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Depression, severe hypoglycemia share bidirectional association in type 1 diabetes
Middle-aged patients with type 1 diabetes diagnosed with depression are at least twice as likely to experience a severe hypoglycemic or hyperglycemic event requiring an ED visit or hospitalization compared with patients without depression, with the greatest risk observed in the first 6 months after a depression diagnosis, according to findings published in Diabetes Care.
In an analysis of medical records, researchers also found that patients with type 1 diabetes who experienced a dysglycemic event were at least twice as likely to later be diagnosed with depression compared with those who did not experience severe hyperglycemia or hypoglycemia.
“The vast majority of research on depression and severe dysglycemic events has had samples comprised of people exclusively or predominantly with type 2 diabetes, even though these events are much more common among people with [type 1 diabetes],” Paola Gilsanz, ScD, a postdoctoral fellow in the division of research at Kaiser Permanente in Oakland, California, and colleagues wrote in the study background. “People with [type 1 diabetes] are up to four times more likely to experience severe hypoglycemia and about three times more likely to experience [diabetic ketoacidosis] than those with [type 2 diabetes].”
Gilsanz and colleagues analyzed data from 3,742 patients enrolled with Kaiser Permanente Northern California aged at least 50 years with type 1 diabetes participating in an aging study between 1996 and 2015 (mean age, 56 years; 79% white). Researchers analyzed medical records for diagnoses of major depressive disorder, depressive type psychosis and dysthymic disorder and diagnoses of severe dysglycemic events that resulted in hospital admission or ED care. Researchers used Cox proportional hazard models to estimate any associations between depression and severe dysglycemia in both directions.
Within the cohort, 20% of patients had depression at baseline and an additional 21% were diagnosed during the study. There were 376 cases of severe hyperglycemia and 641 cases of severe hypoglycemia during follow-up; 5% of the cohort experienced both. Mean follow-up time was 5.9 years for analyses examining hyperglycemia and 5.1 years for analyses examining hypoglycemia as the outcome.
After adjusting for demographic factors, HbA1c and vascular complications, depression was associated with more than a twofold risk for severe hyperglycemia (HR = 2.47; 95% CI, 2-3.05) and a near doubling of risk for severe hypoglycemia (HR = 1.89; 95% CI, 1.61-2.22). The risk was markedly stronger during the first 6 and 12 months after a depression diagnosis, according to researchers.
Additionally, patients with diagnosed depression were five times more likely to experience a severe hyperglycemic event (HR = 5.16; 95% CI, 3.88-6.88) and four times more likely to experience a severe hypoglycemic event (HR = 4.05; 95% CI, 3.26-5.04) in the first 12 months vs. those without a depression diagnosis.
In analyzing patients with type 1 diabetes who did not have depression at baseline, those who experienced severe hyperglycemia were more than twice as likely to be diagnosed with depression during follow-up as those who did not experience severe hyperglycemia (HR = 2.39; 95% CI, 2-2.84), with risk persisting after adjustment for demographic factors, HbA1c and vascular complications. Patients without baseline depression who experienced a severe hypoglycemic event were 75% more likely to be diagnosed with depression vs. those who did not experience severe hypoglycemia (HR = 1.75; 95% CI, 1.5-2.05), with results again persisting after adjustment for demographics, HbA1c and vascular complications.
“In our study, the risk for severe hypo- or hyperglycemic events was especially high during the first year after depression diagnosis, highlighting the need for increased clinical vigilance for these patients during the vulnerable period,” Gilsanz told Endocrine Today. “Our results emphasize the need for multifaceted interventions to minimize the morbidity associated with type 1 diabetes.”
Gilsanz said further research is needed in identifying pathways linking severe hypo- and hyperglycemic events and depression, which could uncover potential targets of intervention to break the cyclical association between them. – by Regina Schaffer
For more information:
Paola Gilsanz , ScD, can be reached at Kaiser Permanente, Division of Research, 2000 Broadway, Oakland, California 94612; email: paola.gilsanz@kp.org.
Disclosures: The authors report no relevant financial disclosures.