OBJECTIVETo prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes.RESEARCH DESIGN AND METHODSA longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000–2002 and followed through 2005–2007. Advanced microvascular complications included blindness, end-stage renal disease, amputations, and renal failure deaths. Advanced macrovascular complications included myocardial infarction, stroke, cardiovascular procedures, and deaths. Medical record review, ICD-9 diagnostic and procedural codes, and death certificate data were used to ascertain outcomes in the 5-year follow-up. Proportional hazard models analyzed the association between baseline depression and risks of adverse outcomes.RESULTSAfter adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes (hazard ratio 1.36 [95% CI 1.05–1.75]) and adverse macrovascular outcomes (1.24 [1.0–1.54]).CONCLUSIONSAmong people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities. Clinical and public health significance of these findings rises as the incidence of type 2 diabetes soars. Further research is needed to clarify the underlying mechanisms for this association and to test interventions to reduce the risk of diabetes complications among patients with comorbid depression.

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Background-Many patients with diabetes fail to achieve American Diabetes Association Guidelines for glycemic, blood pressure and lipid control. Depression is a common comorbidity and may affect disease control through adverse effects on adherence and physician intensification of treatment.

Objective-To test whether depression is associated with an increased risk of incident diabetic foot ulcers. Methods-The Pathways EpidemiologicStudy is a population-based prospective cohort study of 4839 patients with diabetes in [2000][2001][2002][2003][2004][2005][2006][2007]. The present analysis included 3474 adults with type 2 diabetes and no prior diabetic foot ulcers or amputations. Mean follow-up was 4.1 years. Major and minor depression assessed by the Patient Health Questionnaire-9 (PHQ-9) were the exposures of interest. The outcome of interest was incident diabetic foot ulcers. We computed the hazard ratio (HR) and 95% CI for incident diabetic foot ulcers, comparing patients with major and minor depression to those without depression and adjusting for sociodemographic characteristics, medical comorbidity, glycosylated hemoglobin (HbA 1c ), diabetes duration, insulin use, number of diabetes complications, body mass index, smoking status, and foot self-care. Sensitivity analyses Please address requests for reprints to Dr. Lisa H. Williams at 125 16 th Ave E, mail stop CSB-5, Seattle, WA 98112. The authors have no relevant financial interests to disclose. All authors had access to the data and a role in writing the manuscript.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access Author ManuscriptAm J Med. Author manuscript; available in PMC 2011 August 1. Results-Compared to patients without depression, patients with major depression by PHQ-9 had a two-fold increase in the risk of incident diabetic foot ulcers (adjusted HR 2.00, 95% CI: 1.24, 3.25). There was no statistically significant association between minor depression by PHQ-9 and incident diabetic foot ulcers (adjusted HR 1.37, 95% CI: 0.77, 2.44).Conclusion-Major depression by PHQ-9 is associated with a two-fold higher risk of incident diabetic foot ulcers. Future studies of this association should include better measures of peripheral neuropathy and peripheral arterial disease, which are possible confounders and/or mediators. Keywordsdiabetes; depression; foot ulcers; complications Among individuals with diabetes, depression is common and associated with multiple adverse outcomes. Depressive symptoms were associated with a higher risk of developing self-reported macrovascular and microvascular complications in a large study of older Hispanic Americans with type 2 diabetes. 1 Mild to severe depressive symptoms were associated with the development of retinopathy 2 and proteinuria 3 in younger African American adults with type 1 diabetes. In addition, several studies in patients with type ...

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OBJECTIVEPrior research has shown that less social support is associated with increased mortality in individuals with chronic illnesses. We set out to determine whether lower propensity to seek support as indicated by relationship style, based on attachment theory, is associated with mortality in patients with diabetes.RESEARCH DESIGN AND METHODSA total of 3,535 nondepressed adult patients with type 1 and type 2 diabetes enrolled in a health maintenance organization in Washington State were surveyed at baseline and followed for 5 years. Relationship style was assessed at baseline. Patients with a greater propensity to seek support were classified as having an interactive relationship style and those less inclined to seek support as having an independent relationship style. We collected Washington State mortality data and used Cox proportional hazards models to estimate relative risk (RR) of death for relationship style groups.RESULTSThe rate of death in the independent and interactive relationship style groups was 39 and 29 per 1,000 individuals, respectively. Unadjusted RR of death was 1.33 (95% CI 1.12–1.58), indicating an increased risk of death among individuals with an independent relationship style. After adjustment for demographic and clinical covariates, those with an independent relationship style still had a greater risk of death compared with those with an interactive relationship style (hazard ratio 1.20 [95% CI 1.01–1.43]).CONCLUSIONSIn a large sample of adult patients with diabetes, a lower propensity to reach out to others is associated with higher mortality over 5 years. Further research is needed to examine possible mechanisms for this relationship and to develop appropriate interventions.

Problem-Depression is associated with a higher risk of macrovascular and microvascular complications and mortality in diabetes, but whether depression is linked to an increased risk of incident amputations is unknown. We examined the association between diagnosed depression and incident non-traumatic lower limb amputations in veterans with diabetes.Methods-This was a retrospective cohort study from 2000-2004 that included 531,973 veterans from the Diabetes Epidemiology Cohorts, a national Veterans Affairs (VA) registry with VA and Medicare data. Depression was defined by diagnostic codes or antidepressant prescriptions. Amputations were defined by diagnostic and procedural codes. We determined the HR and 95% CI for incident non-traumatic lower limb amputation by major (transtibial and above) and minor (ankle and below) subtypes, comparing veterans with and without diagnosed depression and adjusting for demographics, health care utilization, diabetes severity, and comorbid medical and mental health conditions. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusions-Diagnosed depression is associated with a 33% higher risk of incident major lower limb amputation in veterans with diabetes. Further study is needed to understand this relationship and to determine whether depression screening and treatment in patients with diabetes could decrease amputation rates. Results-Over NIH Public Access

Objectives Depression is the most common psychiatric disorder in patients with chronic kidney disease (CKD). We sought to determine the association of major depression with mortality among diabetic patients with late stage CKD. Method The Pathways Study is a longitudinal, prospective cohort study initiated to determine the impact of depression on outcomes among primary care diabetic patients. Subjects were followed from 2001 until 2007 for a mean duration of 4.4 years. Major depression, identified by the Patient Health Questionnaire-9 (PHQ-9), was the primary exposure of interest. Stage 5 CKD was determined by dialysis codes and estimated glomerular filtration rate (<15ml/min). An adjusted Cox proportional hazards multivariable model was used to determine the association of baseline major depression with mortality. Results Of the 4128 enrolled subjects, 110 were identified with stage 5 CKD at baseline. Of those, 34 (22.1%) had major depression. Over a period of 5 years, major depression was associated with 2.95-fold greater risk of death (95% CI=1.24–7.02) compared to those with no or few depressive symptoms. Conclusion Major depression at baseline was associated with a 3-fold greater risk of mortality among stage 5 CKD diabetic patients. Given the high mortality risk, further testing of targeted depression interventions should be considered in this population.