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Diabetes distress, depression affect medication adherence
Patients with greater levels of diabetes-related distress and depression are less likely to adhere to their medications vs. patients reporting lower levels of distress and depression, according to recent findings.
“Elevations in depressive symptoms and/or diabetes-related distress should be recognized as a predictor of problems with medication adherence in adults with type 2 diabetes,” Jeffrey S. Gonzalez, PhD, associate professor of psychology at the Ferkauf Graduate School of Psychology of Yeshiva University, New York, and the department of medicine at the Albert Einstein College of Medicine, told Endocrine Today. “This was true regardless of the measurement approach taken to assessing emotional distress and was true even when medication adherence was assessed by objective means — through the use of an electronic cap that would track the openings and closings of participants’ medication bottles.”
In an observational longitudinal study, Gonzalez and colleagues analyzed data from 104 adults with type 2 diabetes assigned an oral diabetes medication or insulin who were recruited from specialty and primary care clinics (mean age, 57 years; 64.4% women; 26.9% Hispanic; mean BMI, 35.7 kg/m²; mean diabetes duration, 12.5 years). Participants completed validated questionnaires (17-item diabetes distress scale; 9-item patient health questionnaire) and in-person interviews at baseline to evaluate depression and provided a blood sample to assess HbA1c. Researchers provided patients with a medication event monitoring system (MEMS) bottle cap to track one diabetes-related medication for a mean of 3 months. Patients also completed interviews regarding medication adherence.
Within the cohort, 46.2% of participants scored above the threshold for clinically significant diabetes distress. In addition, 21% of participants screened positive for major depressive disorder, but only 36% of those met diagnostic criteria for current or previous major depressive disorder. Mean 3-month adherence in the cohort was 76.1% for electronic monitoring and 83.7% for self-reported levels.
Researchers found that patients who screened positive on the patient health questionnaire scale had lower electronically monitored adherence vs. those who screened negative (62.52% vs. 79.8%; P = .005). In addition, each of the continuous variables for emotional distress was negatively associated with electronically monitored adherence in bivariate analyses, except for cognitive-affective symptoms (P = .16).
In regression analyses, researchers found that baseline diabetes distress was an independent predictor of both electronically monitored (beta = –0.29; P = .001) and self-reported (beta = –0.24; P < .02) adherence at follow-up. Self-reported depression, also an independent predictor of electronically monitored and self-reported adherence, attenuated the effects of diabetes distress, according to researchers.
In an analysis of somatic and cognitive-affective depressive symptom dimensions as predictors of adherence, researchers found that only somatic depressive symptoms were independently associated with electronically monitored, and not self-monitored, adherence.
“One of the surprising findings is that our analyses that tried to dig into the assessment of depression suggested that somatic symptoms that are captured by these measures accounted for much of the observed relationship between depression symptom scores and medication adherence,” said Gonzalez, who also is associate director of the New York Regional Center for Diabetes Translational Research, based at Einstein. “We saw little evidence for a unique effect of cognitive-affective symptoms of depression that we usually think about as the hallmark symptoms of the disorder, like sad mood, loss of interest, hopelessness, self-blame and guilt, etc. Instead of those symptoms, we found that symptoms related to problems with sleep, appetite, fatigue and other physical changes associated with depression were independently associated with nonadherence to medication over time.”
Gonzalez said it is important for clinicians to discern the explanations for reported somatic symptoms, which could represent a major depressive episode, situational stress, confounding with symptoms of a physical illness or side effects of a prescribed medication. – by Regina Schaffer
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Jeffrey S. Gonzalez, PhD, can be reached at the Diabetes Research Center, Albert Einstein College of Medicine, 1300 Morris Park Ave., Rousso Building, Bronx, NY 10461; email: jeffrey.gonzalez@einstein.yu.edu.
Disclosure: The researchers report no relevant financial disclosures.