Women who have diabetes and depression have a significantly higher risk for all-cause mortality and cardiovascular disease (CVD), new research suggests.
In a cohort study of more than 78,000 women older than 54 years, investigators found a 35% increased risk for any death for those with diabetes only, a 44% increased risk for those with depression only, and twice the risk for those with both compared with their counterparts with neither condition.
When considering only deaths from CVD, women with diabetes had a 67% increased mortality risk, women with depression had a 37% increased risk, and women with both had more than 2.7 times the increased risk.
"Our findings suggest that these 2 conditions of depression and diabetes, which often go hand in hand, create a vicious cycle or what I call 'a double whammy' in terms of health outcomes," investigative team member Frank Hu, MD, PhD, professor of nutrition and epidemiology at the Harvard School of Public Health in Boston, Massachusetts, told Medscape Medical News.
"So I think it's very important for patients and clinicians to address these conditions at the same time in terms of prevention and management," he added.
The study is published in the January issue of Archives of General Psychiatry.
Coexisting Conditions Common
Symptoms of depression affect between 20% and 25% of patients with diabetes — which is "nearly twice as many" as individuals without diabetes, investigators note.
"It is generally suggested that depression is associated with poor glycemic control, an increased risk of diabetes complications, poor adherence to diabetes management by patients, and isolation from the social network," they write.
Although previous research shows depression and diabetes are each associated with an increased risk for mortality, "data evaluating the joint effects of these conditions on mortality are sparse."
For the study, researchers evaluated data from the Nurses Health Study, a cohort of 78,282 female registered nurses (97.6% white) between the ages of 54 and 79 years, who responded to a questionnaire.
Depression was determined by self-report, antidepressant use, or a score of 52 or less on the 5-item Mental Health Index (MHI-5; indicating severe depressive symptoms). Type 2 diabetes was confirmed by a self-reported supplementary questionnaire.
Exclusion criteria included a history of gestational, type 1, or secondary diabetes and missing information on antidepressant use, depressive symptoms, or diagnosis.
All participant information was assessed at baseline in 2000 and at 6-year follow-up.
Higher Mortality Rates
Results showed that 14.2% of the women had depression only, 5% had diabetes only, and 1.3% had both. At follow-up, 4654 total women had died from any cause; 979 of these deaths were from CVD.
Women who had both diabetes and depression had lower MHI-5 scores and physical activity levels, had higher body mass indexes, and were less likely to have spouses at baseline than those who had neither condition or either alone. They also had higher baseline rates of hypertension, heart disease, stroke, or cancer.
In addition, "the prevalence of depression in participants with diabetes (20.5%) was higher than that in the individuals without diabetes (15.1%)," the investigators write.
Age-adjusted relative risks (RRs) for all-cause and CVD mortality were significantly higher for women with depression only and diabetes only compared with those with neither condition and were substantially higher for those with both.
Table 1. Age-Adjusted RRs of Death According to Diabetes and Depression Status
Mortality Type Depression Only, RR (95% CI) Diabetes Only, RR (95% CI) Both Conditions, RR (95% CI)
All cause 1.76 (1.64 – 1.89) 1.71 (1.54 – 1.89) 3.11 (2.70 – 3.58)
CVD 1.81 (1.54 – 2.13) 2.67 (2.20 – 3.23) 5.38 (4.19 – 6.91)
CI = confidence interval; CVD = cardiovascular disease; RR = relative risk
"These associations were attenuated after multivariate adjustment for other demographic variables, body mass index, smoking status, alcohol intake, physical activity, and major comorbidities (including hypertension, hypercholesterolemia, heart diseases, stroke, and cancer) but remained significant," the investigators write.
After these adjustments were made, women who had both conditions were again found to have the highest RRs for all cause and CVD mortality.
Table 2. Multivariate RRs of Death According to Diabetes and Depression Status*
Mortality Type Depression Only, RR (95% CI) Diabetes Only, RR (95% CI) Both Conditions, RR (95% CI)
All cause 1.44 (1.34 – 1.54) 1.35 (1.21 – 1.51) 2.07 (1.79 – 2.40)
CVD 1.37 (1.16 – 1.62) 1.67 (1.36 – 2.05) 2.72 (2.09 – 3.54)
CI = confidence interval; CVD = cardiovascular disease; RR = relative risk
*Multivariate model plus major comorbidities.
"Furthermore, the combination of depression with a long duration of diabetes mellitus (>10 years) or insulin therapy was associated with a particularly higher risk of CVD mortality after multivariate adjustment (RRs, 3.22 and 4.90, respectively)," the study authors note.
"Considering the size of the population that could be affected by these 2 prevalent disorders, further consideration is required to design strategies aimed to provide adequate psychological management and support among those with longstanding chronic diseases, such as diabetes," they add.
"I think this study has important clinical implications in addressing diabetes control and depression prevention," said Dr. Hu. "The important question is, 'How can clinicians better help patients deal with both conditions at the same time?'
"Patients with diabetes should watch out for any depressive symptoms or signs and should also receive psychosocial support to help them reduce stress associated with diabetes management. And those with depression should have their blood sugar more closely monitored."
Dr. Hu noted that he would like to see future studies addressing potential mechanisms of depression plus diabetes. "Why do these 2 conditions tend to go together? And why is the combination of them together associated with such a high risk of mortality? I think both biological and behavioral factors contribute. But I think we need more detailed studies to look into this."
Confirmatory Findings
"I think this study is valuable for its overall perspective, but I'm not sure it's different than what you would find with other chronic diseases, except for a couple things that actually aren't mentioned in the paper," Gerald Bernstein, MD, from the Friedman Diabetes Institute at Beth Israel Medical Center in New York City, told Medscape Medical News.
"People with diabetes have elevated blood sugar. And one of the things not addressed in this study was the level of control of the blood sugar in these nurses that were looked at. The researchers talk about medication and duration but not whether it was well or poorly controlled," explained Dr. Bernstein.
He noted that although it might not be possible now, "it would be nice" if the investigators could go back and provide a graph comparing blood sugar control and the frequency of depression.
"The other interesting thing was that the depressive quality increased progressively with the complexity of treatment. So 'no medication' was one level, oral medication was at another, and people who took insulin actually had the worst. This makes sense because many people, though they shouldn't, think that insulin is a marker that they're doomed and that it's an end-stage intervention. So I think the documentation of this as a reality is important," said Dr. Bernstein.
He explained that the Diabetes Benefit Program he directs at his institute is aimed at diabetes educators, which include social workers/psychologists "because it's important to understand the role of depression in this disorder."
"It's 1 thing to teach about exercise, nutrition, and how to take care of medication, but we make sure we don't ignore the psychodynamics of this disease. It's a multilevel intervention aimed at preventing complications."
Overall, Dr. Bernstein noted that this study "is not a new observation. The importance was the sheer volume of people that they were looking at. So there's value in this observation that is confirming what other people have seen in the past."
The study was funded by grants from the National Institutes of Health and from the National Alliance for Research on Schizophrenia and Depression. The study authors and Dr. Bernstein have disclosed no relevant financial relationships.
In a cohort study of more than 78,000 women older than 54 years, investigators found a 35% increased risk for any death for those with diabetes only, a 44% increased risk for those with depression only, and twice the risk for those with both compared with their counterparts with neither condition.
When considering only deaths from CVD, women with diabetes had a 67% increased mortality risk, women with depression had a 37% increased risk, and women with both had more than 2.7 times the increased risk.
"Our findings suggest that these 2 conditions of depression and diabetes, which often go hand in hand, create a vicious cycle or what I call 'a double whammy' in terms of health outcomes," investigative team member Frank Hu, MD, PhD, professor of nutrition and epidemiology at the Harvard School of Public Health in Boston, Massachusetts, told Medscape Medical News.
"So I think it's very important for patients and clinicians to address these conditions at the same time in terms of prevention and management," he added.
The study is published in the January issue of Archives of General Psychiatry.
Coexisting Conditions Common
Symptoms of depression affect between 20% and 25% of patients with diabetes — which is "nearly twice as many" as individuals without diabetes, investigators note.
"It is generally suggested that depression is associated with poor glycemic control, an increased risk of diabetes complications, poor adherence to diabetes management by patients, and isolation from the social network," they write.
Although previous research shows depression and diabetes are each associated with an increased risk for mortality, "data evaluating the joint effects of these conditions on mortality are sparse."
For the study, researchers evaluated data from the Nurses Health Study, a cohort of 78,282 female registered nurses (97.6% white) between the ages of 54 and 79 years, who responded to a questionnaire.
Depression was determined by self-report, antidepressant use, or a score of 52 or less on the 5-item Mental Health Index (MHI-5; indicating severe depressive symptoms). Type 2 diabetes was confirmed by a self-reported supplementary questionnaire.
Exclusion criteria included a history of gestational, type 1, or secondary diabetes and missing information on antidepressant use, depressive symptoms, or diagnosis.
All participant information was assessed at baseline in 2000 and at 6-year follow-up.
Higher Mortality Rates
Results showed that 14.2% of the women had depression only, 5% had diabetes only, and 1.3% had both. At follow-up, 4654 total women had died from any cause; 979 of these deaths were from CVD.
Women who had both diabetes and depression had lower MHI-5 scores and physical activity levels, had higher body mass indexes, and were less likely to have spouses at baseline than those who had neither condition or either alone. They also had higher baseline rates of hypertension, heart disease, stroke, or cancer.
In addition, "the prevalence of depression in participants with diabetes (20.5%) was higher than that in the individuals without diabetes (15.1%)," the investigators write.
Age-adjusted relative risks (RRs) for all-cause and CVD mortality were significantly higher for women with depression only and diabetes only compared with those with neither condition and were substantially higher for those with both.
Table 1. Age-Adjusted RRs of Death According to Diabetes and Depression Status
Mortality Type Depression Only, RR (95% CI) Diabetes Only, RR (95% CI) Both Conditions, RR (95% CI)
All cause 1.76 (1.64 – 1.89) 1.71 (1.54 – 1.89) 3.11 (2.70 – 3.58)
CVD 1.81 (1.54 – 2.13) 2.67 (2.20 – 3.23) 5.38 (4.19 – 6.91)
CI = confidence interval; CVD = cardiovascular disease; RR = relative risk
"These associations were attenuated after multivariate adjustment for other demographic variables, body mass index, smoking status, alcohol intake, physical activity, and major comorbidities (including hypertension, hypercholesterolemia, heart diseases, stroke, and cancer) but remained significant," the investigators write.
After these adjustments were made, women who had both conditions were again found to have the highest RRs for all cause and CVD mortality.
Table 2. Multivariate RRs of Death According to Diabetes and Depression Status*
Mortality Type Depression Only, RR (95% CI) Diabetes Only, RR (95% CI) Both Conditions, RR (95% CI)
All cause 1.44 (1.34 – 1.54) 1.35 (1.21 – 1.51) 2.07 (1.79 – 2.40)
CVD 1.37 (1.16 – 1.62) 1.67 (1.36 – 2.05) 2.72 (2.09 – 3.54)
CI = confidence interval; CVD = cardiovascular disease; RR = relative risk
*Multivariate model plus major comorbidities.
"Furthermore, the combination of depression with a long duration of diabetes mellitus (>10 years) or insulin therapy was associated with a particularly higher risk of CVD mortality after multivariate adjustment (RRs, 3.22 and 4.90, respectively)," the study authors note.
"Considering the size of the population that could be affected by these 2 prevalent disorders, further consideration is required to design strategies aimed to provide adequate psychological management and support among those with longstanding chronic diseases, such as diabetes," they add.
"I think this study has important clinical implications in addressing diabetes control and depression prevention," said Dr. Hu. "The important question is, 'How can clinicians better help patients deal with both conditions at the same time?'
"Patients with diabetes should watch out for any depressive symptoms or signs and should also receive psychosocial support to help them reduce stress associated with diabetes management. And those with depression should have their blood sugar more closely monitored."
Dr. Hu noted that he would like to see future studies addressing potential mechanisms of depression plus diabetes. "Why do these 2 conditions tend to go together? And why is the combination of them together associated with such a high risk of mortality? I think both biological and behavioral factors contribute. But I think we need more detailed studies to look into this."
Confirmatory Findings
"I think this study is valuable for its overall perspective, but I'm not sure it's different than what you would find with other chronic diseases, except for a couple things that actually aren't mentioned in the paper," Gerald Bernstein, MD, from the Friedman Diabetes Institute at Beth Israel Medical Center in New York City, told Medscape Medical News.
"People with diabetes have elevated blood sugar. And one of the things not addressed in this study was the level of control of the blood sugar in these nurses that were looked at. The researchers talk about medication and duration but not whether it was well or poorly controlled," explained Dr. Bernstein.
He noted that although it might not be possible now, "it would be nice" if the investigators could go back and provide a graph comparing blood sugar control and the frequency of depression.
"The other interesting thing was that the depressive quality increased progressively with the complexity of treatment. So 'no medication' was one level, oral medication was at another, and people who took insulin actually had the worst. This makes sense because many people, though they shouldn't, think that insulin is a marker that they're doomed and that it's an end-stage intervention. So I think the documentation of this as a reality is important," said Dr. Bernstein.
He explained that the Diabetes Benefit Program he directs at his institute is aimed at diabetes educators, which include social workers/psychologists "because it's important to understand the role of depression in this disorder."
"It's 1 thing to teach about exercise, nutrition, and how to take care of medication, but we make sure we don't ignore the psychodynamics of this disease. It's a multilevel intervention aimed at preventing complications."
Overall, Dr. Bernstein noted that this study "is not a new observation. The importance was the sheer volume of people that they were looking at. So there's value in this observation that is confirming what other people have seen in the past."
The study was funded by grants from the National Institutes of Health and from the National Alliance for Research on Schizophrenia and Depression. The study authors and Dr. Bernstein have disclosed no relevant financial relationships.
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