Major Depression Associated with Increased Risk of Severe Hypoglycemia

A prospective study finds an increased risk in time to first severe hypoglycemic event and subsequent hypoglycemic events in diabetic patients with depression….

Previous evidence suggests hypoglycemic episodes may result from behavioral, physiologic, and therapeutic factors. Errant medication use, poor self-blood glucose monitoring, alcohol use and lack of regular meals are among various behavioral factors leading to poor glycemic outcomes. Despite knowing these risk factors, very few studies have been conducted to determine the effects of depression on increased risk of hypoglycemic events.

Katon et al. proposed a prospective study to determine an association of depression with risk of hypoglycemic episodes requiring either an emergency department visit or hospitalization. The author indicated that major depression occurs in 18% of patients with diabetes and is closely associated with lack of appropriate dieting, exercise, glucose monitoring and adherence to medication. Katon et al. also state that depression has also been linked to an increased risk of microvascular and macrovascular complications, dementia and hypoglycemic episodes.

The researchers hypothesized, "That comorbid depression would be associated with time to the first severe hypoglycemic episode and number of severe hypoglycemic episodes over a 5-year period." Adults 18 years and older were selected for observation from nine primary care clinics in Western Washington between 2000 and 2002. Eligible patients were identified following completion of the Patient Health Questionnaire-9 (PHQ-9), a validated indicator of major depression determined by American Psychiatric Association (DSM-IV) criteria for major depression. Medical records were reviewed for eligible patients over the 5 years period of 2002 to 2007. The primary outcome of interest was an ICD-9 code for a hypoglycemic episode requiring an emergency department visit or hospitalization.

A total of 4,117 patients with diabetes were analyzed. 495 patients were identified as having depression while 3,622 patients were not depressed. A proportional hazard model was used to analyze the association of depression and risk of severe hypoglycemic episodes. Poisson regression was used to determine whether depression status was associated with the number of hypoglycemic episodes. Unadjusted analyses showed patients with depression had a significantly shorter time to a first severe hypoglycemic event and higher incidence of severe hypoglycemic events.

After adjusting for sociodemographic, health risk behaviors and clinical variables, the authors again reported that depressed patients with diabetes had a significantly shorter time to the first severe hypoglycemic episode as well as increased incidence of more episodes.

Katon et al. concluded, "In this study, comorbid major depression was found to be a risk factor for severe hypoglycemic episodes in adults with diabetes. Research is needed to assess whether recognition and effective treatment of depression among persons with diabetes prevents severe hypoglycemic episodes, as well as the increased risk of complications and mortality."

Katon,WJ, Young, BA., Russo, J. et al. "Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes." Annals of Family Medicin. May/June 2013 vol. 11 no. 3 245-250. doi: 10.1370/afm.1501