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Correlation of Depression and Severe Dysglycemia in T1DM

Jan 27, 2018
 

Patients with type 1 diagnosed with depression said to be in danger of experiencing more severe episodes of hypoglycemia and hyperglycemia.

Are severe hypoglycemic, or hyperglycemic events to blame for a new onset of depression in people with type 1 diabetes?  Or, is depression the main culprit in causing severe episodes of dysglycemia as proven with type 2 diabetes?  Previous studies, such as study by Nicole Gendelman et al., have shown that patients who are suffering from type 1 diabetes are twice as common to be diagnosed with depression, compared to patients without diabetes. However, the etiology of the relationship between the two is not known. A detrimental cycle between series of depressive episodes and severe hyper- or hypoglycemia could be related, therefore, a study was needed to uncover if there is a two-way link between dysglycemia and depression in type 1 diabetes mellitus.

Study researchers considered patients with type 1 diabetes from the diabetes and aging integrated healthcare delivery system – Kaiser Permanente Northern California (KPNC) – for recruitment in the cohort. Utilizing KPNC registry from 1996 to 2015, subjects with type 1 diabetes who were 50 years of age or older, who had a minimum of two ICD-9 codes corresponding to T1D, who were receiving only insulin as their antihyperglycemic agent, and who had records of filling insulin prescriptions were enrolled in the cohort.  Subjects were deemed to be depressed if their charts included one of the ICD-9 codes matching diagnosis of depression. Admission to the hospital or visit to the ER due to hyper- or hypoglycemia was regarded as a severe episode of dysglycemia. In total, there were 3,742 subjects whose data was included in the cohort. Excluded from the depression-hyperglycemia cohort were those individuals who experienced hyperglycemia at baseline; similarly, those who had baseline hypoglycemia were omitted from the hypoglycemia-depression cohort. Subjects were censored after the first severe episode of dysglycemia, death, at the conclusion of the KPNC study, or those who had a hiatus in KPNC membership. Dysglycemia risk was assessed at 6 months, 1 year, and over 1 year following the diagnosis of depression.

One-fifth of the participants had depression at the commencement of the study; throughout the duration of the cohort, an additional 21% of subjects were diagnosed with depression. Overall, severe hyperglycemia and hypoglycemia occurred in 11% and 20% of individuals, whereas both events were suffered in 5% of the participants. In the depression-hyperglycemia cohort, depression was associated with a two-fold risk of a severe hyperglycemic event, as shown with the hazard ratio of 2.47. Depression significantly increased the risk of hypoglycemia as well, HR of 1.89. Risk of hyper- or hypoglycemia was greatest during the first 6 months following the diagnosis of depression; patients with depression had a seven times higher chance of experiencing an episode of severe hyperglycemia, and were five times as likely to suffer a hypoglycemic event when compared to their non-depressed counterparts. For the period up to one year after the diagnosis of depression, the probability of hyper- or hypoglycemia was elevated by five- and four-fold, respectively. Non-depressed subjects were less likely to experience a severe hyperglycemic event when compared to an individual who was diagnosed with depression over a year ago. However, in depression-hypoglycemia cohort, individuals who were diagnosed with depression over 1 year ago were not at an increased chance of severe hypoglycemia. Furthermore, it was found that the subjects who did not have depression at baseline, but who had experienced a single event of severe dysglycemia, were more likely to be diagnosed with depression. A severe hypoglycemic incident lead to a 75% increased chance of developing depression, while severe hyperglycemia was associated with a 50% augmented risk of depression.

The results from the cohort by Paola Gilsanz and colleagues proved the relationship between depression and dysglycemia to be linked, bi-directionally. The importance of the results presented should serve as a stepping stone for more research that needs to be completed, so that we can truly understand the impact of depression and severe dysglycemia on morbidity and mortality.  The study took into account the patients who were diagnosed with depression, but one has to ask themselves for each diagnosed patient, how many more were suffering from depression silently? Clinicians should act more vigilantly in diagnosing depression, and treating it as deemed appropriate, in order to relieve the danger we have seen here. Lastly, considering the fact that the risk of severe dysglycemia is highest during the first 6 months of depression diagnosis, a study that investigates the relationship between dysglycemia and depression in younger patients with T1D is needed.

Practice Pearls:

  • Depression is associated with an increased risk of severe hyperglycemia and hypoglycemia by approximately 50%.
  • The highest chance for a severe dysglycemic event to occur is during the first 6 months following a diagnosis of depression.
  • Severe hyperglycemia or severe hypoglycemia lead to an increased risk of developing depression by 50% and 75%, respectively.

References:

Paola Gilsanz, Andrew Karter, Micheal Beeri, et al. “The Bidirectional Association Between Depression and Severe Hypoglycemic and Hyperglycemic Events in Type 1 Diabetes”.  Diabetes Care, American Diabetes Association. Dec 2017. care.diabetesjournals.org/content/early/2017/12/14/dc17-1566.  Accessed on Jan. 2018.

Nicole Gendelman, Janet Snell-Bergeon, Kim McFann, et al. “Prevalence and correlates of depression in individuals with and without type 1 diabetes”. Diabetes Care, American Diabetes Association 2009. http://care.diabetesjournals.org/content/32/4/575.long. Accessed on Jan. 2018.

Lamija Zimic, PharmD(c), University of South Florida, College of Pharmacy