Depression in Chinese patients with type 2 diabetes: associations with hyperglycemia, hypoglycemia, and poor treatment adherence

Abstract

BackgroundWe hypothesize that depression in type 2 diabetes might be associated with poor glycemic control, in part due to suboptimal self‐care. We tested this hypothesis by examining the associations of depression with clinical and laboratory findings in a multicenter survey of Chinese type 2 diabetic patients.Method2538 patients aged 18–75 years attending hospital‐based clinics in four cities in China underwent detailed clinical‐psychological‐behavioral assessment during a 12‐month period between 2011 and 2012. Depression was diagnosed if Patient Health Questionnaire‐9 (PHQ‐9) score ≥10. Diabetes self‐care and medication adherence were assessed using the Summary of Diabetes Self‐care Activities and the 4‐item Morisky medication adherence scale respectively.ResultsIn this cross‐sectional study (mean age: 56.4 ± 10.5[SD] years, 53% men), 6.1% (n = 155) had depression. After controlling for study sites, patients with depression had higher HbA 1c (7.9 ± 2.0 vs. 7.7 ± 2.0%, P = 0.008) and were less likely to achieve HbA 1c goal of <7.0% (36.2% vs 45.6%, P = 0.004) than those without depression. They were more likely to report hypoglycemia and to have fewer days of being adherent to their recommended diet, exercise, foot care and medication. In logistic regression, apart from young age, poor education, long disease duration, tobacco use, high body mass index, use of insulin, depression was independently associated with failure to attain HbA 1c target (Odds Ratio [OR] = 1.56, 95%CI:1.05–2.32, P = 0.028). The association between depression and glycemic control became non‐significant after inclusion of adherence to diet, exercise and medication (OR = 1.48, 95% CI 0.99–2.21, P = 0.058).ConclusionDepression in type 2 diabetes was closely associated with hyperglycemia and hypoglycemia, which might be partly mediated through poor treatment adherence.

Poor medication adherence in diabetes: What's the problem?

“…In this issue of the Journal, for example, three articles highlight a number of these factors. In a large cross‐sectional study of adults with type 2 diabetes (T2D) across four cities in China ( n = 2538), Zhang et al . found that poor medication adherence (self‐reported) was associated with “probable depression”, defined as Patient Health Questionnaire‐9 (PHQ9) scores >10.…”

“…当我们考虑导致PMA的原因时，往往都有一个诱人的假设，即最关键的因素就是患者缺乏相关知识或教育，或者患者是属于“否认”的某种类型，或者患者仅仅是“不依从”（一种模糊且不精确的赘述观念，不能用来解释任何东西）。但是最近有证据指明了更精确且易于理解的导致PMA的原因，有助于了解我们的患者在遇到障碍时所做出的理性反应。在这期杂志中，举例来说，有3篇文章强调了一系列的这类因素。在横跨中国的4个城市进行的一项大型成年人2型糖尿病（T2D）横断面研究中（ n = 2538），Zhang等 4 发现用药依从性差（自我报告）与“抑郁症可能性”之间具有相关性，抑郁症的定义为患者健康问卷‐9（Patient Health Questionnaire‐9，PHQ9）得分>10。在世界上其他国家的许多受试者样本中也能发现类似的相关性 5 ，虽然常见的类似PHQ9的抑郁症问卷得分升高更有可能代表的是糖尿病相关的困扰而不是临床上的抑郁症 6 。Larkin等 7 通过互联网调查后报告了807名患者的（90%合并T2D）应答情况，发现报告的导致PMA的最常见原因是健忘、担心副作用或药物可能有害以及费用。对数据进行进一步分析后发现，患者较少与他的医生或者其他医疗保健专业人员进行沟通同样也与PMA相关。最近报告的几个研究结果相类似，若患者信任他们的医生则用药依从性就更好 8,9 。不幸的是，在Larkin等 7 的研究中没有使用经过验证的方法，并且他们也没有将实际问题包括在内，所以我们在推广这些研究结果时必须小心。最后，Miller等 10 在医疗费用专项调查中对依从性差的非老龄成年糖尿病患者进行了研究，计算后发现对这些患者需要增加现金成本才能够获得充分的药物治疗效果。在这个模型中，作者推断39.6%的未参加保险的患者需要在药物上花费≥收入的10%。…”

CIMMYT Series on Carbohydrates, Wheat, Grains, and Health: Role of Carbohydrates and Grains in Nutrition and Neurological Disorders: Headache, Attention Deficit Hyperactivity Disorder, and Depression,

“…When feeling depressed, people have a tendency to overconsume high-glycemic CHOs (120). Both hypo-and hyperglycemia were related to depression in studies of patients with type 2 diabetes in Mexico, Peru, China, and Japan (121)(122)(123). Better glycemic control was associated with less depression, and depression was associated with poorer control.…”

Leisure Time Physical Activity and Hypertension: Evidence from the China Health & Nutrition Survey, 2004-2011

“…Part of the sample attrition could be due to substantial migration out of rural China since the 1980s. The young, aged from 15 to 40, make up a large proportion of participants that dropped out of the study between 2004 and 2011 [23]. Nevertheless, other studies have suggested that the potential bias associated with the attrition should not be a grave concern, because among large-scale surveys in developing countries, the CHNS is one of the most successful panel studies with relatively low attrition rates [24,25].…”