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Death from Depression Growing Concern: Now Linked to More Deaths Among Older Diabetics

Patients with both diabetes and depression had increased risk of about 36% to 38% of dying from any cause

Oct. 1, 2008 – Depression is rapidly becoming the suspect in many deaths, particularly among older people, who are suffering with a severe physical malady. There was a call just this week for all heart patients to be tested for depression and, today, a new study finds depression associated with a higher death rate among Medicare beneficiaries with diabetes.

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The study tracked 10,704 Medicare beneficiaries with diabetes for a two-year period and concluded those with depression had a higher death rate from all causes.

The findings are published in the October 2008 issue of the Journal of General Internal Medicine.

Lead author Dr. Wayne Katon, professor of psychiatry and behavioral sciences at the University of Washington (UW), noted that previous research indicates that depression and diabetes is a potentially lethal mix among young to middle-aged patients.

Depression also puts patients at greater risk of complications from their diabetes. This more recent study suggests that depression is also a risk factor for mortality in older patients with diabetes.

Most Medicare beneficiaries, like the ones in this study, are over age 65. The mean age of the participants was 75.6 years.

They were enrolled in a disease management program in Florida and were surveyed at the start of the study with a health assessment questionnaire. Evidence of depression among members of the group came from physician diagnosis, patient reports of having a prescription for an antidepressant in the year before the survey, or patient answers to a brief screening test.

How do older adults experience depression? White males 85 and older have the highest suicide rate Depression is not a normal part of aging, according to the National Institute of Mental Health, but when senior citizens have a depression it may be overlooked, because older people show different and less obvious symptoms. They also may be less willing to acknowledge feelings of sadness or grief. “In addition,” according to the NIMH, “older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. "Some older adults may experience what some doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. “Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. "Such hardening of vessels prevents normal blood flow to the body's organs, including the brain. Those with vascular depression may have, or be at risk for, a co–existing cardiovascular illness or stroke. “Although many people assume that the highest rates of suicide are among the young, older white males age 85 and older actually have the highest suicide rate. "Many have a depressive illness that their doctors may not detect, despite the fact that these suicide victims often visit their doctors within one month of their deaths. “The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both. “Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults. "Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication. >> More at NIMH on Depression

For the next two years, the research team recorded the death and cause of death of participants through bi-monthly checks of Medicare claims and eligibility files, or from phone calls with the participants' families.

The research team found that patients with both diabetes and depression had an increased risk of about 36 to 38 percent of dying from any cause during the two-year follow-up.

Participants with a physician diagnosis of depression were significantly younger than their cohorts, more likely to be female, had more severe medical illness, were less likely to be African-American, and more likely to be Hispanic.

These variables were controlled for in the analysis of increased risk. A total of 12.1 percent of participants who had both disorders died during that period. Among those without depression, 10.4 percent died.

Participants who had been treated with one or more antidepressant medications in the year before the study had a 24 percent increased risk of mortality, compared to non-depressed participants.

According to the study authors, those patients may have been treated with antidepressants because their depressive symptoms were more severe and persistent than those of more mildly depressed patients who weren't prescribed antidepressants.

There was no difference in the rate of cardiovascular or cerebrovascular events between those treated with antidepressants and those who had no indication of depression.

"Rates of mortality from vascular disease may be decreasing in recent years among patients with diabetes due to more aggressive treatment of high blood pressure, cholesterol, and glucose levels," the researchers surmised, "as well as widespread use of preventative medications such as aspirin and beta blockers."

According to the authors, there may be several reasons why depression worsens chronic diseases such as diabetes. Depression has been associated with inadequate self-care and harmful habits like smoking or overeating. Depression is also associated with nervous system and endocrine system problems, and with inflammatory markers.

The authors noted their study's limitations: the participants were from one geographic region of the United States, and the follow-up period was relatively short. Defining depression in part by physician diagnosis and treatment, they added, may have selected for participants with more severe illness. The study was also not able to obtain information on education, income, weight, smoking habits, physical activity, or compliance in taking medication.

Editor’s Notes:

In addition to Katon, the researchers included Drs. Ming-Yu Fan and Jurgen Unutzer from the UW, Dr. Jennifer Taylor from Green River Health in Tampa, Fl.; Dr. Harold Pincus from Columbia University and the Rand Corporation; and Michael Schoenbaum from the National Institutes of Health (NIH) in Bethesda, Md.

Grants from the National Institute of Mental Health of the NIH funded the study.

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What Is Depression?

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better.

Many people with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment. Intensive research into the illness has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling disorder.

What are the different forms of depression?

There are several forms of depressive disorders. The most common are major depressive disorder and dysthymic disorder.

Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once–pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.

Dysthymic disorder, also called dysthymia, is characterized by long–term (two years or longer) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include:

Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions.

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.1

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.2

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes-from extreme highs (e.g., mania) to extreme lows (e.g., depression). Visit the NIMH website for more information about bipolar disorder.

What are the symptoms of depression?

People with depressive illnesses do not all experience the same symptoms. The severity, frequency and duration of symptoms will vary depending on the individual and his or her particular illness.

Depression Test Online  - NYU Medical School

Symptoms include:

   ● Persistent sad, anxious or "empty" feelings
   ● Feelings of hopelessness and/or pessimism
   ● Feelings of guilt, worthlessness and/or helplessness
   ● Irritability, restlessness
   ● Loss of interest in activities or hobbies once pleasurable, including sex
   ● Fatigue and decreased energy
   ● Difficulty concentrating, remembering details and making decisions
   ● Insomnia, early–morning wakefulness, or excessive sleeping
   ● Overeating, or appetite loss
   ● Thoughts of suicide, suicide attempts
   ● Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

>> More at NIMH on Depression

>> Download the PDF (25 pages)

 

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