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Depression and Hyperglycemic Crisis 

Feb 15, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Antonio Bess, Pharm D Candidate, Florida Agricultural & Mechanical University School of Pharmacy

People who have diabetes and depression have a higher risk of complications from both diseases; hyperglycemic crisis is one potential risk.

Diabetes and depression are diseases that are thought to have a bidirectional relationship, meaning one condition could put a person at risk for developing the other state. Depression can lead to poor hygiene and a lack of self-care, while the diagnosis of diabetes could cause psychological stress and lead to depression. Diabetes has chronic and acute complications that can be exacerbated by depression, one of these being a hyperglycemic crisis episode. Hyperglycemic crisis is a term used to group diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS), both of which are potentially life-threatening and can lead to permanent neurological damage. One study showed a 2.47-fold increase in the development of a hyperglycemic crisis episode in patients with depression compared to those without. This study aimed to investigate the risk of a hyperglycemic crisis episode in patients with concomitant diabetes and depression, and to examine the relationship between the duration of antidepressant use and the risk of a hyperglycemic crisis episode (HCE).  


Patients were chosen from 2 studied cohorts in which individuals were chosen from the National Health Insurance Program database of Taiwan. Overall, 26,746 patients with diabetes and depression were selected from casecohort, and 106,853 patients without depression were selected from a control cohort. Patients were matched by gender, age, CCI score, and index year (earliest year diabetes was diagnosed). In both groups, females outnumbered males, ages 30-49 were the majority, and 69.8% of Charlson Comorbidity Index (CCI) scores were 0.  To be included in the study, participants had to meet the following criteria: at least two outpatient diagnoses of depressive disorder or one hospitalization with depressive disorder. Patients with a history of hyperglycemic crisis episodes were excluded. All participants were followed until an incident occurred, death, or the end of 2013 (whichever comes first). The average amount of time of follow up was 6.2 years for both cohorts. In the casecohort group, patients were grouped by antidepressant use (non-users, short term, long term). For non-users, short term, and long term use, the proportions for each group were 22.2%, 27%, and 50.8% respectively. 

The results of the study found incidence rates of hyperglycemic crisis episodes to be 2.87 and 2.50 per 1000 personyears for the case and control cohorts, respectively. After adjusting for age CCI score, index date and gender, the casecohort showed a greater risk for HCE (HR: 1.78, 95% CI: 1.56-2.03). For the entire group, males had a higher risk than females (HR estimate was 1.37). Greater risks were also found with persons who had CCI scores of 1-2 and >/=3 (HR: 2.28 and 3.47 respectively). Regarding antidepressant use, both cohorts showed a reduced risk of hyperglycemic crisis episodes with long term use (HR: 0.41, 95% CI: 0.34-0.49).  

This study concluded that people with diabetes and depression were at an increased risk for hyperglycemic crisis episodes compared to those without depression. Variables that increased the risk of a hyperglycemic crisis episode were duration of antidepressant use, male gender, and higher CCI scores. Symptoms of depression can create problems that alter diabetes care, such as lack of motivation and not being able to find interest or pleasure in everyday activities. Also, sleep, mood, and appetite changes can put someone at risk for a hyperglycemic crisis episode. A person in a depressive state might not recognize the signs and symptoms of hyperglycemia and therefore, could fail to report it to a physician or take proper care. A lack of continuity in diabetes care could result in poor glycemic control.  

This study had several limitations. It didn’t consider how the severity of depression and diabetes could affect the risk of HCE. Individual medical and psychiatric comorbidities were not taken into consideration because this study only weighed them based on the CCI score. Variables such as lifestyle, BMI, socioeconomic status, and family history were not considered, which could affect results in the study. All the participants were residents of Taiwan as well. This study did highlight the need to control both diabetes and depression to reduce a person’s risk for a hyperglycemic crisis episode. 

Practice Pearls  

  • Inadequate depression control, male gender, and comorbidities increase the risk of HCE in patients with depression and T2DM. 
  • Each disease can help develop the other, so earlier management is essential. 
  • Comorbidities increase the risk of severe complications from any disease. 


Lee, Haw-Ming, et al. “Risk of Hyperglycemic Crisis Episode in Diabetic Patients with Depression: A Nationwide Population-Based Cohort Study.” Journal of Diabetes and Its Complications, Dec. 2019, p. 107509, doi:10.1016/j.jdiacomp.2019.107509.x 

Gilsanz, Paola, et al. “The Bidirectional Association Between Depression and Severe Hypoglycemic and Hyperglycemic Events in Type 1 Diabetes.” Diabetes Care, vol. 41, no. 3, American Diabetes Association Inc., Mar. 2018, pp. 446–52, doi:10.2337/dc17-1566. 


Antonio Bess, Pharm D Candidate, Florida A&M University 


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