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Research ArticleOriginal Research

Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes

Wayne J. Katon, Bessie A. Young, Joan Russo, Elizabeth H. B. Lin, Paul Ciechanowski, Evette J. Ludman and Michael R. Von Korff
The Annals of Family Medicine May 2013, 11 (3) 245-250; DOI: https://doi.org/10.1370/afm.1501
Wayne J. Katon
1Department of Psychiatry, University of Washington Medical School, Seattle, Washington
MD
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  • For correspondence: wkaton@u.washington.edu
Bessie A. Young
2Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Kidney Research Institute, University of Washington, Seattle, Washington
MD, MPH
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Joan Russo
1Department of Psychiatry, University of Washington Medical School, Seattle, Washington
PhD
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Elizabeth H. B. Lin
3Group Health Research Institute, Seattle, Washington
MD, MPH
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Paul Ciechanowski
1Department of Psychiatry, University of Washington Medical School, Seattle, Washington
MD, MPH
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Evette J. Ludman
3Group Health Research Institute, Seattle, Washington
PhD
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Michael R. Von Korff
3Group Health Research Institute, Seattle, Washington
ScD
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    Figure 1

    Recruitment diagram for depression, diabetes, hypoglycemia study.

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    Table 1

    Descriptive Statistics For the Study Sample (N = 4,117)

    Study VariableTotalNot Depressed n=3,622 (88%)Depressed n=495 (12%)P Value
    Any prebaseline hypoglycemic episode,a % (No.)3.7 (153)3.1 (113)8.1 (40)<.001
    Any postbaseline hypoglycemic episode,b % (No.)6.9 (283)6.4 (230)10.7 (53)<.001
    Female, % (No.)48.1 (1,981)46.7 (1,690)58.8 (291)<.001
    Age, mean (SD), y63.4 (13.4)64.0 (13.3)59.4 (13.8)<.001
    White, % (No.)80.1 (3,299)80.3 (2,910)78.6 (389).37
    Married, % (No.)65.4 (2,693)66.8 (2,418)55.6 (275)<.001
    Some college (≥1 year), % (No.)76.2 (3,134)76.6 (2,774)72.4 (360).06
    Type 2 diabetes, % (No.)95.6 (3,933)95.4 (3,457)96.2 (476).47
    Duration of diabetes, mean (SD), y9.6 (9.4)9.6 (9.6)9.6 (8.3).87
    Taking insulin, % (No.)30.6 (1,259)28.9 (1,047)42.8 (212)<.001
    RxRisk score, mean (SD)c3,133.7 (2,441.0)3,093.0 (2,386.3)3,431.4 (2,793.5).01
    Hypertension diagnosis, % (No.)74.5 (3,069)74.3 (2,687)75.7 (373).54
    Diabetes complications, mean (SD), No.1.4 (1.3)1.4 (1.3)1.6 (1.4)<.001
    Body mass index, mean (SD)31.5 (7.3)31.1 (6.8)34.8 (9.3)<.001
    Current smoker, % (No.)8.4 (347)7.6 (276)14.3 (71)<.001
    Physical activity score, mean (SD)d2.7 (2.2)2.8 (2.2)1.9 (1.4)<.001
    • ↵a Percentage with hypoglycemic episode in 5 years prebaseline.

    • ↵b Percentage with hypoglycemic episode in 5 years postbaseline.

    • ↵c For this study population, scored on a range from 71 to 21,950, where higher numbers indicate greater morbidity.

    • ↵d Scored on a range from 0 to 7, where higher numbers indicate more days per week of exercise.

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    Table 2

    Hazard Ratios for Major Depression for Time to an Hypoglycemic Event or for Relative Risk for Number of Hypoglycemic Events (N=4,117)

    Covariate AdjustmentTime to Hypoglycemic Event HR (95% CI)Number of Hypoglycemic Events RR (95% CI)
    Unadjusted1.89 (1.39–2.56)1.91 (1.49–2.43)
    Adjusted
     Prior hypogycemic eventa1.65 (1.21–2.25)1.69 (1.32–2.17)
     Prior hypogycemic eventa and demographic characteristicsb1.78 (1.30–2.44)1.76 (1.37–2.26)
     Prior hypogycemic eventa and demographicb and clinicalc characteristics1.41 (1.03–1.94)1.39 (1.08–1.80)
     Prior hypogycemic eventa and demographic,b clinical,c and health risk behaviord characteristics1.42 (1.03–1.96)1.34 (1.03–1.74)
    • HR=hazard ratio; RR=relative risk.

    • ↵a At least 1 hypoglycemic event in the 5 years before entering study.

    • ↵b Demographic characteristics: age, sex, race (white vs nonwhite race/ethnicity), education (some college, high school, or less), and marital status (married or partnered, single).

    • ↵c Clinical characteristics: diabetes duration, insulin use, RxRisk score, hypertension diagnosis, diabetes type 1 or 2, and diabetes complication score.

    • ↵d Health risk behavior characteristics: body mass index, current smoking, and physical activity.

Additional Files

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    Supplemental Appendix 1. Potential Cofounders; Supplemental Appendix 2. Differences Between Nonconsenting and Consenting Patients

    Files in this Data Supplement:

    • Supplemental data: Appendix 1-2 - PDF file, 2 pages, 106 KB
  • The Article in Brief

    Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes

    Wayne J. Katon , and colleagues

    Background Psychosocial and clinical factors can be associated with hypoglycemia (low blood glucose levels) in patients with diabetes, but there has been little research into the relationship between depression and severe hypoglycemic episodes. This study examines that association.

    What This Study Found Patients with diabetes and major depression are at increased risk of severe hypoglycemic episodes requiring hospitalization or a visit to the emergency room. Over a 5-year period, depressed adult patients with diabetes had a significantly higher risk of a severe hypoglycemic episode and a greater number of hypoglycemic episodes compared with nondepressed patients.

    Implications

    • The increased risk of severe hypoglycemic episodes in patients with depression may be due to poor self-care or psychobiologic changes associated with depression.
    • The authors call for research to assess whether recognition and effective treatment of depression among diabetic patients prevents severe hypoglycemic episodes, as well as increased risk of complications and mortality.
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The Annals of Family Medicine: 11 (3)
The Annals of Family Medicine: 11 (3)
Vol. 11, Issue 3
May/June 2013
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Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes
Wayne J. Katon, Bessie A. Young, Joan Russo, Elizabeth H. B. Lin, Paul Ciechanowski, Evette J. Ludman, Michael R. Von Korff
The Annals of Family Medicine May 2013, 11 (3) 245-250; DOI: 10.1370/afm.1501

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Association of Depression With Increased Risk of Severe Hypoglycemic Episodes in Patients With Diabetes
Wayne J. Katon, Bessie A. Young, Joan Russo, Elizabeth H. B. Lin, Paul Ciechanowski, Evette J. Ludman, Michael R. Von Korff
The Annals of Family Medicine May 2013, 11 (3) 245-250; DOI: 10.1370/afm.1501
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