hard to get to the pharmacy or open the bottle. Poor cognition may make you forget to take your medicines,” Bogner says. “People are looking very hard to try to figure out the connections, but adherence . . . comes up over and over.”
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Hillary Bogner, MD
Occupation
Assistant Professor of Family Medicine and Community Health, University of
Pennsylvania
After 12 weeks of monitoring for medication adherence, 60.9 percent of patients who received the integrated approach were found to achieve improved blood sugar test results, compared to only 35.7 percent patients who received only the usual primary care. Additionally, patients in the integrated care group were also more likely to show signs of remission of depression in comparison with patients in the usual care group (58.7 percent vs. 30.7 percent, respectively).
“Our study calls for a greater emphasis within healthcare systems on the development and promotion of clinical programs to enhance medication adherence, particularly among patients with chronic medical conditions and depression,” said Dr. Bogner. “An integrated approach to depression and type 2 diabetes treatment may facilitate adoption in practices with competing demands for limited resources.”
I am worried that I might be getting depressed because of my diabetes, what would my symptoms be?
The symptoms of depression are numerous, and will be different in each individual case.
However, the following symptoms can be consistent with depression caused by diabetes.
Persistent sadness or anxiety, a feeling of hollowness
An overriding feeling of hopelessness and negativity
Feeling helpless and powerless to change your situation
Loss of interest in activities or pleasures
Lower energy and increased fatigue
Insomnia, oversleeping, awakening early in the morning
Concentration problems, memory problems and indecisiveness
Dwelling on death or suicide
Restlessness
Weight change and decreased or increased appetite
Each of these symptoms by themselves does not necessarily mean that depression is present. Also, if the feelings are inconsistent or only occurring rarely, this may be quite normal.
Additional authors include Knashawn H. Morales, ScD, and Heather F. de Vries, MSPH, and Anne R. Cappola, MD, ScM, from Penn.
The current study was supported by an American Diabetes Association Clinical Research Award (1-09-CR-07). Dr. Bogner was supported by the National Institute of Mental Health grant (MH082799). Dr. Morales was supported by a National Institute of Mental Health mentored Career Development Award (MH073903). The research is based on a pilot study supported by the Penn Institute on Aging, where Drs. Bogner and Cappola are both fellows of the Institute.
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University of Pennsylvania School of Medicine.
