Elsevier

Primary Care Diabetes

Volume 4, Issue 4, December 2010, Pages 215-222
Primary Care Diabetes

Original research
Correlates of depression among people with diabetes: The Translating Research Into Action for Diabetes (TRIAD) study

https://doi.org/10.1016/j.pcd.2010.07.002Get rights and content

Abstract

Aim

The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care.

Methods

Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data.

Results

Nearly 18% of patients had major depression, with prevalence 2–3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care.

Conclusions

In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.

Introduction

Depression is a common co-morbid condition among adults with diabetes with prevalence estimates ranging from 8.3% to over 30% – as much as three times higher than in non-diabetic populations [1], [2], [3], [4], [5]. Depression has been associated with worse diabetes-related outcomes including poorer glycemic control, other cardiovascular disease risk factors, a greater diabetes symptom burden and poorer quality of life [6], [7], [8], [9]. Patients with diabetes and co-morbid depression have been found to be at an increased risk of death from all causes, including those unrelated to diabetes [10], [11], [12]. Depression has been associated with suboptimal self-care and poor treatment adherence, thus contributing to adverse outcomes [13], [14], [15], [16]. Co-morbid depression also results in higher utilization for both medical and mental health care, and higher health care costs [15], [17], [18]. Furthermore, previous studies have shown that co-morbid depression may often be unrecognized and untreated in individuals with diabetes [19], [20], [21]. With emerging evidence that depression treatment improves patient outcomes [22], [23], [24], [25], it is important to clarify which diabetes patients are at risk for depression, and the relationships between depression, quality of care and outcomes for diabetes.

Estimates of the prevalence of co-morbid depression with diabetes vary widely. A number of methodological factors affecting these estimates have been identified, including differences in depression measures, population size and characteristics, study design and the inclusion of confounding variables [1], [2], [26]. These methodological issues are further compounded in studies of outcomes associated with co-morbid depression. Health systems factors can directly and indirectly affect quality of care for diabetes, depression and associated outcomes [27], [28], [29], but have received very little attention. Few previous diabetes studies have been designed to include sufficient diversity in patient characteristics and health system factors, as well as an adequate sample size, to assess the independent association of a broad range of patient characteristics and outcomes associated with depression.

The Translating Research Into Action for Diabetes (TRIAD) study, with nearly 12,000 diabetes patients varying in age, race/ethnicity and socioeconomic position, receiving care under many different health care plans across the U.S., offers the opportunity to better elucidate the relationships of depression with patient characteristics, quality, and outcomes. The three specific aims of this diabetes study were to measure the association of co-morbid depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care.

Section snippets

Methods

The main objective of the TRIAD study was to measure quality of care and outcomes among a diverse population of people with diabetes receiving care under varying managed health care systems located throughout the U.S. The TRIAD study design, key hypotheses and sampling frame have been described elsewhere [30]. Six centers (Pacific Health Research Institute, Hawaii; University of California, Los Angeles; Kaiser Permanente Northern California; University of Michigan; Indiana University; and the

Sample characteristics

The mean age of the 8790 TRIAD study follow-up participants was 61.8 years, 53% were female, and more than 90% had type 2 diabetes. Mean duration of diabetes was 13.5 years. Among study participants, 44% were white, non-Hispanic, 16% were Asian/Pacific Islander, 16% were Hispanic, 15% were African American and 9% belonged to other racial or ethnic groups.

Unadjusted results

Unadjusted results showed an overall rate of major depression (PHQ score >10) of 18% (Table 1). Depression rates were highest among women,

Depression prevalence and important correlates

Methodological issues associated with previous studies have resulted in large differences in estimates of co-morbid depression prevalence rates, as well as conflicting results about the impact of depression upon outcomes. The most frequently identified issues are limited sample size, the use of different measures of depression, the lack of a control group, and the failure to adequately include important confounding variables [1], [26]. Health system factors in particular have received very

Conclusions

While there are many previous studies of diabetes and co-morbid depression, the results of this study are based on the largest and most diverse sample of patients and health care systems ever undertaken. The TRIAD study sampling design, and the collection of comprehensive covariate data, enabled the independent assessment of a broad range of correlates and outcomes associated with depression.

The strong association of socioeconomic status and co-morbid depression was clear. The association of

Conflict of interest

Two co-authors have served as consultants for pharmaceutical companies (Herman – Amylin Pharmaceuticals, Eli Lilly and Company, GlaxoSmithKline, Merck and Co., Sanofi-Aventis; and Marrero – Eli Lilly and Company, Sun Pharmaceuticals). Two have received grants (Karter – an unrestricted grant to study therapy effectiveness from Novartis; and Herman – Sanofi-Aventis). Dr. Herman has also received honoraria from several pharmaceutical companies and Dr. Ettner and Bair have served on pharmaceutical

Acknowledgements

This study was jointly funded by Program Announcement number 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases.

The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding organizations.

Significant contributions to this study were made by members of the Translating Research Into Action for Diabetes (TRIAD) Study

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    The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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