CMAJ July 4, 2006; 175 (1). doi:10.1503/cmaj.060612.

2006 CMA Media Inc. or its licensors

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Low risk of depression in diabetes? Would that it were so
Deborah J. Wexler
Deborah J. Wexler is with the Department of Endocrinology, Massachusetts General
Hospital, Boston, Mass.
Correspondence to: Dr. Deborah Wexler, Department of Endocrinology,
Massachusetts General Hospital, 55 Fruit St., Boston MA 02114, USA;
dwexler@partners.org
Practitioners who care for patients with diabetes are familiar with the problems of comorbid depression:
decreased compliance with treatment, increased risk of complications and disability, and diminished
health-related quality of life. The large body of data outlined by Brown and colleagues1 has
demonstrated that the prevalence of depression is increased in diabetes and vice-versa. How, then, are we
to understand their finding1 that type 2 diabetes does not increase the risk of depression?
Using administrative databases that capture 99% of Saskatchewan's population, these authors identified
31 635 adults with type 2 diabetes newly diagnosed between 1992 and 2000, and followed them for an
average of 4.5 years. Patients with type 2 diabetes were identified by outpatient or inpatient service
codes for diabetes; gestational diabetes was excluded. The study cohort was limited to those dispensed a
hypoglycemic drug to be taken orally; subjects who met the case definition within the preceding 3 years
(1989 through 1991) were excluded. Controls were 57 141 people without diabetes who were randomly
selected from the database and matched to cases only by the date of identification of diabetes.
Similarly, patients in the cohort who experienced depression were identified by the diagnosis codes for
depressive disorders and prescriptions for antidepressant medications. Again, patients who met this
definition during the 3 years preceding the study period were excluded. With this method, a greater
proportion of cases (4.9% of patients with diabetes) than controls (3.8% of patients without diabetes)
were excluded from the study cohort because of prior depression. In the remaining cohort, the authors
modelled the hazard ratio of new-onset depression according to presence of diabetes both in crude
models and in models adjusted for age, sex, number of physician visits, insulin usage and comorbidities
(including arthritis, cancer, stroke, coronary artery disease and peripheral arterial disease).
With these selection criteria, the authors included subjects with generally recent-onset, mild type 2
diabetes, and excluded depression-prone subjects (i.e., those with a history of depression). Although type
2 diabetes can be quite advanced at the time of diagnosis, most patients with type 2 diabetes do not
develop serious complications within 5 years of diagnosis. Moreover, by including only subjects treated
with oral hypoglycemics, Brown's group excluded as well those patients with severe comorbidities (e.g.,
renal failure, heart failure) that preclude oral hypoglycemic use; such comorbidities are known to be
associated with depression. As a result of their selection criteria, the authors have suggested that patients
with relatively recent-onset diabetes, and with little in the way of advanced complications, are not at
higher risk for depression than people without diabetes.
However, their data belie their title, since even patients with new-onset diabetes had an increased risk of
depression; those with more severe diabetes had an even higher risk. In this study's Saskatchewan
population, patients with diabetes had a statistically significant 10% increased risk of developing
depression in crude analyses. Patients treated with insulin which the authors appropriately consider to

be a proxy for severity of disease had an unadjusted 34% increase in their risk of developing
depression. After adjusting for peripheral arterial disease (and thereby controlling for the effect of severe
complications), diabetes alone was no longer associated with increased risk of depression, whereas
complications of diabetes marked by the presence of peripheral arterial disease were.
Other studies have shown that mild, asymptomatic, type 2 diabetes is not associated with depression or
impaired quality of life, whereas symptomatic comorbidities and insulin use appear to be risk factors.25
Population-based studies, as opposed to those carried out in clinical settings, have shown relatively high
quality of life in patients with type 2 diabetes.6,7 Brown and colleagues' results are consistent with those
of prior studies and suggest that although asymptomatic early diabetes may not increase the risk for
depression, the risk of depression is increased when all patients with diabetes are taken into account.
The onset of type 2 diabetes is far more insidious than many other diseases such as stroke, which has an
abrupt and devastating onset, or arthritis, which is usually diagnosed after pain has developed; both of
these conditions are strongly associated with depression in this and other studies. In the absence of
hyper-or hypoglycemia, patients with early type 2 diabetes may be asymptomatic. Once complications
emerge, the prevalence and risk of depression climbs. Brown and colleagues' findings remind us that we
should focus our attention among patients newly diagnosed with diabetes on prevention of
complications, while at the same time remaining sensitive to the risk of depression if, despite all efforts,
complications of diabetes develop.
Footnotes
This article has been peer reviewed.

CMAJ July 4, 2006; 175 (1). doi:10.1503/cmaj.051429.

2006 CMA Media Inc. or its licensors
www.cmaj.ca
Type 2 diabetes does not increase risk of depression
Lauren C. Brown, Sumit R. Majumdar, Stephen C. Newman and Jeffrey A.
Johnson
From the Departments of Public Health Sciences (Brown, Majumdar, Newman,
Johnson), Medicine (Majumdar) and Psychiatry (Newman), University of Alberta,
and the Institute of Health Economics (Brown, Majumdar, Johnson), Edmonton,
Alta.
Correspondence to: Dr. Jeffrey A. Johnson, Institute of Health Economics, 10405
Jasper Ave., Rm. 1200, Edmonton AB T5J 3N4; fax 780 448-0018;
jeff.johnson@ualberta.ca
Background: Although diabetes mellitus has a strong association with the presence of depression, it is
unclear whether diabetes itself increases the risk of developing depression. The objective of our study
was to evaluate whether people with diabetes have a greater incidence of depression than those without
diabetes.
Methods: We conducted a population-based retrospective cohort study using the administrative
databases of Saskatchewan Health from 1989 to 2001. People older than 20 years with newly identified
type 2 diabetes were identified by means of diagnostic codes and prescription records and compared
with a nondiabetic cohort. Depression was ascertained via diagnostic codes and prescriptions for

antidepressants. Cox regression analysis was used to estimate hazard ratios (HRs) and 95% confidence
intervals (CIs) after adjusting for age, sex, frequency of visits to physicians and presence of
comorbidities.
Results: We identified 31 635 people with diabetes and 57 141 without. Those with diabetes were older
(61.4 v. 46.8 yr; p < 0.001), were more likely to be male (55.4% v. 49.8%; p < 0.001) and had more
physician visits during the year after their index date (mean 14.5 v. 5.9; p < 0.001). The incidence of
new-onset depression was similar in both groups (6.5 v. 6.6 per 1000 person-years among people with
and without diabetes, respectively). Similarity of risk persisted after controlling for age, sex, number of
physician visits and presence of prespecified comorbidities (adjusted HR 1.04, 95% CI 0.94 1.15).
Other chronic conditions such as arthritis (HR 1.18) and stroke (HR 1.73) were associated with the onset
of depression.
Interpretation: Using a large, population-based administrative cohort, we found little evidence that type
2 diabetes increases the risk of depression once comorbid diseases and the burden of diabetes
complications were accounted for.

2005 by the American Diabetes Association

www.care.diabetesjournal.org
Depression and Diabetes
A large population-based study of sociodemographic, lifestyle, and clinical factors associated with
depression in type 1 and type 2 diabetes
Anne Engum, MD1,2, Arnstein Mykletun, MA3, Kristian Midthjell, MD, PHD4, Are Holen, MD, PHD1
and Alv A. Dahl, MD, PHD5
1

Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology,

Verdal, Norway
2
Nord-Trndelag Hospital Trust, Department of Psychiatry, Hospital Levanger, Levanger, Norway
3
Research Centre for Health Promotion, University of Bergen, Bergen, Norway
4
HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of
Science and Technology, Verdal, Norway
5
The Norwegian Radium Hospital, Oslo, Norway
Address correspondence and reprint requests to Anne Engum, MD, Department of Psychiatry, Hospital
Levanger, N-7600 Levanger, Norway. E-mail: anne.engum@hnt.no

ABSTRACT

OBJECTIVEThe purpose of this study was to investigate factors associated with depression in type
1 and type 2 diabetes and test whether these differ from factors associated with depression in the
nondiabetic population.

RESEARCH DESIGN AND METHODSIn an unselected population study comprising 60,869

individuals, potential sociodemographic, lifestyle, and clinical factors were investigated in participants with
and without diabetes. The associations between hyperglycemia and depression in types 1 and 2 diabetes
were also studied. The levels of depression were self-rated by using the Hospital Anxiety and Depression
Scale.
RESULTSSeveral factors were correlated with depression in types 1 and 2 diabetes. However, these
factors were not different from those of the nondiabetic population. Comorbid chronic somatic diseases
were associated with depression in type 2 but not type 1 diabetes. In type 2 diabetes, those without
comorbidity had the same odds of depression as the nondiabetic population with no chronic somatic
diseases. No significant associations were found for hyperglycemia in relation to depression in type 1 and
type 2 diabetes.
CONCLUSIONSType 2 diabetes without other chronic somatic diseases did not increase the risk of
depression. Factors associated with depression in type 1 and type 2 diabetes were shared with the
nondiabetic population.
Abbreviations: HADS, Hospital Anxiety and Depression Scale HADS-D, Hospital Anxiety and
Depression Scale, depression items HUNT, Nord-Trndelag Health Study, Norway
INTRODUCTION

Past research has shown that a relationship exists between depression and diabetes (1). Depression has
been associated with hyperglycemia (2), diabetes-related complications (3), and perceived functional
limitations of diabetes (4). Moreover, depression among individuals with diabetes has also been
associated with potential sociodemographic, lifestyle, and clinical factors shared with the general
population. The contributions of socioeconomic status (5), marital status (6), obesity (7), smoking habits
(8), and physical limitations and inactivity (9) have been extensively tested.
When the relationship between diabetes and depression is examined, the role of comorbid chronic somatic
diseases has to be taken into account (10). In general, previous research has indicated a higher prevalence of
depression in samples of patients with various chronic somatic diseases. The coexistence of chronic somatic
diseases is common (11,12), and there is a strong connection between symptoms of depression and the
number of different chronic diseases (13,14).
Nevertheless, the question remains: Are the factors associated with depression in types 1 and 2 diabetes
different from those in the nondiabetic population? We have not been able to find any studies that include
interaction tests to investigate whether factors associated with depression actually interact with having
diabetes. Multiple health problems, as well as personal, social, and community factors, may combine to
bring about depression in individuals with diabetes. Several of the factors claimed to be linked to depression
are not limited to those with diabetes and may be related to the general psychological distress of having a
chronic disease (4).
In a large study of the general population, the relationship between diabetes and reported symptoms of
depression were studied. This study investigated the role of some sociodemographic, lifestyle, and clinical
factors associated with depression in types 1 and 2 diabetes and examined whether these factors were
different from those of the nondiabetic population.
RESEARCH DESIGN AND METHODS

The population study was part of the second Nord-Trndelag Health Study, Norway (HUNT 2). The data
were collected from 1995 to 1997. All inhabitants of Nord-Trndelag County aged 20 years received
written invitations together with questionnaires and appointed dates for physical tests and blood
samples. In the questionnaires, the participants were asked about demographic characteristics, health
status, lifestyle, health habits, and their living conditions. Of 92,100 individuals invited, 65,648 (71.3%)
responded. The youngest and oldest age-groups had the lowest rates of attendance, whereas the highest
rates were found among women and middle-aged persons.
Our sample comprised individuals aged 2089 years with valid ratings of depression, self-report of
diabetes, data about marital status, level of education, smoking habits, BMI, and physical activity. Included
were also self-reports about somatic diseases and physical impairments. The nondiabetic population
comprised 59,329 individuals. A total of 223 had type 1 diabetes, 958 had type 2 diabetes, and 359
individuals had other subtypes of diabetes or did not take the verifying blood tests and were left
unclassified. In this study, the main topic was to compare individuals with types 1 and 2 diabetes with
nondiabetic responders. Accordingly, individuals with unclassified diabetes were excluded from the
analyses.
Psychological features
Symptoms of depression were screened using the Hospital Anxiety and Depression Scale (HADS) (15,16).
The scale consists of seven items for depression (HADS-D) and seven for anxiety. Only HADS-D scores
were utilized in this study. A main characteristic of HADS-D is that items covering somatic symptoms of
depression have been eliminated to avoid false-positive results when used in somatic settings. In this study,
we used the recommended cutoff of eight for caseness of depression. However, this should not imply a level
of clinical depression, which cannot be inferred from the screening instrument used in the present study.
HADS has been extensively tested and has well-established psychometric properties (17). Several studies
have demonstrated good sensitivity, specificity, and receiver operating characteristics of HADS. High
correlation between HADS scores has been obtained in relation to other questionnaires and structured
interviews detecting depression (18,19).
Somatic health
The initial selection of individuals with diabetes was based on self-reports. Metabolic control was
determined by HbA1c (A1C) in all individuals who had diabetes. A1C values reflect the average level of
blood glucose in the past 3 months. The test is widely accepted as a reliable and valid index of metabolic
control. In addition, all participants indicating a history of diabetes (n = 1,638) received a specific
questionnaire about the disease and 1,540 responded. Of those, 1,181 participated in additional fasting
blood test for glucose, C-peptide, and anti-GAD antibodies. According to autoantibodies to GAD, C-peptide
tests, and information on start of insulin treatment, the responders were further divided into types 1 and 2
diabetes. C-peptide was tapped by the radioimmunoassay method (Diagnostic System Laboratories,
Webster, TX), and anti-GAD antibodies were measured via immunoprecipitation by using [3H]leucine
translation-labeled GAD65 as the indicator.
A total of 19,979 individuals reported a history of one or more of the following health problems:
cardiovascular diseases (including angina pectoris, myocardial infarction, stroke, and hypertension),
musculoskeletal diseases (including ankylosing spondylitis, osteoarthritis, rheumatoid arthritis, and
osteoporosis), thyroid diseases (including hypothyroidism, goiter, and hyperthyroidism), cancer, and
asthma. A dichotomous variable for "somatic diseases" was defined as one or more of the above-mentioned
health problems, as opposed to none.
The participants were asked to assess how much their function was impaired or restricted with regard to
vision, hearing, and movement. Two dichotomous variables were made from the self-reported data about the

presence (moderately or severely impaired vision and/or impaired hearing and/or restricted movement) or
absence of physical impairment.
The variable "somatic complaints" including symptoms such as pain, stiffness, or gastrointestinal symptoms
(dyspepsia, nausea, or diarrhea) were divided into one or more complaints versus none.
Demographic and lifestyle variables
Education was classified into low and high: low levels of education covered compulsory education ( 9
years), whereas high education was defined as >9 years of school. Two dichotomous categories were
developed for marital status: single (unmarried, widowed, divorced, or separated) versus married or
cohabiting.
Lifestyle variables covered information about smoking, BMI, and physical activity. Smokers were defined
dichotomously into current smokers or not. BMI was treated as a continuous variable. The participants were
asked to give information about how many hours they spent on physical activity in their spare time during
the last year (hours per week). In a dichotomous variable, physical inactivity was scored as positive
whenever the person spent <1 h per week on physical activities.
Statistics
The t test or 2 test were used to investigate differences on demographic characteristics, somatic health, and
depression as measured by HADS-D between type 1 or type 2 diabetes and the nondiabetic population.
Then bivariate analyses between depression and demographic, lifestyle, and somatic variables were
computed in type 1 and type 2 diabetes and in the nondiabetic population.
To determine whether the factors identified in type 1 or type 2 diabetes as correlating with depression were
specific or shared with the nondiabetic population, logistic regression models were used with depression as
a dependent variable. The factors, type 1 (or type 2) diabetes, and the interaction term between the factors
and type 1 (or type 2) diabetes were used as independent variables in 20 separate runs. The models were
adjusted for demographic, lifestyle, and clinical variables that were related to the exposure and that in a
stepwise logistic regression were related to the outcome (depression) with P < 0.20. All the variables in the
full models contributed to the models and were retained. No factors were strongly correlated in a
collinearity analyses. The Hosmer-Lemeshow goodness-of-fit test was used to assess model fit. If the
interaction term was positive, the factor was more associated with depression in type 1 or type 2 diabetes
than in the nondiabetic population and accordingly less associated if the interaction term was negative. We
examined the potential for effect modification by including interaction terms between age and sex with each
factor in the analyses.
The relationship between A1C and HADS-D was investigated by linear regression analyses adjusted for age
and sex in type 1 and type 2 diabetes. The dependent variable, HADS-D, was fairly normally distributed
both in type 1 (skewness = 1.092, kurtosis = 1.458) and in type 2 diabetes (skewness = 0.813, kurtosis =
0.353).
We undertook both unadjusted and adjusted logistic regression analyses to assess the associations between
groups with and without chronic somatic diseases as independent variables and depression (HADS-D 8) as
the dependent variable with the "no chronic disease" group serving as the reference category. In a stepwise
logistic regression, all covariates were significantly related to the outcome and were retained in the model.
All the factors were correlated, but a collinearity analyses revealed no factors were strongly correlated with
one another.
The level of significance was set at P < 0.05. All tests were two way and SPSS-PC 12.0 was used as the
statistical package.
The National Data Inspectorate and the Board of Medical Research Ethics in Health Region IV of Norway
approved the HUNT 2 study.

RESULTS

In Table 1, the characteristics of participants with type 1, type 2, and no diabetes were compared with
regard to demographics, lifestyle variables, somatic health, and depression as measured by HADS-D.
Compared with the nondiabetic population (n = 59,329), individuals with type 1 (n = 223) and type 2
diabetes (n = 958) were more likely to be depressed (15.2 and 19.0%, respectively, vs. 10.7% in the
nondiabetic population). In both type 1 and type 2 diabetes, participants were older, were more often male,
had low levels of education, were considerably more obese, and smoked less. In addition, they reported
more somatic diseases and more physical impairment. Furthermore, individuals with type 2 diabetes were
more physically inactive and also reported more somatic complaints.

In the nondiabetic population, 31.8% (n = 18,896) reported one or more chronic somatic diseases:
cardiovascular diseases, 13.6%; musculoskeletal diseases, 13.2%; thyroid diseases, 5.2%; cancer, 3.4%; and
asthma, 8.4%. In type 1 diabetic subjects, 60.5% (n = 135) reported comorbidity: cardiovascular diseases,
43.0%; musculoskeletal diseases, 19.7%; thyroid diseases, 13.0%; cancer, 4.0%; and asthma, 7.2%. In type
2 diabetic subjects, 74.0% (n = 709) reported comorbidity: cardiovascular diseases, 55.4%; musculoskeletal
diseases, 28.9%; thyroid diseases, 9.3%; cancer, 8.5%; and asthma, 13.4%.
Factors correlated with depression
Bivariate analyses between depression (HADS-D 8) and demographic, lifestyle, and somatic covariates
(Table 2) revealed several significant correlations with depression in type 2 diabetes. Those having
depression compared with subjects without depression had significantly lower levels of education (72.5 vs.
64.7%) and were less physically active (77.2 vs. 62.8%). The subjects with depression also had a higher
proportion of comorbid somatic diseases (83.5 vs. 71.8%), subjective somatic complaints (75.3 vs. 55.2%),
and physical impairment (45.65 vs. 32.0%). In type 1 diabetes, low levels of education (62.5 vs. 40.0%) and
physical impairment (50.0 vs. 27.0%) were significantly correlated with depression. Logistic regression
analyses (both crude and adjusted) demonstrated that the factors correlated with depression in type 1 and
type 2 diabetes were not different from those of the nondiabetic population; the interaction terms (type 1
and type 2 diabetes by factors) were not significantly different from the odds ratio (OR) of 1. The
interaction with age and sex did not modify the results.

Association between hyperglycemia and depression

The associations between hyperglycemia and depression were tested by using linear regression analyses
with HADS-D and A1C as continuous variables and adjustments for age and sex. The analyses
demonstrated nonsignificant associations for both type 1 diabetes (b = 0.094, P = 0.164) and type 2
diabetes (b = 0.030, P = 0.357).
Association between comorbidity and depression
Dividing the participants into subgroups with and without diabetes and with and without other chronic
somatic diseases, the odds of depression were compared with the reference category without any reported
chronic somatic diseases (Table 3). The associations were adjusted for age, sex, marital status, level of
education, smoking, physical inactivity, BMI, somatic complaints, and physical impairment. In the
nondiabetic population, those with chronic somatic diseases had significantly higher odds of depression in
both crude (OR = 1.93) and adjusted (OR = 1.16) analyses. In type 1 diabetes, the odds of depression were
also higher in those with comorbid chronic somatic diseases, but the difference did not reach significance
when adjusted. Individuals with type 2 diabetes without comorbidity were not at higher risks of depression

than those in the reference category when adjusted. However, comorbidity between diabetes and chronic
somatic diseases carried the highest adjusted odds of depression (OR = 1.38). In analyses of the subtypes of
comorbid chronic somatic diseases, only the comorbidity between cardiovascular diseases and type 2
diabetes was significantly associated with depression (data not shown).

CONCLUSIONS

There were three major findings in this study. First, comorbid chronic somatic diseases were associated
with depression in type 2 diabetes but not in type 1 diabetes. Individuals with type 2 diabetes without
comorbidity had the same odds of depression as the nondiabetic population without any reported
chronic somatic diseases. Second, hyperglycemia was not associated with depression in type 1 or type 2
diabetes. Finally, the factors correlated with depression in type 1 and type 2 diabetes were shared with the
nondiabetic population.
The prevalence of depression was significantly higher in subjects with types 1 and 2 diabetes compared
with the nondiabetic population. Several factors were correlated with depression in type 2 diabetes, such as
low levels of education, physical inactivity, subjective somatic complaints, and physical impairment. In
type 1 diabetes, low levels of education and physical impairment were correlated with depression. In types 1
and 2 diabetes, a large proportion of subjects had one or more comorbid chronic somatic diseases with
cardiovascular diseases being the most prevalent condition. Comorbidity was associated with depression in
type 2 diabetes but not in type 1 diabetes. In type 2 diabetes, those without comorbidity had the same odds
of depression as the nondiabetic population without chronic somatic diseases. This suggests that type 2
diabetes without other chronic somatic diseases does not increase the risk of depression. The result is in
accordance with previous research. In a previous study (14), it was reported that increased risk of depressive
symptomatology in diabetes occurred only when comorbid diseases such as cardiac diseases were present.
Another study showed that the impact of diabetes itself on depression was not strong but that depression
was connected to comorbid diseases (20).
In the present study, hyperglycemia was not associated with depression in type 1 or type 2 diabetes. We
actually found an inverse relationship between A1C and level of depression in both types of diabetes,
although the associations were not significant. The existing literature is inconsistent with regard to the
relevance of poor glycemic control and depression. A meta-analysis (2) reviewed 28 studies and measured
associations of depression in relation to glycemic control. They concluded that depression was associated
with hyperglycemia in patients with types 1 and 2 diabetes but revealed neither the mechanism nor the
direction of the association. The results of the meta-analysis were rather heterogeneous, as the study designs
and methods differed considerably. The authors suggested that the relationships might have been stronger in
patients with clinical rather than with subclinical depression.
Our findings are in accordance with those of some other studies. Kruse et al. (21) did not find positive
associations between depression and A1C in a community sample. In addition, they concluded that
individuals with diabetes and A1C level <7% more often had affective disorders than those with poor
glycemic control. In the general population, patients with high A1C levels reported slightly but significantly
higher levels of well-being than patients with low A1C levels (22). One study (23) suggested that
personality traits might be important in achieving glycemic control. Lower scores on neuroticism and
associated personality features of anxiety, hostility, depression, self-consciousness, and vulnerability were
associated with poor glycemic control. Less dysphoric emotions may lower the motivation for maintaining
the self-care regimen, which was suggested as the explanation for the decreased metabolic control.

Factors correlated with depression in type 1 and type 2 diabetes were not different from those in the
nondiabetic population. In general, sociodemographic, lifestyle, and clinical variables are often reported to
correlate with depression in diabetic populations, leaving the impression that these are of particular
relevance to individuals with diabetes. Our findings indicate that this is far from the case. There are no
obvious reasons for why factors correlated with depression would have a particular impact on persons with
diabetes. Nevertheless, contributors to depression have been examined within rather diverse clinical and
epidemiological diabetic populations. By reviewing prior research, we have been unable to find any reports
demonstrating that factors correlated with depression interact with diabetes.
Findings of this study indicate that factors correlated with depression in diabetes have the same relevance as
those in the general population and that the presence of comorbid chronic somatic diseases might explain
the association between type 2 diabetes and depressive symptoms. This supports the notion that the general
burden of having chronic diseases is linked to depression. Comorbidity between diabetes and other chronic
somatic diseases may increase the risks of depression as a result of the psychosocial consequences of the
diseases due to an additive effect of the perception of having the diseases as disabling or an awareness of
having a chronic disease. As illustrated in a population-based study (13), individuals in whom diabetes has
already been diagnosed had significantly higher rates of depressive symptoms than those with newly
diagnosed diabetes. In addition, having a number of coexisting chronic conditions was a significant and
independent predictor of depressive symptoms. Furthermore, a community-based study showed that general
aspects such as physical limitations might be more important determinants of depression than specific
diagnoses (24).
However, this conclusion does not exclude other hypotheses addressing the connections between depression
and diabetes. The analyses of this study indicated increased risks of depression in type 2 diabetes only when
comorbid cardiovascular diseases were present; this is a frequently occurring macrovascular complication
in type 2 diabetes. The result may support theories suggesting that depression increases the risks of
developing type 2 diabetes and diabetes-related vascular complications (25). Hypotheses have advanced that
underlying factors may include increased insulin resistance and reduced glucose uptake (26). Another
hypothesis is that stress-induced disturbances of the hypothalamopituitary adrenal axis and the development
of visceral obesity as a pathway to type 2 diabetes in individuals with genetic susceptibility (27).
The study was carried out on an unselected population, thus reducing selection bias. The population was
large enough to allow for statistical adjustments of potential moderators. Some limitations of the present
study have to be addressed. First, HADS is a self-report symptom scale that measures depressive symptoms
only. Studies of HADS (18,19,28) have shown that the cutoff point chosen has sensitivity and specificity of
0.80 for depression as defined in the Diagnostic and Statistical Manual of Mental Disorders III/III-R.
Second, our study focused on current, not lifetime, psychiatric disorders. Third, the sample was
predominantly of white origin and race as a possible correlate may not be studied. Fourth, the diagnosis of
diabetes and other chronic somatic diseases was based on self-reported data. This approach may lead to
underreporting of diagnoses. It seems unlikely, however, that this is a major bias as earlier research has
reported relatively good agreement between self-report and in-person interview with regard to chronic
somatic diseases such as diabetes (29,30). Finally, it is also worth considering that a proportion of the
nondiabetic population might have undiagnosed diabetes. In this study, only 218 (0.003%) individuals in
the nondiabetic population had increased nonfasting blood glucose levels 11 mmol/l, indicating the
diagnosis of diabetes.
Received for publication December 13, 2004. Accepted for publication May 3, 2005.
The Cochrane Central Register of Controlled Trials (CENTRAL) 2006 Issue 3
Copyright 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Title

Association between symptoms of depression and glycaemic control may be

unstable across gender.
Links
Export Central Citation

Author(s)

Pouwer F, Snoek FJ

Source

Diabetic medicine : a journal of the British Diabetic Association.

Date of Publication

2001 Jul

Volume

18

Issue

Pages

595-8

Abstract

AIMS: Lloyd and colleagues (Diabetic Med 2000; 17, 198-202) have described
an association between poor glycaemic control and moderate to severe
depression in male but not in female diabetes patients. However, the validity of
this study may be limited by its small sample size and the influence of
uncontrolled confounders. Therefore, we set out to replicate this study by
investigating the associations between depression and glycaemic control in
larger samples, while controlling for potential confounders. METHODS: Outpatients with diabetes (n = 174) and 1437 patient members of the Dutch
Diabetes Association (DDA) completed the Hospital Anxiety and Depression
Scale. Demographic and clinical characteristics were obtained using medical
records (out-patients) or self-report (DDA). RESULTS: After controlling for
number of complications, years of education and body mass index, depression
showed significant, low positive correlations with HbA(1c) in three of the four
female samples and in one of the four male samples. Only for out-patients with
Type 2 diabetes was the correlation between HbA(1c) and depression
significantly higher for women when compared with men (0.19 vs. 0.04; P =
0.02). CONCLUSIONS: The association between depression and HbA1c may
be stronger in women with Type 2 diabetes. Oestrogen levels and self-care
behaviours may play a mediating role in this association. Further research is
required before we can conclude that the association between symptoms of
depression and glycaemic control differs across gender. Diabet. Med. 18, 595598 (2001)

Medical Subject Headings Anxiety [blood]; Blood Glucose [*metabolism]; Body Mass Index; Depression
(MeSH)
[*blood]; Depressive Disorder [*blood]; Diabetes Mellitus, Type 1 [blood;
*psychology]; Diabetes Mellitus, Type 2 [blood; *psychology]; Educational
Status; Hemoglobin A, Glycosylated [*analysis]; *Sex Characteristics
MeSH check words
Adult;
Female;

Humans;

Male;

Middle Aged

Correspondence Address

Department of Medical Psychology, Research Institute for Endocrinology,

Reproduction and Metabolism, Vrije Universiteit Medical Centre, Amsterdam,
The Netherlands. f.pouwer.emgo@med.vu.nl

Accession Number

PUBMED 11553192

Publication Type

Clinical Trial; Journal Article; Randomized Controlled Trial

ID

CN-00373832