OBJECTIVE -We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. RESEARCH DESIGN AND METHODS -In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services.RESULTS -This predominantly type 2 diabetic population had a mean HbA 1c level of 7.8 Ϯ 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA 1c tests was 2.2 Ϯ 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI Ͼ30 kg/m 2 , and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 Ϯ 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipidlowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients.CONCLUSIONS -In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes. Diabetes Care 27:2154 -2160, 2004T he World Health Organization estimates that at least 170 million individuals suffer from diabetes globally, and this figure is likely to double by 2030 (1). Diabetes-related complications are major causes of morbidity and mortality. Optimal outcomes in diabetes require diligent and daily self-management, including eating a healthy diet, exercising, and regular glucose monitoring (2-4). The American Diabetes Association publishes standards of medical care yearly to promote the importance of achieving optimal glycemic control (HbA 1c Ͻ7%) (2). Comprehensive treatment includes lifestyle modifications; pharmacological control of hyperglycemia, hypertension, and hyperlipidemia; and preventive care such as monitoring for glycemic control or retinopathy. Depression not only affects mood but compromises functioning as well (5,6). Among diabetic patients, depression is twice as common as compared with matched control subjects without diabetes (7,8). When depression accompanies diabetes, there is evidence of poorer glycemic control, decreased physical activity, higher obesity, and potentially more diabetes end-organ complications and impaired function (9 -14). There is also evidence that de...

A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.

OBJECTIVE -The goal of this study was to determine the behavioral and clinical characteristics of diabetes that are associated with depression after controlling for potentially confounding variables. RESEARCH DESIGN AND METHODS-A population-based mail survey was sent to patients with diabetes from nine primary care clinics of a health maintenance organization. The Patient Health Questionnaire was used to diagnose depression, and automated diagnostic, pharmacy, and laboratory data were used to measure diabetes treatment intensity, HbA 1c levels, and diabetes complications.RESULTS -Independent factors that were associated with a significantly higher likelihood of meeting criteria for major depression included younger age, female sex, less education, being unmarried, BMI Ն30 kg/m 2 , smoking, higher nondiabetic medical comorbidity, higher numbers of diabetes complications in men, treatment with insulin, and higher HbA 1c levels in patients Ͻ65 years of age. Independent factors associated with a significantly higher likelihood of meeting criteria for minor depression included younger age, less education, non-Caucasian status, BMI Ն30 kg/m 2 , smoking, longer duration of diabetes, and a higher number of complications in older (Ն65 years) patients.CONCLUSIONS -Smoking and obesity were associated with a higher likelihood of meeting criteria for major and minor depression. Diabetes complications and elevated HbA 1c were associated with major depression among demographic subgroups: complications among men and HbA 1c among individuals Ͻ65 years of age. Older patients with a higher number of complications had an increased likelihood of minor depression. Diabetes Care 27:914 -920, 2004A recent meta-analysis of 39 studies in patients with diabetes reported an estimate of major depression in 11% of patients based on structured psychiatric interviews and elevated depression symptoms in 31% based on depression-rating scales (1). Prior research on sociodemographic predictors of depression in patients with diabetes has shown high risk for female sex (2-4), younger age (2-4), less education (2-6), and less income (1,3,4,7). Depression has also been found in two recent metaanalyses to have significant associations with increased HbA 1c levels (8) and diabetes complications (9). Most of the studies included in these meta-analyses had small, nonrepresentative samples and did not fully characterize the depressed versus the nondepressed patients in terms of the number of complications, type of diabetes, insulin dependence, behavioral risk factors (i.e., smoking, obesity), medical comorbidity, socioeconomic variables, race, or ethnicity (1,8,9). The lack of reporting of sociodemographic and clinical variables in most studies is a significant limitation, as analyses of the association between depression and diabetes severity and HbA 1c have often not controlled for potentially important confounding variables (1,8,9).The small sample sizes also precluded the study of potentially important interactions such as the effect of age and sex on ...

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