People with type 2 diabetes who also have symptoms of distress or depression are more likely than others to miss or skip their diabetes medications, according to a recent study.
"Although it would seem intuitive to expect that depression would make the already difficult job of diabetes self-management that much harder, the available data have not been very clear," lead author Jeffrey S. Gonzalez of Yeshiva University in New York said by email.
It is clear, however, that treating depression may be necessary though it is unlikely to be sufficient to improve treatment adherence and diabetes self-management, Gonzalez told Reuters Health.
"Diabetes-related distress reflects the emotional and psychological reactions to the burden and stress associated with diabetes and its management," Gonzalez and his coauthors write in the journal Diabetes Care.
Physical symptoms of depression like poor sleep or appetite as well as low energy can overlap with symptoms of diabetes and with side effects some patients blame on their diabetes medications, the researchers write.
To identify the effects of distress and depression on whether patients adhere to their medications, researchers recruited 104 men and women with type 2 diabetes. The participants answered questions about their diabetes-related emotional distress and depression symptoms, and researchers interviewed them for further detail about their depression experience. Participants also provided blood samples for researchers to assess how well controlled their diabetes was.
Just over 46 percent of participants had clinically significant diabetes distress, and 21 percent had some depression symptoms, although only five individuals met the criteria for major depressive disorder.
Over the next three months the researchers monitored participants' medication use via electronic bottle caps in addition to having them answer the question at the end of the study, "What percentage of the time did you take all your diabetes medications" as prescribed. Based on the bottle cap data, the average was 76 percent of the time.
People with higher levels of self-reported or researcher-assessed depressive symptoms or distress tended to have fewer days on medication than others, the study found.
Depending on the disease stage and medication, missing or skipping medications prescribed for blood sugar, blood pressure or cholesterol is usually not acutely dangerous for people with type 2 diabetes, said Frank J. Snoek of VU University Medical Center Amsterdam, who was not part of the new study.
"Overall, the consequences are mostly felt on the long-term, by means of complications resulting from uncontrolled blood sugar levels, hypertension and high lipid levels," leading to damage of the kidneys, feet and nerves or to cardiovascular events like stroke, he told Reuters Health by email.
When the study team analyzed the relationship between depression and medication adherence, they found that physical depression symptoms like poor sleep and daytime fatigue were the biggest predictors of whether people took their meds regularly and distress levels became less significant.
"When we think of clinical depression, or major depressive disorder, we typically think of the hallmark symptoms of depressed mood, loss of interest, negative thoughts about the self and future, etc.," Gonzalez said. But in this case, symptoms involving problems with sleep and appetite, as well as fatigue, were more closely and independently related to medication non-adherence, he said.
"If there is a causal relationship, it's likely to be cyclical where depression leads to non-adherence which in turn leads to poor control and poorer health, creating further stress and worsening of depression," he said.
Diabetes does raise the risk of subsequent depression, he added.
"Living with and managing diabetes can often be a burden for patients and stressful circumstances can often trigger emotional distress and, sometimes, depression," Gonzalez said. "The point of diagnosis is a good time to evaluate patients' distress and their available resources to deal with it," but too often mental health care is not part of the diabetes discussion.
Tying medication doses to particular routines that occur regularly in the person's life, like morning coffee, may be more effective than tying them to a particular time of day, he said.
"Ideally, providers would approach medication management of diabetes as a collaborative process that is sensitive to the patient's goals and concerns," Gonzalez said.